Lecture 9: Integumentary Conditions

Describe some differences in pediatric skin anatomy and physiology.

• children’s epidermal layer is less bound to dermal layer

• increased exposure to iatrogenic risk factors

• increased exposure to body fluids

• limited/no ability to self care or self report

• higher risk of accidental injury

• higher risk of inflammatory conditions

What can children’s epidermal layer being less bound to the dermal layer indicate for them?

• poor adherence can result in separation of layers

• much higher risk of separation in preterm infants

Name two factors that can enhance skin healing.

• moist clean environment

• good nutrition

Name 7 factors that can delay skin healing.

• immunocompromised

• impaired circulation

• stress

• infection, antiseptics, medication

• foreign bodies

• mechanical friction

• co-existing diseases/morbidities

Name 3 types of lesions.

• erythema

• ecchymoses

• petechiae

Describe eythema.

reddened area caused by increased amounts of oxygenated blood in the dermal vasculature

Describe ecchymoses.

localized red and purple discolorations caused by extravasation of blood into dermis and subcutaneous tissues

Describe petechiae.

pinpoint, tiny, and sharp circumscribed spots in the superficial layers of the epidermis

What is a primary lesion?

a skin change that occurs on previously healthy skin, directly caused by a disease process and not a result of external factors like scratching or treatment

What is a secondary lesion?

Changes that result from alteration in the primary lesions, such as those caused by rubbing, scratching, medication, or involution, and healing

What should be reduced to manage iatrogenic risks?

• pressure over bony prominences

• friction and shear

• epidermal stripping

• contact with irritants

What should be promoted to manage iatrogenic risks?

• optimal oxygenation

• hydration and nutrition

• circulation

• movement

Name 2 care priorities in the management of ostomies.

• maintain position and patency of tubes

• protect surrounding skin

What are 3 ways to protect the surrounding skin of an ostomy?

• prevent/reduce skin exposure to fluids

• keep as clean and dry as possible

• use barriers like creams, protective and /or absorbent wound products, ostomy wafers

What population is diaper dermatitis common in? Peak occurence?

infants; 9 to 12 months of age

In what population of babies of diaper dermatitis more common?

formula-fed infants

Etiology of diaper dermatitis?

prolonged and repetitive contact with irritant

What does diaper wetness cause that facilitates diaper dermatitis?

• higher friction

• greater abrasion damage

• increased transepidermal permeability

• increased microbial counts

What happens to the pH that can contribute to diaper dermatitis? How?

• increase in pH

• breakdown of urea in the presence of fecal urease

What is candida albicans?

perineal inflammation and maculopapular rash with satellite lesions that may cross the inguinal fold

What are the 4 main nursing interventions for diaper dermatitis?

• reduce contact with irritant

• keep skin dry

• protect skin

• minimize friction

Name 2 strategies to help reduce contact with irritants in diaper dermatitis.

• changing diaper as soon as wet or soiled

• do not use perfumed products/wipes

Name 2 strategies to help keep skin dry in diaper dermatitis.

• expose healthy or slightly affected area to air

• use absorbent diapers

Name 2 strategies to help protect skin in diaper dermatitis.

use barrier creams and reapply with each change

Name 2 strategies to help minimize friction in diaper dermatitis.

• avoid frequent washing/firm rubbing

• monitor for secondary infection and treat accordingly

What are the 4 elements of descriptive diagnosis in atopic dermatitis (eczema)?

1. Intense pruritus

2. associated with asthma and allergies

3. dermatological manifestations appear subsequent to scratching

4. improvement in humid environments

During which seasons is eczema worse? Why?

Fall/Winter when houses are heated and dry

Usual locations of eczema?

face and creases

Management of eczema in terms of dressings?

• bathe in tepid water with mild or no soap

• apply topical medications as required

• dress in warm moist dressing/clothes, with dry outer layer

• cool wet compresses/dressings

• evaluate for secondary infections

• address itch, scratching, pain, stress, fatigue, sleep disturbance

Outcomes of skin hydration/protection management?

• low risk of scarring if no secondary infections

• most children will spontaneously permanent remission

Name 5 contributing factors for burns.

• location

• causative agent

• age of child

• respiratory involvement

• general health

Name 2 characteristics of burn injuries.

• extent of injury described as TBSA

• depth of injury

What are the 4 depths of injury?

• superficial

• partial thickness

• full thickness

• full thickness + underlying tissue

Pathophysiology of thermal injury?

edema and severe capillary damage

What constitutes a major burn?

greater than 30% TBSA

What response does a major burn usually cause?

increase in capillary permeability that allows plasma, proteins, fluids, and electrolytes to be lost

How does thermal injury cause anemia?

• caused by direct heat destruction of RBCs

• hemolysis of injured RBCs

• trapping of RBCs in the microvascular thrombi of damaged cells

• increased RBC fragility

What happens to metabolism in thermal injury? Why?

increased metabolism to main body heat

With thermal injury, where does blood flow increase?

heart, brain, kidneys

With thermal injury, where does blood flow decrease?

GI tract

Elements of emergency management of burns?

• stop burning process

• keep the child warm => do not cool large burns

• assess child’s condition

• ABC: always give O2 for moderate-severe burns

• cover burn to prevent contamination

• transport child to appropriate level of care

• pain management

• fluid replacement therapy

When is fluid replacement therapy most critical?

in the first 24 hours

When is O2 given for emergency management of burns?

moderate-severe burns

What do burns increase the risk of in terms of fluids and electrolytes?

hypovolemia and sodium losses

What can be used to maintain tissue perfusion in burns?

crystalloid solution like NS or RL

Depending on the TBSA, IV infusion is started immediately to maintain urine output at what value for those under 30 kg?

1-2 mL/kg

Depending on the TBSA, IV infusion is started immediately to maintain urine output at what value for those over 30 kg?

30-50 mL/hr

In what situation may additonal fluids be required?

• delay in treatment

• underestimation of extent of burn, especially with electrical burns

• pulmonary injuries - fluid loss in lungs

Commonly used groups of medications for the management of burns?

• antibiotics

• analgesics

• anesthetics

Name 3 elements in the care of minor burns.

1. Wound cleansing

2. Debridement

3. Ideal burn dressing

Name 5 aspects to consider when choosing the ideal burn dressing.

• reduce risk of infection

• require infrequent changing with minimal discomfort

• promote re-epithelialisation

• cost effective

• cover wounds with antimicrobial ointment or use occlusive dressing or both

Name 4 types of biological skin coverings.

• allograft

• xenograft

• synthetic skin coverings

• split-thickness skin grafts

Name the 4 elements of major burn care.

• primary excision

• debridement

• topical antimicrobial medications

• biological skin coverings

3 aspects of rehab after major burns?

• active rehabilitation when wound coverage achieved

• prevention and management of contractures

• pressure suits - prevent/control scars/optimize movement/protect skin