Lecture 7.1 - Integumentary Flashcards
What factors can enhance skin healing?
Moist, clean environment
Good nutrition
What are some factors that can delay skin healing?
Immunocompromised status, stress, impaired circulation.
Infections, foreign bodies, friction/shear
Medications + comorbidities
How do children’s epidural layer differ from adults?
Epidermal layer less bound to dermal layer
–> Increased separation, even higher risk in preterm infants
What factors make pediatric patients more susceptible to skin injury?
Weaker epidermal adherence
Increased exposure to body fluids + iatrogenic risk factors
Limited ability to self-care or report discomfort
Higher risk of accidental injury and inflammatory conditions (such as eczema)
What characteristics of a rash must be assessed?
Location + Extent
–> Color, type, infection, swelling, bleeding
–> Pain, pruritis
What history information should be assessed when a child has a rash?
Age of onset, family Hx
Hypersensitivities
–> Allergies in general, hay fever
–> Asthma
–> Exposure to irritants
What is erythema?
Redness caused by increased blood in vasculature
What is ecchymoses?
Bruises - extravasation of blood
What are petechiae?
Pinpoint spots in superficial layers of dermis
What are primary lesions?
Lesion with causative factor
What is a macule?
Flat, non-palpable < 1 cm
–> brown, red, purple, white, or tan
E.g., freckles, flat moles, rubella,
What is a papule?
Elevated, palpable< 1 cm
–> any colour
E.g., warts
What is a vesicle? Bulla?
Elevated and superficial lesion filled with serous fluid
–> Vesicle < 1 cm
–> Bulla > 1 cm
What is a secondary lesion?
Results from changes in primary lesion
How can we manage iatrogenic risks for skin breakdown?
Reduce pressure over bony prominences, friction + shear, epidermal stripping, contact with irritants
Promote oxygenation, hydration + nutrition, circulation, movement
What kinds of fluids are often given in a central line?
Hypertonic solutions
–> 3% saline, TPN
What are the care priorities for skin protection with ostomies?
Maintain position + patency of tubes
Protect skin
–> reduce exposure to fluids
–> Clean/dry
–> Use barriers (creams, protective products, ostomy wafer)
What is the peak age of occurrence for diaper dermatitis?
9-12 months
Is diaper rash more common in breast or formula fed infants?
Incidence is greater in formula-fed infants
What is the etiology of diaper dermatitis?
Prolonged and repetitive contact with irritants. Wetness produces:
–> Higher friction, greater abrasion, increased trans-epidermal permeability, increased microbial counts
Increase in pH from breakdown of urea in the presence of fecal urease
Does diaper rash always occur in response to prolonged wetness?
Not necessarily - irritants can also include detergents, wipes, soaps
What is the plan of care with diaper dermatitis?
Provide relief
Eliminate cause
–> Most common: environmental
–> Second: Allergies
Reduce risk of 2° bacterial infection and promote healing
How does the presentation of perineal candida albicans differ from diaper dermatitis?
Diaper rash - tends to be continuous and follow diaper
Candida - satellite lesions + maculopapular rash
What are the order of nursing interventions for diaper rash?
- Reduce contact with irritants
–> change diaper, do not use perfumed wipes - Keep skin dry
- Protect skin
–> Barrier creams - Minimize friction + monitor for infection
What is atopic dermatitis? What makes it better or worse?
What other conditions is it associated with?
Eczema
–> Intense pruritis - inflammatory chronic skin disease
–> Dermatological manifestations appear subsequent to scratching. Lesions disappear if scratching stops
–> Improvement in humid environments - worse in fall and winter when houses are dry and heated
Associated with asthma and other allergies (family Hx)
What are priority interventions with atopic dermatitis
- Hydrate skin
–> Cool, moist dressings - Relieve itching
–> And cover skin to prevent scratching
–> Antihistamines, corticosteroid - Minimize flare ups or inflammation to avoiding triggers
–> Avoid extreme heat and allergies - Prevent and control secondary infection
Where is atopic dermatitis more common?
Knees, elbows, cheeks, behind the knee
Why are children at higher risks for burns and complications from them?
Skin more fragile to temperature - burns are more likely to be deeper.
–> Increased ECF volume makes them more susceptible to fluid loss related to compromised skin
Psychosocial/developmental considerations
What kinds of burns are most common in children?
Scalds account for 50%
What age group is more susceptible to burn injuries?
Children under 5
Extent and degree of burn injury is described in which ways?
Extent - Total body surface area
Degree - depth of injury
A child presents with a burn where the epidermis remains intact and without blisters. There is blanchable erythema.
What kind of burn is this?
How would you expect the patient’s pain level to be?
What course of healing is to be expected?
1° (partial thickness - epidermal involvement only)
–> Painful
Discomfort lasts up to 3 days, desquamation will occur in 3-7 days.
A child presents with a wet, shiny, weeping burn. It has blisters and blanches with pressure.
What kind of burn is this?
How would you expect the patient’s pain level to be?
What course of healing is to be expected?
2° (Partial thickness - dermal involvement)
–> Very painful, sensitive to touch and air currents
Healing depends on the depth and whether infection can be prevented. Superficial can take less than 21 days, deeper burns will take longer.
A child presents with a burn that has a dry surface with visible thrombosed vessels. It is not blanchable.
What kind of burn is this?
How would you expect the patient’s pain level to be?
What course of healing is to be expected?
3° (Full-thickness - subcutaneous involvement)
–> Insensate with decrease pinprick sensation
Autografting will be required
A child presents with a burn through all layers of the skin, including the skin and subcutaneous tissue. There is visible charring.
What kind of burn is this?
How would you expect the patient’s pain level to be?
What course of healing is to be expected?
4° (Full thickness - fascial, muscle, or bone involvement)
–> Insensate
Amputation will be likely and autografting will be necessary for healing.
What TBSA burn can be life threatening for a child?
10%
What is considered a major burn?
Greater than 30% of TBSA
–> Systemic response to increase capillary permeability - protein, plasma, fluid, electrolyte loss
Why might a larger burn injury have less edema?
Hypovolemia slows edema rate
Anemia can result from thermal injury. Why?
Destruction of RBCs by heat and trapping of RBCS in microvascular thrombi of damaged cells. Overall increased RBC fragility.
Where is blood prioritized in someone with a burn?
Shunted to heart, brain, kidneys
Decreased blood flow to GI tract
Why does the body have increased energy needs after a burn?
Increased metabolism to maintain body heat.
What is the emergency management for burns?
- Stop burning
–> Only remove clothes is they come easily (wet is easier)
–> Cool water over burn - beware of hypothermia in large burns and do not cool them
Assess the child’s condition - ABCs and oxygen if needed
Maintain tissue perfusion - use NS or RL
Cover burn to prevent infection, pain management, fluid replacement therapy
What is critical in the first 24 hours of burn management?
Fluid replacement therapy!
There is a high risk for what complications in children with burns?
Hypovolemia and Na loss
How should fluids me administered in a child with a burn covering >15-20% of TBSA?
IV infusion right away!
Maintain good urine output
–> 1-2 ml/kg for kids under 30kg
–> 30-50 ml/h for kids over 30 kg
In what situations might additional fluids be needed following a burn?
Delay in treatment, pulmonary involvement - increased fluid loss with have occured
Underestimation of extent of burn
–> Especially with electrical burns
How can we manage contractures in those healing from burns?
Specialized compression gloves/garments
Consider nutrition, pruritis, pain management
How would you care for a minor burn?
- Wound cleansing
- Debridement
- Ideal burn dressing
–> Reduced infection risk, requires infrequent changing, promotes granulation, cost effective
What is the ideal burn dressing?
Antimicrobial, requires infrequent changing, promotes granulation, cost effective
How do you care for major burns?
Primary excision
Debridement
Topical antimicrobial medication
Biological skin covering
–> Xenograft, allograft
–> Synthetic covering, mesh grafts
What are the priorities in rehabilitation after major burns?
Active rehab when wound coverage is achieved
–> Prevent contractures, pressure suits to prevent scarring
What is the difference between an erosion and an ulcer?
Erosion - loss of all or part of epidermis
Ulcer - loss of dermis and epidermis
What are the most common irritants causing diaper rash?
Environmental - wetness, friction, etc.
Followed by allergies
