chapter 45 notes

Chapter 45 

1. COMMON MEDICAL TREATMENTS FOR SKIN CONDITIONS

Wet Dressing

• Use: Crusting, oozing, helps remove crusts
  
  

• Nursing:
  
  

  • Use Burow’s, Domeboro, or saline solutions
    
    

  • Premedicate for pain if needed
    
    

  • Provide atraumatic dressing care
    
    

Sunscreen

• Use: All kids >6 months
  
  

• Nursing:
  
  

  • Use PABA-free SPF 15+
    
    

  • Apply 30 mins before exposure; reapply every 2 hrs
    
    

  • Water-resistant types needed for swimming
    
    

  • Use even on cloudy days
    
    

Bathing

• Use: Itchy/irritated skin
  
  

• Nursing:
  
  

  • Use lukewarm water
    
    

  • Recommend fragrance-free, dye-free soaps like Aveeno, Basis, Lubriderm
    
    

  • Pat skin dry; leave moist before applying meds/moisturizer
    
    

2. DRUGS FOR INTEGUMENTARY DISORDERS (SUPER SPECIFIC)

Systemic Corticosteroids

 (Prednisone, etc.)

• Used For: Severe contact dermatitis
  
  

• Nursing:
  
  

  • Give with food
    
    

  • Masks infection signs
    
    

  • Monitor BP, glucose in urine
    
    

  • Don’t stop abruptly: adrenal crisis risk
    
    

  • Watch for Cushing syndrome
    
    

  • Taper dose over time
    
    

Isotretinoin

• Used For: Severe acne not responding to antibiotics
  
  

• Nursing:
  
  

  • Pregnancy risk—do NOT get pregnant!
    
    

  • Monitor: CBC, lipids, LFTs, β-hCG monthly
    
    

  • Monitor for suicide risk
    
    

Coal Tar

• Used For: Psoriasis, atopic dermatitis
  
  

• Nursing:
  
  

  • Stains fabrics
    
    

  • Strong smell
    
    

  • Apply at bedtime; rinse in AM
    
    

Silver Sulfadiazine

• Used For: Burns
  
  

• Nursing:
  
  

  • Cover with occlusive dressing
    
    

  • Apply twice daily
    
    

  • Don’t use with sulfa allergy
    
    

  • Forms painful gel
    
    

  • May cause transient neutropenia
    
    

  • Do NOT use on face or infants <2 months
    
    

Topical Antibiotics

• Used For: Mild acne, impetigo, folliculitis
  
  

• Nursing:
  
  

  • Apply to cleansed skin
    
    

  • Monitor for neomycin allergy
    
    

Systemic Antibiotics

• Used For: Moderate-severe acne, cellulitis, etc.
  
  

• Nursing:
  
  

  • Check allergies before
    
    

  • Complete full course
    
    

Topical Corticosteroids

• Used For: Atopic/contact dermatitis
  
  

• Nursing:
  
  

  • Do not use high potency on face/genitals
    
    

  • Don’t cover with occlusive dressing
    
    

  • Absorption high in infants
    
    

Topical Antifungals

• Used For: Tinea, candidal diaper rash
  
  

• Nursing:
  
  

  • Thin layer
    
    

  • Full treatment course to avoid reoccurrence
    
    

Systemic Antifungals

• Griseofulvin: Take with fatty food, 4-week course
  
  

  • Monitor LFTs, CBC, causes photosensitivity
    
    

• Ketoconazole: Give with food to reduce GI upset
  
  

Benzoyl Peroxide

• Used For: Acne
  
  

• Nursing:
  
  

  • Use with antibiotics
    
    

  • Shake before use
    
    

  • Avoid eyes and mucosa
    
    

Topical Retinoids

 (tretinoin, adapalene, tazarotene)

• Side Effects: Dryness, burning, photosensitivity
  
  

• Nursing:
  
  

  • Use SPF 15+ sunscreen
    
    

Immune Modulators

 (Tacrolimus, pimecrolimus)

• Used For: Atopic dermatitis resistant to steroids
  
  

• Nursing:
  
  

  • Only >2 years old
    
    

  • Avoid sunlight
    
    

  • May cause burning, flu-like sx, HA
    
    

Antihistamines

 (Diphenhydramine, Hydroxyzine)

• Used For: Severe pruritus/allergic skin conditions
  
  

• Nursing:
  
  

  • Give 3-4x/day unless sedation interferes with ADLs
    
    

3. BACTERIAL SKIN INFECTIONS

Nonbullous Impetigo

• Findings: Papules → vesicles → honey-colored crust
  
  

• Treatment:
  
  

  • Topical mupirocin
    
    

  • Cephalosporins if extensive
    
    

  • Cool compress 2x/day
    
    

Bullous Impetigo

• Findings: Red macules → bullae
  
  

• Treatment: Cephalosporins, hygiene
  
  

Folliculitis

• Findings: Red, raised around hair follicles
  
  

• Treatment: Warm compresses, hygiene, topical abx
  
  

Cellulitis

• Findings: Erythema, edema, warmth, pain
  
  

• Treatment:
  
  

  • Mild = cephalexin or amoxicillin/clavulanic acid
    
    

  • Periorbital/orbital = IV abx
    
    

  • Soak eye area 20 mins every 2-4 hrs
    
    

Staph Scalded Skin Syndrome

• Findings: Diffuse red skin, blistering
  
  

• Treatment:
  
  

  • Mild = oral cephalexin
    
    

  • Severe = like burn: IV abx + fluid management
    
    

4. FUNGAL INFECTIONS

Nursing for Fungal Infections

:

• Capitis = no school for 1 week after tx
  
  

• Wash linens in hot water
  
  

• Avoid sharing brushes, hats, towels
  
  

• Tinea corporis = contagious, but can return to daycare after tx starts
  
  

• Versicolor pigmentation may take months to normalize
  
  

5. INFLAMMATORY SKIN CONDITIONS

Diaper Dermatitis

• Cause: Nonimmune response to urine/stool
  
  

• Signs: Red, macerated, shiny rash
  
  

• Nursing:
  
  

  • Use creams with vit A, D, E, zinc oxide
    
    

  • Change diapers often
    
    

  • Avoid rubber pants, harsh wipes
    
    

  • Pat dry, not rub
    
    

Atopic Dermatitis (Eczema)

• Signs: Itchy, inflamed, red, swollen skin
  
  

• Linked to: Food allergies, asthma
  
  

• Nursing:
  
  

  • Promote hydration
    
    

  • Avoid hot water, perfume, dyes, fragrance
    
    

  • Use non-scented moisturizers (Cetaphil, Aquaphor, etc.)
    
    

  • May need corticosteroids or immune modulators
    
    

Contact Dermatitis

• Cause: Cell-mediated allergic reaction (e.g., poison ivy, nickel, soaps)
  
  

• Timeframe: 24-48 hrs after exposure
  
  

• Nursing:
  
  

  • Wash area within 10 mins
    
    

  • Use barrier creams
    
    

  • Apply corticosteroids for inflammation
    
    

  • Teach to avoid trigger (e.g., nickel, poison ivy)
    
    

1. ERYTHEMA MULTIFORME

• Uncommon in kids; acute, self-limiting hypersensitivity reaction.
  
  

• Causes: Viral infections (adenovirus, EBV, Mycoplasma), drugs (penicillin, sulfa, barbiturates).
  
  

• Lesion Progression: Erythematous macules → papules → plaques → target lesions (over days).
  
  

• Nursing Management:
  
  

  • Discontinue drug/food if cause.
    
    

  • Encourage oral hydration.
    
    

  • Use oral antihistamines, analgesics.
    
    

  • If lesions painful, may use mouthwashes or topical anesthetics.
    
    

2. STEVENS-JOHNSON SYNDROME / TOXIC EPIDERMAL NECROLYSIS

 (Box 45.1)

• Early signs: Fever, flu-like symptoms for 1–3 days before rash.
  
  

• SJS: Skin detachment <10%.
  
  

• TEN: Skin detachment >30%.
  
  

• Mortality: ~10% (SJS), ~30% (TEN).
  
  

• Requires: ICU admission, fluid & electrolyte monitoring, ophthalmology if eye involvement.
  
  

3. URTICARIA

• Cause: Type I hypersensitivity (foods, drugs, animals, infection, heat, cold).
  
  

• Onset: Minutes to hours.
  
  

• Resolution: May take up to 6 weeks.
  
  

• Signs: Pruritic, blanching hives; angioedema; may migrate.
  
  

• Management:
  
  

  • Antihistamines, corticosteroids, topical antipruritics.
    
    

  • Severe cases: Subcutaneous epinephrine + IV diphenhydramine and corticosteroids.
    
    

  • Medical alert bracelet recommended.
    
    

4. SEBORRHEA

• Infants: Scalp (cradle cap), behind ears, eyebrows, diaper area.
  
  

• Adolescents: Dandruff, behind ears/scapulae.
  
  

• Treatment:
  
  

  • Wash with mild shampoo.
    
    

  • Apply mineral oil, wait 15 mins, then gently scrub with soft brush.
    
    

  • Use selenium sulfide or ketoconazole shampoo if prescribed.
    
    

5. PSORIASIS

• Autoimmune; hyperproliferation of epidermis.
  
  

• Lesions: Silvery plaques on elbows, scalp, genitalia, knees, buttocks.
  
  

• Therapeutic Management:
  
  

  • Hydration, topical corticosteroids, tar preparations.
    
    

  • UV light therapy may help.
    
    

  • Avoid scratching—use mineral oil + warm towels to soften plaques.
    
    

6. ACNE

Acne Neonatorum

• Appears at 2–4 weeks old; due to maternal androgens.
  
  

• No fever.
  
  

• No treatment needed unless risk of scarring.
  
  

• Teach: Wash gently daily; avoid scented soaps.
  
  

Acne Vulgaris

• Affects 85% of adolescents; begins age 7–10.
  
  

• Caused by androgens, steroids, lithium, phenytoin, isoniazid.
  
  

• Patho: Follicle wall ruptures → inflammation → P. acnes growth.
  
  

• Assessment:
  
  

  • Inspect face, back, chest.
    
    

  • Document lesions, medications, endocrine disorders.
    
    

• Management:
  
  

  • Wash face twice daily with gentle cleanser.
    
    

  • Use topical benzoyl peroxide, salicylic acid, retinoids, antibiotics.
    
    

  • Oral isotretinoin:
    
    

    • Takes 4–6 weeks for results.
      
      

    • Avoid picking.
      
      

    • iPLEDGE required.
      
      

    • Girls must use 2 forms of contraception.
      
      

7. PRESSURE ULCERS

• Most common: Occiput and toes in hospitalized kids.
  
  

• For wheelchair users: Sacral and hip areas.
  
  

• Assessment:
  
  

  • Use wound scale, photo if possible.
    
    

  • Check for erythema, warmth, breakdown.
    
    

• Management:
  
  

  • Turn child every shift.
    
    

  • Use pressure-relieving beds/mattresses.
    
    

  • Maintain nutrition.
    
    

8. MINOR INJURIES

• Cuts, scrapes, abrasions, glass, splinters.
  
  

• Management:
  
  

  • Wash with soap + water, use antibacterial cleanser.
    
    

  • Flush foreign debris, then dress wound.
    
    

  • Change dressing after 23 hrs if left open.
    
    

  • Monitor for warmth, redness, purulent drainage.
    
    

9. BURNS

Classifications

:

• Superficial (1st): Red, dry, painful.
  
  

• Partial-Thickness (2nd): Red, blistered, very painful (Fig 45.20).
  
  

• Full-Thickness (3rd/4th): White/charred, dry, minimal pain (Fig 45.21).
  
  

Time-Based Fluid Shifts

:

• Peak edema: 8–18 hours post-burn.
  
  

• Returns to normal: 48–72 hours.
  
  

Thermal Injury (Box 45.4 Emergency Burn Survey)

:

• Airway assessment: Carbonaceous sputum, hoarseness = smoke inhalation.
  
  

• Primary Survey: ABCs, vitals, breathing, LOC.
  
  

• Secondary Survey: %TBSA (use Fig. 45.22)
  
  

Signs of Abuse (Box 45.3)

:

• Stocking/glove pattern
  
  

• Symmetrical scalding
  
  

• Delay in seeking care
  
  

• Lack of splash marks
  
  

Burn Care: VERY Specific!

Infection Prevention

• If no tetanus vaccine in last 5 years → give tetanus toxoid.
  
  

• 250 units tetanus immune globulin IV if never vaccinated.
  
  

• Use antibiotic ointments.
  
  

• Dressings: biosynthetic, hydrocolloid, silver sulfadiazine
  
  

Pain Control

• Codeine + Tylenol for mild
  
  

• Sedatives, systemic analgesics for severe
  
  

• Pain control critical during dressing changes
  
  

Wound Cleaning

• Remove charred clothing
  
  

• Wash with cool (NOT cold) water + mild soap
  
  

• Avoid ice
  
  

• Use mineral oil to lift crusts
  
  

• Use sterile scissors or gauze for debridement
  
  

• Soak dressings in lukewarm water for easier removal
  
  

Hypothermia Prevention

• Keep child warm
  
  

• Use warmed IV fluids
  
  

• Monitor temperature often
  
  

Fluid Resuscitation

• Use TBSA chart (Fig 45.22) + weight
  
  

• Use Ringer’s Lactate for 1st 24 hrs
  
  

• Add dextrose for infants
  
  

• Maintain UO > 1 mL/kg/hr
  
  

BURN PREVENTION (Teaching Guidelines 45.3)

• Keep hot water heater <120°F
  
  

• Test bath water before use
  
  

• Keep children away from open flames, stoves, candles
  
  

• Turn pot handles inward
  
  

• Place hot liquids out of child’s reach
  
  

• Avoid drinking hot drinks while holding child
  
  

• Teach:
  
  

  • “Stop, drop, and roll”
    
    

  • How to escape fire
    
    

  • Practice fire drills
    
    

SCALD RISK – HOT WATER TIME/TEMP (Fig. 45.25)

• 150°F: 2 seconds = 3rd-degree burn
  
  

• 140°F: 6 seconds = significant burn
  
  

• 130°F: 30 seconds = burn
  
  

• 120°F: Recommended max for home water heater
  
  

BURN CARE AT HOME (Teaching Guidelines 45.4)

First-Degree (Superficial) Burns

• Run cool water until pain lessens
  
  

• Do NOT apply ice
  
  

• Do NOT apply butter/ointment
  
  

• Cover lightly with clean non-stick bandage
  
  

• Give Tylenol or ibuprofen
  
  

• See HCP within 24 hours
  
  

• Clean daily with fragrance-free soap; pat dry
  
  

• Apply thin antibiotic ointment
  
  

• Dress with Adaptic or dry gauze
  
  

More Extensive Burns

• Remove clothing ONLY if loose
  
  

• Check ABCs, initiate CPR if needed
  
  

• Call 911 if:
  
  

  • Shock signs
    
    

  • Severe pain
    
    

  • Burn on face, joints, genitals, hands/feet
    
    

TREATING INFECTED BURNS

• Infection = swelling, pain, dark brown/purple color, foul odor
  
  

• Burn impetigo = bullous lesions, rapidly spreads
  
  

• Start IV antibiotics, culture wounds
  
  

SPECIAL BURN CARE & SKIN GRAFTING (Box 45.5)

• Biobrane = silicone film with collagen
  
  

• Biosynthetic dressings = reduce infection
  
  

• Mepilex Ag = silver foam
  
  

• Autograft = child’s own skin
  
  

• Split-thickness = epidermis + dermis
  
  

• Full-thickness = all dermis removed
  
  

• Cover with non-stick gauze or synthetic to allow healing
  
  

REHAB AND SCARRING

• Most common issue = anxiety, attention/behavior issues
  
  

• Skin grafts often needed
  
  

• Pressure garments:
  
  

  • Worn 1–2 years
    
    

  • Prevent hypertrophic scarring
    
    

• School reintegration and group therapy important for altered body image
  
  

INSECT STINGS & SPIDER BITES

Symptoms

:

• Pruritus, pain, swelling
  
  

• May have IgE-mediated allergic response
  
  

Nursing Management

:

• Remove constricting jewelry/clothing
  
  

• Cleanse, scrape stinger
  
  

• Apply ice intermittently
  
  

• Give diphenhydramine and corticosteroids
  
  

• Teach insect prevention:
  
  

  • DEET <30% (not for babies <2mo)
    
    

  • Don’t disturb nests
    
    

COLD INJURY – FROSTBITE

• Skin temp drops below 32°F
  
  

• First° = red, numb
  
  

• Second° = blisters + erythema
  
  

• Third° = hemorrhagic blisters
  
  

• Fourth° = necrosis/sloughing
  
  

Treatment

:

• Rewarm in 104°F water for 15–30 minutes
  
  

• Administer pain meds
  
  

• Wrap in loose gauze
  
  

• Avoid vigorous massage
  
  

• Prevent: Dress in layers, keep warm/dry, avoid wind
  
  

HUMAN & ANIMAL BITES

• Most common: dog bites
  
  

• Treat: Irrigation, wound closure, abx (oral/systemic)
  
  

• If unknown rabies status, give prophylaxis
  
  

• Secondary infection organisms: Strep, Staph, Pasteurella
  
  

SUNBURN

• Occurs after UV exposure
  
  

• Erythema in <4 hrs, blisters in <6 hrs
  
  

• Treat with:
  
  

  • Cool compresses
    
    

  • Cooling lotions
    
    

  • NSAIDs
    
    

KEY CONCEPTS (From Final Page)

• Infant’s skin: thinner, loses heat, absorbs faster
  
  

• Moisturize skin: key in eczema, psoriasis
  
  

• Burns = significant pain + fluid loss
  
  

• Atopic dermatitis = itch–rash–itch cycle affects self-esteem
  
  

• Teach children to avoid scratching, sun exposure, irritants
  
  

• Teach parents about soap-and-water cleansing for injuries