Infectious disorders of the skin include those caused by viral, bacterial, or fungal infection. The viral exanthems are discussed in Chapter 37. Bacterial and fungal infec- tions of the skin are discussed below.
Bacterial Infections
Bacterial infections of the skin include bullous and nonbullous impetigo, folliculitis, cellulitis, and staphylo- coccal scalded skin syndrome. These bacterial skin infec- tions are often caused by Staphylococcus aureus and group A β-hemolytic streptococcus, which are ordinarily normal lora on the skin. Impetigo, folliculitis, and cellu- litis are usually self-limited disorders that rarely become severe.
Impetigo is a readily recognizable skin rash (Fig. 46.2).
Nonbullous impetigo generally follows some type of skin trauma or may arise as a secondary bacterial infection of as a guide in planning nursing care for the child with
an integumentary disorder. Individualize the plan of care based on the child’s and family’s responses to the health alteration. See Chapter 36 for information about pain management. Additional information will be included later in the chapter as it relates to speciic disorders.
COMMON LABORATORY AND DIAGNOSTIC TESTS 46.1
Test Explanation Indications Nursing Implications
Complete blood count (CBC) with differential
Evaluate hemoglobin and hematocrit, WBC count (particularly the percentage of individual WBCs), and platelet count
Infection or inlammatory process
Normal values vary according to age and gender.
WBC differential is helpful in evalu- ating source of infection.
May be affected by myelosuppressive drugs.
Eosinophils may be elevated in the child with atopic dermatitis.
Erythrocyte sedimentation rate (ESR)
Nonspeciic test used to detect presence of infection or inlammation
Infection or inlammatory process
Send sample to laboratory imme- diately; if allowed to stand for lon- ger than 3 hours, may result in falsely low result.
Potassium hydroxide (KOH) prep
Reveals branching hyphae (fungus) when viewed under microscope
To identify fungal infection Place skin scrapings on a micro- scope slide and add KOH 20%
drop.
Culture of wound or skin drainage
Allows for microbial growth and organism identiication
Identiication of speciic organism
Note sensitivities.
Immunoglobulin E (IgE)
Measurement of serum IgE Atopic dermatitis Often elevated in allergic or atopic disease, though this is a nonspeciic inding. May be increased if the child takes sys- temic corticosteroids.
Patch or skin testing Needle prick testing with allergens
Atopic or contact dermatitis
Have emergency equipment available in the event of ana- phylaxis (rare).
Adapted from Pagana, K. D., & Pagana, T. J. (2010). Mosby’s manual of diagnostic and laboratory tests (4th ed.). St. Louis, MO: Mosby.
After completing an assessment of Eva, the nurse noted the following: hypopigmentation of the skin behind her knees, dry patches on her wrists and face, and slight wheezing heard bilaterally on auscultation. Based on these assessment findings, what would your top three nursing diagnoses be for Eva?
Based on your top three nursing diagnoses for Eva, describe appropriate nursing interventions.
NURSING CARE PLAN 46.1
Overview for the Child With an Integumentary Disorder
NURSING DIAGNOSIS: Impaired skin integrity related to infectious process, hypersensitivity reaction, injury, or mechanical factors as evidenced by rash, inlammation, abrasion, laceration, or disrupted epidermis
Outcome Identification and Evaluation
Integrity of skin surface will be restored: rash, abrasion, laceration, or other skin disruption will heal.
Interventions: Restoring Skin Integrity
• Assess site of skin impairment to determine extent of involvement and plan care.
• Monitor skin impairment every shift for changes in color, warmth, redness, or other signs of infection to identify problems early.
• Determine the child’s and family’s skin care practices to establish need for education related to skin care.
• Individualize the child’s skin care regimen depending on the child’s particular skin condition to most appro- priately care for skin in light of the child’s disorder.
• In the immobile child, use a risk assessment tool (such as a modiied Norton or Braden scale) to identify risk for skin breakdown.
• Position the child on the opposite side of the skin impairment to avoid further skin breakdown.
• Encourage appropriate nutritional intake as adequate nutrients are necessary for appropriate immune function and skin healing.
• Consult the wound and ostomy care nurse special- ist to determine the best approach for individualized wound care.
• Provide dressing change and wound care as pre- scribed to promote wound or burn healing.
NURSING DIAGNOSIS: Risk for infection related to disruption in protective skin barrier
Outcome Identification and Evaluation
Child will remain free from local or systemic infection, will remain afebrile, without additional redness or warmth at skin disruption site.
Interventions: Preventing Infection
• Use appropriate hand hygiene to decrease transmission of infectious organisms.
• Assess the skin impairment site for increased warmth, redness, discharge, or new purulence to identify infection early.
• Assess temperature every 4 hours or more frequently if needed, as children develop fever quickly in response to infection.
• Note white blood cell (WBC) count and culture results, reporting unexpected values to the physician or nurse practitioner so that appropriate treatment may be started.
• Follow prescribed therapies for skin alteration to maintain skin moisture and prevent further breakdown, which may lead to infection.
• Encourage appropriate nutritional intake as adequate nutrients are necessary for appropriate immune function and skin healing.
NURSING DIAGNOSIS: Disturbed body image related to chronic skin changes caused by disease process, burns, or other skin alteration as evidenced by child’s verbalization, reluctance to partici- pate in activities, or social withdrawal
NURSING CARE PLAN 46.1
Outcome Identification and Evaluation
Child will verbalize or demonstrate acceptance of alteration in body, will return to previous level of social involvement.
Overview for the Child With an Integumentary Disorder
(continued)• Assess child or teen for feelings about alteration in skin to determine baseline.
• Acknowledge feelings of anger or depression related to skin changes to provide an outlet for feelings.
• Encourage the child or teen to participate in skin care to give some sense of control over what is occurring.
• Help the child or teen to accept self as the perception of self is tied to knowing oneself and identifying what the self values.
NURSING DIAGNOSIS: Imbalanced nutrition, less than body requirements, related to increased met- abolic state (burns) as evidenced by poor wound healing, dificulty gaining or maintaining body weight Interventions: Promoting Appropriate Body Image
NURSING DIAGNOSIS: Risk for deicient luid volume related to burns
Outcome Identification and Evaluation
Fluid volume status will be balanced, child will maintain urine output of 1 to 2 mL/kg/
hour, oral mucosa will be moist and pink, heart rate will remain within age- and situation- specific parameters.
Interventions: Promoting Fluid Balance
• Assess luid volume status at least every shift, more frequently if disrupted, to obtain baseline for comparison.
• Strictly monitor intake and output to detect imbalance or need for additional fluid intake.
• Weigh the child daily on the same scale, at the same time, in the same amount of clothing as changes in weight are an accurate indicator of fluid volume status in children.
• Provide intravenous luid resuscitation in initial period, followed by encouragement of oral luid intake in the burned child, to compensate for fluid loss through burned areas.
Outcome Identification and Evaluation
Child will demonstrate balanced nutritional state, will maintain or gain weight as appropriate for situation, will demonstrate improvement in wound healing.
Interventions: Promoting Nutrition
• Assess the child’s food preferences and ability to eat to provide a baseline for planning nursing care.
• Consult the nutritionist because nutritional needs are increased related to altered metabolic state as a result of burns.
• Collaborate with the nutritionist, child, and parents to plan meals that appeal to the child to increase the child’s intake.
• Administer vitamin and mineral preparations as prescribed to supplement nutrients.
• Provide smaller, more frequent meals and snacks to promote increased intake.
• Weigh the child daily to determine progress.
Of particular concern are community-acquired bac- terial skin infections caused by methicillin-resistant S.
aureus (CA-MRSA) (So & Farrington, 2008). CA-MRSA most commonly occurs as a skin or soft tissue infection, such as cellulitis or an abscess. Risk factors for CA-MRSA are turf burns, towel sharing, participation in team sports, or attendance at day care or outdoor camps. If the child presents with a moderate to severe skin infection or with an infection that is not responding as expected to ther- apy, it is important to culture the infected area for MRSA.
Therapeutic management of bacterial skin infections includes topical or systemic antibiotics and appropriate hygiene (Table 46.1).
Nursing Assessment
Obtain the history as noted in the nursing process over- view section. Note history of skin disruption such as a cut, scrape, or insect or spider bite (nonbullous impe- tigo and cellulitis). Note body piercing in the adoles- cent, which can lead to impetigo or cellulitis. Measure the child’s temperature. Fever may occur with bullous impetigo or cellulitis and is common with scalded skin syndrome. Inspect the skin, noting abnormalities, docu- menting their location and distribution, and describing drainage if present. Table 46.1 gives speciic clinical man- ifestations of the various bacterial skin infections. Palpate for regional lymphadenopathy, which may be present with impetigo or cellulitis. Blood cultures are indicated in the child with cellulitis with lymphangitic streaking and in all cases of periorbital or orbital cellulitis.
Nursing Management
Administer antibiotics topically or systemically as pre- scribed. Teach the family about antibiotic administration and care of the lesions or rash. Soak impetiginous lesions another skin disorder, such as atopic dermatitis. Bullous
impetigo demonstrates a sporadic occurrence pattern and develops on intact skin, resulting from toxin production by S. aureus.
Folliculitis, infection of the hair follicle, most often results from occlusion of the hair follicle. It may occur as a result of poor hygiene, prolonged contact with contam- inated water, maceration, a moist environment, or use of occlusive emollient products.
Cellulitis is a localized infection and inlammation of the skin and subcutaneous tissues and is usually pre- ceded by skin trauma of some sort (Fig. 46.3).
Staphylococcal scalded skin syndrome results from infection with S. aureus that produces a toxin, which then causes exfoliation. It has an abrupt onset and results in diffuse erythema (reddening of the skin) and skin tenderness (Fig. 46.4). Scalded skin syndrome is most common in infancy and rare beyond 5 years of age (Marino & Fine, 2009).
FIGURE 46.2 Note honey-colored crusting with impetigo.
FIGURE 46.3 Note erythema and edema associated with cellulitis.
FIGURE 46.4 Staphylococcal scalded skin syndrome (SSSS) with ruptured bullae. (Used with permission from Good- heart, H.P. Goodheart’s photoguide to common skin disorders:
Diagnosis and management [3rd ed.]. Philadelphia, PA:
Lippincott Williams & Wilkins, 2009.)
of occlusive emollients. Table 46.1 gives additional information about speciic treatments for bacterial skin infections.
Fungal Infections
Fungi also cause infections on children’s skin. Tinea is a fungal disease of the skin occurring on any part of the body. The part of the body affected determines the second word in the name. Examples of tinea infections occurring on various parts of the body include:
• Tinea pedis: fungal infection on the feet
• Tinea corporis: fungal infection on the arms or legs
• Tinea versicolor: fungal infection on the trunk and extremities
• Tinea capitis: fungal infection on the scalp, eyebrows, or eyelashes
• Tinea cruris: fungal infection on the groin with cool compresses or Burow solution to remove
crusts before applying topical antibiotics. Though impe- tigo is considered a contagious disorder among vulner- able populations, removal from school or day care is not necessary unless the condition is widespread or actively weeping. Prevent transmission of nosocomial MRSA by appropriately isolating children according to the institu- tion’s policy when the child is hospitalized. In children with scalded skin syndrome, reduce the risk of scar- ring by minimal handling, avoiding corticosteroids, and applying soothing ointments as the skin heals.
Educate the family about prevention of bacterial skin infections. Stress the importance of cleanliness and hygiene. Teach the family to keep the child’s inger- nails cut short and to clean the nails with a nail brush at bath time. When a skin disruption such as a cut, scrape, or insect bite occurs, teach the family to clean the area well to prevent the development of cellulitis. Folliculitis may be prevented with diligent hygiene and avoidance TABLE 46.1 BACTERIAL SKIN INFECTIONS
Disorder Skin Findings Usual Treatment
Nonbullous impetigo • Papules progressing to vesicles, then painless pustules with a narrow erythematous border
• Honey-colored exudate when the vesicles or pustules rupture, which forms a crust on the ulcer-like base (see Fig. 46.2)
• Limited amount: treat topically with mupirocin ointment.
• If numerous lesions, oral irst-generation cephalosporin is indicated.
• Clindamycin may be needed for MRSA.
• Remove honey-colored crust with cool compresses BID.
Bullous impetigo • Red macules and bullous eruptions on an erythematous base
• Size may be from a few millimeters to several centimeters.
• Oral irst-generation cephalosporin.
• Good hygiene.
Folliculitis • Red, raised hair follicles • Treat with aggressive hygiene: warm compresses after washing with soap and water several times a day.
• Topical mupirocin is indicated;
occasionally oral antibiotics are required.
Cellulitis • Localized reaction: erythema, pain, edema, warmth at site of skin disruption (see Fig. 46.3)
• Mild cases are usually treated with cephalexin or amoxicillin/clavulanic acid.
• More severe cases and periorbital or orbital cellulitis require IV cephalosporins.
Staphylococcal scalded skin syndrome
• Flattish bullae that rupture within hours
• Red, weeping surface is left, most commonly on face, groin, neck, and axillary region (see Fig. 46.4)
• Mild to moderate cases are treated with oral cephalexin, dicloxacillin, or amoxicillin/clavulanic acid.
• Severe cases are managed similar to burns with aggressive luid management and IV oxacillin or clindamycin.
Adapted from Burch, J. M., & Morelli, J. G. (2011). Skin. In W. W. Hay, M. J. Levin, J. M. Sondheimer, & R. R. Deterding (Eds.), Current pediatric diagnosis and treatment (20th ed.). New York, NY: McGraw-Hill; and Lewis, L. S. & Friedman, F. A. Impetigo.
Retrieved July 7, 2012, from http://emedicine.medscape.com/article/965254-overview.
nylon socks or nonbreathable shoes, or minor trauma to the feet (tinea pedis). Document a history of wearing tight clothing or participating in a contact sport such as wrestling (tinea cruris). Inspect the skin and scalp, not- ing the location, description, and distribution of the rash or lesions (Figs. 46.5, 46.6, 46.7, 46.8, and 46.9). Table 46.2 describes the clinical indings associated with vari- ous types of tinea.
Scraping and KOH preparation show branching hyphae. For tinea capitis, the Wood lamp will luoresce yellow-green if it is caused by Microsporum, but not with Trichophyton. A fungal culture of a plucked hair is more reliable for diagnosis of tinea capitis.
Nursing Management
Maintain appropriate hygiene and administer antifungal agents as prescribed (see Table 46.2). Additional speciics related to the individual fungal disorders are as follows:
• Tinea corporis is contagious, but the child may return to day care or school once treatment has begun. Iden- tify and treat family members or other contacts.
The three organisms most often responsible for tinea are Epidermophyton, Microsporum, and Trichophy- ton, though Malassezia furfur causes tinea versicolor.
Candida albicans may cause an infection of the skin, particularly in a warm, moist area such as the diaper area. In fact, 80% of diaper rashes lasting longer than 4 days are colonized with C. albicans (Marino & Fine, 2009). All fungal skin infections may occur year-round, but tinea versicolor is more common in warm weather.
Therapeutic management of fungal infections involves appropriate hygiene and administration of an antifungal agent. Table 46.2 gives further information about treat- ment. See EBP 46.1
Nursing Assessment
Elicit the health history, noting exposure to another per- son with a fungal infection or exposure to a pet (fungi are often carried by pets). Note onset of the rash and whether it is itchy. Determine if the child has recently visited the barber (tinea capitis). Note contact with damp areas such as locker rooms and swimming pools, use of
TABLE 46.2 MANIFESTATIONS AND MANAGEMENT OF FUNGAL INFECTIONS
Disorder Skin Findings Usual Treatment
Tinea corporis
(ringworm) • Annular lesion with raised peripheral scaling and central clearing (looks like a ring) (see Fig. 46.5)
• Topical antifungal cream is required for at least 4 weeks.
Tinea capitis • Patches of scaling in the scalp with central hair loss
• Risk of kerion development (inlamed, boggy mass that is illed with pustules) (see Fig. 46.6)
• Oral griseofulvin for 4 to 6 weeks.
• Selenium sulide shampoo may be used to decrease contagiousness (adjunct only).
• No school or day care for 1 week after treatment initiated.
Tinea versicolor • Supericial tan or hypopigmented oval scaly lesions, especially on upper back and chest and proximal arms
• More noticeable in the summer with tanning of unaffected areas (see Fig. 46.7)
• Apply selenium sulide shampoo all over body (from face to knees) and allow to stay on skin overnight, rinsing in the morning, once a week for 4 weeks (this may cause skin irritation).
• Topical antifungals in the imidazole family may be used instead.
Tinea pedis
(athlete’s foot) • Red, scaling rash on soles and between
the toes (see Fig. 46.8) • Topical antifungal cream, powder, or spray.
• Appropriate foot hygiene.
Tinea cruris • Erythema, scaling, maceration in the inguinal creases and inner thighs (penis/
scrotum spared)
• Topical antifungal preparation for 4 to 6 weeks.
Diaper candidiasis (also called monilial diaper rash)
• Fiery red lesions, scaling in the skin folds, and satellite lesions (located further out from the main rash) (see Fig. 46.9)
• Topical nystatin with diaper changes for several days.
• See section on diaper dermatitis for additional information.
Adapted from Burch, J. M., & Morelli, J. G. (2011). Skin. In W. W. Hay, M. J. Levin, J. M. Sondheimer, & R. R. Deterding (Eds.), Current pediatric diagnosis and treatment (20th ed.). New York, NY: McGraw-Hill.
• Counsel the child with tinea capitis and parents that hair will usually regrow in 3 to 12 months. Wash sheets and clothes in hot water to decrease the risk of the in- fection spreading to other family members.
• Instruct the child with tinea pedis to keep the feet clean and dry. Rinse feet with water or a water/
vinegar mixture and dry them well, especially between the toes. Encourage the child to wear cotton socks and shoes that allow the feet to breathe. Going barefoot at home is allowed, but lip-lops should be worn around swimming pools and in locker rooms.
• Inform the child with tinea versicolor that return to normal skin pigmentation may take several months.
• Counsel the child or adolescent with tinea cruris to wear cotton underwear and loose clothing. It is impor- tant to maintain good hygiene, particularly after sports practice or a sporting event.
• For management of diaper candidiasis, follow the sug- gestions listed below in the section on diaper dermatitis.
FIGURE 46.5 Tinea corporis: note raised scaly border with clearing in center.
FIGURE 46.6 Note hair breakage and loss with tinea capitis.
FIGURE 46.7 Tinea versicolor. Hypopigmented scaly lesions on the back of a darkly pigmented adolescent. (Used with permission from Goodheart, H.P. Goodheart’s photoguide to common skin disorders: Diagnosis and management [3rd ed.].
Philadelphia, PA: Lippincott Williams & Wilkins, 2009.)
FIGURE 46.8 Tinea pedis. The interdigital pattern of tinea pedis is common. (Used with permission from Goodheart, H.P. Goodheart’s photoguide to common skin disorders:
Diagnosis and management [3rd ed.]. Philadelphia, PA:
Lippincott Williams & Wilkins, 2009.)
FIGURE 46.9 A bright red rash with satellite lesions occurs with diaper candidiasis.