1. Overview of Integumentary Disorders

2. Disorders of the Nails Disorders
Clubbing – abnormal curving / increased angle at the nail bed (often related to O2 deficiency)
Koilonychia– “spoon nail” = malformation of the nail in which the outer surface is concaved or scooped out (often indicates iron deficiency anemia)
Onychia/Onychitis (onych = fingernail) = inflammation of the matrix of the nail
Onychocryptosis (onych = mail, crypt = hidden, osis = abnormal condition)

3. NDisorders of the Nails Continuedil Diseases and Disorders
Onychomycosis = fungal infection of the nail (myc= fungus)
Onychophagia = nail biting (phagia = eating)
Paronychia – infection of the skin fold at the margins of a nail (par = along side)
Subungual hematoma – collection of blood under a nail

4. HaiDisorders of the Hairr Diseases and Disorders
Hirsutism = excessive hairiness (hirsut = hairy)
Abnormal Hair Loss
Alopecia = partial or complete loss of hair (alopec = baldness)
alopecia areatea = autoimmune disorder; well defined bald areas
alopecia capitis totalis
alopecia universalis
Female pattern baldness – hair thins in front and sides
Male pattern baldness- Horseshoe shape area of hair remains in the back and temples

5. Disorders of the Skin Acne vulgaris Albinism Athlete’s foot
– Caused by increased secretion of oil related to increased hormones during puberty
Albinism
– Inherited disorder in which melanin is not produced
Athlete’s foot
– Contagious fungal infection of the foot

6. Acne Vulgaris
Description: Self-limiting inflammatory process of the hair follicle and pilosebaceous glands
Cause/Incidence: Etiology unknown; predominately during adolescence
Manifestations:
Inflammatory acne - pimples, pustule, nodules, and cysts
Non-inflammatory: open and closed comedones (blackheads or whiteheads)
Treatment:
Drying agents - e.g., Benzoyl peroxide/Retin-A
Topical antibiotic (clindamycin, erytromycin)
Systemic antibiotic/Accutane
Avoid sun exposure when drying agents are used. Otherwise sunlight is helpful
Accutane should not be used during pregnancy

7. Disorders of the Integumentary System (continued)
Cellulitis
– Bacterial infection of the dermis and subcutaneous layer of the skin
Chloasma
– Patchy discoloration of the face
Cleft lip or cleft palate
– Upper lip has a cleft where the nasal palate doesn’t meet properly
Contact dermatitis
– Allergic reaction that may occur after initial contact or as an acquired response

8. Cellulitis
Description: A deep locally diffuse infection of the skin with systemic manifestations and life-threatening potential
Cause/Incidence:
Usually involves face or an extremity.
History of trauma, impetigo, recent otitis media, or sinusitis
In children less than 3 years, facial cellulitis frequently is caused by Haemophilus influenza type b.
Cellulitis of extremities is more often associated with S. aureus and Group a Streptococci.

9. Cellulitis: Manifestations:
Most children look and feel ill, often febrile
Pitting edema over affected area
Classic signs of inflammation, redness, swelling, heat and tenderness/pain
Leucocytosis
Periorbital cellulitis often assoc with otitis media.

10. Cellulitis Management/Treatment: Nursing Considerations:
Systemic antibiotics
Immobilization of affected area
Incision and Drainage with culture
Nursing Considerations:
warm compresses, elevation
Non-occlusive dressing if skin rear or rupture
Management/Treatment:
Systemic antibiotics - usually parenteral until infection subsides then switch to oral for 10 days
Immobilization of affected area
Incision and Drainage with culture
Nursing Considerations:
warm compresses, elevation
Non-occlusive dressing if skin rear or rupture
Teach parents: improvement should be seen in 48 hours

11. Disorders of the Skin (continued)
Decubitus ulcers
– Sores or areas of inflammation that occur over bony prominences of the body
Eczema
– Group of disorders caused by allergic or irritant reactions

12. Atopic Dermatitis (Eczema)
Description- An inflammatory dermatitis that refers to a descriptive category of dermatologic disorders. Eczema is characterized histologically by epidermal changes of intracellular edema, spongiosis, or vesiculation.
Cause/Incidence: Often inherited. Inhaled allergens or food allergens are thought to induce mast-cell responses.
Definition- An inflammatory dermatitis that refers to a descriptive category of dermatologic disorders
Cause/Incidence: Majority of children (60%) develop during infancy. Unknown etiology but occurs more frequently when either parent has eczema. If one parent has AD, there is a 60% chance the child will develop AD or if both parents have AD, there is an 80% chance the child will develop AD.
About 60% of children eczema have a family history of asthma or other allergy.
Infantile eczema freq rel to food allergies
Eczema in older children freq. rel to allergies to dust mites

13. ECZEMA: MANIFESTATIONS
Usually symmetrical, scaly, erythematous patches or plaques with possible exudate and crusting
Pruritus
Unaffected skin dry and rough.
Chronically, relapsing course
Immediate skin test reactivity.
Elevated serum IgE
Manifestations: In infants, red papules usually appear first on cheeks then spread to forehead, scalp, and down extensor surface of extremities. Childhood eczema is char by lesions that are usually symmetrical, scaly, erythematous patches or plaques with possible exudate and crusting. Adolescent eczema is char by lichenification (large, dry thickened lesions or plaques)
Severe Pruritus.
Unaffected skin dry and rough.
Chronically relapsing course.
Immediate skin test reactivity.
Elevated serum IgE

14. Atopic Dermatitis (Eczema)
Management/Treatment
Burow solution (aluminum acetate) compresses.
Topical Steroids
Antihistamines to control itching
Oral antibiotics is widespread breakdown or infection
Moderate amount of bathing followed by application of a lubricating lotion
Humidified heat in the winter.
Management/Treatment
Burow solution (aluminum acetate) compresses. Inflammation is treated with topical steroids.
Tar preparations are sometimes used during flare-ups when symptoms are mild
Antihistamines to control itching
Oral antibiotics is widespread breakdown or infection
Moderate amount of bathing followed by application of a lubricating lotion (e.g. Lubriderm, Nivea, Nutraderm)
Nursing Considerations
Family education concerning the avoidance of allergen/sunburn
Apply mittens to prevent scratching affected areas.
Encourage frequent diaper changes to prevent skin breakdown in infants.
Follow recommended skin hydration program. Humidified heat in the winter.
Reassure parents that the condition is not contagious, will have remissions and generally can be controlled (fifty precent of children with infantile atopic dermatitis will “outgrow it by

15. Disorders of the Skin (continued)
Fungal skin infections
– Skin infections that live on dead outer surface or epidermis
Furuncle
– Boil, or bacterial infection of a hair follicle
Impetigo
– Very contagious bacterial skin infection that occurs most often in children
Kaposi’s sarcoma
– Form of cancer that originates in blood vessels and spreads to skin

16. Impetigo Description: Contagious bacterial skin infection
Cause/Incidence: Staphylococcus, streptococcus or a combination of both. Incubation period is 7-10 days.
Types:
Impetigo contagiosa (nonbullous)
Bullous Impetigo
Definition: Extremely Contagious bacterial skin infection
Cause/Incidence:
Staphylococcus, streptococcus or a combination of both. Incubation period is 7-10 days.
Accounts for approx 10 % of all childhood skin lesions
Types:
Impetigo contagiosa (nonbullous)- caused by Grp A Hemolytic Strep and S. aureus
Bullous Impetigo - cause d by S. aureus
Causative bacteria may be carried in nares and may pass onto the skin, bacteria invade superficial skin in which a break has occurred; infection can be spread after scratching an infected site
Infection commonly acquired thru contact with infected child’s toys, books, towels, etc or Infection may be caused by direct skin contact during play or sports

17. Impetigo
Manifestations: Small papule that becomes vesicular, pustular and then forms a honey-colored crust. Usually no systemic manifestation.
Lesions are rarely painful but pruritis and burning may be present
Non-bullous impetigo begins as a single erythematous macule 2 to 4 mm in diameter that rapidly progresses to a vesicle or pustule; vesicle ruptures leaving a honey-colored crust over the superficial erosion. Lesions spread rapidly to adjacent skin showing linear pattern of child’s scratching
Mild regional lymphadenopathy does occur
Bullous impetigo are usually less than 3 cm diameter with little erythema that erupt on untraumatized skin.
Spreads peripherally

18. Impetigo Management/Treatment Nursing Considerations
Topical bactericidal ointment.
If no response to topical ointment in 72 hours: give systemic antibiotics
Good hand washing. Limit person to person contact.
Nursing Considerations
Measures to prevent the spread
Management/Treatment
Topical bactericidal ointment such as neosporin, bactoban 3 to 4 times a day for 5 to 7 days.
Systemic antibiotics such as dicloxacillin, Keflex or Ceclor, or erythromycin if no response to topical within 72 hours.
Education: Good hand washing. Limit person to person contact.
Nursing Considerations
Take measures to prevent child from spreading lesions such as hand mittening and keeping fingernails short and clean.
Education of parents and child concerning measures to control the spread of impetigo to others.
Infection is communicable for 48 hours after effective antibiotic tx begins.

19. Disorders of the Integumentary System (continued)
Lupus
– Benign dermatitis or chronic systemic disorder
Psoriasis
– Chronic skin disorder in which too many epidermal cells are produced. (lesions of psoriasis are plaques – solid raised area of skin > 0.5 cm in diameter)
Rashes
– May result from viral infection, especially in children

20. Disorders of the Integumentary System (continued)
Scleroderma
– Rare autoimmune disorder that affects blood vessels and connective tissues of the skin
Streptococcus
– Non-motile bacteria that affect many parts of the body

21. Carcinoma
Cancerous Tumor

22. Basal Cell Carcinoma Most common Least malignant Slow growing
Papules that erode in the center
Pearly edge
99% cure rate with early excision

23. Squamous Cell Carcinoma
In keratinocytes of stratum spinosum
Scaly red papule (rounded elevation)
Rapid growth
Meets lymph
Good cure rate if caught early followed by radiation treatment

24. Malignant Melanoma Cancer of melanocytes
Most dangerous, death 1:4 cases
Accounts for 5% of skin cancers
Nevus mole becomes dark, spreads unevenly, bleeds some
Metastatic
Cause: overexposure to UV radiation (sun or tanning bed)
Little chance of survival (better if caught early)
Treatment: surgical excision with chemotherapy

25. American Cancer Society ABCD Rule for Skin Cancer
A – Asymmetry
B – Border Irregularity
C – Colors Different
D – Diameter (larger than 6 mm –pencil eraser)

26. Kaposi’s Sarcoma Purple papules spread to lymph nodes and other organs
Opportunistic disease of AIDS

27. Disorders of the Skin (continued)
Vitiligo
– Condition in which a loss of melanocytes results in whitish areas of skin bordered by normally pigmented areas
Warts (Verrucae)
– Papule caused by human papillomavirus

28. Burns
Description: injury to skin and possibly subcutaneous tissue, caused by chemical, thermal, radiation or electrical causes
Cause/Incidence: May be accidental or non-accidental; second leading cause of injury child < 14

29. Types of Burns
Superficial (first degree) – no blisters, superficial damage to the epidermis (e.g., sun burned)
Partial Thickness (second degree) – blisters, superficial damage to the epidermis
Full Thickness (third degree) – damage to the epidermis, corium, and subcutaneous layers

30. Rule of Nines Assessment: Calculate TBSA involved
> 10% require fluid replacement
assess dept of injury
Assess involvement of body parts; (hands, feet, face and perineal have higher potential for functional impairment; circumferential burns are considered major burns. Assess airway
Pain - may be severe in superficial and partial thickness burns
Third degree burns have no pain due to nerve ending destroyed
Assess renal function and output, vital signs, weight
Monitor bowel function - major burns cause paralytic ileus or occult bleeding from stress ulcers

31. Burns: Management Skin Care: Promote healing/Prevent infection
Pain Management
Fluid Replacement
High calorie, high carb, high protein diet
Active/Passive ROM if possible
Emotional Support

32. Overview of Communicable Disease/Rashes

33. Scarlet Fever: Manifestations
Sore throat, chills, fever, headache (occ. vomiting)
Erythematous papular rash on trunk and extremities (feels like sandpaper)
Strawberry “white” or “red” tongue
Circumoral pallor with erythema of lips, soles and palms

34. Scarlet Fever: Management
Management/Treatment:
Antibiotics
Nursing Considerations:
Bed rest during febrile stage
Analgesics/Antipyretic
Fluids
Prevention of complications and control of spread of disease

35. Communicable Diseases: Scabies
Description: Contagious skin condition caused by human mite - Sarcoptes scabiei
Incidence/Pathophysiology: Transmitted by close personal contact, Female mite burrow into outer layer of the epidermis to lay eggs, larvae hatch in several days and move toward the skin surface, Mite secretions, ova and feces are highly irritating so itching begins about 1 mo after infestation

36. Scabies: Manifestations
Intense pruritis, esp at rest/ bedtime
Infants/young child may be irritable, sleep fitfully
Lesions are linear, grayish burrows 1 to 10 cm long ending in a pinpoint vesicle, papule, or nodules
Skin excoriation from scratching

37. Scabies: Management Management/Treatment: Nursing Considerations:
Scabicida medications crotamiton (Eurax), permethrin 5% (Elimite), or lindane (Kwell, Scavene)
Oral antihistamines, soothing creams, lotions to reduce itching
Antibiotic is secondary infection
Nursing Considerations:
Pt/family education
Prevent spread: Treat all family/close contacts, wash clothes/linens
Scabicida medications crotamiton (Eurax), permethrin 5% (Elimite), or lindane (Kwell, Scavene) Lindane should not be used for infants or young child due to risk of neurotoxcity and seizures
One liberal application should be sufficient
Nursing Considerations:
Pt/family education
- medication application directions must be followed exactly.i.e.,scabicidal lotion needs to be applied to dry, cool skin from chin down.
-May be applied to face if child > 2 mos and lesions are present.
-Leave lotion on for 8 to 12 hrs before washing off.
-All family and close contacts must be treated
Clothing, bedding, towls need to be washed daily in hot water and dried in hot drier
Vacuum rug, floors, and furniture
Items that can’t be wash, seal in plastic bag for 4 days before use
Teach how to id secondary infection

38. Communicable Diseases: Varicella
Description: A viral disease characterized by a pruritic vesicular rash that appears in crops
Cause/Incidence: Varicella-zoster virus, transmitted by direct contact with vesicular fluid; Incubation period 14 to 21 days: Contagious day before rash appears to 1 week after first lesion crusted. Immunity from vaccination or disease

39. Varicella: Manifestations
Prodromal: mild fever and malaise for 24 hrs
Acute: Rash that progresses from macule to vesicle to crusts; eruptions last 5 days and lesions of all types are present at once

40. Varicella: Management
Management/Treatment:
Varicella immunoglobulin for immunocompromised pt within 72 to 96 hrs
Antipruritic lotions
Nursing Considerations:
Avoid Aspirin (assoc with Reyes)
Prevent spread of infection
Mitten hands if necessary
Prevention: Vaccine

41. Communicable Diseases: Rubeola (“Red” Measles)
Description:
Highly contagious, acute viral infection characterized by fever, cough, coryza, conjunctivitis, maculopapular skin rash and Koplik’s spots
Cause/Incidence: Viral etiology; 7 to 14 day incubation, Communicable several days before rash appears to 5 days after rash; Immunity = vaccination or disease

42. Rubeola: Manifestations
Prodomal: fever, lethargy, cough, coryza, photophobia, Koplik’s spots on buccal mucosa
Acute: red, flat rash (lasting about a wk) begins behind ears, spreads to face, trunk, and extremities

43. Rubeola: Management Management/Treatment: Nursing Considerations:
Symptomatic
Nursing Considerations:
Monitor for complications - bacterial super-infections, pneumonia, otitis media, encephalitis

44. Communicable Diseases: Rubella (German Measles)
Description:
Mild disease characterized by erythematous maculopapular discrete rash; postauricular and suboccipital lymphandenopathy
Cause/Incidence:RNA virus classified as rubivirus, transmitted by direct contact with nasopharyngeal secretions. Incubation - 14 to 21 days; Communicable 1 wk before and 5 days after onset of rash. Immunity=disease or vaccination

45. Rubella (German Measles): Continued
Manifestations:
Prodromal: low grade fever, headache, sore throat and cough
Acute: Flat rash begins on face and spreads to body; lasts 3 days
Management/Treatment:
Antipyretics/symptomatic
Complications: rare
Prevent spread of infection

46. Communicable Diseases: Mumps (Parotitis)
Description: Viral, communicable disease characterized by swelling of the parotid glands
Cause/Incidence: Mumps virus; Transmission: droplet or direct contact; Incubation 14 to 21 days; Communicability:1 week before parotoid swelling until 1 week after swelling begins
Immunity: from disease or vaccination

47. Mumps: Manifestations
Prodromal: fever, headache, earache that worsens with chewing
Acute: Swelling of parotid glands

48. Mumps: Management Management/Treatment: Nursing Considerations:
antipyretics
fluids and soft diet
Nursing Considerations:
Monitor for complications: Orchitis, encephalitis, deafness
Prevent spread
Prevention: vaccination

49. Communicable Diseases: Roseola (exanthema subitum)
Description:
mild, viral disease
Cause/Incidence:
caused by herpes virus type 6 (HHV-6)
common 6 mos to 2 yrs

50. Roseola: Continued Manifestations: Cause/Incidence:
Starts with high fever > 103 and irritability lasting 2-3 days
Followed by rosy pink rash develops - first on trunk then to neck, face, & extremities
Cause/Incidence:
Control fever (febrile seizures common)
Fluids

51. Fifth Disease - erythema infectiosum
Description: A communicable disease of childhood that causes a rash
Cause/Incidence: Etiology unknown; possibly spread thru resp tract; most contagious 1 week before rash appears. Once rash appears no longer contagious
Risk to developing fetus and to immuno-suppressed children
Treatment: supportive
Complications rare: self-limiting arthritis or arthragia, encephalitis, or myocarditis

52. Fifth Disease: Manifestations
Red rash on face that looks like “slapped cheeks”
Lacy pink rash on the backs of the arms and legs, torso, and buttock

53. Stevens-Johnson Syndrome
Description: an acute cutaneous disorder, severe form of erythema multiforme
Cause/Incidence: Possible hypersensitivity to certain drugs; secondary to resp infection
Management:
Identification and elimination of underlying cause (Antibiotic if necessary)
Prevention of secondary infection
Pain relief

54. Stevens-Johnson Syndrome: Manifestations
Fever, malaise, cough, sore throat, diarrhea, vomiting, chest pain, myalgia
Bulla with a grayish-white membrane on the mucous membranes of the lips, eyes, oral/nasal mucosa, genitalia, and rectum
Extensive skin lesions

55. Fungal Infections
Descriptions: Superficial infections that live on the skin and not “in” the skin.
Cause/Incidence:
Fungi grow best in warm, moist places
Causative fungi are usually opportunistic and not usually pathogenic unless they enter a compromised host

56. Fungal Infections: Tinea Pedis
Description: - fungal infection of the foot (Althelete’s foot )
Cause/Incidence: Most common fungal infection. Caused by species of the genera Microsporum and Trichophyton. Transmitted by direct contact with skin containing fungi, and fungi in damp areas

57. Tinea Pedis: Continued
Manifestations: Interdigital lesions (fissures); Vesicles/erosions on instep, Pruritus, Diffuse scaling
Management:
Miconazole, clortrimazole, or haloprogin
Burrow solution compresses
Nursing Considerations:
Teach foot hygiene
Observe for secondary infection
Prevent transmission
Tinea Cruris (jock itch) treated the same as athlete’s foot

58. Fungal Infections: Ringworm (Tinea Capitis or Tinea Corporis)
Description: A fungal infection of the scalp or body
Cause/Incidence: Microsporum and Trichophyton; transmitted by direct contact
Management:
Oral grisofulvin
Selenium Sulfate shampoo to reduce fungi on hair
Topical antifungal agents - e.g.,Miconazole
Antihistamine for itching
Prevention of secondary infection
Education regarding transmission
Nursing Mnagemtn: discuss SE of Oral grisofulvin - educate about common SE - headache,, GI upset, fatigue, insomnia, photosensitivity
Prevent spread

59. Ringworm: Manifestations
One or more irregular, erythematous, slightly raised, scaly patches
Lesions tend to spread but central clearing occurs resulting in “ring”
Pruritus

60. Fungal Infections: Candida
Description: A yeast infection that occurs in the mouth, esp in infants
Cause/Incidence: may be acquired in newborns from maternal vaginal infection or transmitted by poor hygiene
Manifestations: Oral thrush = white plaques on the mucous membrane; Diaper Dermatitis- char by “beefy” red erythematous areas with surrounding papules and pustules
Management: Nystatin; no isolation required