Integumentary & Infectious Disorders in Children (Exam Notes)

Chapters covered: 33 (pg 887-896), 50 (pg 1526-1529, 1536-1537)
Copyright © 2023 by Elsevier Inc. All rights reserved.

Primary Prevention of Disease

• Immunization: Essential for preventing outbreaks of infectious diseases, immunizations should be updated according to CDC recommendations to ensure high levels of community immunity. Vaccines have been instrumental in reducing the incidence of many infectious diseases and contribute to the overall health of the population.

• Controlling Spread of Disease:

  • Reducing risk of cross-transmission of organisms through measures such as social distancing, use of personal protective equipment (PPE), and quarantine when necessary.

  • Implementing infection control policies in schools and child care settings to minimize risk of outbreaks.

  • Importance of hand hygiene: Regular hand washing with soap and water for at least 20 seconds, or the use of alcohol-based hand sanitizers when soap is unavailable, is critical in preventing the spread of infections among children.

Certain Groups at Risk for Serious Complications

• Immunodeficiency: Individuals with weakened immune systems, whether due to congenital factors, chronic diseases, or medication-induced compromise, are at higher risk for severe infections.

• Generalized Malignancies: Children undergoing treatment for cancer, especially those receiving chemotherapy or radiation, have weakened immune systems and are particularly vulnerable to infections.

• Immunologic Disorders: Conditions such as systemic lupus erythematosus or autoimmune disorders can impact immune responses and increase susceptibility to infections.

• Infants Younger than 1 Year: This age group is at heightened risk for infections due to immature immune systems and lack of prior exposure to pathogens. Vaccination schedules are crucial during this time.

• Hemolytic Disease: Increased risk for complications in specific disorders, such as sickle cell disease or other hemoglobinopathies, where infections can lead to significant morbidity and mortality.

Communicable Diseases of Childhood

Key Diseases

• Chickenpox (varicella)

• Diphtheria

• Fifth disease (Erythema infectiosum)

• Roseola infantum (Exanthem Subitum)

• Mumps

• Measles (rubeola)

• Pertussis (whooping cough)

• Poliomyelitis

• Rubella (German measles)

• Scarlet fever

Chickenpox (Varicella)

• Agent: Caused by the varicella-zoster virus (VZV), a member of the herpes virus family.

• Spread: Primarily through direct contact with rash lesions, respiratory droplets from coughing or sneezing, airborne, and contact with contaminated objects.

• Incubation Period: 2 to 3 weeks (usually between 14 to 16 days).

• Communicability: Highly contagious; can be transmitted from 1-2 days before the onset of the rash until all lesions have crusted over.

  • 1 to 2 days before lesions appear until all lesions have formed crusts

• Clinical Manifestations:

  • Prodromal stage: Symptoms include low-grade fever, fatigue, loss of appetite, and headache, which may last 1-2 days.

  • Characteristic pruritic rash: Progresses from macule to papule to vesicle to crusting; rash typically starts on the trunk and then spreads to the face and extremities.

  • distribution: starts in the center of the trunk, spreads to the face, and proximal extremities

  • Duration: About 1 week for all lesions to crust.

• Complications: Include pneumonia, bleeding disorders, bacterial superinfection of skin lesions, and encephalitis.

• Management:

  • Antiviral agents such as Acyclovir are recommended for high-risk patients.

  • Antihistamines may help relieve itching.

    • diphenhydramine hydrochloride (benadryl)

  • NSAID to reduce fever

  • Proper skin care to prevent secondary bacterial infections is crucial.

  • Vaccination recommendations include the varicella vaccine at age 12-15 months, with a booster between 4-6 years.

  • maintain isolation precautions

  • keep child away from high-risk ppl until vesicles have dried (usually 1 wk from onset)

  • keep cool and administer topical calamine lotion as needed

  • teach to apply pressure instead of scratching

  • keep nails clean and short, and apply mittens if the child scratches

  • change linens daily

Diphtheria

• Agent: Caused by the bacterium Corynebacterium diphtheriae.

• Spread: Transmitted through direct contact with a person-to-person via respiratory droplets.

• Incubation Period: Typically 2 to 5 days.

• Clinical Manifestations: Symptoms vary based on the infection site:

  • Nasal diphtheria resembles the common cold with nasal discharge.

  • Tonsillar-pharyngeal involves a sore throat, low-grade fever, tachycardia, loss of appetite, lymphadenitis (bulls neck), and the formation of a characteristic grayish-white membrane in the throat. In severe cases, death within 6-10 days

  • Laryngeal diphtheria presents with fever, hoarseness, and stridor, posing a risk for airway obstruction.

• Complications: Serious complications include myocardial damage (cardiomyopathy between 2 to 3 wks), peripheral neuropathy, and airway obstruction due to swelling.

• Therapeutic Management:

  • Administration of equine antitoxin is indicated

  • antibiotics such as Penicillin G or Erythromycin to eradicate the bacteria.

  • Complete bed rest to prevent myocarditis

  • Tracheostomy for airway obstruction

  • treat exposed contacts

  • follow isolation precautions until negative for C. Diphtheriae

    • 2 negative cultures and use contact precautions

  • suctioning & humidified oxygen as needed

Fifth Disease (Erythema infectiosum)

• Agent: Caused by Parvovirus B19.

• Spread: Primarily through respiratory droplets and blood.

• Incubation: 4 to 14 days, up to 21 days

• Communicability: onset of manifestations before rash appears

• Clinical Manifestations:

  • stage 1: erythema on face, chiefly on cheeks (slapped face appearance); disappears by 1-4 days

  • stage 2: about 1 day after rash appears on face, maculopapular red spots appear, symmetrically distributed on upper and lower extremities; rash progresses from proximal to distal surfaces and may last > 1 week

  • stage 3- rash subsides but reappears if skin is irritated or traumatized (sun, heat, cold, friction)

  • secondary itchy rash that can appear on the rest of the body, especially on the soles of the feet

  • Complications:

    • self-limited arthritis and arthralgia (arthritis may become chronic); more common in adult women

    • may result in serious complications (anemia, hydrops) or fetal death if the mother is infected during pregnancy (primarily 2nd trimester)

    • Children with immunodeficient or chronic red blood cell disorders (such as sickle cell anemia) may develop severe anemia with the 5th disease

    • myocarditis (rare)

  • Nursing care management

    • isolation is not necessary

Roseola Infantum (Exanthem Subitum)

• Agent: Caused by Human Herpesvirus type 6/7.

• Spread: Transmitted via the saliva of a healthy adult person, entry via nasal, buccal, or conjunctival mucosa. In most cases, have no contact with an infected person. limited to children < 3 yrs with peak at 6 to 15 months

• incubation: 5 to 15 days

• communicability: unknown

• complications: recurrent febrile seizures & encephalitis

• Clinical Manifestations:

  • High fever (sometimes > 104°F),

  • followed by a rash after the fever resolves. The rash is typically less pruritic and lasts 1-2 days.

  • bulging fontanel

• Therapeutic management

  • nonspecific, antipyretics

• Management:

  • standard precations

  • Education on fever control (antipyretic)

  • seizure precautions ifthe child is prone to having

Mumps

• Agent: Caused by the Paramyxovirus.

• Spread: Primarily through direct contact and respiratory droplets.

• Incubation Period: Ranges from 14 to 21 days.

• communicability: immediately before and after swelling begins

• Clinical Manifestations:

  • painful, swollen parotid glands

  • fever & muscle aches

  • headaches

  • earache made worse by chewing

  • fatigue & loss of appetite

  • Complications: Serious complications may include orchitis, deafness, encephalitis, oophoritis, mastitis, myocarditis, arthritis, hepatitis, and viral meningitis.

• Management:

  • therapeutic management

    • Symptomatic & supportive: analgesics for pain and antipyretics for fever

    • IV fluids if needed for child who refuses to drink or vomits because of meningoencephalitis

  • Maintain isolation during the communicability period

  • Encourage rest and decreased activity

  • Analgesica for pain; if the child is unwilling to swallow pills or tablet med use the elixir form

  • to relieve orchitis, provide hot or cold packs for analgesia, and scrotal elevation

  • Encourage fluids and bland foods

  • hot or cold compresses to the neck

Measles (Rubeola)

• Agent: Caused by the Rubeola virus.

• Spread: Highly contagious, spread through contact and respiratory droplets.

• incubation: 10 to 20 days

• Clinical Manifestations:

  • 3 to 4 days before rash

    • mild to moderate fever, conjunctivitis, fatigue, cough, runny nose, red eyes, & sore throat

  • Rash

    • Koplik spots (tiny white spots) appear in the mouth 2 days before the rash, red or reddish- brown rash beginning on the face spreading downward, spike in fever with rash

• Complications: Common complications include ear infections, pneumonia, encephalitis, death, and laryngitis

• Therapeutic Management:

  • supportive; bed rest and antipyretics, childhood immunization

    • antibiotics to prevent secondary infections in high-risk children, and vitamin A (dose based on age)

  • isolation until 5th day of rash

  • encourage rest and fever control, along with seizure precautions if at risk for seizures

  • eye care- dim light if photophobia present; clean eyelids with warm saline solution to remove secretions or crusts

  • cough control with a cool mist vaporizer

Pertussis (Whooping Cough)

• Agent: Caused by Bordetella pertussis.

• Spread: Transmitted via contact and respiratory droplets. Indirect contact with freshly contaminated articles

• incubation: 7 to 10 days

• communicability: greatest during the catarrhal stage before the onset of the paroxysmal stage

• Clinical Manifestations:

  • common cold manifestations: runny nose/ congestion, sneezing, mild fever, mild cough

  • severe coughing starts in 1 to 2 wks: coughing fits, violent & rapid coughing, loud “whooping” sound upon inspiration

• Complications: Serious complications can include pneumonia, seizures, apnea, encephalopathy, death, ear infections (otitis media), hemorrhage, weight loss and hernia

  • teens and adults: weight loss, loss of bladder control, syncope, rib fractures, pneumonia

• Management:

  • maintain isolation during the catarrhal stage; if the child is hospitalized, standard and droplet (standard and droplet precautions)

  • antibiotic therapy: (erythromycin, clarithromycin, azithromycin)

  • supportive care:

    • hospitalization is sometimes required for infants who are dehydrated, increased O2 intake, and humidity, adequate fluids

  • Encourage adolescents to obtain Tdap

  • nasopharyngeal culture for diagnosis

Rubella (German Measles)

• Agent: Caused by the Rubella virus.

• Spread: Transmitted through contact and respiratory droplets.

• incubation: 14 to 21 days

• communicability: 7 days before to 5 days after the rash appears

• Clinical Manifestations:

  • low-grade fever and sore throat

  • headache

  • malaise

  • cough

  • lymphadenopathy

  • red rash that starts on the face and spreads to the rest of the body, lasting 2 to 3 days

• Complications:

  • generally are. can cause birth defects in the fetus of infected women during pregnancy.

• therapeutic management

  • no treatment needed other than antipretics and analgesics

• nursing care management

  • maintain droplet isolation

  • reassure parents of the benign nature of illness

  • comfort measures

  • avoid contact with preg woman

  • monitor rubella titler in preg adolescents

Scarlet Fever

• Agent: Caused by Group A beta-hemolytic streptococci (S. pyogenes).

• Spread: Transmitted via direct contact, droplet, and ingestion of contaminated food (milk)

• incubation: 2 to 5 days with a range of 1 to 7 days

• communicability: incubation period& clinical illness approximately 10 days: during 1st 2 wks of the carrier phase but may persist months.

• Clinical Manifestations:

  • prodromal stages: abrupt high fever; tachycardia; vomiting; headache; halitosis; abdominal pain

  • enanthema: enlarged tonsilis; edematous , reddended, and covered with patches of exudates; pharynx edematous and beefy red: during day 1 and 2 tongue coated and papillaebecomes red & swollen (white strawberry tongue), by 4th or 5th day white coat sloughs off leaving prominent papilae (red strawberry tongue)

  • exanthema: rash appears within 12 hrs after prodromal signs; red pin-head-sized punctate lesions become generalized but absent from face; face flushed with circumoral pallor; rash more prominent on a fold of joints.

  • end of 1st wk, desquamation begins and is typically complete by wk 3.

• Complications:

  • peritonsillar & retropharyngeal abscess, otitis media, acute glomerulonephritis, acute RF,

• Management:

  • standard and droplet precautions until 24 h after initiation of treatment

  • ensure compliance with oral antibiotics therapy (IM benzathine Penicillin G )

  • rest during febrile phase, analgesis for sore throat; antipruritics for rash if bothersome

  • encourage fluids during the febrile phase; avoid irritating liquids (citrus juices) or rough foods (chips); when child can eat, begin with a soft diet

  • Discard the toothbrush; avoid sharing drinking and eating utensils

Bacterial Infections of the Skin

• identify etiological agents or agents

• issues with the development of different strains that are resistant to antibiotic therapies

• prompt treatment with effective therapies

• using health promotion behaviors to prevent the spread of infection

• compliance with established therapies

• prevent complications

Skin Infections Overview

Types:

• Viral Infections:

  • leads to inflammation or proliferation

  • many communicable diseases present with a characteristic rash

  • Prevention of transmission

  • isolation procedures

  • antiviral meds

• Fungal Infections:

  • identified dermatophytoses

  • can present in various locations of the body, can be localized and/or systemic

  • Prevention of transmission

  • hygiene procedures

    • should not exchange grooming items, headgear, scarves, or other articles of apparel that have been affected, and provide their own towel.

  • antifungal meds (terbinafine, itraconazole, and fluconazole)

Contact Dermatitis

• Description: An inflammatory reaction of the skin to chemical substances, natural, or synthetic materials that evoke a hypersensitivity response or direct irritation

• clinical manifestations

  • sharp demarcation between inflamed and normal skin on an erythematous base.

  • persistent pruritus

• Management:

  • primary goal is to prevent further exposure of the skin to the offending agent

    • most commonly plants, animals, metal irritants, convex surfaces of diaper area, vegetable irritants, synthetic fabrics and dyes, cosmetics, perfumes, and soaps

  • Pruritus: most common complaint with skin lesions

  • cooling baths or compresses

  • prevent scratching

    • mittens/covering for young kids

    • short nails

    • antipruritic meds

      • Diphenhydramine hydrochloride and hydroxyzine are most commonly used

Scabies

• Description: endemic infection by the scabies mite

• Clinical manifestations: maculopapular lesions distributed in intertriginous areas. Monitor for discrete papules, burrows or vesicles

• high degree of transmission through prolonged close personal contact

• Management:

  • anyone in close contact with the child needs treatment

  • treat with a scabicide

    • permethrin 5% (elemite) when older than 2 months

    • 10% crotamiton (cream or lotion or oral ivermectin

  • Avoid the use of lindane

    • Danger of neurotoxicity

Pediculosis Capitis (Head Lice)

• infestation that can occur in multiple areas of the body, common in school-age kids

• high degree of transmission

  • eggs hatch in 7 to 10 days

  • white eggs are nits

• treatment

  • permethrin 1% cream (nix)

  • pyrethrin (rid)

  • Remove nit cases

• prevent the spread of lice

  • continued inspection

  • isolation of self-care products for the individual

  • machine wash hot water and dryer for involved contact products (sheets, pillowcases, and blankets)

  • removal of non-washable items or sealing in a plastic bag for at least 14 days

  • follow through with med therapy

  • family education