Lecture 11 – Unit 3.4 Nursing Care for Health Problems of Toddlers and Preschool Children Skin Alterations in Children Wong 9th edition pp.423-432, 435-445,

Lecture 11 – Unit 3.4 Nursing Care for Health Problems of Toddlers and Preschool Children Skin Alterations in Children Wong 9th edition pp , , 8th edition pp , Gail McIlvain-Simpson, MSN, PNP-BC We are going to cover Health Problems associated with the integumentary system and other diseases associated with the skin. Revised 10/30/12

Learning Objectives At the end of this discussion learners will be able to: Discuss skin alterations & importance in addressing this issue Discuss nursing assessment and management of skin lesions. Compare and contrast primary skin lesions. Discuss 3 common nursing management points regarding atopic dermatitis. Name 2 reasons the incidence of childhood communicable diseases have significantly declined. Discuss 2 teaching points for parents regarding communicable diseases.

Learning Objectives continued
Discuss key points and nursing management of the following diseases: fifth disease, roseola, and scarlet fever. Discuss diagnosis, symptoms, nursing management and treatment of pinworms. Describe lead poisoning, its impact on children, nursing management and treatment. Discuss childhood poisonings and nursing interventions for its prevention. Describe diagnosis, treatment and anticipatory guidance for: impetigo, tinea capitis, pediculosis capitis and Lyme disease

Skin Alterations in Children
What is key job of skin? You need to know the anatomy and physiology of the skin to understand the signs and symptoms of skin diseases and how to skin describe skin alterations . What is the primary function of skin? Acts as barrier

Skin Lesions Etiologic Factors
Contact with injurious agents, hereditary factors, external factors; & systemic diseases Highly individualized responses Child’s age is an important factor Contact with injurious agents: infective organisms, toxic chemicals & physical trauma Hereditary factors External factors (allergens) Systemic diseases (measles, lupus, nutritional deficiency) Children have highly individualized responses Age is impt – infants subject to birthmarks & atopic dermatitis, school age susceptible to ringworm of scalp & acne present in adolescents

Integument of Infants & Young Children
Epidermis loosely bound to dermis More susceptible to superficial bacterial infections More likely to have associated systemic symptoms Reacts to a primary irritant versus sensitizing antigen Epidermis loosely bound to the dermis (causes layers to separate easily from an inflammatory process)in infants & small children Preterm infants may blister with removal of tape from skin Skin of older children ia thinner & cells of strata are more compressed.

Pathophysiology of Dermatitis
Accounts for more than half the skin problems in children Inflammatory changes in skin Changes reversible More permanent issues with chronic problem Inflammatory changes in skin – grossly similar but different in course & causation

Integumentary - Nursing History
Painful, itching, tingling Restless or irritable Favor or avoid a body part New exposure New food New medications Any allergies? Playmates with similar lesions Plants, insects, or chemicals History is very important, so as nurses we are going to do an assessment and ask questions!! So we ask:::: Questions to ask - above Access to chemicals, been in the woods, around a woodpile Eaten a new food Taking any medications Have any allergies Observe their behavior

Diagnostic Evaluation
What piece of the nursing process is key ? Assessment – inspect and palpate Observation Distribution, size & arrangement

Adolescent female Originally from AAP
Originally from AAP Face & upper body (areas exposed to heat) Less on legs

Nursing Assessment Inspect - Describe color, shape, size, distribution of lesions Palpate for temperature, moisture, elasticity and edema Case study You are assigned to a child. During your AM assessment you notice a skin lesion on their back. What are you going to do? Objective findings size & arrangement External causes – physical, chemical, allergens Internal – meaqsles, chicken pox Assessment Accurately describe any deviation in the character of the skin, The color, shape, size and distribution of the lesions or wounds are noted.

Descriptive Characteristics
Erythema Ecchymosis Petechiae Primary lesions Secondary lesions Distribution pattern Configuration and arrangement Pg 1010 Erythema (redness of the skin surface) –reddened areas caused by increased amounts of oxygenated blood in the dermal vasculature Ecchymosses (bruises) – localized red or purple discoloration caused by blood into dermis and subq tissue Petechiae – pinpoint, tiny, sharp circumscribed spots in superficial layers of epidermis Primary – skin changes produced by causitive factors (macules, papules) Secondary – changes that result from changes to the primary lesion (rubbing, scratching, medication, or healing) Distribution – localized or generalized Configuaration - size, shape & arrangement of a lesion or group of lesions (i.e. diffuse, confluent) Diffuse spread about/ confluent – merged, not distinct from one another.

Many new cases in the US are from immigrants who have not been immunized.
The measles vaccine is the best protection you can get to prevent this disease. Introduced in 1963, this vaccine has led to a 99% reduction in the incidence of measles. However, because many children did not get the vaccine or received only one dose, a measles epidemic struck the U.S. between 1989 and CDC If one person has it, 90% of their susceptible close contacts will also become infected with the measles virus. The virus remains active and contagious on infected surfaces for up to 2 hours. Measles spreads so easily that anyone who is not immunized will probably get it, eventually.

Here is a child with rubella, first appearing on the face and rapidly spreads down the neck, arms, trunk and legs and by the first day the body is covered with pinkish red maculopapular rash. It disappears in the same order it began and is usually gone by the third day.

Primary Skin Lesions Here is some information regarding primary skin lesions of children. Figure 30.1 pg 1011 Wong Macule – freckles, rubella Papule – wrts Vesicle – chicken pox Pustule – impetigo, acne Cyst – sebaceous cyst

PRIMARY SKIN LESIONS Result of different stimuli either internal or external. 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. Vesicle – elevated, circumscribed, superficial & filled with serous fluid less than 1 cm in diameter (a small blister) Blister - a skin bleb filled with clear fluid Pustule – elevated & superficial, filled with purulent fluid (a skin elevation filled with pus) Cyst – elevated, circumscribed papule filled with liquid or semi solid material

Therapeutic Management
Prevent further damage Eliminate cause Prevent complications Provide relief Therapeutic Management is the Major aim of treatment so we: Eliminate the cause to Prevent further damage- most impt major aim Prevent complications Provide relief from discomfort while tissues heal Most commoncausitive agent are environmental factors.

Relief of symptoms Pruritus management Topical therapy
Systemic Therapy Pruritus mgt Cooling the affected area & increasing skin ph Lukewarm tepid or Cool bath alkaline applications Clothing and be linens should be soft and light weight. Goal: Preventing scratching to help prevent secondary infection Fingernails short, well-trimmed, mittens may be needed Meds to help Benadryl, Atarax Non pharmacologic or mild analgesic Topical Therapy ease discomfort and prevent further injury and facilitate healing. Depends on nature & location of lesion Wash hands and assess skin Wet compresses Burow’s solution aluminum acetate helps relieve itch Choice of active ingredient, proper vehicle or base, cosmetic effect, cost, instructions for use. Dermatitis acute – mild & bland topical treatment Broken or inflamed skin – more absorbant than intact skin Ointment – provide protection from moisture used in diaper area Creams – absorbed by the skin and used for areas where you need non greasy. For corticosteroid – thin film, and massage into skin (only use for one week) Systemic Thrapy May be used as an adjunct to topical therapy Corticosteroids, antibiotics, and antifungal agents. Antipruritic medications - Benadryl, Atarax For corticosteroid – thin film, and massage into skin (only use for one weeks) Do not put anything into a wound that you would not put in the eye.

Contact Dermatitis Inflammatory reaction of the skin to chemical substances (natural or synthetic) Causes a hypersensitivity response or direct irritation Initial 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 List is endless: poison ivy, urine (ph, wetness, fecal irritants), animal fur Clothing, sun, chemical exposures

Treatment of Contact Dermatitis
Major goal – to prevent further exposure of the skin to offending substance Based on severity If exposed cleanse as soon as possible

Atopic Dermatitis Eczema
Pruritic eczema Usually occurs during infancy & is associated with allergic tendency (atopy) 3 Forms based on age & distribution of lesions: Infantile eczema Childhood Pre adolescent & adolescent Infantile begins at 2-6 mos/remission by 3 yrs of age Childhood occurs at 2-3 years of age Preadolescent – 12 years of age

Atopic Dermatitis Diagnosed via combination of history & morphologic findings Cause unknown Majority of those affected have eczema, asthma, food allergies or allergic rhinitis Controlled but not cured Worse in fall & winter

Atopic Dermatitis Management
Major goals: hydrate skin, relieve pruritis, reduce flare-ups, prevent & control secondary infection. Avoid skin irritants & overheating Administer meds Shorten fingernails & toenails Enhance skin hydration – apply emollients while skin is wet

Nursing Care Management
Take history – Atopy in family Previous involvement Controlling pruritus Dietary modifications Family Support

Poison Ivy, Oak, Sumac Contact with these yields streaked, spotty or oozing and painful impetiginous lesions Urushiol oil (shoes, tools, toys) Cleanse with alcolhol, shower Tx calamine, burows, Aveeno bath, corticosteroids Lesions do not spread by scratching, but can become secondarily infected.

Skin Disorders related to Animal Contacts
Managed by cold compresses, calamine lotion and prevention of secondary infection Arthropods – insects, ticks, spiders (brown recluse & black widow harmful), scorpions Bees remove stinger

Communicable Diseases
Why has the incidence of childhood communicable diseases significantly declined? Why have serious complications resulting from such infections been further reduced? Why do nurses need to be familiar with infectious agents? 1. Since the advent of immunizations, the incidence of childhood communicable disease has declined significantly. 2. With the use of antibiotics and antitoxins, serious complications serious complications resulting from such infections have been further reduced. Despite this progress, infectious diseases do occur. Infectious disease not always minor & still are health concerns despite these advances. 3. Nurses must be familiar with infectious agents: a) to recognize the disease and b) institute appropriate preventative & supportive measures.

Nursing Process for the Child with Communicable Disease
Assessment- signs & symptoms Diagnosis – ID of disease Planning- expected patient outcome Implementation- intervention strategies Evaluation Assessment – Assess for signs and symptoms of a communicable disease and its consequences Diagnosis – ID of infectious disease is of primary importance to prevent exposure to susceptible individuals. Nurses in child care centers, school & outpatient areas are first to see issues. Nurse must have a high index of suspicion to recognize diseases needing medical & nursing interventions. What are some nursing diagnoses 1.Risk for infection related to susceptible host & infectious agents 2. Acute Pain related to skin lesions, malaise, 3. Impaired social interaction related to isolation form peers 3. Impaired skin integrity related to scratching from pruritus 4. Risk for impaired skin integrity 4. Interrupted family processes related to a child with an acute illness 5. Risk for caregiver role strain Planning - Expected patient outcomes include; child will not spread infection to others, child will not experience complications, child will have minimum discomfort, child and family will receive adequate emotional support. Implementation: Numerous intervention strategies discussed in Chapter 14 Pg th edition of Wong

What to assess if suspicion of communicable disease?
Recent exposure to known case Prodromal symptoms Immunization history History of having the disease It is impt to assess for the following items when a communicable disease is suspected: Recent exposure to known case Prodromal symptoms – symptoms that occur between early manifestations of the disease & its overt clinical syndrome, or evidence of constitutional symptoms such as a fever or rash. Immunization history History of having the disease

Components of Prevention
Prevent disease Prevent spread Prevent complications Primary prevention – (also sanitation) Modern sanitation impt in eradication of infectious diseases immunizations is key Important part of health promotion (only small percentage of those who receive have an adverse reaction) What is your greatest weapon & priority available to reduce spread of disease ? Handwashing before & after care & after handling contaminated item. Antibiotics, isolation technique, handwashing Control of disease to others & yourselves – For hospitalized child – need to follow infection control policies of hospital. Prevent complications: Certain groups of children are at risk for serious or even fatal complications, especially the viral disease chicken pox & erythema infectiosum (fifth disease) Immunodeficient children, receiving steroids or on immunosuppressive therapy, or those having malignancy or immunologic disorder. Need to notify PCP immediately. With children/parents – teach handwashing, reinforce, how to cough etc. Direct & indirect contact

A child is admitted with an undiagnosed exanthema – what should be done in this case?
Strict transmission-based precautions (contact, airborne, droplet and standard precautions instituted until a diagnosis is confirmed). CDC isolation is based on what _ method of disease transmission) What are some examples of the diseases that require precautions ?– chickenpox, measles, TB CDC Isolation of clients according to methods of transmission (extent of illness does not help with this decision) Infectious disease spread unfortunately because individual feels ok & is out & about. Exanthm - skin

Communicable Disease Know what it looks like How it acts What to do
What is the danger?

What to know about Infections or Communicable Diseases?
Occurs in humans of all ages Certain ones occur in specific age or developmental groups Can be transmitted by direct or indirect route Can have total systemic involvement or sequelae May develop slowly after prolonged incubation period

Symptomatic and Supportive Care
Isolation Skin care Antipyretics, analgesics, anti inflammatories Rest Hydration/Fluids Comfort measures

Impetigo Contagiosa (Bacterial)
Superficial bacterial infection of skin Easily spread - very contagious Staph or strep Reddish macule, becomes vesicular Now let’s talk about Bacterial infections Skin has bacterial flora (staph & strep) harm depends on invasiveness, toxicity & skin integrity plus immune and cellular defenses of host. They are easily spread by self-inoculation Begins as reddish macule, then become vesicular, ruptures becoming superficial moist erosion. Spreads peripherally in sharply marginated irregular outlines Exudate dries to form heavy, honey-colored crusts Crusts easily removed and reveal smooth, red, moist surfaces on which new crusts soon develop Very pruritic Minimal or asymptomatic systemic effects Impetigo around nose and mouth, chin. Children are sent home from school. Soften with Burrow solution

Treatment of Impetigo Use of Burow solution
Topical use of bactericidal ointment Systemic administration of oral or parenteral antibiotics in severe or extensive cases Tends to heal without scarring Common in toddler, preschooler May superimpose on eczema TREATMENT FOR IMPETIGO 1:20 Burrows solution Topical bactericidal ointment can be use - neomycin, bacitracin at least tid or qid Oral or parenteral antibiotics in severe cases CLINDMYCIN MAY BE HAVE TO BE USED IF MRSA Cephalosporins are also used. An antiseptic preparation (Betadine or Hibiclens) can be used to cleanse the skin and reduce bacterial content in vicinity of infection to prevent spread GOOD HYGEINE Usually heals without scarring Oral antibiotic or warm compresses MRSA – washing clothes in hot water,chlorine bath once or twice weekly2.5 ml bleach in 13 gallons of water (1/2 cup in standard tub)

Viral Diseases of Childhood
Childhood communicable diseases Such as fifth disease Intracellular parasites

What is this? Healthy child
Originally from AAP Herpes Zoster or SHINGLES is an intensely painful varicella that is localized to a single dermatome body area or a body area innervated by a particular segment of the spinal cord. Picture – lateral trunk region Varicella occurs primarily in children younger that 15 years of age. Herpes zoster is a reactivation of the varicella virus which has been dormant for many years in the dorsal root ganglia. It becomes active mostly in the child/adult that is immunocompromised.

Fifth Disease Erythema Infectiosum
Agent - Human parvovirus B19 (HPV) Source- infected persons, mainly school age Transmission – Respiratory secretions, blood & blood products Clinical Manifestations - rash in three stages: a) “Slapped- cheek” rash on the face b) 1 day after rash on face, maculopapular red spots c) Rash reappears if skin irritated or traumatized Clinical Manifestation - rash in three stages, “slapped-cheek” rash on the face (disappears in 1-4 days), 1 day after rash on face, maculopapular red spots appear, symmetrically distributed on upper & lower extremities; rash progresses from proximal to distal surfaces & may last a week or more Also has circumoral pallor

Fifth Disease (Erythema infectiosum)
Weinberg, S. et al, Color Atlas of Pediatric Dermatology, McGraw-Hill, New York, 1998 Can go to school with rash Highly contagious before disease

Fifth Disease - Management
Complications -may result in fetal death (if mother is infected during 2nd trimester of pregnancy. Aplastic crisis in children with hemolytic disease. Self-limited arthritis and arthralgia. Nursing care – symptomatic & supportive/isolation of child not necessary, except hospitalized child (immunosuppressed or with aplastic crises) What is the symptomatic and supportive care? Isolation, skin care, antipyretics, analgesics, or anti inflammatories, rest hydration (fluids), and comfort measures.

Roseola Exanthema Subitum
Agent - Human Herpes virus type 6 (HHV-6) Source - Possibly acquired from saliva of healthy adult person, entry via nasal buccal or conjunctival mucosa Transmission –year round, no reported contact with infected individual in most cases (usually limited to children under 3 years of age but peak age is 6-15 months) Communicability unknown

Roseola (Exanthema Subitum)
Clinical manifestations – Persistent high fever for 3 to 4 days in a child who appears well/quick drop in fever to normal with appearance of rash. Rose pink macules to maculopapules appearing first on trunk, then spreading to neck, face & extremities. Lymphadenopathy , inflamed pharynx, cough Non pruritic rash fades on pressure so when you press on the area the rash fades.

Roseola (Exanthema Subitum)

Roseola - Management Treatment: nonspecific
Nursing care – symptomatic, antipyretics to control fever (can have febrile seizure) discuss precautions if they are prone to fever. Teach parents about antipyretic therapy.

Scarlet Fever Agent: Group A beta-hemolytic streptococci
(called scarlatina in the past) diagnosed with a throat culture/strep test Source: Usually from nasopharyngeal secretions of infected persons and carriers. Transmission: direct contact, airborne droplets, indirectly by contact with contaminated article or ingestion of contaminated milk or food. Period of communicability: 10 days – during incubation period & during clinical illness: during first 2 weeks of carrier phase Agent: Group A beta-hemolytic streptococci caused by toxin released by the strep bacteria which is the same that causes strep throat (called scarlatina in the past) diagnosed with a throat culture/strep test

Scarlet Fever Abrupt high fever, increased pulse, vomiting, headache, chills, malaise, halitosis, abdominal pain Enanthema – tonsils enlarged, edematous & reddened White strawberry tongue day 1 Red strawberry tongue day 4-5 Exanthema: rash appears within 12 hrs of prodromal signs Rash is tiny pinkish-red spots that cover whole body (absent on face/flushed with circumoral pallor) scarlet spots or blotches, giving a boiled lobster appearance. progresses to “sunburn with goose pimples” (feels like rough sandpaper) Sloughing on palms & soles – complete by 2 weeks White strawberry tongue day 1 (tongue is coated & papillae become red & swollen), Red strawberry tongue day 4-5 – white coat sloughs off Complications pweritonsillar and retrophayngeal abscess.

Scarlet Fever http://www.dermnetnz.org/dna.strept/scarlet.html
Top picture is the white strawberry tongue. Bottom picture is the red strawberry tongue.

Scarlet Fever – Management
Penicillin or oral cephalosporin Nursing Care: Droplet precautions until 24 hours after treatment initiated Compliance with antibiotic therapy Encourage rest and fluids Measures to decrease discomfort of sore throat TREATMENT : FULL COURSE OF PENICILLIN OR cephalosporin, Supportive = NURSING CONSIDERATIONS: bedrest, antipyretics, analgesics ENCOURAGE FLUIDS AVOID CITRUS DRINKS Gargles, lozengers, cool sprays COMPLICATIONS OF SCARLET FEVER ARE OTITIS MEDIA, PERITONSILLAR ABSCESS, SINUSITIS, CARDITIS, acute glomerulonephritis, acute rheumatic fever, polyarthritis

Tinea Capitis (Fungal)
Ringworm of scalp Scaly circumscribed patches and or patchy scaling areas of alopecia Pruritic Person to person or animal to person transmission Fungal infections are superficial infections that live on, not in, the skin IS Confined to the dead keratin layers. Lesions in scalp but may extend to hairline or neck Scaly, circumscribed patches and/or patchy scaling areas of alopecia Common cause of hair loss mos to regrow hair Severe, deep inflammatory reactions may occur Pruritic Microscopic examination of scales diagnostic Person to person transmission (also animal to person) Rarely permanent loss of hair Atopic individuals more susceptible

Tinea Capitis-Treatment
Oral griseofulvin - for weeks or months Oral ketaconazole Selenium sulfide shampoos Topical antifungal agents(clortrimazole) inactivates organisms on hair TREATMENT IS ANTIFUNGAL SUCH AS: Oral grisofulvin – often given for weeks or months anti fungal – inhibits the miosis of fungal cells Oral ketaconazole for difficult cases Selenium sulfide shampoos – at least 2-3x/wk Topical antifungal agent (clotrimazole)used to inactivate organisms on the hair not effective as a cure infection occurs within the hair shaft and below the surface of the scalp NO SCHOOL OR DAYCARE FOR SEVERAL days Atopic individuals more susceptible

Tinea Capitis - Teaching
No exchange of anything that touches area Use own towel Protective cap at night Examine pets Watch public seats with headrests It is a important to be vigilant about personal hygiene. Person to person or animal to person transmission Rarely permanent loss of hair

Pinworms - Enterobiasis
Agent: enterobius vermicularis the most common helminthic (worms) infection in US Transmission: Pinworms are transferred via fecal oral route. Can also be airborne Crowded conditions promote spread

Pinworm Life Cycle Eggs ingested or inhaled and hatch in small intestine Hatch in upper intestine Mature & migrate through intestine After mating adult females migrate out anus and lay eggs Eggs transferred to mouth by fingers from scratching or from soiled night clothes, underclothes, bed linen or other contaminated objects. Can also be inhaled because the eggs float in air, that why it is so easily transmitted. Prone to reinfection Eggs ingested or inhaled Hatch in small intestine, travel to the colon and attach to bowel wall. Are infective in 6 hours. Matures in 2-3 weeks. Takes one month to go from eggs to adult persist in indoor environment for 2-3 weeks After mating adult female migrates down to the anal area and lays eggs. Adult lives 2 months Eggs transferred to mouth by fingers from scratching or from soiled night clothes, underclothes, bed linen or other contaminated objects, can be inhaled because the eggs float in air, that why it is so easily transmitted. Possible vagina and urethral infection can occur. They can be airborne!!

Pinworm - Symptoms Intense itching of perianal area
General irritability Restlessness Poor sleep Bedwetting Distractibility Short attention span Perivaginal itching SO THIS IS WHAT PINWORMS LOOK LIKE Many people have no symptoms o perineal areaense itching ar int Symptoms caused by female laying her eggs & they migrate during the night and burrow into the anal folds and this causes a pinching sensation. Intense itching or perianal area Children have unexplained irritability, especially at night. They have difficultly in sleeping because this is the time that the pinworms migrate down to the anus to lay eggs. Adult may migrate to vagina to produce perivaginal itching The child can have loss of appetite, and become restlessness

Pinworms - Diagnosis Tape test Direct visualization with flashlight
THESE ARE ACTUAL PINWORMS OUTSIDE THE ANUS Diagnosis is through actual visualization of the rectum with a flashlight, or the tape test. Collect specimen in early morning before child has BM or bathe as soon as you wake up. Double sided sticky tape on tongue blade pressed to perianal area. Tape placed on glass slide – sticky side down. May need to check several nights since worms may not migrate each night. Once the pinworm/eggs adhere to the tape and is then brought for diagnostic microscopic examination testing to confirm. Can also check for worms with flashlight. Done with flashlight after child is asleep (MN to 0600). (Child should not wear underpants) Shine light on rectum quickly. See tiny thread-like worms ¼” long crawling around and in and out of anus Eggs not usually seen in stool specimen do not lay eggs in feces

Pinworms - Treatment Medications – Anti helminthic
**Mebendazole (Vermox) Pyrantel pamoate (Antiminth) Pinrid Albendazole TREATMENT MEDICATIONS: mebendazole (vermox) is drug of choice (safe, effective, convenient with few side effects/cannot be used below age 2). Pyrvinum pamoate (Pin rid) stains stool & vomitus bright red. Original dosing and again in 2 weeks to completely erradicate & prevent re-infection SINCE PINWORMS ARE SO EASILY TRANSMITTED ALL HOUSEHOLD MEMBERS SHOULD BE TREATED. Medications 2 dose treatment second dose 2 weeks after first TO PREVENT REINFECTION Vermox – drug or choice

Pinworms – Nursing Care Management
Identify parasite, eradicate organism & prevent reinfection Environmental good hand washing daily showers wash bedding clean pajamas snug underwear fingernails short Nursing care – identifying the parasite, eradicating the organism & preventing re-infection 1. Wash bedding and underwear in hot water Clean pair of long pajamas each night Snug underwear – change daily Keep fingernails short Good handwashing Daily showers – no tub baths Bathe when wake up to reduce egg contamination

Pediculosis Capitis (Parasite)
Head lice Pediculus humanus capitis Common parasite in school age children 6 – 12 million people worldwide each year. Head lice or “cooties” Organism is pediculus humanus capitis – a head louse The Main age group is 3 to 10 years

Million people

Pediculosis Capitis Lay eggs at junction of a hair shaft
Nits hatch in 7-10 days Itching is usually the only symptom Adult louse lives only 48 hrs when away from host Life span of average female 1 month Lays eggs at night at junction of a hair shaft Left – empty nit case/ Right live nit case close to skin – eggs need warm environment Look at scalp for bite marks, redness, nits Spread hair with 2 flat-sides of tongue depressors, observe for any movement Lice visible to naked eye about 1-2 mm long Nits hatch in 7-10 days reach maturity in 2 weeks eggs about 4 mm or ¼ inch from scalp when hatches looks like tiny whitish oval speck adhering to hair shaft yellow to whitish in color Can tell from dandruff that falls off Empty nit cases are translucent more than ¼ inch from scalp Itching around nape of neck

Pediculosis Capitis Symptoms are Pruritic – from crawling insect and insect’s saliva Diagnoses by observation of white eggs (nits) firmly attached to base of hair shafts to able to view: Work under good light natural sunlight is best sit by window or go outside Strong lamp can be used Spread hair with 2 flat-sides of tongue depressors, observe for any movement Adult lice are difficult to see Scratch marks and/or inflammatory papules can be found Most common site- are occipital area, behind ears, nape of neck

Three Steps to Treatment
1.Application of pediculicidal product Permethrin (1%) crème rinse (NIX) Pyrethin Piperonyl butoxide Preparations – RID Lindane shampoos - 1% Kwell, Scabene FDA warning neurotoxic) Malathion 0.5%Ovide 2.Manual removal of nit cases 3. Environmental Getting rid of them time consuming & very hard Permethrine AAP choice resistance Malathion costly,8-12 hrs, not inchildren younger than 2 Lindane Shampoo – 1% Kwell, Scabene FDA issued warning due to potential for neurotoxicity Repeat in 7-10 days Kills hatching nymphs – causes seizures and death Most effective against nits Potential toxic, esp. in infants Permethrin (1%) crème Kills both lice and nits with one application Malathion lotion – re approved/prescription needed/contains flammable alcohol & needs to be on 8-12 hrs. Olive Oil 1997 – Harvard School of Public Health Pyrethin preparations – over the counter, as effective as lindane NIX, RID, A200, pyrinate, R & C shampoo, Pronton, Triple X Application Do not administer after warm bath or shower Causes vasodilatation from heat and increases skin absorption of chemicals Must remain on scalp and hair for several minutes Keep off the rest of the body

Removal of Nit Cases Extra fine-tooth comb “nit-picking”
Examine head daily for 2 weeks Nit removal Wrap in towel for 15 minutes to loosen the nits. Use Extra fine-tooth comb when hair is damp Remove all visible nits Nits are extremely difficult to remove May have to be picked off with fingernails one by one Hence the expression “nit picking” (Smeltzer & Bare) Examine head daily for newly laid nits for at least 2 weeks after removal Each family member should be inspected for head lice daily for at least 2 weeks (Smeltzer & Bare)

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 Environmental More Caucasian girls with straight hair Live lice live for 48 hours away from host Nits can live away from the body and hatch in 7 to 10 days Wash clothing and linens in hot water and dry in a hot dryer for at least 20 minutes Vacuum carpets, rugs, etc. Seal nonwashable items in plastic bags for 14 days Soak combs, brushes, hair accessories in lice-killing products for 1 hour or boiling water for 10 minutes Rubbing alcohol or lysol

As we who have on community rotation and have been in the nurses office of the elementary schools there are many of you who have had to send children for head lice.

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 Lyme Disease Hx - in early 1970's a mysterious clustering of arthritis occurred among children in Lyme, Connecticut and surrounding towns. Lyme disease was first recognized in (NIH) caused by spirochete - spiral-shaped bacterium Borrelia burgdorferi In Europe , a skin rash similar to that of Lyme disease has been described in medical literature dating back to the turn of the century. Lyme disease may have spread from Europe to the US in the early 1900s but only recently be came common enough to be detected (NIH) So when a deer tick feeds on an infected animal and then the tick feeds upon humans it is transmitted to human or a small animal such a mouse deer tick - Ixodes Dammini in northeast The host is - white tailed deer and white footed mice any wild or domestic animal can act as host birds are freq. carriers

Ixodes Dammini Nymph Deer Tick is 2 - 4 mm in length
size of a poppy seed (NIH) the ticks usually feed and mate on deer during part of their life cycle. The recent resurgence of the deer population in the northeast and the influx of suburban developments into rural areas where deer ticks are commonly found has probably contributed to the disease's rising prevalence. (NIH)

Your dog can also be victim to LYME DISEASE.
From “Your Dog may be at Risk from Lyme Disease”, Fort Dodge Laboratories, 1995.

Univ. of Chicago – 2006 article from Infectious Disease Society of America
Evidence Based article on the treatment of Lyme Disease. Has very graphic pictures of engorged ticks. These are a few I was able to include.

Lyme Disease - Stages Stage 1 Tick bite Erythematous papule
Bull’s eye rash Manifestations - stage 1 tick bite days later development of erythema chronicum migrans (ECM) at site of bite lesions - small erythematous papule enlarges rapidly over period of days to weeks becomes large circumferential ring with raised edematous donut like border can be a circular, triangular, or oval-shaped rash (NIH) like a bull's eye rash can be size of a dime to the entire width of a person's back. (NIH) common sites - thigh, groin, axilla lesion - "burning", warm to touch, occ. pruritic may dev. multiple smaller secondary annular lesions without indurated center anywhere but palms and soles disappear in 3-4 weeks rash may be absent in 25% of infected people (NIH) headache, malaise, fatigue, anorexia, stiff neck, generalized lymphadenopathy, splenomegaly, conjunctivitis, sore throat, abdominal pain, cough.

Erythema Migrans - Bull’s eye rash See the BULLS EYE RASH.

Lyme Disease Stages Stage 2 Stage 3
Systemic involvement of neurologic, cardiac and musculoskeletal systems Stage 3 Musculoskeletal pain Arthritis Stage 2 systemic involvement of neurologic, cardiac and musculoskeletal systems appears weeks after completion of cutaneous phase headache - most freg. symptom later signs - meningoencephalitis, cranial nerve palsies, peripheral radiculoneuritis infreg. - cardiac complications 4-5 weeks post ECM av conduction abnormalities - severe heart block syncope, palpitations, dyspnea, chest pain, severe bradycardia usually short term problems (NIH) subtle changes - such as memory loss, difficulty concentrating, change in mood or sleeping habits. (NIH) about 50% of those people not treated with antibiotics develop arthritis (NIH) -intermittently painful joints (primarily the knees) - lasts few days to a few months. - can shift from one joint to another. with spontaneous remissions and exacerbations % of untreated patients will develop chronic arthritis. (NIH) Stage 3 4 - 6 weeks post rash to months to years later musculoskeletal pain -- involve tendons, bursae, muscles and synovia presenting sym. is arthritis -

Lyme Disease Diagnosis Management Symptoms
Lab: Elisa, Western Blot, PCR Management Doxycycline or Amoxicillin Diagnosis BY Hx, observation of lesion, manifestations microbe is difficult to isolate or culture from body tissues or fluids (NIH) ELISA Test is the most used. (enzyme linked immunosorbent assays) – tests for antibodies, does not test for the bacteria. - immunoglobin - IgM and IgG - takes 6 to 12 weeks after infection to be positive. Western Blot – to test for specific antibodies PCR (polymerase chain reaction) – a DNA based test – more sensitive Management > More than 9 years old - tetracycline or doxycycline < Less than 9 years old or pregnant or lactating women- penicillin or amoxicillin for days no doxycycline - can stain the permanent teeth developing in young children or unborn infants (NIH) give erythromycin if allergic to penicillin (NIH) prevents 2nd stage manifestations Neuro manifestations - IV ceftriaxone daily for a month or less. Cardiac manifestations - IV penicillin, ASA or prednisone Arthritis - ASA or NSAID , penicillin po severe arthritis IV ceftriaxone or penicillin

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 light colored clothing Wear a hat Tuck pant legs into socks Wear shoes that leave no part of the foot exposed No DEET for infants & smaller children Nsg - prevention and education deer ticks are found in wooded areas and nearby grasslands and are especially common where the two areas merge. avoid areas where deer are frequently seen. walk in the center of trails - keep away from overhanging grass and brush. 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 .

Lead Poisoning Major preventable environmental health problem (CDC – 1997) Irreversible health effects Brain & nervous system damage Reduced intelligence Learning disabilities . SINCE 2003 NO CHILD HAS BEEN ALLOWED TO ENTER KINDERGARTEN WITHOUT PROOF OF LEAD TESTING.

Lead Poisoning Historical perspective Lead does not decompose
Cultural perspective Risk factors Problem throughout history & throughout the world # of lead sources US – started early 1900’s when white lead added to paints & when tetraethyl lead added to gasoline 1978 – use of lead in household paints banned Gasoline unleaded. With change in policies lead level drastically reduced Lead does not break down into smaller particles or decompose (if deposited in the past still present in soil) – if children play in bare soil they can track lead contaminated dust into house. Children of Hispanic origin – higher risk for poisoning as result of exposure to culturally related items that contain lead Other risk factors: poverty, age less than 6, dwelling in urban areas, living in older rental homes In most cases acute childhood lead poisoning is lead based paint in older home (disclosure required when selling home)or lead based bare soil in yard. Gain entrance into child via Ingestion (normal play & hand to mouth activity) or Inhalation (during remodeling) Exposed pregnant woman by placental transfer LEAD CHIPS HAVE SWEET TASTE

Pathophysiology of Lead Poisoning
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 long term neurocognitive signs Lead can affect renal(kidney) , hematologic & nervous system Of most concern is the vulnerability of the brain & nervous system of the young child 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 long term neurocognitive signs: developmental delay, lower IQ, reading skill deficits, visual spatial problems Most effects are reversible

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 Blood Lead Levels greater than 10 mcg per dl require conscientious follow-up This is the HEALTHY 2010 Objective If receive Medicaid, Chips or WIC benefits Must screen at 12 months and 24 months of age

Anticipatory Guidance
Hazards of lead based paint in older housing Ways to control lead hazards safety How to choose safe toys Hazards accompanying repainting and renovation in homes built before 1978 Other exposure sources

Screening Universal screening- ages 1 & 2
Targeting screening- is acceptable when an area has been determined by existing data to have less risk

Lead Poison Treatment Chelation therapy Medications Succimer
Ca Na2EDTA Chelation = term used for removing lead from circulating blood & theoretically some lead from organ & tissues Chelation therapy given IM or Orally. What Chelation Therapy does is: It bind with ions on lead It makes a water soluble complex excreted by kidneys It depletes the soft and hard (skeletal) tissues of lead reduces toxicity The drugs used are Succimer (DMSA) given po (Sux-I-mer) Decreases lead concentration in brain Oral19 day treatment of Succimer Need adequate fluid intake Ca EDTA given IV or IM, does not remove lead in the brain also removed Calcium and iron is toxic to the kidneys – measure I and O it is a very important nursing action!!

Nursing Care Management
As nurses what is your primary goal? To prevent the child’s initial or further exposure to lead Education Identify the source in the environment Careful history taking is a very valuable tool Hazards of lead based paints in older homes Hazards accompanying repainting & renovations of home to houses built before 1978 Additional exposures (i.e. dinnerware from other countries) See Community focus to reduce lead levels in Wong For those undergoing chelation therapy = prep EDTA use local anesthetic procaine Rotate sites to prevent fibrosis EDTA & lead toxic to kidneys – record careful Intake and output Talk about CDC & AAP website

Ingestion of Injurious Agents
Significant health concern Majority occur in children younger than 6 years of age Can occur with medications & many other substances What happened in 1970 that drastically reduced the incidence of poisonings in children? The passage of the Poison Prevention Packaging Act: required certain potentially hazardous drugs and household products be sold in child resistant containers which led to a drastic decrease of poisonings in children.

Most Common Poisonings
Cleaning substances Cosmetics & Personal care products Plants Foreign bodies Pharmaceuticals Leading causes of poisonings are common household products Improper use poisonings is when: -Both parents give same med to child or misread recommended dose on label -excessive dosing – “if one is good, two are better” or misread label and sometimes parents really think this will help Pharmaceuticals such as analgesics, cough & cold preparations, topical preparations, antibiotics , vitamins, hormones. Also cosmetics & personal care items (perfume & aftershave), cleaning products (bleach, pine sol, plants) or foreign bodies.

Poisonings First Priority – Assess the child Terminate exposure
Identify poison Prevent poison absorption p First priority is the child not the poison (immediate concern for life support - airway, breathing, circulation) Do an emergency assessment of the child Then stabilize the child It is estimated that approximatly 2 million children are poisoned each year 60% are less than 6 years of age Terminate exposure to toxic substance by empty mouth of pills, plant parts, etc. Flush eyes and or skin with tap water or NSS Remove contaminated clothing can give sip of water to dilute some poisonings but not large amounts will enhance drug’s escape through the pylorus once in small intestine there is rapid absorption (remember all absorption is done in the small intestine) Identify poison

Principles of Emergency Treatment
Advise parents to Call Poison Control Center before initiating any intervention PCC begin treatment at home or take to emergency room Treat the child first, not the poison (vital signs, respiratory or circulatory support) Terminate exposure Identify the poison

Gastric Decontamination
Remove ingested poison: Absorbing toxin with activated charcoal Gastric Lavage Increase bowel motility (catharsis) Immediate treatment of poisoning is to remove ingested poison by absorbing the toxin with Activated Charcoal, perform gastric lavage or increase bowel motility(catharsis). Each ingestion treated individually Syrup of ipecac no longer recommended – prolonged vomiting = undesirable and unsafe event

Activated Charcoal Most commonly used method of gastric decontamination 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 Most commonly used method of gastric decompression - odorless, tasteless, fine black powder that absorbs many compounds and creates a stable complex. (read area above) Can mix with diet soda & use opaque container (looks like black mud) Reduce systemic absorption of poison

Gastric Lavage Performed to empty stomach of toxic contents.
Procedure associated with serious complications: gastrointestinal perforation, hypoxia, aspiration No longer recommended in all 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 Need to protect airway

Antidotes Minority of poisons have specific antidotes
Used to counteract the poison Highly effective & should be available in all Emergency facilities Examples – N-acetlcysteine for acetaminophen poisoning, oxygen for carbon monoxide inhalation, naloxone for opioid overdose

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 Each year overdoses of acetaminophen account for 56,000 ER visits per year and 458 deaths of acute liver failure reported by the Harvard Women’s Health Watch (retrieved by the www. Health.harvard.edu/press On June 13, 2008) You do not have to memorize this. In Acute overdose only Tylenol is metabolized by the liver and the result is severe hepatic involvement Major cause of adolescent suicide in Great Britain Normal dose mg/kg/dose Toxic is 150 mg/kg (is rapidly absorbed in the GI tract) NAC (N-acetylcysteine)is the Antidote for Tylenol overdose. First 140 mg/kg initially, then 70 mg/kg Given po/ng in cola, water, or fruit juice q4h for 17 doses (3 days) IT Binds with metabolites so the liver is protected (tastes like rotten eggs NAC is most effective if given within 10 hours of ingestion Lower effect if given hours post ingestion Few deaths when used within 24 hours Biggest problem – liver damage hepatic necrosis pain in upper right quadrant Do not give activated charcoal Int

Poison Prevention Ultimate objective – to prevent poisonings from occurring or recurring Think developmentally Prevention is the most important Remember the age group of the child who is poisoned. So crawl around and see what is accessible to you as an adult. Young children and pets will often chew and eat anything within reach, no matter how it tastes. Infants & toddlers explore environment thru oral experimentation Toddlers and preschoolers – developing autonomy – increases curiosity& non compliant behavior (lack of awareness of danger)

Prevention Prevent recurrence
Discuss difficulties of constantly watching & safeguarding children How to identify risk? Ask specific questions or have parents complete a questionnaire designed tom isolate factors that predispose children to poisoning Encourage parents to get down at child’s level & survey surroundings. Passive (have been most successful)- using child resistant closures, limiting number of tablets in one container Actice measures (see Wong – community focus pg 475)

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 Educate children Prevent poisonings from occurring or recurring These are Important facts about poison prevention. Read above Free, professional, 24/7/365 Don’t guess, be sure…

Questions

Lecture 11 – Unit 3.4 Nursing Care for Health Problems of Toddlers and Preschool Children Skin Alterations in Children Wong 9th edition pp.423-432, 435-445,

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Lecture 11 – Unit 3.4 Nursing Care for Health Problems of Toddlers and Preschool Children Skin Alterations in Children Wong 9th edition pp.423-432, 435-445,

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Presentation on theme: "Lecture 11 – Unit 3.4 Nursing Care for Health Problems of Toddlers and Preschool Children Skin Alterations in Children Wong 9th edition pp.423-432, 435-445,"— Presentation transcript:

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