Nursing Management of Skin and Parasitic Diseases

Nursing Management of Skin and Parasitic Diseases Objectives: At the end of this lecture, the student will be able to:  Define 4 skin and 2 intestinal parasitic diseases.  Discuss their etiology and mode of transmission.  List their specific signs and symptoms.  Describe their treatment and nursing management.

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Part A. Nursing Management of some Skin Diseases. 1. 2. 3. 4.

Skin diseases in children may be due to any of the following: Bacteria: as in impetigo contagiosa or miliaria. Fungus: as in Tinea. Chemicals: as in Diaper rash. Parasites: as in scabies or pediculosis.

I. Impetigo Contagiosa (or Impatigo Neonatorum) Definition: It occurs mostly in the newborn because of their lower resistance. It is a superficial localized infection of skin mostly in scalp, face, ear, and nose. It is caused often by staphylococcus and less often by streptococcus. It spreads among contacts by direct and indirect ways.

Signs and Symptoms: 1. Mild itching (in moist areas and body creases). 2. Vesicles, which become purulent rupture and form crusts. 3. These crusts fall off and leave usually no traces.

Treatment and Nursing Care: 1. If only a few lesions. Local treatment is enough. This includes:  Application of hot compresses with saline or starch, poultices help and remove the crusts.  Removal of crusts, in such a way to avoid bleeding and expose denuded skin to sunlight.  Application of bactericidal ointment as bactricin or neomycin, repeated sufficiently to keep lesions completely covered. 2. If extensive involvement, use of systemic antibiotic therapy as penicillin or tetracycline I.M. should be used in addition to local treatment. 3. Routine nursing care according to child’s needs. 4. Strict isolation technique.

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II. Millaria (Prickly Heat) It is caused by superficial bacterial infection after excessive sweating associated with:  Hot weather.  Fever.  Excessive clothing. It is a sign that the infant is covered too much. It affects any part especially face, neck, shoulders, and chest. There are:  Small erythematous papules and vesicles.  Itching.

Treatment and Nursing Care:  Cleanliness with warm water and very mild soap or none rinsing with clean water and drying carefully. Starch bath may relive itching (or starch compresses).  Calamine lotion may be used to soothe itching. It dries the skin as powder does, but doesn’t’ cake when it stay on the irritable area.  Avoid sweating.  Exposure affected area to free air.  Better no ointment, as skin should be kept clean and dry.

III. Ring Worm or Tinea Definition: Superficial fungus infection of skin. It is highly contagious (infectious).

Classification: It is classified according to part of body affected: 1. Ring worm of scalp or tinea capitis (almost limited to children, disappear at puberty). 2. Ringworm of skin or tinea corporis (or vrusis, if inguinal) 3. Ringworm of feet or tinea pedis (athelete’s foot).

Tinea Capitis: It is common among neglected children and is transmitted by human being. It may be also transmitted from an animal as dogs.

Clinical Manifestations:  Lesions are in form of circular patches about 2 inches diameter.  Base of hair is invaded by spores of fungus. It becomes brittle and breaks off, leaving area apparently bald.  Skin of area becomes scaly. The red scalp can be seen with grayish scales over bald areas.  Secondary infection in form of pustules of hair follicles may occur causing mild itching.

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Treatment and Nursing care:  Local treatment with strong antifungal ointment (white field’s ointment).  General treatment: Griseofulvin, orally gives good results.  Head should be covered with a cloth or skullcap. This should be washed and boiled daily to prevent spread of infection.

IV. Diaper Rash (Napkin Dermatitis) In infants, irritation or excoriation of skin beneath diapers is a common annoyance, which occurs when diapers are not changed immediately. It is more common in artificially fed babies.

Signs and Symptoms:  The buttocks may become red and shiny.  Distribution of lesion is conformed to area of soiling.

Causes: The causes may be classified into: 1. Causes related to diaper. 2. Causes related to skin hygiene. 1. Causes related to diaper:  Improperly washed or rinsed diapers.  Certain chemical in clothes as dyes, potash…etc.  Wearing nylon panties for long time.  The improper use of certain disposable diapers.  Unexposure of diapers to sunlight or ironing. 2. Causes related to child’s skin hygiene:  Irritating effect of moisture from sweat, urine or stool.  Burning errythema from organic acids from stools or from ammonia resulting from bacterial decomposition of urine.  Articles applied to baby’s skin (soap, cream, medications…ect).

Prevention of Diaper Rash: 1. Prevention related to diaper:  If using cloth diapers, use only overwraps that allow air to circulate.  Avoid rubber paints.  Change diaper as soon as soiled, especially with stool, whenever possible.  Use super absorbent disposable diapers to reduce skin wetness.  Rinse the diaper thoroughly with non-irritant soap and under clean water.  Avoid use of potash or clor in washing diapers.  Expose diapers to sunlight or ironing.  Avoid using colored diapers with dyes (white diapers made of cotton are the best).

2. Prevention related to skin:

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 Avoid overwashing the skin, especially with irritant soaps.  Apply ointment, such as Zinc Oxide or petrolitum, in thick layer to protect skin, especially if skin is very red or has moist open areas.  Expose healthy or only slightly irritated skin to air.

Treatment and Nursing Care:  Exposure of buttocks to warmth and air by placing a diaper under the infant and lying him on abdomen with shirt folded up above buttocks. If possible, expose area to sunlight or to warmth of an electric light bulb.  Good care of diapers.  Interfere with growth of bacteria producing ammonia by using vinger in rinsing diapers.  Plain cornstarch or cornstarch-based powder is safer.

Nursing Care Plan for the Child with a Skin Disorder: Nursing Diagnosis: Impaired skin integrity related to environmental agents, somatic factors, and immunologic deficit.

Patient Goal: Will exhibit signs of skin healing.

Nursing Interventions: Carry out therapeutic regimens as prescribed or support and assist parents in carrying out treatment plan to promote skin healing. Provide moist environment (ointment) for optimum healing. Administer topical treatments and applications. Administer systemic medications, if ordered. Prevent secondary infection, since these delay healing. Reduce external stimuli that aggravate condition, causing delay in healing. Encourage rest to support body’s natural defenses. Administer skin care and general hygiene measures to promote skin healing.

Expected Outcome: Affected area exhibits signs of healing.

Nursing Diagnosis: Risk for impaired skin integrity related to mechanical trauma, body secretions, and increased susceptibility to infection.

Patient Goal 1: Will maintain skin integrity.

Nursing Interventions: Keep intact skin clean and dry; cleanse skin at least once daily to minimize risk of infection. Inspect total skin area frequently for evidence of irritation or breakdown so that appropriate therapy can be initiated. Protect skinfolds and surfaces that rub together to prevent mechanical trauma to skin. Keep clothing and linen clean and dry to prevent excoriation and infection of skin.

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Apply protective lotion to anal and perineal areas, knees, elbows, ankles, and chin, since excoriation is most likely to occur in these areas. Carry out good perineal care under urine collection device when applicable to prevent impaired skin integrity. Remove adhesives and occlusive dressings carefully to prevent skin trauma.

Expected Outcome: Skin remains clean, dry, and free of irritation.

Patient Goal 2: Will exhibit no evidence of secondary infection.

Nursing Interventions: Maintain careful hand washing before handling affected child. Wear surgical gloves when handling or dressing affected parts if indicated by nature of lesion to prevent contamination of lesions. Teach child and family hygienic care and medical asepsis to prevent secondary infection. Devise methods to prevent secondary infection of lesion in small or uncooperative children. Keep nails short and clean to minimize trauma and secondary infection. Apply elbow restraints to prevent child from reaching skin lesions. Observe skin lesions for signs of infection (increased erythema, edema, purulent exudates, pain, increase temperature) so that appropriate therapy can be initiated.

Expected Outcome: Skin lesions remain confined to primary sites. Skin lesions exhibit no signs of secondary infection.

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V. Skin Parasites 1. Scabies It is a contagious skin disease, caused by the female itch mite (Acarus Scabiei). This parasite burrows itself in the skin for the purpose of depositing eggs. It is easily transferred from person to person.

Clinical Manifestation:  Parts of body involved are those in which skin is thin and moist, i.e. axilla, wrists, between fingers and toes, around abdomen and genitalia. In infants it may occur any where in body.  The lesion appears as dark blue lines indicating the path used by the itch mite to burrow itself, the color is due to its fecal deposits.  Severe itching.  Secondary infections with papules, vesicles and pustules.

Treatment and Nursing Care: This aims at: 1. Killing parasite.

2. Relieving itching.

Specific Treatment: Various preparations containing D.D.T. powder as: Benzyl benzoate, Benzne Hexachloride 33%. 1. A prolonged hot bath followed by 2-3 applications of any of these preparations, each one every 12 hrs. Twelve other hours after last application, another hot bath is taken. This is usually enough to get rid of infestation. 2. If this is not available, old fashion sulphur- ointment 5% may be used. 3. Broad-spectrum antibiotics to combat secondary infection. 4. Cut nails and prevent scratching. 5. It is important to discover all infected persons in the house hold and treat them simultaneously in order to kill the mites, and prevent return of disturbance. 6. All clothes must be dry cleaned or boiled.

2. Pediculosis It is the infestation of child with pediculi (lice). There are three types: 1. Pediculosis Capitis (of hair). 2. Pediculosis Pubic: pubic, in old people, in eyelashes or eyebrows in younger children. 3. Pediculosis Corporis (of body). Each type is caused by a different louse.

Pediculosis Capitis:

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Infestation of scalp, hair and occasionally eyelashes and eyelashes with pediculosis of hair. The lice dwell on the scalp, but deposit eggs or nits on shafts of hair: these are small oval, white greyish and can be seen by naked eyes.

Incidence: Common in neglected, unclean children, easily transferred from child to child in schoolroom or in overcrowded houses. More common in females (long hair).

Clinical Manifestations: 1. Severe itching of scalp, there is slight errythema and purpuric spots at site of attachment to scalp scratching them leads to excoriation, with serous, or sanguinous exudates. Crusts form. 2. Excoriation of face and neck. 3. Posterior cervical lymph glands become enlarged and infected from scalp lesions. 4. Pyogenic bacteria may infect scalp.

Treatment and Nursing Care: It aims at: 1. Killing pediculi.

2. Killing nits.

3. Bringing relief to

child. Modern treatment is effective and similar to treatment of scabies.  Various preparations containing DDT powder (Benzyl 2% Benzoate) ect… in form of two applications about 12 hours apart is usually enough. Or repeat as often as needed. It is better to cover child’s head. Recently, there have been specific shampoo (Hexachlorogamabenzen). The child’s head is washed for minutes. This is then repeated after 24 hours. Followed by fine combing of hair with fine comb.  Nits are destroyed by combing hair with fine toothcomb dipped in hot vinegar.  If hair is heavily infested, cut hair close to scalp.  Clothes and head’s covering should be dry cleaned or boiled and ironed.  They must be dusted with 10% DDT.  Antibiotics, if pustules appear on face and neck.  Children should be cautioned not to exchange hat or comb with other children.  Treat remained of family If infested.

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Nursing Care Plan for Child with Pediculosis Capitis: Nursing Diagnosis: Potential impaired skin integrity related to insect bites, scratching.

Patient Goal: Eradicate lice and nits.

Nursing Interventions: Apply, or teach family to apply, pediculicide shampoo or rinse. Read directions several times in quite environment before application. Make child as comfortable as possible during procedure. Playing “beauty parlor” adds a dimension of fun as well as providing eye safety. Use plastic drape to prevent drug getting on other body parts. Instruct child to shut eyes tightly during application; if irritation occurs, flush well with tepid water. Don’t use hair dryer. Use fine toothcomb on dry or slightly damp hair to remove empty nit cases. Stress importance of second application of pediculicide or shampoo. Contact community agencies for suggestions for reducing epidemics.

Expected Outcome: Child does not become infected with organism.

Nursing Diagnosis: Body image disturbance related to infestation.

Patient Goal: Reassure child and family.

Nursing Interventions: Launder washable items of clothing and linens in hot water and dry in dryer or hot setting for at least 20 minutes. Soak combs, brushes, and other hair utensils in pediculicide shampoo or lotion for 1 hour or in boiling water for 10 minutes (some advocate placing nonwashable, non-cleanable items in a tightly closed plastic bag that remains sealed for 14 days). Vacuum mattresses and upholstered furniture carefully; pediculosis sprays are not recommended.

Expected Outcome: Inspection of scalp reveals no evidence of lice or nits.

Goal 2: Prevent infestation/ reinfestation.

Nursing Interventions: Caution children against sharing combs, hats, caps, scarves, coats, or other items used on or near the hair.

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Explain or reinforce explanation of the condition and its mode of transmission. Treat family member with evidence of infestation. Allay child’s feelings of shame and embarrassment. Reassure family that anyone can get pediculosis with no association with age, cleanliness, and socioeconomic level. Caution family against cutting child’s hair or shaving head as treatment or punishment (cutting long hair may help with removal of nit cases).

Expected Outcome: Child accepts therapy with no evidence of self- consciousness.

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Part B. Nursing Care of some Intestinal Parasite’s Diseases I. Ascariasis Etiology: Ascaris Lumbricoides (round worm) is found commonly in lumen of small intestines.

Mode of Transmission: Ingestion of infective eggs. Eggs are present on toys, contaminating fingers, food, eating dirt when others who are contaminated have defected.

Clinical Manifestations:  Atypical pneumonia when larvae are in lungs.  Migrating larvae cause allergy as asthma or urticaria.  Eosinophilic (increase in Eosinophils, type of WBC).  Intestinal symptoms: - Nausea and Vomiting. - Anorexia and loss of weight.  Insomnia, nervousness, mild fever, irritability, physical and metal lethargy.  Intestinal colic, especially in small children.  Clumped worms may cause: 1. Intestinal obstruction. 2. Perforation of intestinal wall. 3. Intussusception. 4. Paralytic ileus.

Treatment: 1. Piperazine Citrate (Antepar). 2. Orally: 1- 3.5 gm according to child once daily for 2 consecutive days.

Prevention and Nursing Care:  Children and adults must be provided with clean, comfortable toilets. Children must be taught to use them for each defecation.  Wash hands after defecation and before feeding.  Careful washing of toy, raw vegetables.  All infected persons must receive treatment.  In hospital, teach mother about: 1. Careful disposal of stools. 2. Hygienic care and preventive measurs.

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3. Avoid overdosage of Piperazine citrate may cause irritation to intestinal mucosa). 4. Provide with calm environment and adequate diet.

2. Oxyuriasis (Enterobiasis) Also called thread worm. Seat worm of pinworm.

Etiology: It is a parasitic infection produced by pinworm (Enterobiua Vermicularis), which invades coecum and appendix. It is frequent where large groups of children are in close contact.

Mode of Transmission: It spreads by person-to-person contact. 1. It is usually from introduction of eggs by mouth. At night gravid worms migrate to anus. The child infests himself, by contaminating his hands when he scratches the itching skin around the anus or by handling contaminated bed clothes; sleeping garnments or objects. 2. Child may also become infected from breathing air born eggs. 3. Or from retroinfection (eggs ascend anus, then coecum when they mature). So usual route of reinfestations: Anus finger mouth. Anus clothing fingers mouth.

Clinical Manifestations: Are variable. We may find any of the following:  Itching around anus at night leading to irritability or restlessness.  Symptom of acute or subacute appendietitis.  Bacterial infection of skin from pruritus leading eczematous area.  Vaginitis graved worm enter vagina in girls, leads to insomnia, anorexia and loss of weight.  Easinophilia.  Chronic emotional disturbances.

Treatment: It aims at: - Destroying ova and worm in intestines. - Preventing reinfecton form other persons by treating all infected persons together by: 1. Piperzine citrate tablet, syrup 2 gm daily before breakfast for 8 days. 2. Pyrantel.

Nursing Care: 1. Mothers need to know how to prevent reinfection:

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 Child should wear a kind of glove over hands to at high prevent picking up eggs under fingernails as he scratches arms.  Cut nails as short as possible.  Hand hygiene, especially before meals and in morning and after defecation.  Child should wear tight panties or diaper to be unable to reach infested area.  Anus should be cleansed carefully with soap and water after each defecation and application of soothing ointment to relieve itching.  Toilet seat should be scrubbed daily.  Underclothing, bed linen, towels used to dry child should be boiled to destroy eggs. 2. In hospital, child should be prevented from coming in contact with other children. His bedpan should be cleansed and sterilized (disinfectant or boiled) after use. 3. Careful washing of hands of nurse caring for that child. 4. Teach mother about danger of overdosage of anthalmintic drug.

III. Other Intestinal Parasites Common in Children: A-Worms:  Hookworm (ancylostoma in duododenal).  Whipworm (Tricusis Trichuria).  Tapeworm (Taemia Saginata and other in meat proach too).  Gradia Lamblia (Contaminated during water). B-Bilharziasis: (Discussed in details in the 2nd year) schistosama and mansoni which is the first cause of death all over Egypt.

How to prevent Intestinal Parasitic Disease:  Always wash hands and fingernails with soap and water before eating and handling food and after feeding.  Discourage children from scratching bare anal area.  Use superabsorbent disposable diapers to prevent leakage.  Change diapers as soon as soiled and dispose of diapers in closed receptacle out of children’s reach.  Don’t rinse diapers in toilet.  Disinfect toilet seats and diaper- changing areas.  Drink water that is specially treated, especially if camping.  Wash all raw fruits and vegetables or any food that has fallen on the floor or ground.  Teach children to defecate only in a toilet, not on the ground.  Keep dogs and cats away from play grounds or sand boxes.  Avoid swimming in pools frequented by diapered children.  Wear shoes outside.

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