Johnson J., Keogh J. Pediatric Nursing Demystified: A Self-Teaching Guide

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CONCLUSION

The immune system protects the body against invasion of microorganisms.

Microorganisms that cause infection are called pathogens. Two of the most

common are bacteria and viruses. The chain of infection must be followed in

order for the pathogen to infect the body. Infection follows four stages begin-

ning with the incubation period and progressing to the convalescence period.

The immune system uses five methods to protect the body: natural immu-

nity, naturally acquired active immunity, naturally acquired passive immu-

nity, artificially acquired active immunity, and artificially acquired passive

immunity.

A person can become immune by receiving a vaccination. The vaccination

can be live attenuated, inactivated, or toxoids.

Bacterial infections include diphtheria, Haemophilus influenzae type B, Lyme

disease, pertussis, and tetanus. Viral infections include fifth disease, mumps,

roseola infantum, poliomyelitis, rubella, rubeola, varicella, and mononucleosis.

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FINAL CHECKUP

1. The health-care provider orders a live attenuated vaccine to be administered to

a 3-year-old. What question should you ask before administering the vaccination?

a. Has the child been taking corticosteroids for the past 2 weeks?

b. Can the child sit still when you give the injection?

c. Has the child ever received an injection before?

d. Is the parent able to hold the child when the injection is administered?

2. A mother calls you saying that her 1-month-old daughter was exposed to a child

who has diphtheria. What is your best response?

a. Bring your child immediately to the ED.

b. Get your child vaccinated immediately.

c. If you were vaccinated for diphtheria and you gave birth to your daughter, then

your daughter is protected the first 6 months of her life by your antibodies.

d. Don’t be concerned. Diphtheria is not contagious.

3. The health-care provider orders penicillin G for a child who has been diagnosed

with tetanus. The child’s mother tells you that the child is allergic to penicillin.

What should you expect the health-care provider to order?

a. Erythromycin

b. Acetaminophen

c. Antipruitics

d. NSAIDs

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4. A father of a 4-year-old boy diagnosed with roseola infantum questions you why

the health-care provider didn’t order antibiotics. What is your best response?

a. There is no cure for roseola infantum.

b. Roseola infantum is a viral infection and bacterial is used to treat bacterial infections.

c. Roseola infantum is self-limiting.

d. I’ll mention this to the health-care provider.

5. A parent is amazed how the health-care provider, who diagnosed her daughter

as having rubeola, predicted that her daughter would develop a rash in a cou-

ple of days. How would you explain this prediction?

a. Rubeola is going around the area.

b. The health-care provider noticed periorbital edema, which precedes the rash by

4 days.

c. The health-care provider noticed a red flat rash in the buccal mucosa of the patient’s

mouth, which appears 2 days before the rash appears on the patient’s face.

d. The health-care provider probably noticed Koplik spots, which appear 2 days

before the rash appears.

6. A child was rushed to the ED having difficulty breathing with hypotension and

shock after eating a peanut butter and jelly sandwich. The parents ask what

might have gone wrong. What is your best response?

a. The child aspirated the sandwich.

b. The child experienced anaphylaxis as a result of a response by the immune system

to an allergen, which is likely to be peanuts.

c. The child has pneumonia.

d. The child experienced food poisoning.

7. A parent of a child who is diagnosed with mumps asks if she can send her child

to child care because it seems that his parotid glands are no longer swollen. What

is your best response?

a. Yes, he is no longer contagious.

b. No, not until he is examined by the health-care provider.

c. No, he remains contagious for 9 days after the swelling of the parotid glands

subsides.

d. Yes, as long as no other child at the child-care center is infected.

8. A new ED nurse wants to call the hospital’s child protection team to investigate

a child who had a red slapped mark on his cheek. His mother brought him in

with a headache and a low-grade fever and he has slight wheezing on inspira-

tion. How would you respond?

a. Ask the nurse if he assessed the child’s trunk for a flat red spotted rash.

b. Tell the nurse to call the police first.

c. Tell the nurse not to leave the child alone with the parent.

d. Tell the nurse to let the health-care provider make that determination.

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9. Amy, a 9-year-old girl, is showing signs and symptoms of the mumps. What

would be appropriate family and client teaching?

a. You can send your child back to school immediately after the swelling subsides.

b. Your child is not contagious until we note the swelling is fully present.

c. Symptoms may not be noted until 12 or more days after exposure.

d. There is no danger of complications from the mumps, so don’t worry.

10. Why would a health-care provider order antibiotics for a child who has a viral

infection?

a. Antibiotics can slow the progression of some viruses.

b. The viral infection might weaken the immune system, enabling bacteria to infect

the body. Antibiotics are administered as a prophylactic.

c. Antibiotics increase the effectiveness of antiviral medications.

d. Question the order.

ANSWERS

Routine checkup 1

1. b

2. c

Routine checkup 2

1. b

2. a

Final checkup

1. a 2. c 3. a 4. b

5. d 6. b 7. c 8. a

9. c 10. b

CHAPTER

Integumentary

Conditions

Learning Objectives

At the end of the chapter, the student will be able to

1 Using appropriate terms, describe skin lesions and other skin condi-

tions.

2 Assess a child with an integumentary condition.

3 Discuss the common treatment plan for a child with a skin condition.

4 Discuss the nursing implications when caring for a child with a skin

condition.

5 Determine the care needs of a child and family with a skin condition.

Bulla

Cyst

Erythema

Lanugo

Macule

Nodule

Papule

Patch

Plaque

Pruritus

Pustule

Vesicle

Wheal

KEY WORDS

OVERVIEW

The skin serves multiple purposes and is important for maintenance of

health and well-being and also impacts physical appearance and self-esteem.

Skin serves as a protective covering; a barrier against mechanical, thermal,

radiant, and chemical trauma. Key anatomic aspects related to skin include the

following:

䊋 Skin is resistant to penetration by microorganisms, dirt, and other

substances.

䊋 The skin plays a role in heat regulation by permitting heat loss or

retention.

䊋 The skin is a sensory organ with nerve endings that transmit touch, pain,

and temperature.

䊋 The skin has two layers—the epidermis (outer) and the dermis (inner).

䊋 The dermis is primarily connective tissue and thus is affected by colla-

gen diseases.

䊋 Hair grows on the skin at different lengths; hair follicles are devel-

oped fully at birth, the presence of lanugo (fine body hair) indicates pre-

mature birth because it usually disappears by full-term birth.

䊋 Subcutaneous tissues are under the dermis and provide a cushion for the

underlying musculature.

䊋 Sebaceous glands produce sebum (a fatty substance) that increases the

water resistance of the skin.

䊋 Sweat glands are present in areas of the body and function to assist in

release of heat, fluid, and some electrolytes. Sweat glands located in the

axilla, areola of the breast, and anal areas are not active during infancy

and childhood, but they become mature at puberty.

SKIN LESIONS/DERMATITIS

What Went Wrong?

More than half of dermatologic problems are types of dermatitis (inflamma-

tion of the dermis) from various causes. Irritation results in inter- and intra-

cellular swelling and infiltration of the dermis and epidermis with vascular

dilation and cellular infiltration around blood vessels. The type of lesion pro-

duced depends on where and how the response settles in and on the skin. Skin

lesions vary in nature and can result from a multitude of injuries from abra-

sion to penetrating wound to infection, among other factors. Lesions can be

primary resulting from an initial insult, or secondary resulting from healing or

additional breakdown of the original involved area. Primary lesions may be

classified in the following ways:

䊋 Bulla: Vesicle >1 cm in diameter (larger blister)

䊋 Cyst: Palpable, elevated, encapsulated liquid or semisolid filled lesion

with distinct borders (e.g., sebaceous cyst)

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䊋 Macule: A flat, nonpalpable brown, red, purple, white, or tan area with

a distinct regular border less than a centimeter in diameter

䊋 Nodule: A 1- to 2-cm elevated, firm, palpable mass deep in the dermis,

with a distinct border

䊋 Patch: A flat nonpalpable irregular shaped macule that is >1 cm in diam-

eter

䊋 Papule: A firm, elevated palpable brown, red, purple, white, or tan area

with a distinct regular border less than a centimeter in diameter(such as

warts)

䊋 Plaque: A firm, elevated flat rough superficial papule >1 cm in diame-

ter; may be joined (e.g., psoriasis or seborrhea)

䊋 Pustule: Elevated, superficial, distinct, purulent fluid-filled lesion (acne,

impetigo)

䊋 Vesicle: Elevated, superficial, distinct, serous fluid-filled lesion <1 cm

in diameter (blister)

䊋 Wheal: Solid, elevated area of edema with irregular shape, varied

changing diameters with lighter center, pale pink in color (e.g., insect

bites)

Causes vary with type of lesion but could include physical irritant such as

chemical, allergic, traumatic, or infectious assault. Lesion can progress from

smaller single lesion to larger or combined lesions. Secondary lesions occur

with healing, additional trauma such as scratching, or infection to the site.

Secondary lesion types include

䊋 Scale: Elevated keratinized (hardened) cells, flaky, irregular thick or

thin, dry or oily lesion, various size and tan, silver or white in color (e.g.,

psoriasis)

䊋 Crust: Slightly elevated, dried blood, serum, or purulent exudates, var-

ious sizes, brown, red, black, tan, or pale in color (eczema or scab)

䊋 Lichenification: Thickened epidermis, bolder skin markings caused by

rubbing or irritation (chronic dermatitis)

Signs and Symptom

䊋 History may reveal recent infection (measles) or allergic sensitivity (con-

tact dermatitis or drug rash).

䊋 Physical assessment should reveal the distribution, size, shape, and

arrangement of the lesions.

䊋 Itching (pruritus), mild to severe, is a common symptom with some

lesions.

䊋 Other sensations may be reported such as stinging, burning, or crawling.

䊋 Pain or tenderness may be noted with some lesions due to pressure on

or irritation of nerve endings.

䊋 Some lesions appear in association with contact with or ingestion of sub-

stances to which the client is allergic.

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327

䊋 Primary or secondary lesion types may be present depending on duration

of the condition prior to the physical examination.

䊋 Paresthesia (burning or numbness) or anesthesia (absence of sensation)

may be reported depending on extent of nerve disruption.

Test Results

䊋 Studies are needed to rule out collagen disease or immunodeficiency

disease.

䊋 Microscopic examination.

䊋 Cultures.

䊋 Biopsy (skin scraping).

䊋 Cell diagnosis (cytodiagnosis).

䊋 Patch testing.

䊋 Wood light examination.

䊋 Allergic skin testing.

䊋 Blood testing: Complete blood count, sedimentation rate.

Treatments

䊋 Dressings are applied for the following reasons:

• Provides a healing environment with moist gauze

• Protects wound from infections

• Provides compression to reduce bleeding or swelling

• Facilitates the application of medication

• Absorbs drainage

• Debrides necrotic tissue

• Controls odor

• Reduces pain

䊋 Topical ointment may be applied to relieve local discomfort, reduce

swelling, or prevent or resolve infection (such as calamine lotion for

poison ivy contact).

䊋 Pain medication or antihistamine to relieve discomfort or irritation.

䊋 Topical therapies: Cautery or cryosurgery (wart removal), electrodesic-

cation, ultraviolet therapy, laser therapy, acne therapy (chemical peel).

䊋 Systemic medication such as antibiotic for infection or corticosteroid to

reduce inflammation.

Nursing Interventions

䊋 Apply topical treatments and give medications as ordered and monitor

for side effects.

䊋 Monitor for healing or lack of healing and report findings as indicated

so treatment can be changed if needed.

Nursing alert Prolonged administration of corticosteroids can temporarily sup-

press growth, so developmental assessments should be performed regularly.

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䊋 Teach parents and child to avoid skin irritants such as poison ivy, oak,

or sumac and any objects or clothing that touched these plants.

䊋 Teach child and parents how to care for skin and lesions:

• Specify amount and frequency of ointment application; stress that

extra ointment or increased frequency could increase systemic levels

in children so prescribed schedule should be adhered to.

• Caution parents to use clean gauze or applicator for each area being

cleaned to avoid spread of debris.

• Teach parents and child about lesion relative to method of spread

and anticipated time for healing because visible skin lesions may

cause distress due to concern about appearance and self-esteem con-

cerns as well as concerns that lesion may be contagious.

WOUNDS

What Went Wrong?

Wounds are disruptions of the skin integrity that result in a normal or abnormal

tissue repair response by the body. All wounds can be classified as acute or

chronic:

䊋 Acute wounds heal within an expected, usual time frame without com-

plication:

• Abrasions are superficial rubbing or scraping off of epidermis (and

portions into the dermis); most common wound of childhood.

䊋 Chronic wounds require a prolonged time for healing or involve additional

problems such as infection or poor circulation (such as burn injury).

䊋 Generally healing occurs by primary, secondary, or tertiary intention:

• Primary intention involves a clean cut with healing occurring in all

layers of the wound; margins (edges) join without complication;

minimal scar.

• Secondary intention happens with ulcer or cut with jagged edges that do

not meet smoothly or do not meet; debris with cells and exudates gather

and debridement may be needed to remove. Large scar may be noted.

• Tertiary intention involves delayed closure of wound with great risk

of infection; wound may be sutured after infection present; large

deep scar results.

Signs and Symptoms

䊋 Wound appearance depends on type and degree of skin and other tissue

disruption and stage of healing.

䊋 Initially, wound may be red and swollen due to inflammation with blood

and cells of immunity moving to site for healing (phase I healing).

䊋 During the second stage of healing, a collagen mesh begins to form and

appearance is red and shiny with thin layer of epithelial cells; bleeds

easily if traumatized.

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329

䊋 The third and fourth phases of healing involve wound contraction and

maturation. A pink elevated scar with possible itching over time

advances to a pale scar tissue (a child may develop more scar tissue than

an adult).

䊋 Signs of infection may include

• Erythema, redness of the skin due to inflammation, particularly in

the area around the wound

• Edema

• Purulent drainage (exudates)

• Pain

• Increased temperature (systemic and warmth at site)

Test Results

䊋 Wound size measurement with tape or caliper may be performed to

assess healing.

䊋 Wound culture may be done to determine organism in infection.

Treatments

䊋 Healing is promoted by good nutrition, circulation, and avoidance of

irritants, including antiseptics such as Neosporin or Bacitracin or Betadine

(povidone-iodine).

Nursing alert Povidone-iodine should be avoided with open wounds and in chil-

dren with thyroid or renal conditions because it is absorbed into the blood-

stream of small children.

䊋 Pain relief medication.

䊋 Dressings may applied for the following reasons:

• Provides a healing environment with moist gauze

• Protects wound from infections

• Provides compression to reduce bleeding or swelling

• Facilitates the application of medication

• Absorbs drainage

• Debrides necrotic tissue

• Controls odor

• Reduces pain

Nursing Interventions

䊋 Use sterile technique to avoid introduction of organisms into clean

wound.

䊋 Teach child and parents how to care for skin and wound(s):

• Specify frequency of dressing change and medication application;

stress that extra ointment or increased frequency could damage

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330

wound or increase systemic levels in children so prescribed schedule

should be followed.

• Caution parents to use clean gauze or applicator for each area being

cleaned to avoid spread of debris.

• Teach parents and child proper hygiene to avoid wound contamina-

tion or spread of infection from wound.

• Discuss signs of side effects from medication and signs of wound

healing complications that should be reported immediately.

• Discuss acceptable coverings that allow for decreased wound visibility

without trauma or excess pressure on site because visible skin lesions

may cause distress for child or adolescent and impact self-esteem

around peers.

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331

1. The nurse would describe a lesion that is a flat brown mole <1 cm in diameter noted

on a client’s body as a ______________.

Answer:

2. A toddler has a deep laceration contaminated with dirt and sand. Before closing the

wound, the nurse should irrigate with:

a. Povidone-iodine

b. Alcohol

c. Sterile saline

d. Hydrogen peroxide

Answer:

✔ ROUTINE CHECKUP 1

PSORIASIS

What Went Wrong?

Psoriasis is a skin overgrowth and flaking of unknown origin that may be triggered

by stress and has a possible hereditary association. Seldom occurs in children

<6 years of age.

Signs and Symptoms

䊋 Red skin patches with coarse scales over extremities and trunk, scalp,

and face

䊋 Pruritus (itching)