Health Problems of Middle Childhood

Skin of Younger Children

The major skin layers arise from different embryologic origins. Early in the embryonic period, a single layer of epithelium forms from the ectoderm, while simultaneously the corium develops from the mesenchyme. In the infant and small child the epidermis is still loosely bound to the dermis, partly because the rete pegs are flat. This poor adherence causes the layers to separate readily and form blisters during an inflammatory process. This is especially true in preterm infants, who have an even greater propensity to blister formation and separation during careless handling (such as removal of adhesive tape). The skin is thinner than in older children, and the cells of all strata are more compressed.

Several characteristics influence skin responses in infants and young children. Their skin is far more susceptible to superficial bacterial infection compared with older children and adults. They are more likely to have associated systemic symptoms with some infections and are more apt to react to a primary irritant than to a sensitizing allergen. Infants and young children are more frequently affected by chronic atopic dermatitis (eczema). The infant’s skin is much more prone to develop a toxic erythema as a result of skin eruptions or drug reactions and is subject to maceration, infection, and the moisture retention associated with diaper rash.

Pathophysiology of Dermatitis

More than half of dermatologic problems are various forms of dermatitis. This implies a sequence of inflammatory changes in the skin that are grossly and microscopically similar but diverse in course and causation. Acute responses produce intercellular and intracellular edema, the formation of intradermal vesicles, and an initial minimum infiltration of inflammatory cells into the epidermis. In the dermis there is edema, vascular dilation, and early perivascular cellular infiltration. The location and manner of these reactions produce the lesions characteristic of each disorder. The changes are reversible, and the skin ordinarily recovers without blemish and completely intact unless complicating factors such as ulceration from the primary irritant, scratching, and infection are introduced or underlying vascular disease develops. In chronic conditions permanent effects are seen that vary according to the disorder, the general condition of the affected individual, and available therapy.

Clinical Manifestations and Diagnostic Evaluation

The following discussion first explores the history and symptoms, but also notes some objective findings simultaneously. One of the more advantageous aspects of skin lesions is that often the diagnosis is readily established after simple, careful inspection.

Abrasion—Removal of the superficial layers of skin by rubbing or scraping

Avulsion—Forcible pulling out or extraction of tissue

Laceration—Torn or jagged wound; accidental cut wound

Incision—Division of the skin made with a sharp object; cut

Penetrating wound—Disruption of the skin surface that extends into underlying tissue or into a body cavity

Puncture—Wound with a relatively small opening compared with the depth

Process of Wound Healing

Factors That Influence Healing

During the past two decades, understanding of wound healing has revolutionized the interventions used to promote healing. Emphasis has shifted from interventions directed at maintaining a dry environment that promotes eschar formation to those that promote a moist, crust-free environment that enhances the migration of epithelial cells across the wound and facilitates resurfacing. An acute full-thickness wound kept in a moist environment usually reepithelializes in 12 to 15 days, whereas the same wound kept open to the air heals in approximately 25 to 30 days (see Fig. 18-1).

Eschar (thick, fibrin-containing necrotic tissue) also interferes with healing by preventing wound contraction. In most situations it is best to remove eschar and other dead tissue from the wound. Repeated application of occlusive dressings mobilizes the body’s own enzymes to lyse the eschar, a process known as autolysis.

Adequate nutrition is essential for wound healing. In particular, sufficient protein, calories, vitamin C, and zinc are needed for healing of extensive wounds, such as burns. Supplemental nutrition is an integral aspect of treatment of severe wounds.

Numerous factors delay healing (Table 18-1). Some traditional practices are ineffective or even harmful; for example, antiseptics that were once used to help prevent infections (hydrogen peroxide and povidone-iodine [Betadine] solutions) are now known to have cytotoxic effects on healthy cells and minimal effect on controlling infections. Povidone-iodine may be absorbed through the skin in neonates and young children and must be used with caution in patients with thyroid or renal disease.

Dressings

No one dressing meets the needs of all wounds. The traditional dry gauze dressing should not be used on open wounds, since it allows the wound surface to dry, does little to prevent bacterial invasion, and adheres to the dried scab so that removal disturbs the newly regenerating epithelial cells. In most instances, traditional gauze dressings have been replaced by moist wound healing dressings. Moist wound healing increases the rate of collagen synthesis and reepithelialization and decreases pain and inflammation. It also creates an environment for autolytic débridement of necrotic tissue, which creates a clean wound bed and enhances granulation. However, a balance must be achieved between creating a moist wound bed and maintaining a dry periwound area that protects the skin and wound from maceration. The dressing type and frequency of dressing changes help to achieve this balance. The frequency of dressing changes depends on the presence or absence of infection, the type of dressing, the location of the wound, and the amount of drainage. Dressings should always be changed when they are loose or soiled. They should be changed more frequently in areas where contamination is likely (e.g., the sacral area, the buttocks, the tracheal area) or when wound infection is suspected or confirmed.

Dressings serve the following functions: (1) provide a moist healing environment, (2) protect the wound from infection and trauma, (3) provide compression in the event of anticipated bleeding or swelling, (4) apply medication, (5) absorb drainage, (6) débride necrotic tissue, (7) reduce pain, and (8) control odor. To ensure a moist environment, cover wounds with an occlusive ointment or dressing (Table 18-2).

Occlusive dressings can be classified according to their degree of permeability. The term occlusive is synonymous with impermeable, semiocclusive is synonymous with semipermeable, and nonocclusive is synonymous with permeable. No one dressing meets the needs of all types of wounds. The traditional gauze dressing is a permeable dressing that reduces the moisture content in a wound by absorbing exudate and allowing it to evaporate. Traditional gauze dressings should not be used on open wounds because they allow wounds to dehydrate, are permeable to bacteria, increase the probability of wound sepsis, and adhere to the wound when removed, which causes additional trauma to newly regenerating epithelial cells. In many situations traditional gauze dressings have been replaced by new “active occlusive” dressings, which allow for moist wound healing. The use of silver in wound care has reemerged. Silver is impregnated in various dressing vehicles such as foam, hydrocolloid dressings, and wound gels. Several studies suggest that silver decreases the bacteria and bioburden in the wound, which allows optimal wound conditions for granulation and healing (Ovington, 2004). Since the absorption of these products in infants and children is unknown, use caution when applying these dressings in the pediatric population.

Topical Therapy

A variety of agents and methods are available for treatment of dermatologic problems. In selecting a therapeutic program, the practitioner considers (1) the active ingredient of the agent, (2) the vehicle or base, (3) the cosmetic effect, (4) the cost, and (5) instructions for the agent’s use. In addition, keep several basic concepts in mind. Avoid overtreatment. For example, when the dermatitis is acute, topical applications should be mild and bland to avoid further irritation. Broken or inflamed skin, especially in children, is more absorbent than intact skin, and chemicals that are nonirritating to intact skin may be quite irritating to inflamed skin.

Topical applications may be used to treat the disorder, reduce the itching associated with many diseases, decrease external stimuli, or provide external heat or cold. The emollient action of soaks, baths, and lotions provides a soothing film over the skin surface that reduces external stimuli. Ordinarily, tepid or cool applications offer the greatest relief.

Systemic Therapy

Systemic therapeutic agents are often used as an adjunct to topical therapy in dermatologic disorders, and those most frequently used therapeutically are the corticosteroids and the antibiotics. The corticosteroid hormones, with their capacity to inhibit inflammatory and allergic reactions, are valuable in the treatment of severe skin disorders. Dosage is carefully adjusted and gradually tapered to the minimum that is effective and tolerated. In infants and children, the dosage is larger than is usually calculated from body weight ratios. However, prolonged use may temporarily suppress growth.

Antibiotics, which interfere with the growth of microorganisms, are used in cases of severe or widespread skin infection. However, because they tend to produce a hypersensitivity in the patient, they are used with caution. Antifungal agents are the only means for treating systemic fungal infections.

Wound Care

Parents can generally manage small wounds to the skin at home. Instruct parents to wash their hands and then wash the wound gently with mild soap and water, or normal saline Caution them to avoid povidone-iodine, alcohol, and hydrogen peroxide because these products are toxic to wounds. To prevent possible tattooing, an abrasion from which the dirt cannot be removed requires wound cleaning with the patient receiving topical anesthesia. Wounds covering a very large area (>15% of the body) need medical attention with the child undergoing conscious sedation and analgesia. (See Chapter 7.) Open wounds are covered with a dressing, such as a commercial adhesive bandage, although larger wounds may benefit from the use of occlusive dressings (see Table 18-2). If occlusive dressings are applied, instruct the parents on their correct application and removal. For example, hydrocolloid dressings adhere best if a wide margin is left around the wound and the dressing is pressed against intact skin until it adheres. The edges of the dressing can be secured to the skin with waterproof tape. The dressings are removed if leakage occurs or after a specific time interval, usually 7 days.

Evidence-Based Practice—Wound Care

Dressings are removed carefully to protect intact skin and the epithelial surface of the wound from damage. To remove transparent or hydrocolloid dressings, raise one edge of the dressing and pull parallel to the skin to loosen the adhesive. The longer the dressings are left on, the easier they are to remove. Use of a nonalcohol skin barrier protects the skin from epidermal stripping on tape removal. Or the wound may be “picture-framed” with strips of a skin barrier dressing (DuoDERM, Coloplast) on the skin and the adhesive tape secured to the skin barrier. This technique protects the underlying skin with dressing changes. If a dressing sticks to the wound base when it is being removed, saturate the dressing with normal saline, water, or wound cleanser to loosen it.

Lacerations present a special challenge. The injured child and family are usually distressed by the bleeding and are in variable degrees of shock. Parental guilt usually accompanies the injury. Because scalp lacerations bleed so profusely, they are especially frightening. The initial nursing intervention is to apply pressure to the area and attempt to calm the child before further examination. Unless there is bleeding from a severed artery, the wound can be cleansed with a forced jet of sterile tepid water or saline (via syringe) and examined for extent; depth; and foreign material such as dirt, glass, or fabric fragments.

The location of the wound also dictates assessment. For example, wounds over bony areas may contain bone chips, and clear fluid seeping from severe head wounds may indicate cerebrospinal fluid leakage. Apply a pressure dressing for transfer to medical care; prepare the child in a medical facility for suturing. Soak puncture wounds that do not require a tetanus booster in warm water and soap for several minutes. Causing the wound to rebleed may be helpful. Apply an adhesive bandage if desired. Puncture wounds of the head, chest, or abdomen or those that could still contain a portion of the puncturing object must be evaluated.

Caution parents against opening blisters or kissing a wound “to make it better.” The wound can easily become contaminated from germs in the human mouth. If scabs form, they are allowed to slough off without assistance; picking or early removal may cause scarring. Advise parents to seek medical help if there is evidence of infection.

Relief of Symptoms

Most of the therapeutic regimens are directed toward relief of pruritus, the most common subjective complaint. Itching is believed to often result from stimulation of C fibers at the dermoepidermal junction. These fibers are similar to but distinct from pain fibers. Substances released within the skin, histamine and endopeptidases, also elicit itching, although their release triggers are unknown (Barnett, 2001).

Cooling the affected area and increasing the skin pH with measures such as cool baths or compresses to reduce external stimuli to the area, as well as alkaline applications such as baking soda baths to increase skin pH, help to prevent scratching. Clothing and bed linen should be soft and lightweight to decrease the irritation from friction and stimulation.

During any type of treatment, both affected and unaffected skin is protected from damage and secondary infection. Preventing scratching is of primary importance. Older children usually cooperate, although they may need to be reminded to stop scratching or rubbing. In smaller and uncooperative children, techniques and devices such as mittens (especially during sleep) or special coverings are required. Keeping fingernails short, well trimmed, and clean helps reduce the chance of secondary infection.

Antipruritic medications, such as diphenhydramine (Benadryl) or hydroxyzine (Atarax), may be prescribed for severe itching, especially if it disturbs the child’s rest. Pain and discomfort are usually managed with nonpharmacologic measures and mild analgesia. Severe pain requires more potent medication. Occlusive dressings over wounds reduce pain. For suturing wounds a topical anesthetic, tissue adhesive, or intradermal buffered lidocaine can be used. Pain medications should be given before dressing changes and cleansing, with adequate time allowed for the medicine to take effect. (See Pain Management, Chapter 7.)

Topical therapy usually involves application of some type of topical agent, and the mode of application depends on the nature and location of the lesion being treated. For example, soothing lotions, creams, and intermittent wet dressings or soaks help cool and moisten; ointments, lotions, and creams soften and lubricate dry, scaling areas. Nurses and parents are responsible for the application of topical therapeutic agents.

It is especially important to wash the hands before and after application of topical therapies. Assess the skin before the treatment or application of medication and reassess after the treatment is completed. Note any changes and describe them.

Wet compresses or dressings cool the skin by evaporation, relieve itching and inflammation, and cleanse the area by loosening and removing crusts and debris. Any of a variety of ingredients, such as plain water or Burow solution (available without a prescription), can be applied on Kerlix gauze, plain gauze, or (preferably) soft cotton cloths such as freshly laundered handkerchiefs or strips from cloth diaper, sheeting, or pillowcase material.

Dressings immersed in the desired solution are wrung out slightly and applied to the affected area wet but not dripping. They are applied flat and smooth and in such a way that motion is not totally restricted; fingers are wrapped separately, and arms and legs are wrapped so that elbows and knees can bend. Dressings are kept in place by Kerlix or other cotton wrap, tubular stockinette, mittens, or socks (two pairs—one to hold the dressings in place, the other to take up movement) but are left uncovered. When evaporation begins to dry them, the dressings are removed, rewet in the solution, and reapplied to the area using aseptic technique. The solution is not poured or syringed directly over the dressings. As fluid evaporates, the solution becomes increasingly concentrated and thus stronger, which may damage sensitive lesions.

Fresh solution at room temperature is applied at 2-, 3-, or 4-hour intervals and is allowed to remain on the lesion from 30 to 90 minutes. Wet dressings are seldom continued after about 48 hours. The child must be guarded against chilling during treatment, and no more than 20% of the body should be covered at one time to avoid the risk of hypothermia. After treatment, the skin is dried thoroughly by patting with a towel. Application of lotion or other medication may be ordered at this time.

When children are uncooperative in the use of wet dressings, soaks are often used for removal of crusts and for their mild astringent action. The same solution as for wet compresses is used. Gaining young children’s cooperation for hand or foot soaks is difficult unless the procedure is made attractive to them through play. Older infants and toddlers delight in playing with brightly colored objects or poker chips scattered over the bottom of the receptacle, and preschoolers can be challenged to hold a floating item beneath the water’s surface. These activities require supervision; infants and small children often place items in their mouths, and children can easily lose control with water play. Washing dishes, cars, dolls, or doll clothes will occupy many children for some time.

Although older children are able to cooperate, they need something to do during the procedure, such as listening to music or a story, or watching television or a video. A single extremity (a foot or a hand) can be easily soaked by placing the solution and the extremity in a sealable plastic bag. The closure is then zipped snugly around the limb.

Baths are especially useful in the treatment of widespread dermatitis because they evenly distribute the soothing antipruritic and antiinflammatory solution, usually an oatmeal or mineral oil preparation. The solution is added to a tub of water. The temperature of the bath is tepid, and the treatment usually lasts 15 to 30 minutes. Therapeutic baths are always more interesting when the child has toy boats or other items for water play.

Topical agents are applied to skin lesions to ease discomfort, prevent further injury, and facilitate healing. Most preparations are placed directly on the skin and left uncovered; some may be applied under an occlusive dressing. A thin application of the ointment or cream is covered with plastic film and anchored with adhesive or covered with a commercial transparent dressing. Occlusive dressings promote moisture retention and decrease evaporation of the preparation, which increases the penetration of the medication. Apply topical applications systematically with the contour of the body surface (not simply up and down). Children love to be “painted,” so lotion applications can be fun when an ordinary paintbrush is employed.

Regardless of the type of preparation used, parents need detailed information on how to apply it and how long the preparation should remain on the skin or under an occlusive dressing.

Recombinant growth factors are human platelet–derived growth factors that are engineered outside the body. They foster the formation of new granulation tissue by stimulating the migration of fibroblasts, macrophages, smooth muscle cells, and capillary endothelial cells to the wound site (Beaumont and Anderson-Dam, 1998). Becaplermin (Regranex) is the only recombinant growth factor currently approved by the FDA; however, the safety of this product has not been established for children under 16 years of age.

The vacuum-assisted closure (VAC) device uses a subatmospheric technique that involves placing an open-cell foam dressing into the wound, covering with an occlusive dressing, and applying suction. The negative force of the suction is applied from the foam dressing to the wound surfaces. The mechanical force removes excess fluids from the wound, stimulates formation of granulation tissue, restores capillary flow, and fosters closure of the wound (Patel, Kinsey, Koperski-Moen, et al, 2000). VAC has been used to prepare wounds for a skin graft and to treat surgical wounds, burns, and pressure ulcers (Kinetic Concepts, 2003). Recently, VAC therapy has been used in pediatrics. Despite case reports indicating this therapy is beneficial in infants and children, prospective, randomized trials are needed to determine the safety and efficacy of the VAC technique for these age-groups (McCord, Naik-Mathuria, Murphy, et al, 2007; Bookout, McCord, and McLane, 2004).

Home Care and Family Support

Dermatologic conditions always involve the family. Because few situations require hospitalization and children who are hospitalized will complete a therapy program at home, the family must carry out the treatment plan; therefore their cooperation is essential. Regimens that are simple to accomplish in the hospital or office may be frustrating and baffling at home. The family often needs assistance in adapting equipment available in the home to the therapy.

It is important to give the child and family as detailed explanations as possible about both the expected and the unexpected results of treatment, including any ill effects that might occur. Direct the family to discontinue treatment and report the reactions to the appropriate person(s) if unexplained reactions do develop. Discourage the use of over-the-counter medicines unless these have first been approved by the attending practitioner.

Because the skin is the most visible portion of the body, defects in its surface that alter its appearance are sometimes a source of distress to the child and a source of revulsion and rejection by others. Parents of other children may fear that their children will “catch” the disorder. Occasionally the affected child’s own family members reduce their interaction with the child, especially close physical contact, or otherwise demonstrate a distaste for the condition, which the child may interpret as rejection. This is seldom a difficulty with dermatitis of short duration, but chronic conditions can create problems and affect the child’s self-concept (see Family-Centered Care box).

Nursing Care Management

The major nursing functions related to bacterial skin infections are to prevent the spread of infection and to prevent complications. Impetigo contagiosa and methicillin-resistant Staphylococcus aureus (MRSA) infection can easily spread by self-inoculation; therefore caution the child against touching the involved area. Hand washing is mandatory before and after contact with an affected child. Also emphasize hand washing to both the child and the family. Many children with atopic dermatitis are colonized with MRSA in the nares and under the fingernails (Rosenthal, 2004). For many bacterial infections and for MRSA infection in particular, the child should be provided with washcloths and towels separate from those of other family members. The child’s pajamas, underwear, and other clothes should be changed daily and washed in hot water. Razors used for shaving should be discarded after each use and not shared. To prevent recurrence, some infectious disease specialists recommend bathing in a chlorine bath once or twice weekly. A 5-minute soak of 2.5 ml of bleach diluted in 13 gallons of water, or cup of bleach diluted in a standard 50-gallon tub one fourth filled with water, could decrease community-acquired MRSA colonies by more than 99.9% (Fisher, Chan, Hair, et al, 2008; Kaplan, 2008). In addition, mupirocin can be applied to the nares of patients and families twice daily for 2 to 4 weeks to prevent reinfection (Lee, Rios, Aten, et al, 2004; Dohil and Eichenfield, 2005).

Children and parents are often tempted to squeeze follicular lesions. They must be warned that squeezing will not hasten the resolution of the infection and that there is a risk of making the lesion worse or spreading the infection. Children should not puncture the surface of the pustule with a needle or sharp instrument. A child with a stye may waken with the eyelids of the affected eye sealed shut with exudate. Instruct the child or the parents to gently wipe the lid from the inner to the outer edge with warm water and a clean washcloth until the exudate has been removed.

The child with limited cellulitis of an extremity is usually managed at home on a regimen of oral antibiotics and warm compresses. Teach the parents the procedures and instruct them in administration of the medication. Children with more extensive cellulitis, especially around a joint with lymphadenitis or on the face, or with lesions larger than 5 cm (2 inches), may be admitted to the hospital for parenteral antibiotics, incision, and drainage (Fisher, Chan, Hair, et al, 2008; Kaplan, 2008). Nurses are responsible for teaching the family to administer the medication and to apply compresses.

Nursing Care Management

When teaching families about the care of children with ringworm, the nurse should emphasize good health and hygiene. Both 2% ketoconazole and 1% selenium sulfide shampoos may reduce colony counts of dermatophytes. These shampoos can be used in combination with oral therapy to reduce the transmission of the disease to others. The shampoo should be applied to the scalp for 5 to 10 minutes at least three times per week (Roberts and Friedlander, 2005). The child may return to school once therapy is initiated. Because of the infectious nature of the disease, affected children should not exchange with other children any grooming items, headgear, scarves, or other articles of apparel that have been in proximity to the infected area. Infected children should use their own towels and wear a protective cap at night to avoid transmitting the fungus to bedding, especially if they sleep with another person. Because the infection can be acquired by animal-to-human transmission, all household pets should be examined for the disorder. Other sources of infection are seats with headrests (e.g., airplane seats), seats in public transportation, helmets, and gymnasium mats.

Treatment with the drug griseofulvin frequently continues for weeks or months, and because symptoms subside, children or parents may be tempted to decrease or discontinue the drug. The nurse should emphasize to family members the importance of maintaining the prescribed dose and schedule and of taking the medication with high-fat foods for best absorption. Also inform them about possible side effects of the drug, such as headache, gastrointestinal upset, fatigue, insomnia, and photosensitivity. For children who take the drug over many months, periodic testing is required to monitor for leukopenia and assess liver and renal function. Newer antifungal drugs such as terbinafine, itraconazole, and fluconazole may be used when there are adverse reactions to griseofulvin. Currently, these drugs are being studied to determine their efficacy and safety in treating tinea capitis in children but are not approved by the FDA for this indication at this time.

Clinical Manifestations

The inflammatory response causes intense pruritus that leads to punctate discrete excoriations secondary to the itching. Maculopapular lesions are characteristically distributed in intertriginous areas: interdigital surfaces, the axillary-cubital area, popliteal folds, and the inguinal region. There is variability in the lesions. Infants often develop an eczematous eruption; therefore the observer must look for discrete papules, burrows, or vesicles (Fig. 18-6). A mite is identified as a black dot at the end of a minute, linear, grayish brown, threadlike burrow. In children older than 2 years of age, most eruptions are on the hands and wrists. In children younger than 2 years, they are often on the feet and ankles. Children with Down syndrome may not complain of itching; therefore they can get a severe infestation before it is recognized.

The inflammatory response and itching occur after the host becomes sensitized to the mite, approximately 30 to 60 days after initial contact. (In persons previously sensitized to the mite, the inflammatory response occurs within 48 hours after exposure.) After this time, anywhere the mite has traveled will begin to itch and develop the characteristic eruption. Consequently, mites will not necessarily be located at all sites of eruption. A person needs prolonged contact with the mite to become infested. It takes about 45 minutes for the mite to burrow under the skin; consequently, transient body contact is less likely to cause transfer of the mite. The diagnosis is made by microscopic identification from scrapings of the burrow.

Therapeutic Management

The treatment of scabies is the application of a scabicide. The drug of choice in children and infants older than 2 months is permethrin 5% cream (Elimite). Alternative drugs are 10% crotamiton, ivermectin, or 1% lindane cream or lotion. Lindane can be neurotoxic and is contraindicated in several age-groups. Lindane should be reserved for treatment of patients who fail to respond to other preparations (American Academy of Pediatrics, 2009).

Ivermectin, an oral medication, may be used to treat scabies in patients with secondary excoriations for whom topical scabicides are irritating and not well tolerated or whose infestation is refractory (American Academy of Pediatrics, 2009). However, the safety and efficacy of ivermectin for children younger than 5 years of age or children weighing less than 15 kg (33 lb) has not been established.

Because of the length of time between infestation and physical symptoms (30 to 60 days), all persons who were in close contact with the affected child need treatment. This may include boyfriends or girlfriends, baby-sitters, grandparents, and immediate family members. The objective is to treat as thoroughly as possible the first time. Enough medication for the entire family should be prescribed, with 2 oz allowed for each adult and 1 oz for each child.

Nursing Care Management

Nurses instructing families in the use of the scabicide should emphasize the importance of following the directions carefully. If lindane lotion is prescribed, it is applied to cool, dry skin—not following a hot bath. It is applied over the entire cutaneous surface from the neck down and is left on for the recommended time, usually 4 hours for infants and 6 hours for older children and adults. Because scabies is a superficial skin disorder, penetration need not be promoted. One liberal application is sufficient.

When permethrin 5% is used, the cream should be thoroughly and gently massaged into all skin surfaces (not just the areas that have a rash) from the head to the soles of the feet. Skin surfaces between the fingers and toes, the folds of the wrist and waist, the umbilicus, and the cleft of the buttocks should not be missed. A toothpick can be used to apply permethrin cream beneath the fingernails and toenails. Take care to avoid contact with the eyes. If permethrin cream accidentally gets into the eyes, they should be flushed immediately with water. Permethrin cream should remain on the skin for 8 to 14 hours, after which time it can be removed by bathing and shampooing.

Touching and holding the child should be minimized until treatment is completed, and the hands should be washed carefully after contact is made. Nurses should wear gloves when caring for the child. Following treatment, freshly laundered bed linen and clothing should be used, and bedclothes and previously worn clothing should be washed in very hot water and dried at the high setting in the dryer. Aggressive housecleaning is not necessary. Families need to know that although the mite will be killed, the rash and the itch will not be eliminated until the stratum corneum is replaced, which takes approximately 2 to 3 weeks. Soothing ointments or lotions, antihistamines, and topical corticosteroids can be used for itching. Antibiotics may be given for secondary infection.

Clinical Manifestations and Diagnostic Evaluation

Itching, caused by the crawling insect and insect saliva on the skin, is usually the only symptom. Common sites of involvement are the occipital area, behind the ears, and at the nape of the neck. Observation of the white eggs (nits) firmly attached to the hair shafts confirms the diagnosis. Because of their brief life span and mobility, adult lice are difficult to locate. Nits must be differentiated from dandruff, lint, hair spray, and other items of similar size and shape. On inspection, nits are seen attached to the hair shaft. Scratch marks and/or inflammatory papules caused by secondary infection may be found on the scalp in the vulnerable areas (Fig. 18-7).

Therapeutic Management

Treatment consists of the application of pediculicides and manual removal of nit cases. Because of its efficacy and lack of toxicity, the drug of choice for infants and children is permethrin 1% cream rinse (Nix), which kills adult lice and nits (American Academy of Pediatrics, 2009). This product and preparations of pyrethrin with piperonyl butoxide (RID or A-200 pyrinate) can be obtained without a prescription and are more effective and safer than lindane. Most experts advise a second treatment at 7 to 10 days to ensure a cure (America Academy of Pediatrics, 2009; Leung, Fong, and Pinto-Rojas, 2005). However, pyrethrin products are contraindicated for individuals with contact allergy to ragweed or turpentine. If neither permethrin nor pyrethrin products are effective, the prescription drug 0.5% malathion, which has been approved for treatment of head lice, can be used. However, malathion contains flammable alcohol, must remain in contact with the scalp for 8 to 12 hours, and is not recommended for children younger than 2 years of age.

Because of concerns that head lice may be developing resistance to chemical shampoos and that repeated exposure of children to strong chemicals on the scalp may be unwise, effective nonchemical control measures are essential. Daily removal of nits from a child’s hair with a metal nit or flea comb is an essential control measure following treatment with the pediculicide. The child’s entire head should be completely combed every day until no more nits are found. In most instances, a nit comb removes most of the nits. However, in some instances, nits need to be removed by scraping them off strands of hair with the fingernail or using tweezers. Several nit combs are currently available at community pharmacies.

Lice are small and grayish tan, have no wings, and are visible to the naked eye. The nits, or eggs, appear as tiny whitish oval specks adhering to the hair shaft about 6 mm (0.25 inch) from the scalp. The adherent nature of the nits distinguishes them from dandruff, which falls off readily. Empty nit cases, which indicate hatched lice, are translucent rather than white and are located more than 0.25 inch from the scalp (Fig. 18-8).

If evidence of infestation is found, it is important to perform the treatment according to the directions on the label of the pediculicide. Advise parents to read the directions carefully before beginning treatment. Instructions indicate that dead lice and remaining nits are to be removed with an extra-fine-tooth comb (included with many preparations).

Make the child as comfortable as possible during the pediculicide application process, since the agent must remain on the scalp and hair for several minutes. Playing “beauty parlor” during the shampoo is a useful strategy. The child lies supine, with the head over a sink or basin, and covers the eyes with a dry towel or washcloth. This prevents medication, which can cause chemical conjunctivitis, from splashing into the eyes. If eye irritation occurs, flush the eyes well with tepid water.

Live lice survive for up to 48 hours away from the host, but nits are shed into the environment and are capable of hatching in 7 to 10 days. Therefore parents must take measures to prevent further infestation (see Community Focus box). Spraying with insecticide is not recommended because of the danger to children and animals. Families should also be advised that the pediculicide is relatively costly, especially when several members of the household require treatment. Families may be inclined to try home remedies to treat the lice (see Research Focus box).

The psychologic effects of lice infestations are stressful to children. They are influenced by the reactions of others, including their parents, school nurses, and officials. Some children feel ashamed or guilty. Parents are strongly cautioned against cutting a child’s hair or, worse, shaving a child’s head. Lice infest short hair as readily as long hair, and these actions only compound the child’s distress and serve as a continual reminder to their peers, who are prone to taunt children who have a different appearance.

Nursing Care Management

Nurses should emphasize that anyone can get pediculosis; it has no respect for age, socioeconomic level, or cleanliness. The louse does not jump or fly, but it can be transmitted from one person to another on personal items. Children are cautioned against sharing combs, hair ornaments, hats, caps, scarves, coats, and other items used on or near the hair. Children who share lockers are more likely to contract an infestation, and slumber parties place children at risk. Lice are not carried or transmitted by pets.

Nurses or parents should carefully inspect a child who scratches the head more than usual for bite marks, redness, and nits. The hair is systematically spread with two flat-sided sticks or tongue depressors, and the scalp is observed for any movement that indicates a louse. Nurses should wear gloves when examining the hair and use new tongue depressors or examining sticks for each child.

Clinical Manifestations

The disease may be initially seen in any of three stages. Stage 1, early localized disease, consists of the tick bite at the time of inoculation, followed in 3 to 30 days by the development of erythema migrans at the site of the bite. The lesion begins as a small erythematous papule that enlarges radially up to 30 cm (12 inches) over a period of days to weeks. It results in a large circumferential ring with a raised, edematous doughnut like border resulting in a bull’s eye appearance (Fig. 18-10). The thigh, groin, and axilla are common sites. The lesion is described as “burning,” feels warm to the touch, and occasionally is pruritic. The single annular rash may be associated with fever, myalgia, headache, or malaise.

Stage 2, early disseminated disease, occurs 3 to 10 weeks after inoculation. Many patients develop multiple smaller, secondary annular lesions without the indurated center. They may occur anywhere except on the palms and soles, and in untreated patients they disappear in 3 to 4 weeks. Constitutional symptoms, including fever, headache, malaise, fatigue, anorexia, stiff neck, generalized lymphadenopathy, splenomegaly, conjunctivitis, sore throat, abdominal pain, and cough, are often observed. A focal neurologic finding of cranial nerve palsy (seventh nerve palsy) occurs in 3% to 5% of cases.

Stage 3, the most serious stage of the disease, is characterized by systemic involvement of neurologic, cardiac, and musculoskeletal systems that appears 2 to 12 months after inoculation. Lyme arthritis is the most common manifestation with pain, swelling, and effusion. In children the arthritis is characterized by intermittently painful swollen joints (primarily the knees), with spontaneous remissions and exacerbations. Rare neurologic features of pediatric Lyme disease may include chronic demyelinating encephalitis, polyneuritis, and memory problems (Kest and Pineda, 2008).

Cardiac complications, which may appear in a small percentage of persons 4 to 5 weeks after erythema chronicum migrans, are commonly acute atrioventricular conduction abnormalities and may result in severe heart block (Wormser, Dattwyler, Shapiro, et al, 2006). Patients may be asymptomatic but can develop syncope, palpitations, dyspnea, chest pain, and severe bradycardia.

Diagnostic Evaluation

The diagnosis is based primarily on the history, observation of the lesion, and clinical manifestations. Serologic testing for Lyme disease at the time of a recognized tick bite is not recommended (Fix, Strickland, and Grant, 1998). Serologic testing is not standardized, and there is a high frequency of false-negative and false-positive results (Seltzer and Shapiro, 1996), which may lead to unnecessary treatments. Laboratory diagnosis can be established in later stages with a two-step approach that includes the enzyme-linked immunosorbent assay (ELISA) screening test and, if it is positive, Western Blot testing, as outlined by the Centers for Disease Control and Prevention (2009a) and adopted by the American Academy of Pediatrics.

Therapeutic Management

At the time the rash appears or shortly thereafter, children over 8 years of age are treated with oral doxycycline or amoxicillin, and children under 8 years of age are given amoxicillin. For patients who are allergic to penicillin, alternative drugs include cefuroxime and erythromycin (Wade, 2000; Centers for Disease Control and Prevention, 2009a).

The length of treatment depends on the clinical response and other disease manifestations, but it usually lasts from 14 to 21 days (American Academy of Pediatrics, 2009). The treatment is effective in preventing second-stage manifestations in most cases. Neurologic, cardiac, and arthritic manifestations are managed with intravenous or intramuscular antibiotics, such as ceftriaxone or penicillin G. For patients in whom tetracycline is contraindicated or who have allergies to penicillin, parenterally administered ceftriaxone is as effective as doxycycline in the treatment of acute disseminated Lyme disease (Dattwyler, Luft, Kunkel, et al, 1997). Follow-up care is important in ensuring that treatment is initiated or terminated as needed.

Nursing Care Management

The major thrust of nursing care should be educating parents to protect their children from exposure to ticks. In endemic areas tick habitats can include yards and parks, in addition to wooded areas.

Children should avoid tick-infested areas or wear light-colored clothing so that ticks can be spotted easily, tuck pant legs into socks, and wear a long-sleeved shirt tucked into pants when in wooded areas. Children should avoid grass and shrubbery where ticks may be lurking, and children and adults should walk in the center of trails. Parents and children need to perform regular tick checks when they are in infested areas. After a hike, a bare skin check (with special attention to the scalp, neck, armpits, and groin areas) is important to spot any ticks and remove them (see Table 18-10).

Parents should also be alert for signs of the skin lesion, especially if their children are known to have been exposed to the tick vector.

The use of insect repellents such as those containing diethyltoluamide (DEET) or permethrin can protect against insects. Advise parents to use them cautiously. DEET is absorbed through the skin and can cause toxicity in infants and children. These preparations can be used as directed by product insert in children as young as 2 months of age (American Academy of Pediatrics, 2009). The preparation should be sprayed on the child’s clothing, not directly on the skin. Information about Lyme disease is available from the Centers for Disease Control and Prevention.*

Nursing Care Management

A thorough history is necessary to determine the causative agent or allergen associated with the patient’s dermatitis. Nurses frequently detect evidence of contact dermatitis during routine physical assessments. Skin manifestations in specific areas suggest limited contact, such as around the eyes (mascara), areas of the body covered by clothing but not protected by undergarments (wool), or areas of the body not covered by clothing (ultraviolet injury). Generalized involvement is more likely to be caused by bubble bath or soap. Often nurses are able to identify the offending agent and counsel families regarding management. If the lesions persist, are extensive, or show evidence of infection, medical evaluation is indicated.

Clinical Manifestations

Urushiol has an effect as soon as it touches the skin. It penetrates through the epidermis as a mixture of compound molecules called catechols. These catechols bond skin proteins, where it initiates an immune response (Fig. 18-11, A). The full-blown reaction is evident after about 2 days, with redness, swelling, and itching at the site of contact. Several days later, streaked or spotty blisters oozing serum from damaged cells produce the characteristic impetiginous lesions (Fig. 18-11, B). The lesions dry and heal spontaneously, and itching stops by 10 to 14 days.

Pathophysiology Reviewv

Therapeutic Management

Treatment of the lesions includes application of calamine lotion, soothing Burow solution compresses, and/or Aveeno baths to relieve discomfort. Topical corticosteroid gel is effective for prevention or relief of inflammation, especially when applied before blisters form. Oral corticosteroids may be needed for severe reactions, and a sedative such as diphenhydramine may be ordered.

Nursing Care Management

When the child has made contact with the plant, flush the area immediately (preferably within 15 minutes) with cold running water to neutralize the urushiol not yet bonded to the skin. If there is a stream nearby, an effective method is to have the child enter the water (clothes and all) and allow the water to rinse the oil from both skin and clothing. Use of harsh soap is contraindicated because it removes protective skin oils and dilutes the urushiol, allowing it to spread. Hard scrubbing irritates the skin. All clothing that has come in contact with the plant is removed with care and thoroughly laundered in hot water and detergent. Every effort is made to prevent the child from scratching the lesions. Although the lesions do not spread by contact with the blister serum or by scratching, the lesions can become secondarily infected (see Critical Thinking Exercise).

Cactus Spines

Small cactus prickles or spines are troublesome to remove, and attempts are distressing to the child and family. Large spines or clumps can be removed with tweezers. Smaller prickles or spines may be removed by the following methods:

Nursing Care Management

Treatment involves stopping the burning process, decreasing the inflammatory response, and rehydrating the skin. Local application of cool tap water soaks or immersion in a tepid water bath (temperature slightly below 36.7° C [98° F]) for 20 minutes or until the skin is cool limits tissue destruction and relieves the discomfort. After the cool applications, a bland oil-in-water moisturizing lotion can be applied, but petrolatum-based products that trap radiant heat in the tissues should be avoided. Acetaminophen is recommended for relief of discomfort. Partial-thickness burns are treated the same as those from any heat source.

Therapeutic Management

Rewarming is accomplished by immersing the part in well-agitated water at 37.8° to 42.2° C (100° to 108° F). Discomfort is managed with analgesics and sedatives. Care of blistered skin is similar to that described for burns. It is seldom possible to estimate the extent of tissue loss until new skin layers are revealed after the eschar layer separates. Therefore amputation of extremities is usually delayed for 60 to 90 days unless there is evidence of gangrene.

Nursing Care Management

Transfer the frostbite victim to the nearest emergency treatment center. Protect injured parts from trauma and handle gently. Prevent the patient from ambulating on injured feet. Rubbing injured tissues is contraindicated and can cause damage by rupture of crystallized cells. After rewarming, apply a loose dressing. Dry heat is not applied. (See Burns, Chapter 29, and Pain Management, Chapter 7.)