NCLEX-RN: Pediatric Nursing

Pediatric Nursing: Integumentary System

Focus topic: Pediatric Nursing

Pediatric Nursing: System Assessment

Focus topic: Pediatric Nursing

A. History of previous skin conditions, allergies.
B. Inspection.

  •  Observe skin odor (indicative of poor hygiene or infection).
  •  Assess color and pigmentation of skin (as normal within ethnicity, especially in areas less exposed to sunlight), and nail beds, sclera, conjunctiva, lips, and mouth (note cyanosis, pallor, jaundice, yellow or brown discoloration).
  •  Observe moistness of skin and mucous membranes.
  •  Inspect and palpate skin texture for scar tissue, turgor, edema, temperature, and lesions.

C. Note types of abnormal lesions.

  • Macule: small, flat, colored lesion.
  • Papule: small, solid, elevated lesion.
  • Vesicle: elevated lesion filled with fluid.
  • Nodule: larger solid form of papule.
  • Petechia: pinpoint hemorrhage in the skin.
  • Ecchymosis: bruise of variable size initially purple, fades to green and brown (there can be some variability in this process).
  • Tumor: abnormal mass.
  • Hives: eruption of itching wheals.

D. Observe for variations on skin, “birthmarks” in infants.

  • Mongolian spot (hyper pigmented nevi): large, flat, blue, black, or slate-colored area found on buttocks and lumbosacral area, more often in Asian children.
  • Salmon patch or “stork beak mark”: common in all races; flat, pink mark found on eyelids, nasolabial area, or at nape of neck. Most disappear by 1 year.
  • Strawberry nevus: begins as defined grayish, white area, becomes red, raised, well defined. May not be obvious at birth. Most resolve spontaneously by 9 years old.

E. Note distribution of lesions with other symptoms that occur simultaneously to assist with diagnosis.

Pediatric Nursing: System Implementation

Focus topic: Pediatric Nursing

A. Identify and treat cause of skin disorder.

  •  Record the size, shape, and distribution of skin lesions.
  • Note all other concurrent symptoms.
  • Evaluate child’s recent history, particularly medications, new foods, and exposure to communicable diseases.
  •  Isolate possible allergens and remove from environment.

B. Assist in reducing pruritus.

  •  Apply lotion (e.g., calamine lotion), cool compresses, or colloidal oatmeal bath to reduce itching.
  •  Administer antihistamine if ordered.
  •  Apply topical medication if ordered (steroid creams or antibiotic, anti-fungal preparations).

C. Note abnormal change in skin lesions.

  • Describe accurately the placement, size, shape, and distinguishing characteristics of all lesions.
  • Evaluate for changes on a routine basis.
  • Teach family to notify physician if any skin lesions such as birthmarks or moles change shape or color or start to bleed.

D. Observe and record any abnormal coloring.

  •  Describe cyanosis if present. Include location and under what conditions (e.g., during feeding) it occurred.
  • Check the child for other signs of cardiac or respiratory disease.
  •  Evaluate child’s laboratory values if pallor is present to determine presence of anemia. Ask for a 24-hour accounting of diet.
  •  Monitor jaundice for change.

E. Correct any abnormal texture.

  • For poor skin turgor:
    a. Increase the fluid intake.
    b. Monitor intake and output.
    c. Monitor specific gravity.
  • For edema:
    a. Establish and treat the underlying cause.
    b. Give meticulous skin care.
    c. Monitor intake and output.

F. Prevent secondary infections.

  •  Encourage the child not to scratch the lesions.
  •  Apply mittens to hands.
  • Keep child’s hands and nails clean with the nails trimmed.
  • Keep infant clean and dry. Change diapers frequently, apply appropriate protection from diaper rash.

G. Prevent allergic responses.

  •  Assist in obtaining an accurate environmental history including exposure to common household allergens, food, and medications.
  •  Educate the family on changes in the environment that are necessary.

H. Provide teaching and anticipatory guidance, especially in avoiding preventable skin conditions.

  •  Use of sunblock and minimizing exposure to sun.
  •  Signs of skin cancers.
  •  Avoidance of known irritants, maintaining good hygiene and overall health.

Pediatric Nursing

Pediatric Nursing: Skin Disorders

Focus topic:Pediatric Nursing

Pediatric Nursing: Acne Vulgaris

Focus topic: Pediatric Nursing

Definition: The presence of blackheads, whiteheads, and pustules usually found on face, chest, and back; due to plugging of sebaceous glands. Most commonly occurs at the onset of puberty when sebaceous gland activity increases (stimulated by androgens), enlarging and secreting increased amount of sebum.

A. The sebaceous glands become plugged and dilated with sebum.
B. When the enlarged gland is open to the skin surface an open comedo (blackhead) is formed.
C. If the gland does not have an opening, a closed comedo (white head) is formed, which can rupture inward causing abscesses and cysts (and scarring).
D. Propionibacterium acnes, a bacteria, adds to the inflammatory process.

A. Assess areas of inflammation and secondary infection.
B. Assess current self-care practices.
C. Evaluate impact of acne on body image and self-esteem.

A. Instruct adolescent to use gentle cleansing products such as Cetaphil or Neutrogena.
B. Do not use astringents and drying agents.
C. Use sunscreen especially with Accutane (isotretinoin) and Oracea (doxycycline).
D. Provide teaching on prescribed regimen.

  •  Topical medications comedolytic and bacteriocidal: Finacea (azelaic acid), Differin (adapalene), Retin A (tretinoin; vitamin A derivative), Relovox (benzoyl peroxide).
  • Topical antibiotic ointments/gels: Cleocin (clindamycin), Ilotycin (erythromycin).
  •  Advise adolescent that improvement may take several weeks.
  •  Oral antibiotics: Solodyn (minocycline) or Oracea.
  •  Accutane therapy for severe inflammatory acne: suppresses sebum activity and sebaceous gland activity.
    a. Teratogenic.
    b. Must have two negative pregnancy tests prior to starting.
    c. Need for use of two birth control methods if currently sexually active.
    d. Other side effects: cataracts, cheilitis, conjunctivitis, nosebleeds, depression, pruritus, and dry skin.
  • Estrogen therapy can be used instead of Accutane for young women.

E. Advise the client not to “pick and squeeze” the acne lesions, which may cause more scarring. Trained personnel can mechanically express comedones.
F. Provide support and reassurance that condition improves with age; promote self-esteem.

Pediatric Nursing: Impetigo

Focus topic: Pediatric Nursing

Definition: A skin infection usually caused by Staphylococcus. Usually begins as a scratch or scrape that becomes infected.

A. Assess for multiple macular-papular rash seen at various stages of healing.
B. Check rupture of papules, which produce honeycolored serous exudate and form a crust, or scab.
C. Assess location: usually found on face, head, and neck, but may spread over any part of the body.
D. May be superimposed on eczema.

A. Frequent cleansing with mild soap, may remove crusts.
B. Monitor topical [usually Bactroban (mupirocin) ointment and/or systemic antibiotic therapy (cephalosporins or penicillins if severe).
C. Cut nails to avoid scratching in infants and small children.
D. Document size and appearance of lesions.
E. Emphasize communicability of infection, maintaining thorough hand washing (child and caregiver) and overall good hygiene to avoid spread of infection.

Pediatric Nursing: Eczema (Atopic Dermatitis)

Focus topic: Pediatric Nursing

Definition: A superficial dermatitis generally seen in children with allergic tendencies. It usually begins with pruritic, erythematous, papulovesicular lesions and progresses to crusty, thickened areas.

A. Assess for erythema, papules, vesicles, often in the creases of skin, on cheeks.

B. Check drainage if crusting is present.
C. Assess for intense itching.
D. Look for symptoms in children 2 months to 5 years, but may be present in any age group.
E. Assess when symptoms appear; food allergens may place a role in exacerbations.
F. Stress can exacerbate outbreaks.
G. Evaluate family history.

A. Interventions aimed at reducing inflammation and pruritus and hydrating the skin.
B. Remove dust-carrying objects in environment (stuffed animals); eliminate molds, cigarettes, and other allergens. Avoid using wool products.
C. Use mild, unscented laundry products and soaps on the skin.
D. Keep the skin moist by applying emollients such as petroleum jelly (Aquaphor or Eucerin) while skin is still damp after bathing. Can wash using Cetaphil instead of soap and water.
E. Teach parents about symptomatic treatment of lesions.

  •  Topical corticosteroids (use lowest potency that is effective).
  •  Topical calcineurin inhibitors such as Protopic (tacrolimus) and Elidel (pimecrolimus) when topical corticosteroids are not effective for children 2 years old and above.

F. Prevent scratching; secondary infections may occur and require antibiotics.
G. May use antihistamines if pruritus is intense  Claritin (loratadine), Atarax (hydroxyzine), Benadryl (diphenhydramine).
H. Many children outgrow atopic dermatitis by adolescence.
I. Encourage breastfeeding for the first year and delay introduction of solids until 6 months of age.

Pediatric Nursing: Seborrheic Dermatitis

Focus topic: Pediatric Nursing

Definition: A chronic, recurrent dermatitis due to excessive sebaceous discharge, usually found on the scalp in infants (“cradle cap”) or eyebrows. Commonly occurs in infants, may be found in adolescents.

A. Appears as patchy lesions covered by yellowish, oily scales.
B. Observe for signs of secondary infection.

A. Prevent occurrence with improved hygiene.
B. When scales are present, shampoo with an antiseborrheic shampoo like Sebulex (contains sulfur and salicylic acid), Selsun (selenium), or Denorex (tar). Nizoral (ketoconazole 2%) shampoo has been reported to be safe in infants less than 12 months of age.

  •  Shampoo is applied to crusts and allowed to penetrate.
  •  After thorough rinsing, remove crusts gently with soft brush or fine-toothed comb.

C. More severe cases may require topical steroids and/ or antibiotic therapy.
D. Teach parents or adolescents the importance of good hygiene and frequent use of mild shampoos. Reassure that generally cases resolve easily with simple treatment.

Pediatric Nursing: Diaper Dermatitis (Diaper Rash)

Focus topic: Pediatric Nursing

Definition: Erythematous lesions and maceration in the diaper area caused by prolonged contact with urine or feces, chemical irritants, bacteria or fungi, or reactions to foods. Incidence peaks at 9–12 months of age; more common in bottle-fed infants.

A. Observe for reddened, macerated skin, with sharply demarcated edges on exposed surfaces.
B. Evaluate for signs of candidal infection, characterized by “beefy red” central erythema with satellite lesions.
C. Observe for secondary infection.
D. Assess current diapering habits and history.

A. Treatment focuses on teaching.

  • Discuss necessity of keeping area clean and dry. Change diapers as soon as soiled.
  • Avoid alcohol-based wipes and perfumed soaps.
  • Expose skin to air (not heat) for several minutes each day.
  • Apply barrier-type ointment such as Aquaphor when skin is dry.
  • If using cloth diapers, avoid plastic pants use over wraps allowing air to circulate.
  • If candidiasis is present, apply anti-fungal creams as prescribed.

B. Reassure parents that baby will become less irritable as rash clears.

Pediatric Nursing: Cellulitis

Focus topic: Pediatric Nursing

Definition: An infection in the subcutaneous tissue or dermis, usually caused by Staphylococcus aureus, or group A betahemolytic streptococci. Since the introduction of the HIB vaccine, Haemophilus influenzae type B infection occurs infrequently.

A. Observe for redness, swelling, and tenderness in area.
B. Evaluate systemic symptoms; fever, malaise, or enlarged lymph nodes.
C. X-ray evaluation to rule out osteomyelitis; blood cultures; CBC may be done.
D. Obtain vital signs; evaluate for fever, weight and height, aspiration, and culture of inflamed area.
E. Obtain history of injury and previous treatment.

A. Administer or supervise antibiotics.
B. Provide pain relief.
C. Apply warm compresses/soaks as ordered.
D. Administer IV antibiotics and monitor carefully if infection extensive or around eye (periorbital cellulitis).
E. Incision and drainage of cellulitis may be necessary. Community-acquired methicillin-resistant S. aureus (MRSA) cellulitis is common. Parenteral antibiotics that show sensitivity to the organisms are administered in the acute care setting.
F. Provide family support and discharge teaching.


Pediatric Nursing: Burns

Focus topic: Pediatric Nursing

A. Assess degree and extent of burn.
B. Assess prescribed treatment for burn.
C. Assess for complications associated with burns.

  • Fluid and electrolyte imbalances.
    a. In deeper wounds, edema appears around the wound from damage to capillaries.
    b. Loss of fluid at the burn area.
    c. On the second day, large loss of potassium.
    d. Objective of fluid therapy is to maintain adequate tissue perfusion.
  • Circulatory changes.
    a. Drop in cardiac output, initially.
    b. A decrease in blood volume occurs from loss of plasma protein into extra vascular and extracellular spaces.
    c. Moderate amount of hemolysis of red blood cells.
  • Pulmonary changes inhalation injury.
    a. Pulmonary edema.
    b. Obstruction of the air passages from edema of the face, neck, trachea, and larynx.
    c. Restriction of lung mobility from eschar on chest wall.
  •  Renal changes.
    a. Renal insufficiency caused by reaction to hypovolemic shock.

b. A decreased blood supply to kidneys results in decreased renal perfusion.
c. In burns of 15–20% of the body surface, there is a decreased urinary output that must be avoided or reversed.
d. Urinary tract infections are frequent.

  • Gastrointestinal changes.
    a. Acute gastric dilation.
    b. Paralytic ileus.
    c. Curling’s ulcer producing “coffee ground” aspirant.
    d. Hemorrhagic gastritis bleeding from congested capillaries in gastric mucosa.

A. Maintain optimum circulating fluid volume.
B. Relieve pain.

  •  Reduce anxiety and fear.
  •  Medicate appropriately before dressing changes or procedures.

C. Maintain pulmonary function.
D. Provide adequate nutrition.

  •  Give twice the normal amount of calories.
  •  Give three to four times the normal requirement for protein.
  •  Provide small, frequent, and attractive meals.
  •  Encourage child, who is frequently anorexic, to eat. Have parents bring foods from home.

E. Support ability to cope with lifelong disfigurement.

  • Support use of appliances to minimize scarring.
  •  Seek referrals for psychological problems associated with disfigurement.
  • Prepare child and family for common issues encountered with long-term plastic surgery.
  •  Minimize distortion of self-image and lowering of self-esteem due to disfigurement; encourage participation in group activities.

F. Design activities for the burned child while child is hospitalized.

  •  Actively involve the child (e.g., act out part of a story verbally).
  •  Provide television, books, and games.
  •  Allow the child to associate with friends.
  •  Reduce risk for impaired mobility adhere to physical therapy schedule.

G. Counsel parents.

  •  Parents and child have difficulty dealing with disfigurement and need assessment and interventions.
  •  Parents frequently feel guilty, although they are usually not at fault and need assistance working out these  feelings.
  •  Refer to appropriate support groups.
  •  Anticipatory guidance.





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