The Integument SystemThe skin & associated disorders
NUR 331 On-line study self-studyDr. Sara Mitchell
Purposes of the skin Protection Impermeability Heat regulation Sensation
Purposes of the skin Protection
Protects against trauma, including mechanical, thermal, chemical, & radiant
Protects by the oily slightly acid secretions of the sebaceous glands which limit the growth of bacteria
Purposes of the skin Impermeability
Seals the skin from the environment
Protects against loss of essential body constituents to the environment.
Purposes of the skin Heat regulation
Skin adjusts heat loss to heat production to maintain the thermal balance of the body.
Purposes of the skin Sensation
Perceptions (touch, pain, heat, cold) are transmitted through the nerves that permeate the skin.
Betrays emotions/feelings
What makes skin in children different? Eccrine glands do not reach mature function
until 2-3 years of age. Skin is more alkaline in the first weeks of life. Subcutaneous fat is poorly developed. The newborn’s skin is thin an friable. IgA is decreased until 2-5 years of age.
What makes skin in children different? Lack of maturity of eccrine glands makes
infants & young children less able to regulate body temperature
Decreased SQ fat predisposes to hypothermia Thin skin makes it more susceptible to
external irritants and to infection
Test your knowledge1. Purposes of the skin include _______, ______, _________, and ____________.2. The skin adjusts heat loss to heat production to maintain the _______ _____ of the body.3. Skin in children is different because of which of the following?
A. skin is more acidic in the first few weeks of lifeB. IgA is increased until around 2-5 years of ageC. Decreased SQ fat predisposes to hypothermia
1. protection ,impermeability, heat regulation, sensation 2. thermal balance 3. C
Test Your KnowledgeRead pages 758-768 and answer the following
questions:4. Which of the following factors hinder wound healing?
A. Dry wound environmentB. Nutritional deficienciesC. Impaired circulationD. all of the above
5. Which of the following factors aids in wound healing?A. Leaving wound open to dry outB. Cleaning with hydrogen peroxide and betadineC. Cooling the affected area
4. D 5. C
Test your knowledge
6. The major nursing function related to bacterial skin infections are to prevent the spread of infection and to prevent complications. A. True B. False
7. Most communicable diseases of childhood are associated with ______ caused by ________.
6. A 7. rashes/viruses
Infections of the skinCaused by bacteria
The major nursing functions related to bacterial skin infections are to prevent the spread of infection and to prevent complications.
Bacterial Infections - Name a few(see page 767 in textbook)
Impetigo Cause Course Management Caution
Cellulitis See page 767 in your textbook and figure 18-7 on page 767
What causes impetigo and how does it progress? Caused by group A beta
hemolytic and/or staph aureous
Course is as follows: Begins as a single reddish
maculae, then becomes vesicular
Ruptures easily, leaving superficial moist erosion
Tends to spread peripherally
Exudate dries to form a heavy honey-colored crust
Impetigo: How is it managed? Gentle washing with soap and water Apply topical antibiotic ointment May occasionally need oral antibiotics
Antibiotics in the penicillin or cephalosporin family are generally prescribed. Erythromycin is used for those allergic to penicillin.
Impetigo is VERY contagious Children diagnosed with impetigo should be instructed to
stay home from daycare/school for 24 hours after beginning medications
Test your knowledge Joey is a 7-year-old boy who comes to the school nurse’s office with the
complaint of itchy rash on his face. As the school nurse, you assess the rash to be reddened papules and pustules with a yellow crust occurring around his mouth and nose.
8. What is your first priority A. Assess his temperature and lung sounds B. Have the child wash his hands and call his parents to have Joey see the do
ctor C. Apply calamine lotion to the affected areas D. All of the above.
9. Which of the following statement demonstrates effective learning by Joey’s parents regarding his treatment? A. “I should keep Joey’s towels separate from my other children.” B. “Joey should bath in Aveeno baths at night to help with the itching.” C. “I should wash Joey’s linen in hot water and soak his combs in boiling wat
er.” D. “Joey should take Acyclovir until all of the lesions are gone.”
8. B 9.A
Infections of the skinCaused by viral agents
Most communicable diseases of childhood are associated with rashes caused by viruses
Viral skin infections :Name a few Warts
Caused by human papillomavirus Occurs anywhere but usually appear on exposed
areas such as fingers, hands, face, and soles of feet.
Hard to get rid of. Tend to disappear spontaneously
Treatment includes cryotherapy, surgical removal, or salicyclic acid
More viral skin infections
Herpes simplex virus Type I – causes clod sores & fever blisters Type II – causes genital lesions and is
sexually transmitted Management directed toward keeping
lesions moist with burrows solution. Topical or antivirals may be used. Lesions are made worse by steroids. May be fatal in children with decreased immunity.
Test your knowledge 10. Treatment for warts includes which of the following?
A. cryotherapy B. surgical removal C. salicylic acid D. all of the above
11. Warts are caused by the human herpes virus. A. True B. False
12. Children with ringworm should be instructed to avoid contact with other children for how long after treatment has begun? A. 1 day B. 2 days C. 3 days D. It doesn't matter10. D; 11. B; 12. B
Another skin eruption caused by a virusVaricella-also known as Chicken Pox What causes it?
varicella zoster viruses When does it generally occur?
Most often occurs in late winter and early spring How is it spread?
It is spread by direct contact and droplet (airborne) transmission
More on Chicken Pox Is Chicken Pox contagious?
It is very contagious. It can be spread starting 1-2 days before eruption of lesions and until the time when all lesions have crusted.
When can children return to school or day care? Not until ALL lesions have crusted which is usually about
1 week. It is not necessary to wait until all the scabs fall off to let
the child return to a normal schedule
Chicken Pox – Sign & Symptoms Red, itchy rash on skin.
Rash begins as small, red bumps that look like pimples or insect bites.
Red bumps develop into thin-walled blisters filled with clear fluid, which becomes cloudy
Blisters break, leaving open sores, which finally crust over to become dry, brown scabs.
Fever 100-1020F (may occasionally be higher)
Chicken Pox – about the rash Lesions erupt in successive
crops, usually beginning on the trunk and then spreading to the face and scalp.
The characteristic rash involves crops of teardrop vesicles on an erythematous base.
The classic lesion has been described as an "oval teardrop on an erythematous base" or a "dew drop on a rose petal.“
A characteristic feature of the rash is that the lesions can be in all stages of development simultaneously.
Chicken Pox – what is the Incubation period?
The incubation period for chicken pox is 10 to 21 days after exposure.
Most cases appear within 14 to 17 days. For example, if one child in a family breaks out with chickenpox picked up at school, siblings probably will show symptoms about 2 weeks later.
ChickenPox – What is the treatment Relieve the itch!
Cool or tepid oatmeal baths with every 3 to 4 hours as needed (baths do not spread chickenpox)
Calamine lotion (avoid the face, especially the eyes) Antihistamines, such as benadryl, may also be used for
itching Soft/bland foods as indicated as there may be painful pox
lesions in the mouth Acetaminophen or ibuprofen or fever and general aches Antiviral medications such as acyclovir may occasionally
be prescribed at the physicians discretion
Chicken Pox – What are the complications?
Viral pneumonia Encephalitis Secondary skin infection
Chicken Pox – How is it related to shingles? Anyone who has had chickenpox as a child is at risk
shingles later in life. After infection with chickenpox, some of the varicella
zoster virus may remain inactive in the nerve cells near the spinal cord.
Many years later, the virus can reactivate and resurface as shingles.
When it reactivates, it affects the nerves to the skin. Symptoms, such as a tingling feeling, itching, or pain
followed by a rash with red bumps and blisters appear only on the area of the skin that the nerve goes to.
What about the chicken pox vaccinehttp://www.vaccineinformation.org/varicel/qandavax.asp
In use since 1995 70-85% effective at preventing mild infection
and more than 95% effective in preventing moderate to severe disease.
Given to all children older than 12 months of age, as well as adults who have not had the disease.
Chicken Pox – test your knowledge13. Tommy has been diagnosed as having chicken pox. His mom ask you how the
disease is spread. Your best response is:A. by direct contact with the lesionsB. by an infected person breathing on youC. by kissing an infected personD. all of the above
14. Tommy’s best friend has chicken pox. His mom is worried about Tommy getting the disease as well and ask you what the early signs are. Your best response is: A. Symptoms develop 3-5 days after exposure B. Lesions usually begin on the trunk C. The rash begins as small, red bumps that look like pimples D. B & C E. A only
13. D; 14. D
Chicken Pox – test your knowledge15. It has been 10 days since his exposure to chicken pox and Tommy has not
developed signs of the disease. His mom ask if he is out of the woods. Your best response is what? A. It is unlikely Tommy will develop chicken pox from this exposure B. The incubation period for chicken pox is 5-7 days C. Most cases of chicken pox appear within 14 to 17 days of exposure. D. It is impossible to tell if Tommy will develop chicken pox.
16. Tommy does not develop chicken pox but his brother does. Tommy’s mom ask what she should do to treat the disease. Your best response is what? A. Avoid baths because of risk of causing the pox to spread. B. Apply calamine lotion for the itch C. Give acetaminophen for fever and aches D. A only E. B & C
15. C; 16. E
Chicken Pox – test your knowledge17.Tommy’s mom needs to return to work. She ask when her son
while likely to able to return to school. Your best response is what? A. When all of the scabs have fallen off B. When all lesions have crusted and are no longer fluid
filled vesicles C. When she hasn’t seen any new lesion for 48 hours D. All of the above
17. B
Skins infections caused by fungi Tinea captitis – fungal infection of the scalp
Tinea corporis – fungal infection of the body
Tinea curis – fungal infection of the scrotal and genital area
Tinea pedis -athlete's foot
Skins infections caused by fungi Management
Skin infections: treated with topical antifungal creams for 6-8 weeks
Scalp infections: because the fungi are deep in the hair shaft tinea capitis must be treated with systemic antifungal medications such as grieseofulvin for 6-weeks
Ringworm is contagious. Children with ringworm should be instructed to avoid contact with other for 48 hours after treatment is started.
Different forms of tinea – What does it look like?
Tinea Capitis
Tinea Corporis- face & trunk
Tinea cruris – groin, buttocks, & scrotum Tinea Pedis
Scabies Definition –an endemic infestation caused by the scabies mite
sacroptes scabiei. The mite can barely be seen by the naked eye
Clinical manifestations – the mite burrows under the skin causing an allergic reaction. Recognized by their tracks …small lines in the skin that look like scratches about ¼ inch long. Usually appear at wrists, buttocks, underarms, groin, and especially in the webs between fingers and toes.
Therapeutic management – scabicide such as Elimite (5% permethrin)
Nursing considerations – education about transmission and management
More on scabies
Pediculosis capitis:a fancy name for head lice or “cooties” Definition – an infestation of the
scalp by Pediculus humanus capitus
Clinical manifestations –causes intense itching. Very common especially in school children
Therapeutic management – comb nits out. Treat with 1% permethrin shampoo.
Nursing considerations – head lice are very contagious. All family members should be treated. Anything that has come in contact with the scalp, brush, hats, bed linens, ect.. needs to be cleaned
Poison Ivy,Oak, Sumac:itchy, itchy, itchy page 767 in textbook
Definition A contact dermatitis that occurs when skin comes in
contact with the dry or succulent portion of any of the three of these plants. The offending substance is an oil called urushiol
Clinical manifestations Contact produces localized, streaked, or spotty, oozing
and painful impetigious lesions. The substance begins to take effect as soon as it touches the skin. It soaks in and causes an immune response. A full-blown reaction is evident after about 2 days.
Poison Ivy Rash –What does it look like? The oil contained in the
plant leaves irritates the skin.
The redness and blistering from the rash is often arranged in streaks or lines, because the leaf brushes across the body in a line as an individual walks past.
Poison Ivy,Oak, Sumac:itchy, itchy, itchy (continued)
Therapeutic management The primary goal of treatment is to lessen the itch and prevent
secondary infection. Calamine lotion, baths in aveeno or baking soda are helpful in relieving the itch. Oral benadryl can be used as well as topical hydrocortisone. If the out break is extensive or if it is near the eyes systemic steroids (i.e. prednisone) is often used.
Nursing considerations Wash area immediately with cold running water to neutralize the
urushiol. Remove and wash all clothing that may have come in contact with the plant.
Poison Ivy,Oak, Sumac:itchy, itchy, itchy (continued)
Common myth Poison ivy, oak, or sumac can not be spread from
person to person. There must be contact with the urushiol oil before a contact dermatitis response can occur. Contact can be directly from a plant, from clothing, or perhaps from the fur of a family pet who has been romping in the woods.
Test your knowledgeA mother calls the clinic nurse to ask advice regarding her child and
possible contact with poison ivy.18. If the contact was in the last 15 minutes, which of the following
actions should be recommended? A. Wash the child with dishwasher detergent B. Flush the skin with cold running water C. Have the child bathe in warm water D. Have the child shower in hot water.
19. Clothing the child was wearing should be A. Burned B. Placed in a plastic bag and put out with the trash C. Placed in the laundry hamper along with other clothes D. Washed separately in hot water and detergent
Answers 18. B; 19. D
Sunburn:Ochy,Ochy, Ochy Prevention
Sunscreen and sunblocks. SPF 15 or greater. Avoid mid day sun exposure
Treatment Involves stopping the
burning process, decreasing the inflammation process, and rehydrating the skin. Cool tap water soaks or immersion in a tepid water bath for 20 minutes or until the skin is cool. Apply moisturizing lotion. Use Tylenol for discomfort.
Atopic Dematitis:Ou wee baby What is it?
Also referred to as eczema. It is a chronic inflammation of the dermis and epidermis which causes itching, edema, papules, erythema, excoriation, serous discharge and crusting.
Who gets it? * see page 580 in your
textbook for the different age groups. There is often a family history of eczema of some other chronic allergy related condition.
Atopic Dematitis:Ou wee baby (continued)
Management Basic skin care
Frequent baths but also apply moisturizing lotion within three minutes after bath (while the skin is still damp.
Atopic Dematitis:Ou wee baby (continued)
Medications to relieve itch or secondary infection Topical steroids Oral antihistamines Antibiotics for secondary infection
Education, Education, Education! Parents must understand this is a chronic condition
that reoccurs. There is no one time fix. If they do not understand this they will only be frustrated with the medical system for not “curing” their child
Diaper Rash:What are the causes Caused by a prolonged and
repetitive contact with an irritant, i.e. urine, feces, soap, detergents.
Wetness, increased skin Ph, and fecal irritants all work together to cause the rash.
Diaper Rash:What is the treatment Use zinc oxide paste to
help create a moisture barrier so that the irritated skin can heal
Clean the area very gently
Use a cleanser only after the infant has had a bowel movement
Use nonirritating wipes Use super-absorbent
diapers. Research has shown that some diapers with super absorbency and petroleum layers helps reduce the incidence of diaper rash