pediatric nursing

1. Infectious
Disease in
Children
 Joyce Buck, PhD(c), MSN, RN-C, CNE
 Joy A. Shepard, PhD, RN-C, CNE

2. Learning Outcomes
 Describe structure and function of the immune system
 Explain why children are more vulnerable than adults to
communicable diseases
 Describe process of infection and modes of transmission
 Summarize role of vaccines in reduction and elimination of
communicable diseases
 Prepare a nursing care plan for children of all ages needing
immunizations
 Differentiate common communicable diseases
 Describe medical and nursing management of common
communicable diseases
2

3. Infection Definition
 Invasion and multiplication of microorganisms in or
on body tissue that produce signs and symptoms as
well as an immune response
 Such reproduction injures the host by causing cell
damage from microorganism-produced toxins or
intracellular multiplication or by competing with the
host metabolism
3

4. Immune System
 Prevent entry of or removal of foreign substances
 Body’s innate (natural) defenses
 Skin, body pH, maternal antibodies, inflammatory
response, phagocytic response
 Natural killer cells: attack infected cells
 Complement proteins: work with antibody activity
4

5. Immune Response
 Normally the immune system responds to an
invasion of foreign substances, or antigens, in
numerous ways.
 It produces antibodies, or proteins that work
against antigens, the foreign substances that trigger
the immune response.
 The immune system also produces other types of
cells, such as T –lymphocytes and natural killer (NK)
cells
5

6. Types of Immune Protection:
Natural (Innate)
 This protection, present at birth, isn’t learned and
doesn’t depend on previous contact
 Natural immunity includes barriers against disease,
such as skin and mucous membranes, and
bactericidal substances of body fluids, such as
intestinal flora and gastric acid
 Some species are naturally immune to some
diseases
6

7. Types of Immune Protection:
Naturally Acquired Active
 Person’s immune system works to produce
antibodies
 Immune system produces antibodies after exposure
to disease (requires contact with the disease)
 This protection lasts for life
 The risk of the child developing adverse effects is
high because he contracts the disease
7

8. Types of Immune Protection:
Artificially Acquired Active
 Person’s immune system works to produce
antibodies
 Medically engineered substances are injected to
stimulate the immune response against a specific
disease
 All immunizations are included
8

9. Types of Immune Protection:
Naturally Acquired Passive
 Fetus/baby receives mother’s antibodies
 No active immune process is involved; the
antibodies are passively received
 Occurs during pregnancy, in which certain
antibodies (immunoglobin G) are passed from the
maternal into the fetal bloodstream
 Also occurs during breast-feeding
9

10. Types of Immune Protection:
Artificially Acquired Passive
 Person is given someone else’s antibodies
 Short-term immunization by the injection of antibodies, such as
gamma globulin, that are not produced by the recipient's cells
(no stimulation of immune response)
 The antibodies provide immediate protection that lasts for weeks
or months
 Examples: Intravenous gamma-globulin to treat Kawasaki
disease; Synagis (palivizumab) monoclonal antibody (IM) to
prevent respiratory syncytial virus (RSV) in children at high risk
of RSV disease
10

11. Acquired Immunity
 Humoral
 Antibodies (created by
B-lymphocytes)
 Cell-Mediated
 T-cells (mature in
thymus)
 Assist B-lymphocytes to
make antibodies
11

12. Figure 22-1 The primary immune response encompasses a cascade of events that involve
humoral and cellular immunity.
12

13. Humoral Immunity
 Responsible for destroying bacterial antigens
 B Lymphocytes, produced in the bone marrow, gut,
& other lymphoid tissue, are the central factor in
humoral immunity and develop into plasma cells that
produce antibodies
 Antibodies are a type of protein called
immunoglobulins (IgM, IgG, IgA, IgD, & IgE)
13

14. Immunoglobulins
 IgM, IgG, & IgA act to control a number of body
infections
 IgE useful in combatting parasite infections and part
of the allergic response
 The role of IgD is unknown
14

15. Table 22-1 Classes of Immunoglobulins
15

16. Primary Immune Response
 When a child is 1st exposed to an antigen, the B-
lymphocyte system begins to produce antibodies
that react specifically to that antigen
 Takes ~ 3 days
16

17. Secondary Immune
Response
 Subsequent encounters with the antigen trigger
memory cells
 Occurs within 24 hours
17

18. Cell-Mediated (Cellular)
Immunity
 Uses T-Lymphocytes, produced mainly in the
thymus, to provide cellular immunity and protect
against most viruses, fungi, slowly developing
bacterial infections, such as TB, and tumors
 Also control timing of response in delayed
hypersensitivity reactions, such as PPD test
 Also responsible for rejection of foreign grafts, such
as transplants
18

19. Types of T-Lymphocytes
 Killer T cells
 Suppressor T cells-inhibit B-Lymphocytes from
differentiating into plasma cells
 Helper T cells-aid in the proliferation & immunologic
function of other cells
19

20. Infant Vulnerability to
Infection
 Immune system not fully developed
 Maternal antibodies offer limited protection
 Diminishes with time
 Immunization protection incomplete
20

21. Children’s Vulnerability
to Infection
 Developing immune system
 Exposure to infections from
others
 Close contact with adults,
other children
 Poor hygiene habits
 Encourage handwashing
 After toileting, before eating
 Use disposable tissues
 Educate adult caregivers
21

22. Disease Transmission
 Direct or indirect transmission
 Three factors required for disease to occur
 Infectious agent (pathogen)
 Effective means of transmission
 Susceptible host
22

23. Chain of Infection
 Infectious/ Causative agents
 Any microbe that can produce disease
 Bacterial, viral, fungal, protozoan
 Reservoir
 Environment or object in or on which a microbe can survive and, in
some cases, multiply; can be an inanimate object, a human being, an
animal, or an insect
 Portal of exit
 Path by which an infectious agent leaves its reservoir; usually it’s the
site where the organisms grow; portals of exit associated with human
reservoirs include the respiratory, genitourinary, and GI tracts; the
skin and mucous membranes; and the placenta
 Excretions, secretions
23

24. Chain of Infection Cont’d…
 Mode of transmission
 Means by which the infectious agent passes from the portal of exit in
the reservoir to the susceptible host; infections may be transmitted by
one of four modes:
 Contact, Airborne, Enteric (Oral-Fecal), Vector-borne
 Vector: animal, human, object
 Portal of entry
 Path by which an infectious agent invades a susceptible host
 Membranes, eyes, nose, skin, blood
 Susceptible host
 Required for the transmission of infection to occur; an infectious
agent is more likely to invade the body of a weakened host rather
than a healthy one and launch an infectious disease
24

25. An effective chain of infection transmission requires a suitable habitat or
reservoir for the pathogen. To prevent or control the spread of infection, one of
the links in the chain must be broken, such as eliminating one or more of the
habitats or reservoirs (e.g., insecticide spraying to kill mosquitoes that carry
malaria). Isolating an infected individual interferes with disease transmission,
and killing the pathogen eliminates the causal agent.
25

26. Iatrogenic (Nosocomial)
Infections
 Acquired due to treatment
 Contaminated equipment
 Nonsterile technique
 Contact with other children in clinical setting
26

27. 27

28. Infection Control Measures
 Prevent Systemic Infections
 Hand hygiene
 Sterile technique: invasive procedures
 Isolation as needed
 Promote Skin Integrity
 Promote Nutritional Balance
 Manage Medications
 Emotional Support
28

29. Infectious diseases are easily transmitted in
settings such as childcare centers where
multiple children handle common objects and
then put fingers in their mouths.
29

30. Stages of Infection
 Incubation
 The disease may develop almost instantaneously, or this
period may last for years
 During this time, the pathogen is replicating, and the
infected person is contagious and can transmit the
disease
 Prodromal stage
 This stage occurs after incubation
 The still-contagious host complains of feeling unwell;
complaints are vague
30

31. Stages of Infection Cont’d…
 Acute illness
 Microbes are actively destroying host cells and
affecting specific host systems
 The patient recognizes which area of the body is
affected; complaints become more specific
 Convalescent stage
 The body’s defense mechanisms have begun to
confine the microbes, and damaged tissue is healing
31

32. Infectious Process
 Organisms in body
 Multiply within body
 Bacteria, fungus, protozoa
 Production of toxins
 Infect cells
 Virus forces cells to replicate virus
32

33. Body’s Response to Infection
Neutrophils-
phagocytic cells
that defend against
bacteria
33

34. Body’s Response to Infection
 Complement system proteins-component of blood
serum consisting of 11 protein compounds; activates
in response to antigen-antibody functions, resulting
in a generalized inflammatory reaction that kills
foreign cells
 Also plays a role in causing some autoimmune
diseases
34

35. Body’s Response to Infection
 Immune cells also secrete proteins called cytokines
that carry messages for immune system function
 Lymphocytes, monocytes, & macrophages all
secrete cytokines that have a variety of effects on
the target cells
35

36. Body’s Response to Infection
 Macrophages - ingest antigens and signal T-cells
that antigens are present
36

37. Body’s Response to Infection
 Fever
 Macrophages release endogenous pyrogens
 Hypothalamus releases prostaglandins
 Body temperature rises
 Heat speeds immune response
37

38. Pediatric Differences
 Infants & children have differing amounts of some
immunoglobulins
 IgG is the only immunoglobulin that crosses the
placenta
 As a result, a newborn’s levels are similar to those of
the mother
 This maternal IgG disappears by 6-8 months
 Infant’s IgG increases gradually til mature levels are
reached at 7-8 years
38

39. Pediatric Differences
 IgM levels are low at birth, rise markedly at 1 week
of age, & continue to increase til adult levels are
reached around 1 year
 IgA & IgE are not present at birth
 Manufacture of those begins by 2 weeks of age
 Normal levels are not achieved til around 6-7 years
39

40. Figure 22-2 Different types of immunoglobulins mature at variable times throughout childhood.
Children have high levels of some types of immunoglobulins, while others may be low at certain
periods during development.
40

41. Pediatric Differences
 Cell-mediated immunity achieves full function early
in life
 Early in fetal life, the thymus begins producing T
cells
 By birth, many of these cells are present
 The thymus is large at birth, grows during childhood,
reaches peak size just before puberty, then
decreases in size
41

42. Pediatric Differences
 Other lymphoid tissue, such as the spleen & tonsils
are also comparatively large in young children
 Newborns have somewhat lower numbers of natural
killer (NK) cells than older children & adults, which
decreases their ability to respond to certain antigens
 Levels of some complement proteins are lower in
newborns than in older children and adults, which
also delays & hampers their response to certain
infections
42

43. Infections: Management
 Diagnostic tests
 Culture and sensitivity
 Radiographs
 Treatment
 Drugs: antibiotics,
antifungals, antivirals
 Antibiotic overuse
encourages resistant strains
 Fever management
 Antipyretics
 Isolation precautions
 Hydration
 Skin/oral mucous-
membrane management
 Family support
43

44. Nursing Considerations
 Isolation: physical and psychosocial effects
 Types of isolation on the pediatric unit
 Teach parents
 Fever a symptom, not disease
 Infection prevention
 Home antibiotic administration:
 Give all; don’t share
44

45. Immunizations
45

46. Vaccines
 Introduce antigen
 Trigger antibody creation
 Create active immunity
 Introduce antibodies
 Create passive immunity
46

47. Types of Immunizations:
Live, Attenuated
 A live organism, grown under suboptimal conditions, results in
a live vaccine with reduced virulence
 Vaccine confers 90% to 95% protection for 20+ years with a
single dose
 Promotes full range of immunologic responses
 Vaccine inactivated by heat
 Examples: measles, mumps, and rubella (MMR) vaccine;
varicella vaccine
 Influenza intranasal spray (LAIV) (Live)
 Given to children older than age 5 without a history of chronic
lung disease (asthma)
47

48. Types of Immunizations:
Inactivated
 An inactivated vaccine offers a weaker response
than a live vaccine, necessitating frequent boosters
 A toxoid is treated with formalin or heat and
rendered nontoxic but still antigenic; it provides 90%
to 100% protection
 A killed vaccine doesn’t promote replication; it
provides 40% to 70% protection
 The diffusible fraction of a virus is the part of the
microorganisms capable of inducing immunity
48

49. Types of Immunizations:
Inactivated
 Examples of inactivated vaccines include the diphtheria
and tetanus toxoids, the Salk polio vaccine, the
pertussis vaccine, the hepatitis B vaccine, the hepatitis
A vaccine, and HPV
 Influenza IM injection (TIV)
 Given annually to children ages 6 to 59 months
 Vaccinate children age 5 or older if they are high risk
(heart disease, lung disease, diabetes, renal dysfunction,
immunosuppresion, long-term aspirin therapy, asthma, or
any other chronic illness)
49

50. 50http://www.cdc.gov/vaccines/parents/downloads/parent-ver-sch-0-6yrs.pdf

51. Vaccine Facts
 Save thousands from death and injury every year
 Do not harm immune system
 No links to autism, inflammatory bowel disease,
multiple sclerosis, asthma, diabetes
 Reduce risk of infection
 Do not eliminate risk
51

52. 52

53. Table 16-2 Common
Misconceptions About Vaccines
53

54. Nursing Care: Immunizations
 Assess
 Immunization record, current health
 Mild illness, fever not contraindication
 Potential contraindications
 Previous reactions
 Allergies to vaccine components
 Presence of serious medical condition/ pregnancy
54

55. Nursing Care: Immunizations
 Withhold the DTaP vaccine if the child has a progressive and
active CNS problem or has had a previous serious reaction
 Don’t vaccinate with a live virus if the child’s immune system
is suppressed or if he has received gamma globulin within the
past 6 weeks, is allergic to the contents of the immunization,
or has been on chemotherapy
 Don’t give the tuberculin purified protein derivative test (PPD)
and the measles vaccine at the same time; the measles
vaccine may make a tuberculosis (TB)-positive person appear
to be TB-negative
55

56. Nursing Care:
Immunizations
 Do place a reminder in the child’s health record to
alert health professionals about child’s need for
immunizations
 Do give vaccines when the child has a minor illness,
even with a low-grade fever and antibiotic treatment,
or has a recent exposure to an infectious agent
 Give multiple vaccines at the same time in separate
sites
56

57. 57

58. Nursing Diagnoses
 Risk for Infection
 Related to incomplete immunizations
 Knowledge Deficit
 Related to potential side effects
 Acute Pain
 Related to injections or anxiety
 Risk for Injury
 Related to vaccine reactions
58

59. Nursing Interventions
 Advocacy for immunizations
 Information: benefits, risks, side effects
 Written and verbal
 Obtain consent
 Be efficient and use topical anesthetic and comfort
measures
 Longer needles = fewer local reactions
59

60. Educate Parents
 Local pain, redness, & swelling are common; use ice
 APAP & NSAID’s for fever, joint pain, muscle aches,
& fatigue (1-2 days)
 S/S of severe allergic reaction: flushed face,
swelling of face, mouth or throat, wheezing or other
difficulty breathing, shock (confusion, lack of
movement or response, or unconsciousness),
abdominal cramping: call 911
60

61. 61

62. Give immunizations quickly and efficiently.
Do not prolong the wait and let fear grow.
The child will be anxious, especially if more
than one injection must be given.
62

63. Video: Doctor Perfected the
Method of Giving Children Shots
63

64. Immunization Documentation
 Date of immunization
 Vaccine given
 Manufacturer, lot #, expiration date
 Site and route of administration
 Name/title/address of nurse
 Information given to parents
 Immunization record, instructions for home
 Adverse effects: type, response
64

65. Communicable Diseases
65

66. Communicable Diseases
 Vaccines reduce incidence
 No vaccine for many other diseases
 Initial symptoms
 Fatigue, weakness, rash, fever, irritability,
tachycardia, vomiting, diarrhea, respiratory difficulties
 Vectors
 Contact with human, animal, polluted water
66

67. Infectious Diseases
 Children susceptible to
 Chickenpox, diphtheria, enteroviruses, fifth disease,
haemophilus influenza B, influenza, measles,
meningococcus, mononucleosis, mumps, pertussis,
pneumonia, poliomyelitis, roseola, rotavirus, rubella,
streptococcus A, tetanus
67

68. Rubeola (Regular Measles)
(p. 388)
 General information
 Acute, highly contagious infection that causes a
characteristic maculopapular rash
 Can be severe or fatal in patients with impaired cell-
mediated immunity; mortality highest in children younger
than age 2 and adults
 Caused by rubeola virus
 Spread by direct contact or by inhalation of contaminated
airborne droplets; portal of entry in the upper respiratory
tract
68

69. Rubeola (Measles)
69

70. Koplik Spots
70

71. Rubeola (Measles)
 Assessment findings
 Fever, periorbital edema, conjunctivitis
 Koplik’s spots (tiny gray-white specks surrounded by
red halo) on oral mucosa opposite the molars that
may bleed
 Red, blotchy rash that begins on the face and
becomes generalized
 Severe cough, rhinorrhea, lymphadenopathy
71

72. Rubeola (Measles)
 Complications
 Secondary bacterial infection
 Autoimmune reaction
 Bronchitis, otitis media, pneumonia
 Encephalitis
72

73. Rubeola (Measles)
 Nursing interventions
 Institute respiratory isolation measures for 4 days
after rash onset
 Encourage bed rest during the acute period
 Report measles cases to local public health officials
 Administer antipyretics for fever, as ordered
 Keep the child well-hydrated
 Dim lights
73

74. Mumps (Parotitis) (pp. 389-390)
 General information
 Acute inflammation of one or both parotid glands and
sometimes the sublingual or submaxillary glands
 Caused by a paramyxovirus found in the saliva of an
infected person
 Transmitted by droplets or by direct contact with the
saliva of an infected person
74

75. 75

76. Mumps (Parotitis)
 Assessment findings
 Myalgia
 Anorexia
 Malaise
 Headache, an earache aggravated by chewing, and pain
when drinking sour or acidic liquids
 Fever
 Swelling and tenderness of the parotid glands
 Simultaneous or subsequent swelling of one or more
other salivary glands
76

77. Mumps (Parotitis)
 Complications
 Epididymoorchitis
 Meningoencephalitis
 Male infertility (rare)
 Pancreatitis
 Transient sensorineural hearing loss (typically unilateral)
 Arthritis
 Nephritis
 Nursing interventions
 Apply warm or cool compresses to the neck area to relieve pain
 Report all cases of mumps to local public health officials
77

78. Rubella (German Measles)
(p. 392)
 General information
 Acute, mildly contagious viral disease that causes a
distinctive maculopapular rash (resembling that of
measles or scarlet fever and lymphadenopathy)
 Caused by rubella virus (a togavirus)
 Virus enters the blood stream, usually through the
respiratory tract
78

79. Rubella
79

80. Infant with Congenital Rubella
Syndrome
80

81. Rubella (German Measles)
 Assessment findings
 Rash accompanied by a low-grade fever
 Exanthematous, maculopapular, mildly pruritic rash;
typically begins on the face and spreads rapidly, covering
the trunk and extremities within hours
 Small, red, petechial macules on the soft palate
(Forschheimer spots) preceding or accompanying the
rash
 Suboccipital, postauricular, and postcervical lymph node
enlargement
81

82. Forschheimer Spots
82

83. Rubella (German Measles)
 Complications
 Arthritis
 Postinfectious encephalitis
 Thrombyocytopenia purpura
 Congenital rubella
 In fetal infection (rare after 20 weeks’ gestation):
intrauterine death, spontaneous abortion, congenital
malformations of major organ systems
83

84. Rubella (German Measles)
 Nursing interventions
 Institute isolation precautions until 5 days after the rash
disappears; keep an infant with congenital rubella in isolation
for 3 months, until three throat cultures are negative
 Keep the patient’s skin clean and dry
 Ensure that the patient receives care only from nonpregnant
caregivers who aren’t at risk for rubella; as ordered,
administer immune globulin to nonimmunized people who
visit the patient
 Report confirmed rubella cases to local public health officials
84

85. Varicella (Chickenpox) (p. 385)
 General information
 Acute, highly contagious infection that can occur at
any age
 Caused by the varicella-zoster virus, which also
causes herpes zoster (shingles)
 Transmitted through direct contact (primarily with
respiratory sections, less common with skin lesions)
and indirect contact (through airwaves)
85

86. 86

87. Varicella (Chickenpox)
 Assessment findings
 Fever
 Crops of small, erythematous macules on the trunk or scalp
 Macules progress to papules and then clear vesicles on an
erythematous base (so-called dewdrops on rose petals)
 Vesicles become cloudy and break easy; then scabs form
 Rash spreads to face and torso; less distribution of rash to extremities
 Rash is a combination of red papules, vesicles, and scabs in various
stages
 Ulcers on mucous membranes of the mouth, conjunctivae, and
genitalia
87

88. Varicella (Chickenpox)
 Complications
 With scratching due to severe pruritus: infection, scarring,
impetigo, furuncles, and cellulitis
 Reye’s syndrome
 Myocarditis
 Bleeding disorders
 Arthritis
 Nephritis
 Hepatitis
 Pneumonia
 Meningitis
88

89. Varicella (Chickenpox)
 Nursing interventions
 Institute strict isolation measures until all skin lesions have crusted
 Observe an immunocompromised patient for manifestations of
complications, such as pneumonitis and meningitis, and report them
immediately
 Provide skin care comfort measures (calamine lotion, cornstarch, oatmeal
baths, sponge baths, or showers); administer oral antihistamines (preferred
over topical itch medications)
 Keep the child’s fingernails short and clean
 Don’t give aspirin when a viral infection is suspected; the combination of
these may result in Reye’s syndrome, an acute encephalopathy with
cerebral cortex swelling but without inflammation, accompanied by impaired
liver function and hyperammonemia
 Advise the parents that the child can’t return to day care or school until all
the lesions are crusted
89

90. Fifth Disease (Erythema
Infectiosum) (p. 386)
 General information
 Contagious disease characterized by rose-colored
eruptions diffused over the skin, usually starting on
the cheeks
 Caused by human parvovirus B19
 Transmitted by way of the respiratory tract
90

91. 91

92. Fifth Disease (Erythema
Infectiosum)
 Assessment findings
 Mildly erythematous pharynx and conjunctivae
 Intensely red facial rash, forming a “slapped face”
appearance 4 to 7 days after resolution of symptoms
 Rash on extensor surfaces of extremities 1 day after
facial rash appears
 Rash on flexor surface and trunk 1 day later and
lasting 1 or more weeks
92

93. Fifth Disease (Erythema
Infectiosum)
 Complications
 Arthritis
 Arthralgia
 Myocarditis (rare)
 Encephalitis (rare)
93

94. Fifth Disease (Erythema
Infectiosum)
 Treatment
 Isolation isn’t necessary
 Cut the child’s fingernails to avoid injury from
scratching
 Provide lukewarm water baths with baking soda to
soothe itching
94

95. Head Lice (p. 998)
 Definition
 Also known as pediculosis
capitis
 A contagious infestation
with any of the small
wingless insect or lice
order of Anoplura
 It is estimated that 6 to 10
million children per year
are infected with lice
95

96. Head Lice
 Causes
 Sharing of clothing and
combs
 Close personal contact
with peers
96

97. Head Lice
 Pathophysiology
 Lice feed on human blood and lay their eggs (nits) in body hairs
 After the nits hatch, the lice must feed within 24 hours or die; they
mature in about 2 to 3 weeks
 When a louse bites, it injects a toxin into the skin that produces mild
irritation and a purpuric spot
 Repeated bites cause sensitization to the toxin, leading to more
serious inflammation
 Treatment can effectively eliminate lice
 Complications
 Excoriation
97

98. Head Lice
 Assessment findings
 Pruritus of the scalp
 Visual examination of lice
eggs, which look like white
flecks, firmly attached to hair
shafts
 Black specks at the base of
the hair
 Diagnostic test findings
 Diagnostic tests aren’t
necessary because
diagnosis is based on visual
examination
98

99. Head Lice
 Medical management
 Removal of lice and eggs using a fine-toothed comb
 Medications
 Permethrin (Nix) shampoos
 Pyrethrins (RID)
 Ulesfia 5% benzyl alcohol lotion
 Lindane – in resistant cases, TOXIC
 Malathion lotion (Ovide)
 Preventive drug therapy for other family members and
classmates
99

100. Head Lice
 Nursing interventions
 Carefully follow the manufacturer’s directions when applying
medicated shampoo (especially Lindane) to avoid
neurotoxicity
 Repeat treatment in 7 to 12 days to ensure that all eggs have
been killed
 Instruct the child’s parents to wash bed linens, furniture, hats,
combs, brushes, and anything else that came in contact with
the hair to prevent reinfestation
 Explain the importance of refraining from exchanging combs,
brushes, headgear, or clothing with other children
 Place stuffed toys in a sealed plastic bag for 2 weeks
100

101. 101

102. Scabies (p. 999)
 Definition
 Transmissible skin infestation with Sarcoptes scabiei
var. hominis (itch mite)
 Characterized by burrows, severe pruritus, and
excoriations
 Causes
 Transmissible by direct (skin to skin) contact or
contact with contaminated articles for up to 48 hrs
102

103. 103

104. Scabies: Pathophysiology
 Mites burrow into the skin on contact, progressing 2 to 3 mm
per day
 Females live about 4 to 6 weeks and lay about 40 to 50 eggs,
which hatch in 3 to 4 days
 Pruritus occurs only after sensitization to the mite develops
 With initial infestation, sensitization requires several weeks
 With reinfestation, sensitization develops within 24 hours
 Dead mites, eggs, larvae, and their excrement trigger an
inflammatory eruption of the skin in infested areas
104

105. Scabies
Complications
Excoriations
Secondary
bacterial infection
Abscess
formation
Septicemia
 Assessment findings
 Intense pruritus (↑severity at
night)
 Gray-brown threadlike burrows
(0.5 to 1 cm long) with tiny papule
or vesicle at one end
 Flexor surfaces of wrists, elbows,
axillary folds, waistline, nipples,
genitalia; in infants, the burrows
may appear on the head and neck
 Papules, vesicles, crusting,
abscess formation, and cellulitis
with secondary infection
105

106. Scabies: Diagnostic Test
Findings
 Examining scrapings from a burrow under the
microscope
 Wound culture demonstrating secondary bacterial
infection
 Mineral oil burrow-scraping reveals mites, nits, or
eggs, and feces or scybala
 Resolution of infestation with therapeutic trial of a
pediculocide confirms the diagnosis
106

107. Scabies: Medical
Management
 Bathing with soap and water before/ after treatment
 Scabicides or pediculicide in a thin layer over the entire skin surface;
application should be repeated in 1 week to ensure thorough treatment
 Permethrin, left on for 8 to 12 hours
 Lindane cream, left on for 8 to 12 hours
 Shouldn’t be used if the skin is raw or inflamed
 Applied from the neck down, covering the entire body
 Crotamiton (Eurax), left on for 5 days
 6% to 10% sulfur solution
 Systemic antibiotics
 Antipruritics
 In infants, include the head in treatment
 Avoid the use of topical steroids, which may potentiate the infection
107

108. Scabies: Nursing
Interventions
 Prevent secondary infection and spread of scabies
 Trim fingernails short
 Isolate the child until treatment is completed
 Use meticulous hand-washing technique
 BP cuffs sterilized in autoclave
 Decontaminate linens, towels, clothing, & personal
articles
 Disinfect the room after discharge
108

109. Scabies: Nursing
Interventions
 Administers medications as ordered
 Notify a child’s school of infestation
 Encourage verbalization of feelings
 Observe wound and skin precautions for 24 hours
after treatment with a scabicide
 Anticipate treating family members and close
contacts because parasite is transmitted by close
personal contact and through clothes and linens
109

110. Impetigo: Definition (p. 984)
 A contagious superficial bacterial skin infection
 Most commonly appears on the face and extremities
 Causes
 Bacterial infection from group A beta-hemolytic
streptococci; may also be due to staphylococci
 Spread by autoinoculation through scratching
110

111. 111

112. Impetigo: Pathophysiology
 Two types:
 May occur simultaneously and be clinically indistinguishable
 Nonbullous impetigo
 Eruption occurs when bacteria inoculate traumatized skin cells
 Lesions begin as small vesicles, which rapidly erode
 Honey-colored crusts surrounded by erythema are formed
 Bullous impetigo
 Eruption occurs in nontraumatized skin via bacterial toxin or
exotoxin
 Lesions begin as thin-walled bullae and vesicles
 Lesions contain clear to turbid yellow fluid; some crusting exists
112

113. Impetigo: Pathophysiology
 May complicate chickenpox, eczema, and other skin disorders marked by
open lesions
 Predisposing factors
 Poor hygiene
 Anemia
 Malnutrition
 Warm climate
 Most outbreaks occur in the late summer and early fall
 In the US, impetigo occurs most commonly in the Southern states
 Highly contagious until all lesions are healed
 The infection is spread by direct contact
 The incubation period is 2 to 5 days after contact
 Common in children ages 2 to 5
113

114. Impetigo: Complications
 Acute glomerulonephritis
 More likely to occur when many members of the
same family have impetigo
 Ecthyma (an infection that occurs usually as a result
of untreated impetigo; may be followed by
pigmentation and scarring of the skin)
 Exfoliative eruption (staphylococcal scalded-skin
syndrome) in neonates, infants, and children
younger than age 5
114

115. Impetigo: Assessment
Findings
 Painless itching
 Nonbullous impetigo
 Small, red macule or vesicle that becomes pustular within a few hours
 Lesions can occur anywhere, but usually occur on the face around the
mouth and nose
 Characteristic thick, honey-colored crust formed from the exudates
 Satellite lesions caused by autoinoculation
 Pruritus
 Burning
 Regional lymphadenopathy
 Infants and children develop aural impetigo or otitis externa; lesions usually
clear without treatment in 2 to 3 weeks, unless there is an underlying
disorder such as eczema
115

116. Impetigo: Assessment
Findings
 Bullous impetigo
 Thin-walled vesicle
 Thin, clear crust formed from exudates
 Lesions that appear as a central clearing
circumscribed by an outer rim
 Most commonly appear on the face or other exposed
areas
116

117. Impetigo: Diagnostic Test
Findings
 Gram stain of vesicular fluid showing infecting
organism
 Culture and sensitivity testing of exudates or
denuded crust showing infecting organism
 Elevated white blood cell count
117

118. Impetigo: Medical
Management
 Removal of exudates by washing the lesions 2 to 3
times per day with soap (or antibacterial soap) and
water
 Warm soaks or compresses of normal saline or a
diluted soap solution for stubborn crusts
 Prevention by using benzoyl peroxide soap
118

119. Impetigo: Medications
 Antibiotics for 10 days
 Penicillinase-resistant penicillins such as dicloxacillin
 Cephalosporins, such as cephalexin (Keflex)
 Azithromycin (Zithromax)
 Clarithromycin (Biaxin)
 Retapamulin (Altabax)
 Topical antibiotics for minor infections such as mupirocin
ointment (Bactroban)
 Antihistamines
 Therapy shouldn’t be delayed for laboratory results, which can
take up to 3 days
119

120. Impetigo: Nursing
Interventions
 Follow standard precautions
 Prevent secondary infection and the spread of
impetigo
 Keep fingernails short
 Cover the child’s hands if necessary
 Cover the lesions
 Encourage the patient not to scratch
 Use meticulous hand-washing technique
120

121. Impetigo: Nursing
Interventions
 Remove crusts by gently washing with bactericidal soap
and water
 Soften stubborn crusts with warm compresses
 Administer medications as ordered
 Remember to check for penicillin allergy
 Encourage verbalization of feelings about body image
 Comply with local public health standards and
guidelines
 Review the importance of not sharing towels,
washcloths, or bed linens with other family members
121

122. Ringworm (Dermatophytoses)
(p. 987)
 Fungal infections that affect skin, hair, or nails
 Spread: person-to-person, animal-to-person, indirect
contact with clothing or linens
 Diagnosis: microscopic examination of hair & scalp
scrapings (wet mount potassium hydroxide [KOH])
 See “Clinical Manifestations of Tinea Infections” (p.
988) – tinea capitis; tinea corporis; tinea cruris; tinea
pedis
122

123. 123

124. Ringworm: Nursing
Management
 All family members should be assessed
 Avoid contact with child’s hair & hair accessories
 Give oral griseofulvin with fatty foods (e.g., whole
milk, peanut butter) to enhance absorption
 Hair regrowth is slow and may take 6 to 12 months
124