Nursing Care Of Children With Cellular and Integumentary Problems Dr. Nataliya Haliyash Nursing Care of Children

Nursing Care Of Nursing Care Of Children With Cellular Children With Cellular

and Integumentary and Integumentary ProblemsProblems

Dr. Nataliya Haliyash

Nursing Care of Children

Cellular AlterationsCellular Alterations

Childhood CancersChildhood Cancers

Five-year-old Alec Zhloba, suffering from leukemia, looks on in a children cancer unit at a hospital in Gomel, Belarus, in this March 19, 1996 file photo.

The deadly explosion in reactor No.4 in the Chernobyl nuclear power plant on April 26, 1986, sent radioactive clouds through Ukraine, Belarus and most of Europe, causing the world's worst nuclear accident. (AP Photo/Efrem Lukstaky)

Lecture objectivesUpon completion of this chapter, the reader will be able to:

Identify the different treatment modalities used to treat cancer in children.

Explain how the different treatment modalities affect malignant cells.

Discuss the nursing management of common side effects of treatment modalities.

Describe the clinical manifestations, treatment, and nursing management of common malignancies in children.

Identify the emotional and educational needs of families who have children with cancer.

Discuss the long-term, late effects of childhood cancer therapy.

Treatment Modalities

• Goal: to rid the body of all malignant cellsGoal: to rid the body of all malignant cells Surgery Chemotherapy Radiation Therapy Bone Marrow Transplants Biological Response Modifiers Or a combination of all of the above

Surgery removal of all visible andmicroscopic cancer cells

• Biopsy • Tumor staging • Assess response to surgery • Palliative

Types of biopsy

Fine needle aspiration biopsy. This test uses a thin, hollow needle in a syringe to collect a small amount of fluid and cells from the suspicious area.

Core needle biopsy. A core biopsy uses a slightly larger needle to obtain a cylinder of tissue. It is often done instead of a fine needle aspiration biopsy because it provides more tissue for the pathologist to review.

Surgical biopsy.

In a surgical biopsy, a surgeon makes an incision in the skin and removes some or all of the suspicious tissue. It is often used after a needle biopsy shows cancer cells, or it can be used as the first method to obtain tissue for diagnosis. There are two types of surgical biopsies:

An incisional biopsy removes a piece of the suspicious area for examination. An incisional biopsy may be used for soft tissue tumors, such as those from muscle or fat tissue, to distinguish between benign (noncancerous) lumps and cancerous tumors called sarcomas.

An excisional biopsy removes the entire lump. An excisional biopsy, which was more common before the development of fine needle aspiration, may be used for enlarged lymph nodes or breast lumps, or in situations where the lump is small enough to be completely removed in one procedure.

Bone marrow aspiration and biopsy. A bone marrow aspiration and biopsy is a diagnostic

examination of the bone marrow, the spongy tissue inside of bone that has both fluid and solid parts. The sample is usually collected from the back of the hip bone. For this test, the patient’s skin is numbed with a local anesthetic, and a needle is inserted into a bone in the hip until it reaches the bone marrow. A small amount of bone marrow fluid is removed and examined under a microscope. This is called an aspirate. The doctor may also use a hollow needle in the same location to withdraw a solid core of bone marrow. This is called a biopsy. This test is used to determine if a person has a blood disorder or a blood cancer, such as leukemia or multiple myeloma. It can also be used to find out if a cancer that started in another part of the body has spread to the bone marrow.

Tumor staging

Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and if it is affecting the functions of other organs in the body.

The staging system used by doctors is the TNM system of the American Joint Committee on Cancer (AJCC).

TNM is an abbreviation for tumor (T), node (N), and metastasis (M), or cancer that has spread to other areas of the body.

Tumor staging T:T: The letter "T" (local tumor growth) describes the extent of the cancer

in its original location. Each cancer is described using a term T0, T1, T2, T3, or T4. The larger or more extensive the tumor, the larger the number assigned. The T number reflects a combination of the size and the extent to which the tumor invades nearby structures.

N:N: The letter "N" (regional lymph node) describes whether the is cancer present in the lymph nodes near the tumor, and, in some types of cancer, how many of these lymph nodes contain cancer cells. The lymph nodes are tiny, bean-shaped organs that are located throughout the body that help fight infections as part of the immune system. Each cancer may be assigned one of these terms: N0 (meaning no cancer is found in the nodes), N1, N2, or N3. In many instances, the more lymph nodes with cancer, the larger the number assigned. For other tumors, the location of the nodes that have cancer may determine the N rating.

M:M: The letter "M" (distant metastasis) describes if the cancer has metastasized from its original (primary) location to other distant areas of the body. Each cancer is assigned either M0 (no metastasis), or M1 (metastasis has occurred).

Tumor staging Central nervous system tumors (brain Central nervous system tumors (brain

cancers).cancers). Because malignant (cancerous) brain tumors do not normally spread outside of the central nervous system (CNS, brain and spinal cord), only the "T" description of the TNM system applies. Currently, there is no universal staging system for central nervous system tumors.

Childhood cancers.Childhood cancers. AJCC does not include childhood cancers in its staging manual. Most childhood cancers are staged separately, according to other staging systems.

Chemotherapy

• Effective against systemic cancers • Classified into

– Alkylating agents– Antimetabolites– Antitumor antibiotics– Plant alkaloids– Corticosteroids– Miscellaneous agents

Side Effects

Systems with rapidly reproducing cells– GI, hematopoietic, hepatic, renal,

integumentary and reproductive systems– Myelosuppression

Anemia – Pallor fatigue and HA Thrombocytopenia <20,000/mm3 Neutropenia ANC< 500/mm3 Immunosuppression

Side Effects

Gastrointestinal Effects– • Mucositis– • Nausea and vomiting

Hepatic Effects– • Elevated liver enzymes– • Liver fibrosis

Renal Effects– • BUN and Creatinine

Mucositis

The pathobiology of mucositis

Nursing Tip:Nausea and vomiting

Giving chemotherapy at bedtime may alleviate nausea and vomiting in children. It may allow them to sleep through the emetic effects.

Playing soft music, such as lullabies, or recording a caregiver singing soft songs is soothing and distracting and may alleviate symptoms of nausea and vomiting.

Side Effects

Integumentary– • Alopecia– • Vesicants

Reproductive Effects Fertility may be affected Oligomenorrhea Excessive bleeding Sterility in males may be permanent

Alopecia, bruising

Nursing Tip:Coping with alopecia

Role-play with the child as to what to say when someone asks,"What happened to your hair?“

Children returning to school have many anxieties regarding their acceptance back into their peer group because of the many changes in their appearance.This activity helps to develop coping strategies to deal with alopecia.A school visit from the oncology team nurse to speak with the child's teacher and classmates can help the transition back to school.

Radiation Therapy

• Deliver therapeutic doses of ionizing radiation

• Lymphomas solid tumors and brain tumors

• Palliative

Side Effects of Radiation

• Hematopoietic • Mucositis • Esophagitis • Skin damage • Radiation pneumonitis • Somnolence syndrome

Bone marrow transplant (BMT)

• Replacement of hematopoietic cells • Leukemia Lymphoma and certain solid

tumors

3 phases of BMT3 phases of BMT • Pre-transplant • Transplant • Post transplant

Bone marrow transplant (BMT)

Transplant stage– • Cytoreduction– • Bone marrow infusion

Post transplant– • Period of pancytopenia– • Graft vs host disease (GVHD)

LEUKEMIA

Board term used to describe a group of malignant diseases in which normal bone marrow elements are replaced by abnormal immature lymphocytes. (Blast cells)

Most common childhood malignancy– • Acute lymphocytic leukemia ALL– • Acute myelogenous leukemia AML

Peak incidence between 2 and 5 years of age

Immature lymphocytes. (Blast cells)

LEUKEMIA

Clinical Manifestations • Fever • Bone pain • Pallor • Bruising

LEUKEMIA

DiagnosisDiagnosis • Bone marrow aspiration

– > 25% of abnormal lymphoblasts is diagnostic

White blood count for prognosis Lumber puncture to assess for CNS

disease Chest xray

bone marrow testbone marrow test

Bone marrow smear of a patient with chronic myelogenous leukemia.

LEUKEMIA

TreatmentTreatment Systemic medication done in 3 phases

– Induction phase: reduce tumor burden to undetectable levels or remission

– Can be done outpatient basis– Drugs used to induce remission

• Vincristine (Oncovin)• L-asparaginase (Elspar)• Prednisone

LEUKEMIATumor lysis syndrome- complication of

treatment IV hydration containing Sodium bicarbonate– Allopurinol (Zyloprim)

Remission is defined • No evidence of leukemia on physical exam • Bone marrow evaluation • Peripheral blood counts • CNS fluid • Or extramedullary site

LEUKEMIA

The second phase of treatment is consolidationThe second phase of treatment is consolidation • Goal to eradicate any residual leukemic

cells and starts once remission is attained • Hospitalization required • CNS prophylaxis with chemotherapy

administered intrathecally • Radiation to brain and spinal cord • Radiation to testes in males with testicular

involvement • Intense and lasts about six months

LEUKEMIA

The maintenance phaseThe maintenance phase • Follows consolidation phase • Maintains control of the leukemia • Chemotherapy administer oral, IV or

IM • May need IV vincristine and IT therapy • Therapy continues for 2 ½ to 3 years

LEUKEMIA

Bone marrow transplant – a treatment option for children with ALL who attain a second remission after a relapse and have a compatible donor.

LEUKEMIA

Nursing careNursing care • Monitor VS every 4 hours and prn • Proper hand washing • Inspect skin daily • Inspect mouth for ulcers • Do not use vaporizers • Place on neutopenic diet • Do no give live virus vaccines

LEUKEMIA

Nursing careNursing care • Isolate the child from children who are sick • Give VZIG within 96 hours of exposure • Give acetominophen for fever • Monitor activity in sever thrombocytopenic

pt • Administer anti emetic before therapy • Offer small frequent meals • Daily weights

Acute Myelogenous Leukemia A condition in which malignant myeloid blasts

in the bone marrow

Clinical presentationClinical presentation • Benign flu like symptoms • Bleeding • Gingival hypertrophy • Chloromas

– Chloromas usually present as reddish-blue, not green, thickenings in the skin, but pressing the blood out of the nodule unmasks a green color for a few seconds.

Acute Myelogenous Leukemia

DiagnosisDiagnosis • Bone marrow aspiration of > 25%

malignant myeloid blast • Treat underlying anemias, bleeding,

infections and hyperuricemia • Treatment phases: remission induction

and contiuation


Chemotherapy agents use in remission Chemotherapy agents use in remission inductioninduction

• Cytarabine (Ara-C) • Daunorubicin (Daunomycin)Chemotherapy agents use in continuation Chemotherapy agents use in continuation

therapytherapy • Cytarabine (Ara-C) • Cyclophosphamide (Cytoxin) • Daunorubicin (Daunomycin) • Etoposide (VePesid)


Treatment of possible CNS involvementTreatment of possible CNS involvement • Cytarabine (Ara-C) • Methotrexate (MTX)

• Radiation of the head • Bone marrow transplant • Treatment intense requires hospitalization

Brain Tumors

• Most common solid tumor of childhood • Most occur in children under the age

of ten

Medial view of the brain of a child in cross-section.

Brain Tumors

Diagnosis • MRI’s • CT scan

Treatment • Surgery • Radiation therapy (not recommended <3) • Chemotherapy:

Brain Tumor MRI

Nursing Tip:Sedation for neurodiagnostic testing

Adequate sedation is necessary in obtaining the needed neurodiagnostic information to confirm the diagnosis of a brain tumor.

Sedation protocols vary from institution to institution, but sleep deprivation can enhance the effects of sedation.

Advising caregivers to put the child to sleep an hour or two later the night before a procedure and then waking her or him a few hours earlier will enhance the effects of the medication.

All children who are sedated must be monitored carefully with pulse oximetry and telemetry to prevent complications of oversedation.

Brain Tumors

Nursing Management

Preoperative neurological assessment • VS • LOC • Strength and equality of grips • Head circumference • Assess of anterior fontanel in infants

Brain Tumors

Nursing Management • Providing support for parents or

caregivers • Frequent monitoring for post op

increased intracranial pressure • Monitor fluid and electrolytes • Administer medications such as

steroids

Wilm’s tumor

Nephroblastoma– arising from the kidney

• Rapidly growing tumor • Seen in children ages 2 to 6

Wilm’s tumor is a cancerous tumor of the kidney that occurs in children.

Wilm’s tumorClinical manifestationsClinical manifestations • Mobile abdominal mass • Microscopic or gross hematuria • Hypertension • Abdominal pain • Malaise • Fever • Primary site for metastasis is the lungsTreatmentTreatment • Nephrectomy and lymph node sampling • Chemotherapy and radiation may be done postoperatively

Wilm’s tumor

Nursing Assessments • Parents may notice abnormal swelling in child’s abdomen • Essentially normal examine except for palpable abdominal mass which does not cross the midline The mass must not be palpated beyond the initial assessment because excessive manipulation can lead to tumor seeding

Neuroblastoma

• Solid tumor found only in children • Most children diagnosis by age two • Diagnosis: X-rays, CT Scan, Bone

marrow • Treatment depends on presence and extent of metastasis

Osteosacroma

• Most common bone malignancy in children • Aggressive tumor • Symptoms can be attributed an injury or

“growing pains” • Most common site is the distal femur • Site of metastasis is the lungs • Associated with teen age years- a period of

rapid bone growth

Osteosacroma

Clinical Manifestations • Progressive, insidious, intermittent

pain at the tumor site • Palpable mass • Limping • Progressive limited range of motion • Eventually a pathological fx at the

tumor site

Ewing’s scarcoma

• Common bone tumor • Has no defining characteristics–

therefore may be difficult to diagnosis • Found in mid shaft of long bones, such

as femur, vertebrae, ribs and pelvis • Gross metastasis uncommon

Ewing’s scarcoma

Clinical manifestationsClinical manifestations • Pain • Soft tissue swelling around the bone • With metastasis anorexia, fever, malaise, fatigue and weight loss • With a vertebral tumor may be neurological symptoms • With rib tumor may be respiratory symptoms

Retinoblastoma

• Rare malignant tumor of the eye found only in children

• May be assess by parents who see a white reflection in the eye instead of red

• Most often occurs as multiple independent tumors on the retina

• Average eye of diagnosis is 11 to 23 months of age

Retinoblastoma

Clinical manifestationsClinical manifestations • Leukokoria – cat’s eye reflex • Vision loss • Pain • Redness and inflammation of the eye • Strabismus • Squinitng

Only treatment known is enucleation of theOnly treatment known is enucleation of the eyeeye

← cat’s eye reflex

Child's right eye → completely covered with a tumor associated with retinoblastoma. (Custom Medical Stock Photo Inc.)

IntegumentaryIntegumentary AlterationsAlterations

Childhood Childhood Skin Skin DiseasesDiseases

The Skin

Epidermis-– Epithelial cells– Melanocytes- provides difference in skin color– Keratinocytes-fibrous, water-repellent protein that

gives the epidermis its tough, protective quality Dermis-

– Second, deeper layer– Blood cells, nerve fibers, and lymphatic vesicles– Hair follicles, sebaceous glands, and sweat glands

The Skin

Subcutaneous tissue– Below the dermis & not part of the skin– Attaches skin to muscle & bone– Stores fat– Regulates temperature– Provides shock absorption

The Skin

– Sebaceous glands• Contain sebum to soften and lubricate the skin

and hair• Secretion stimulated by sex hormones

– Sweat glands• Eccrine glands-forehead, palms, and soles• Apocrine sweat glands- axillary, anal, and genital• Ceruminous glands-external ear canal for

cerumen

The Skin

– Nails-• Nail bed• Color ranges from pink to yellow or brown

depending on skin color• Pigmented bands in nail bed normal for dark

skinned people• Protects ends of fingers and toes

The Skin

Hair– Grows over most of body except lips,

palms & soles– Color is inherited & depends on amount of

melanin– Protects and warms the head

Common Assessment Abnormalities Alopecia- absence of hair Comedo – blackheads & whiteheads Cyst – fluid filled sac d/t obstructed duct or

gland Ecchymosis – bruise Erythema – redness occurring in patches Hematoma – extravasion of blood causing

swelling d/t trauma

Common Assessment Abnormalities Hirsutism – male distribution of hair in

women Keloid – hypertrophied scar beyond

margin of trauma Mole – benign overgrowth of melanocytes Petechiae – pinpoint deposits of blood

under the skin Telangiectasia – dilated, superficial small

blood vessels found on face & thighs

Primary Skin Lesions

Macule – flat, nonpalpable, less than 1 cm Papule – elevated, solid, palapable, less than 0.5 cm Vesicle – circular, superficial collection of serous

fluid, less than 1 cm. Plaque – elevated, solid, palpable, more than 0.5 cm. Wheal – firm, edematous Pustule – elevated, superficial, filled with purulent

fluid Nodule – elevated , solid, extends into dermis,

circumscribed border, 0.5 – 2 cm Tumor – elevated, solid, extends into dermis,

irregular border, greater than 2 cm

Secondary Skin Lesions Fissure – linear cracks Scale - excess shedding of dead keratinized tissue Scar – abnormal formation of connective tissue Ulcer – irregular, crater-like loss of epidermis &

dermis Atrophy – depression in skin from thinning of the

epidermis or dermis Excoriation – area where epidermis is missing,

exposing dermis

Mongolian spots

Mongolian spots are areas of bluish-black hyperpigmentation that most frequently occur over the lumbosacral area of dark-skinned infants.These areas are normal skin variations and tend to fade as the child gets older.

The presence of Mongolian spots should be included as a part of the child's documentation. Mongolian spots can be misdiagnosed as bruises, commonly found in child abuse.

Are found in 80-90 % of African-American and Asian and Hispanic American babies

Mongolian spots

Nursing Diagnoses

Impaired skin integrity Situational low self esteem Ineffective health maintenance Altered body image Social interaction, impaired

Common Benign Conditions

Pruritis Psoriasis Acne

Pruritis

Itching If a chronic problem…

– C/S of scrapings– Fungal studies– Cutaneous patch testing

Pharmacology– Antihistamines, Tranquilizers, and

Antibiotics

Pruritis

– Nursing Intervention• Therapeutic baths

– Aveno, colloid , alpha-keri

• Administer creams, pastes, or ointments• Comfortable, cool room temperature• Monitor skin for infection

Psoriasis

Chronic, noninfectious skin condition characterized by raised, reddened, round circumscribed plaques covered by silvery white scales. Size varies.

Cause unknown; some evidence supports autoimmune.

Stress, sunlight, hormonal fluctuations, and some medications can induce.

Psoriasis

Psoriasis

Pharmacology– Corticosteriods– Tar preparations-suppress miotic activity

Amevive (alefacept) injection- suppress rapid turnover of epidermal cellsAntimetabolites (Methotrexate)

Treatments– Sunlight– Ultraviolet Light Therapy-decreases the growth

rate of epidermal cells

ACNE

Acne vulgaris effects 85% of the population. The peak incidence is age 17 to 18 years of age. Family history, premenstrual flares, and sometimes stress can cause a flare up.

Cosmetics containing lanolin, petrolatum, vegetable oils, lauryl alcohol, butylsterate, and oleic acid can increase comedome production. Exposure to oils in cooking grease can be a precursor in adolescents.

Acne

Acne is a disease that involves the sebacceous glands & hair follicles of the face, neck, chest, and upper back..

Characterized by comedones & inflammatory lesions

Adequate rest, moderate exercise, a well-balanced diet, reduction of emotional stress, and elimination of any foci of infections are all part of general health promotion.

AcneAcne

three-year-old child with large acne

Acne

Retin-A is the only drug that disrupts the abnormal follicular keratinization that produces microcomedones. It is available in cream, gel, or liquid. A pea-sized dot of medication is used. It should not be applied until 30 minutes after washing face to prevent burning.

Topical benzyl peroxide is antibacterial and can be

used to treat mild cases. The medication can have a bleaching effect on sheets and clothes.

Other antibacterials used topically are Clindamycin, Erythromycin and Metronidazole. When combined with benzyl peroxide, glycolic acid or Retin-A penetration improves

Acne

Accutane is a potent and effective oral agent. It decreases sebum production. This medication needs to be managed by a dermatologist. Adolescents with multiple, active, deep dermal or subcutaneous cyctic and nodular acne lesions are treated for 20 weeks.

Side effects include dry skin, dry mucous membranes, nasal irritation, dry eyes decreased night vision, photosensitivity, arthralgia, headaches, mood changes, depression, and suicidal ideation. The most significant is tetragenic effects. It is contraindicated in pregnancy. If the young women are sexually active, they must be on some kind of contraceptive. Tetracycline longterm

Acne

Gentle cleansing with a mild cleanser once or twice daily is needed. Antibacterial soaps are not effective and may cause drying.

Nursing care is focused on supportive and

educating the child and parent. Teenagers need to understand that it takes 4 to 6 weeks to see improvement.

Infections of the Skin

Bacterial, Viral & Fungal

Bacterial Infections

Impetigo- Staphylococcus. Reddish macule, vesicle, then erupts. Dries to a honey-colored crusts. Topical, oral, or IV antibiotics.Contagious. Seen in toddler and preschool.

Folliculitis-Staph aurous. Pimple- infection of hair follicle. On legs of women or bearded faces of men. Contagious. Never pop or squeeze.


Furnucle-Boil. Larger lesion with more redness and edema . Painful. Moist compress

Systemic antibiotics. Contagious. Never pop or squeeze

Carbuncle-Multiple boils. Wide spread inflammation. Moist compress. Systemic antibiotics. Never pop or squeeze.

Treatment: good hand washing, antibiotics, good hygiene, warm compresses


Cellulitis – inflammation of subcutaneous tissue following break in skin -Caused by staph of strep. Treat with anitbiotics

Erysipelas – involved the dermis – Caused by strep. Treatment is IV antibiotics (PCN usually) to prevent septicemia

Cellulitis of face

Viral Infections

Warts (Verrucae) – caused by HPV (human papilloma virus).– Common wart – fingers– Planter warts – soles of feet– Flat wart – forehead – Condylomata acuminata – venereal warts– Treatment

• Salicylic acid, Cyrotherapy, Liquid Nitrogen

Viral – Herpes Simplex

Vesicle type lesion Type 1 – above the waist – cold sores Type 11 – below the waist – STD, Genital

herpes Signs/Symptoms – burning, tingling Diagnosed with Tzanck smear – identifies

herpes but doesn’t differentiate between simplex & zoster

Treatment – Zovirax (Acyclovir), moist compresses & white petrolatum

Herpes Simplex – Clinical Manifestations

In newborn infants, HSV infection can manifest as the following:

(1) disseminated disease involving multiple organs, most prominently liver and lungs;

(2) localized central nervous system (CNS) disease; (3) disease localized to the skin, eyes, and mouth.

Neonatal herpetic infections often are severe, with attendant high mortality and morbidity rates, even when antiviral therapy is administered. Recurrent skin lesions are common in surviving infants and can be associated with CNS sequelae if skin lesions occur frequently during the first 6 months of life.

Herpes Simplex – Clinical Manifestations CHILDREN BEYOND THE NEONATAL

PERIOD AND ADOLESCENTS. Most primary HSV infections are

asymptomatic. Gingivostomatitis, which is the most common

clinical manifestation in this age group, usually is caused by HSV type 1 (HSV-1). – fever, irritability, tender submandibular adenopathy,

and an ulcerative enanthem involving the gingiva and mucous membranes of the mouth, often with perioral vesicular lesions.

Copyright ©2006 American Academy of Pediatrics

Red Book Online Visual Library, 2006. Image 060_57. Available at: http://aapredbook.aappublications.org/visual. Accessed November 29, 2007

Herpes Simplex. This is a close-up of a herpes simplex lesion of the lower lip on the 2nd day after onset. Also known as a cold sore, this lesion is caused by the contagious herpes simplex virus Type-1 (HSV-1), and should not be confused with a canker sore, which is not contagious. The

HSV-1 virus remains in the body throughout an exposed personâ€™s entire life.



Herpes Simplex. Herpes simplex stomatitis, primary infection of the anterior oral mucous membranes. Tongue lesions also are common with primary herpes simplex virus infections.



Herpes Simplex. This 7yr. old child with a history of recurrent herpes labialis presented with a periocular herpes simplex vesicular outbreak.



Herpes Simplex. The patient with extensive eczema herpeticum and primary herpetic gingivostomatitis.



Herpes Simplex. Herpes Simplex. Neonatal herpes simplex skin lesions.

Viral – Herpes Zoster

AKA Shingles Caused by varicella zoster which also

causes chickenpox Painful Treatment – Acyclovir & Narcotics Isolate from people who have not had

chickenpox

Fungal Infections Candidiasis – caused by Candida albicans

– Occurs with immunosuppression & following antibiotics, T-lymphocytes dysfunction, other immunologic disorders, and endocrinologic diseases

– Candida albicans is ubiquitous. Like other Candida species, C albicans is present on skin and in the mouth, intestinal tract, and vagina of immunocompetent people.

– Clinical Manifestations: Mucocutaneous infection results in oral-pharyngeal (thrush) or vaginal candidiasis.

Candidiasis (Moniliasis, Thrush)

Candida (thrush) infection in a 1-week-old neonate. Candida albicans (thrush) infection of the tonsils and uvula of

an otherwise healthy 6-month-old infant. The white exudate may resemble curds of milk.

Severe Candida diaper dermatitis with satellite lesions ↓

Candida (monilia) rash with typical satellite lesions in an infant boy.

Fungal Infections – the “tineas”

Etiology : dermatophytes, a group of closely related fungi that invade the outer keratin layer of the skin and its appendages, the hair and nails

Tinea pedis – athlete’s foot Tinea capitis – scalp ringworm Tinea corporis – body ringworm Tinea cruris – groin – jock itch Treatment – antifungal cream or solution,

Griseofulvin, Diflucan Contagious


Red Book Online Visual Library, 2006. Image 132_08. Available at: http://aapredbook.aappublications.org/visual. Accessed August 31, 2007

Tinea Capitis (Ringworm of the Scalp). Three-year-old male with a Tinea lesion on the occiput for 1 month. The mother had been applying a topical antifungal agent but the lesion became

progressively larger. The patient was treated successfully with griseofulvin.


Red Book Online Visual Library, 2006. Image 132_09. Available at: http://aapredbook.aappublications.org/visual. Accessed October 19, 2007

Tinea Capitis (Ringworm of the Scalp). An 8-year-old boy with a bald spot, hair loss, and enlarging posterior cervical lymph node for 2 weeks. The node was described as tender, not fluctuant, and without erythema of the overlying scalp. The area of hair loss was boggy and

fluctuant. The patient responded well to treatment with griseofulvin.


Red Book Online Visual Library, 2006. Image 132_17. Available at: http://aapredbook.aappublications.org/visual. Accessed October 19, 2007

Tinea Capitis (Ringworm of the Scalp). Photograph of an individual with ringworm, or tinea capitis of the scalp caused by Microsporum gypseum. Although it is rare, M gypseum, a natural

soil habitant, can cause tinea on humans and animals. This fungus usually produces a single inflammatory skin lesion which has scaly patches and hair loss, or broken hair shafts.

Treatment

Griseofulvin, the agent most commonly used to treat tinea capitis is better absorbed in the presence of fatty foods.

Caregivers should be taught to administer the medication with foods high in fat such as peanut butter or ice cream to enhance the drug's effectiveness.

Children receiving griseofulvin for longer than three months should receive laboratory testing for leukopenia, anemia, and elevated liver enzymes.

INFESTATIONS

Infestations from pediculosis and scabies are among the most prevalent communicable diseases that affect children.

Pediculosis CLINICAL MANIFESTATIONS: Itching is the most common symptom, but many children are

asymptomatic. Adult lice or eggs (nits) are found in the hair, usually behind the

ears and near the nape of the neck. Excoriations and crusting regional lymphadenopathy. In temperate climates, head lice deposit their eggs on a hair

shaft 3 to 4 mm from the scalp. Because hair grows at a rate of approximately 1 cm per month, the duration of infestation can be estimated by the distance of the nit from the scalp.

ETIOLOGY: Pediculus humanus capitis is the head louse. Both nymphs and adult lice feed on human blood.


Red Book Online Visual Library, 2006. Image 095_04. Available at: http://aapredbook.aappublications.org/visual. Accessed December 9, 2007

Pediculosis Capitis. Head lice (nits on hair shaft).



Pediculosis Capitis. Head louse, baby louse, and hair.



Pediculosis Capitis. Nits on the hair shaft.

Pediculosis: treatment Permethrin (1%): over-the-counter 1% cream

rinse that is applied to the scalp and hair for 10 minutes after washing and towel drying the hair. – repeated application 7 to 10 days later is necessary. – advantages : a low potential for toxic effects and a

high cure rate. – Do not rewash the hair for I to 2 days following

treatment.

Lindane (1%). An organochloride available only by prescription. It should be used as second-line treatment on the basis of safety concerns. It must be rinsed out no longer than 4 minutes after application and should not be used more than once to treat a lice infestation

Pediculosis: treatment

the hair should be thoroughly combed to remove all nits and lice.

A fine-toothed comb, often included in the pediculocide package, should be used.

An application of 50% distilled white vinegar and 50% water or formic acid solution prior to combing may aid in loosening the nits from the hair shaft.

Pediculosis Isolation Of The Hospitalized Patient: In addition to

standard precautions, contact precautions are recommended until the patient has been treated with an appropriate pediculicide.

Household and other close contacts should be examined and treated if infested.

Bedmates and immediate members of the household of infested individuals should be treated prophylactically.

Children should not be excluded or sent home early from school because of head lice. "No-nit" policies requiring that children be free of nits before they return to child care or school have not been effective in controlling head lice transmission and are not recommended

Common Allergic Conditions

Contact dermatitis - Hypersensitivity response/ chemical irritation, i.e Latex glove allergy

Urticaria – allergic phenomena causing hives

Treatment – remove the irritant & give antihistamines

Atopic DermatitisAtopic Dermatitis

A chronic, relapsing inflammation of the dermis and epidermis resulting in itching, edema, papules, erythema, excoriation, serous discharge, and crusting.

Although atopic dermatitis is commonly known as "eczema," it actually is one disease in a group of eczematous conditions.

Is associated with allergy with a hereditary tendency

Atopic DermatitisAtopic Dermatitis Cause unknown, thought to be related to IgE, T

lymphocytes, monocytes, and other inflammatory cells.

The prime cause is food allergy. A child who is born with a tendency towards allergy can become sensitized to any number of food through breast milk. For the infant who is not breast-fed, the situation is very complicated if he or she becomes allergic to cow's milk at an early stage.

About 10% of the population has been affected by atopic dermatitis at some point in their lives compared with 2-5% in 1960

Most common in infants and young children (75%). Increased risk for associated asthma or hayfever

Familial history: foods, cold weather, stress can be the cause

Atopic DermatitisAtopic DermatitisClinical signsClinical signs: pruritus and scratching. lack of adequate sleep dryness and roughness on the young infant's

skin erythema, and papules develop after the skin

has been irritated. excoriation, and subsequent serous

discharge and crusting. African-Americans are more likely to have

follicular and papular lesions.

Atopic DermatitisAtopic Dermatitis Lesions present in three stages:

Acute lesions – extremely pruritic erythematous papules, which

may occur with excoriation, erosion, serous exudate, and crusting.

Subacute stage:– the papules are excoriated with fine scaling. Mild

lichenification, or thickening of the skin with exaggeration of its normal markings

Chronic phase:– marked lichenification, fibrotic papules and hyper-

or hypopigmentation

Atopic infant. The infant with atopic dermatitis is often quite

unhappy, the skin is very itchy, and sleeping is difficult.

Hyperlinear palms and lichenification. Atopic patients often

develop accentuation of the palmar creases.

Factors associated with exacerbationof atopic dermatitis

• Dust mites • Pets/animal dander • Pollens • Soaps/detergents • Food allergies • Changes in climate and temperature • Sweating • Infections • Textiles • Emotional stressors

Treatment Food allergy test Correct the diet Strengthen the immune system Inhibit inflammatory chemicals Deal with the itch, to prevent secondary infection from

scratchingDietDiet

Avoid food which cause any allergy. Avoid all processed, refined food in cans and packages. Reduce intake of meat, eggs and dairy products. Drink organic honey or other organic health products.

CareCareAvoid cosmetics, harsh soap and shampoo. Get more rest and

exercise. There are organic skin care at livelifeorganic too.

The EndThe End

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Nursing Care Of Children With Cellular and Integumentary Problems Dr. Nataliya Haliyash Nursing Care of Children