Nursing management of children with common disorders of skin, eye and ear, Lecture notes of Nursing

Download Nursing management of children with common disorders of skin, eye and ear and more Lecture notes Nursing in PDF only on Docsity! Nursing management of children with common disorders of skin, eye and ear Unit-16  skin disorders Scabies Definition Scabies is an endemic infestation produced by the scabies mite, sarcoptes scabies characterized by papules, vesicles, pustules with intense itching. Scabies Transmission/ etiology o Caused by human itch mite (Sarcoptes scabies). o Direct, prolonged, skin–to-skin contact o Sexual contact o Exposure is most common in nursing homes, hospitals, institutions, and day- care settings; can also be spread in households o Indirect transfer from clothing, towels and bedding o Transmission occurs as long as person is infested and untreated, including incubation period Pathogenesis The female S. scabiei var hominis mite lays 60-90 eggs in her 30-day lifespan, although less than 10% of the eggs result in mature mites. Eggs incubate and hatch in 3-4 days (90% of the hatched mites die). Larvae (3 pairs of legs) migrate to the skin surface and burrow into the intact stratum corneum to make short burrows, called molting pouches (3-4 days). Larvae molt into nymphs (4 pairs of legs), which molt once into larger nymphs before becoming adults. Mating takes place once, and the female is fertile for the rest of her life; the male dies soon after mating. Nursing management Nursing Assessment  History. Patient history can reliably suggest the presence of scabies; lesion distribution and intractable pruritus that is worse at night, as well as scabies symptoms in close contacts (including multiple family members  Physical examination: presence of lesions Nursing Diagnosis  Risk for infection related to tissue damage.  Impaired skin integrity related to edema.  Acute pain related to injury to biological agents.  Disturbed sleep pattern related to itchiness and pain of lesions Nursing Interventions To Prevent infection.  Wash hands and teach patient and SO to wash hands before contact with patients and between procedures with the patient;  Encourage fluid intake  Teach the patient, family, and caregivers, the purpose and proper technique for maintaining isolation  If infection occurs, teach the patient to take antibiotics as prescribed.  Instruct patient to take the full course of antibiotics even if symptoms improve or disappear. To Restore skin integrity • Monitor status of skin around wound • Monitor patient’s skin care practices, noting the type of soap or other cleansing agents used, temperature of water, and frequency of skin cleansing • Tell patient to avoid rubbing and scratching • Provide gloves or clip the nails if necessary • Instruct patient, significant others, and family in the proper care of the wound including hand washing, wound cleansing, dressing changes, and application of topical medications). To Relieve pain. • Acknowledge reports of pain immediately • Provide rest periods to promote relief, sleep, and relaxation • Provide analgesics as ordered, evaluating the effectiveness and inspecting for any signs and symptoms of adverse effects • Determine the appropriate pain relief method. Staphylococcal scalded skin syndrome(sss) Staphylococcal scalded skin syndrome (SSSS) is a serious skin infection caused by the bacterium Staphylococcus aureus. This bacterium produces an exfoliative toxin that causes the outer layers of skin to blister and peel, as if they’ve been doused with a hot liquid. SSSS — also called Ritter’s disease — is rare, affecting up to 56 people out of 100,000. It’s most common in children under 6. Etiology  The condition is mediated by hematogenously spread exotoxin produced by S. aureus present in infected site distant from the involved skin (e.g. otitis media, pneumonitis) and rarely in skin.  SSSS starts from a localised staphylococcal infection that is a producer of the two causative exotoxins (epidermolytic toxins A and B).  The disorder usually affects newborns and infants <2 yr of age. Clinical features • SSSS usually starts with fever, irritability and widespread redness of the skin. • Within 24-48 hours’ fluid-filled blisters form. These rupture easily, leaving an area that looks like a burn • Tissue paper-like wrinkling of the skin is followed by the appearance of large fluid-filled blisters (bullae) in the armpits, groin and body orifices such as the nose and ears. • Rash spreads to other parts of the body including the arms, legs and trunk. • In newborns, lesions are often found in the diaper area or around the umbilical cord. • Top layer of skin begins peeling off in sheets, leaving exposed a moist, red and tender area Pathophysiology • SSSS starts from a localised staphylococcal infection that is a producer of the two causative exotoxins (epidermolytic toxins A and B). • Outbreaks of SSSS often occur in childcare facilities. • An asymptomatic adult carrier of Staphylococcus aureus introduces the bacteria into the nursery. About 15-40% of healthy humans are carriers of Staphylococcus aureus, that is, they have the bacteria on their skin without any sign of infection or disease (colonization). • However, staphylococcal skin infections are seen commonly in infants and younger children, thus an obvious increased risk of SSSS. • Staphylococcus aureus is also commonly found in infections of the throat, ears and eyes. Diagnosis Diagnosis of SSSS depends on: • History and physical examination • Tzanck smear: is scraping of an ulcer base to look for Tzanck cells (multi nucleated giant cell) • Skin biopsy, which shows intraepidermal cleavage at the granular layer • Bacterial culture from skin, blood, urine or umbilical cord sample (in a newborn baby Treatment  Supportive measures  Antistaphylococcal antibiotics, administered initially parenterally then orally.  Systemic administration of anti-staphylococcal antibiotics.  Gentle cleansing with saline, Burrow solution, or 0.25% silver nitrate compresses. Acute superficial bacterial skin infection characterized by pustules and honey/ red coloured crusted erosions or sores especially around the nose and mouth.\ Etiology  Occur most frequently on the exposed parts of the body  Contagious  Occur most frequently in childhood  Mostly during summer  live in a warm, humid climate  compromised immune system, such as from HIV  Skin conditions such as eczema, dermatitis, or psoriasis, sunburn or other burns, itchy infections such as lice, scabies, herpes simplex. Pathogen  Coagulasepositive Staphylococcus Aureus, Group A beta-hemolytic streptococci  Group A beta-hemolytic streptococci and the phage type 71 and 80/81 S. aureus skin infections are sometimes followed by glomerulonephritis. Clinical types  Impetigo vulgaris  impetigo bullosa  Impetigo neonatorum  Granuecthyma Management Clean the skin and cure the wound and itching skin diseases Systemic treatment: • sulfanilamide antibiotics or other antibiotics • Topical therapy • High dose and sensitive antibiotics  Topical therapy: - Principle: sterilize, diminish inflammation, astringe and desiccate - 1% camphor、5% sulfurcalamine lotion, 0.5% novobiocin ointment - Remove the crusts, topical antibiotics ointment - Isolation and disinfection Prevention  Bathe and wash the hands often to cut down on skin bacteria.  Cover any skin wounds or insect bites to protect the area.  Keep nails clipped and clean.  Don’t touch or scratch open sores. This will spread the infection.  Wash everything that comes into contact with the impetigo sores in hot water and laundry bleach.  Change bed linens, towels, and clothing that come in contact with the sores often, until the sores are no longer contagious.  Clean and disinfect surfaces, equipment, and toys that may have come in contact with impetigo.  Don’t share any personal items with someone who has impetigo. Ecthyma vulgaris Definition Is a deep non-follicular dermal pustule. Its emergence is caused by erosion and scratches. Pustules with purulent contents are soon converted into soft greenish, often layered crust; after its removal a bleeding ulcer with soft borders is observed, which heal with cicatrization after 2-3 weeks. The lesion in ecthyma vulgaris is a deep dermal pustule with no involvement of the follicles. Etiology and pathogenesis Streptococci are the causative agents although there are reports on the formation of staphylococcal and mixed streptococcal-staphylococcal infections. Factors contributing to the development of ecthyma are;  erosions and scratches  reduction of general body resistance during or after various infectious diseases  metabolic disorders, chronic alcoholism  localized disturbance in lymph and blood circulation, and hypovitaminosis. Treatment  The lesions are treated as those of impetigo.  Mikulicz ointment is prescribed for poorly healing ulcers.  General treatment consists of invigorating and stimulation therapy  high-calorie diet  In torpid cases, long acting sulfonamides and antibiotics are prescribed. Folliculitis Definition Inflammation of follicles, primarily hair follicles. Folliculitis: inflammation of hair follicle from Infection Etiology • Chemical irritation • Injury • Infectious Causes - Staphylococcus aureus (most common) , Streptococcus species , Mixed bacterial infection Risk Factors Local trauma  Abrasion  Surgical wounds or draining abscess  Shaving Aggravates Staphylococcus aureus folliculitis Exposure to Occlusive Dressing  Tar  Adhesive Plaster  Plastic Occlusive Dressings Treatment Folliculitis:  Eliminate provocative agents • Systemic antibiotics for wide spread lesions, presence of constitutional symptoms and lymphadenopathy and spreading infection. • Antistreptococcal antibiotics (e.g.: -injectable procaine penicillin) for erysipelas and cellulitis • Erythromycin group for impetigo contagiosa and ecthyma • Antistaphylococcal antibiotics (e.g. cloxacillin) for bullous impetigo and follicular infections. • Antibacterial soap, do not shave the affected area (folliculitis), warm compresses • For recurrent infections, rule out underlying skin disease, evaluate for carrier state and treat accordingly. • For larger abscess like furuncles, most carbuncles surgical incision and drainage. Common disorders of ear Otitis Externa Definition It is an infection of the outer opening of the ear and ear canal. Also referred to as swimmer’s ear or External otitis. It results from the exposure of moisture. It occurs most commonly among children between the ages of seven and twelve and among the elderly. Classification • Acute: Lasts less than 6 weeks. Typically, due to bacterial infection • Chronic: Lasts more than 3 months. Due to Allergies or autoimmune diseases. Etiology • Swimming in the contaminated water. • Objects in ear (cotton swabs or other small objects to clear the ear canal, hearing aid, ear plugs). • Infections: Staphylococcus aureus, Candida albicans, pseudomonas aeruginosa • Other trauma Risk factors • Diabetes • Psoriasis • Atopic dermatitis • Eczema • Asthma • HIV Pathophysiology Infection from the external ear canal spreads Through the fissures of Santorini, small perforations in the cartilaginous portion of the external ear canal Infection spreads medially to the tympanomastoid suture, and along venous canals and fascial planes The compact bone of the skull base becomes replaced with granulation tissue Bone destruction Progressive spread of infection to skull base foramina causes cranial neuropathies Clinical manifestations • Red, swollen ear canal • discharge from ear. • Itchiness. • Fever • Ear pain (Pain worsened when external ear is touched). • Temporary conductive loss. • Severe cases: Ear canal narrowed through exudates. Diagnosis  History collection  Physical examination: redness in the ear, fullness of ear.  Lab test: gram staining and culture of discharge.  Imaging test: CT scan, MRI of head, radionuclide scan. Management The goal of treatment is to stop the infection and allow ear canal to heal. ϙ Avoid getting affected ear wet. ϙ Remove any discharge/debris by gently swabbing outer ear with cotton wool. ϙ Remove anything from affected ear which may cause an allergic reaction such as hearing aids, earplugs, earrings. ϙ Debridement: the infected debris should be gently and thoroughly removed from the canal with suction or dry cotton swabs under adequate lighting ϙ Painkillers such as ibuprofen, Paracetamol. ϙ Burow’s solution: Mixture of aluminium sulphate and acetic acid. It is used against the bacterial infection. ϙ Antibiotic +Corticosteroid eardrops is used. Such as ciprofloxacin and hydrocortisone. ϙ Antifungal eardrops: Nystatin. ϙ Dry ear precautions (e.g. wearing shower cap, avoiding swimming) are strongly advised for both external otitis and fungal external otitis. Complications • Abscesses • Narrowing of ear canal • Inflamed or perforated eardrum • Cellulitis • Malignant otitis externa: Mostly occur with person with diabetes mellitus Prevention • Keep ears dry • Swim wisely • Avoid putting foreign objects in ear • Use caution after an ear surgery or infection. Impacted cerumen (Wax) Decrease retraction of tympanic membrane Serous exudates in middle ear Pus formation Tympanic membrane rupture Acute otitis media Clinical manifestations  History of upper respiratory tract infection  Pain in the affected ear  Restlessness  Continuous crying and fever  Vomiting and diarrhea may occur  Red and bulging tympanic membrane  Perforation of ear drum leading to discharge from ear with reddish brown fluid. Diagnosis  History  Physical examination  Otoscopic examination  Culture  Audiometry and tympanometry Management- medical • Antibiotic therapy (amoxicillin, erythromycin, cephalosporin) for 10 to 15 days • Analgesics • Antipyretics • Decongestants • Local heat application Surgical management • Myringotomy or tympanotomy: (incision in the tympanic membrane) • Tympanocentesis- aspiration of middle ear (to drain the middle area collection) complication  chronic otitis media  perforation  hearing loss  poor speech develop Otitis media with effusion/ chronic otitis media Also known as; Glue ear, Serous otitis media, Chronic nonpurulant otitis media Definition Chronic accumulation of mucus/non-purulent effusion within the middle ear and in mastoid air cell system (Middle Ear Cleft). Duration >12 weeks Etiology  upper respiratory tract infection  allergic rhinitis  Eustachian tube deformity  cleft palate  inappropriate treatment of acute otitis media  sinusitis Clinical features • Mild to moderate hearing loss • Feeling of ear blockage or pressure in the ear • Tympanic membrane is found dull and reduced mobility • Ear pain Classification 1. chronic suppurative otitis media 2. chronic non suppurative otitis media Chronic suppurative otitis media Definition Chronic suppurative otitis media is middle ear infection with perforation of the eardrum and fluid discharge from the ear that has lasted at least 6weeks. Clinical features  Recurrent otorrhea: watery & mucoid  Deafness: conductive type  Pain: absent  Otoscopy: perforation of tympanic membrane  Infection like: rhinitis, sinusitis, adenoiditis  Cholesteatoma: a cyst like mass of squamous epithelium extending from the ear drum into the middle ear. It may cause slow expansions and destruction of ossicles with tympanosclerosis Pathophysiology Acute otitis media permanent perforation mucopurulent discharge Complications • Mastoiditis • Abscess formation in mastoid and neck • Inner ear infection with sensory hearing loss • Facial palsy • Meningitis • Intracranial abscess chronic non suppurative otitis media (serous otitis media) Pathophysiology Upper respiratory tract infection or otitis media Fluid collection in the middle ear and obstruction of Eustachian tube • Cholesteatoma in the middle ear may block drainage of the ear leading to mastoiditis. • Causative organisms Streptococcus pneumonia, streptococcus pyogenes, staphylococcus aureus, Haemophilus influenzae and morexalla catarrhalis clinical features • Pain, tenderness and swelling in the mastoid region • Otalgia, redness over the mastoid region • Fever, headaches • Drainage from the ear occurs in more serious cases • Irritability and lethargy Diagnosis  History collection  Physical examination  MRI  CT scan  Culture of the drainage  Blood tests Management - Antibiotics – ceftriaxone IV - Myringotomy or tympanostomy to insert a tympanostomy tube into the ear drum to the inner ear for draining. - Mastoidectomy – a procedure in which a portion of the mastoid bone is removed and the infection drained. A second surgery may do after mastoidectomy to correct the ossicles and the perforated tympanic membrane. (tympanoplasty and ossiculoplasty) Postoperative care  Antibiotics and analgesics  Follow up date will fix for the removal of stitches and bandage  Cover the operative site while bathing (petroleum jelly covered cotton ball)  Avoid strenuous activity  Avoid air travel  Avoid putting pressure on ear If left untreated it can cause hearing loss, blood clot, meningitis and brain abscess Complications of surgery  Facial nerve paralysis  Sensorineural hearing loss  Vertigo  Change in taste (metallic taste)  Tinnitus Hearing impairment (Deafness) Definition Hearing impairment, also called deafness or hearing loss, occurs when there’s a problem with or damage to one or more parts of the ear. It may be temporary or permanent, organic or inorganic, peripheral or central in origin. Etiology Ѿ Genetic: familial deafness, Pierre Robinson syndrome, chromosomal abnormalities like trisomy 21 Ѿ Intrauterine infections: rubella, CMV, syphilis, toxoplasma, chickenpox Ѿ Teratogenic exposure during pregnancy: drug therapy with quinine, streptomycin, thalidomide, irradiation, loop diuretics, Ѿ mechanical obstruction of external auditory canal by wax and foreign body Ѿ Neonatal hyperbilirubinemia Ѿ Cretinism Ѿ Direct injury to ear, head injury, constant exposure to loud noise Ѿ Malnutrition, vitamin B complex deficiency Ѿ Brain damage, cerebral palsy, birth asphyxia, encephalitis, birth injury Ѿ Mumps, measles, chickenpox, suppurative otitis media, meningitis Classification The healthy child can hear tones between 0 to 25 decibel range. 1) Slight hearing impairment- 15- 25 decibels. 2) Mild hearing impairment- 25-40 decibels 3) Moderate hearing impairment- 40-65 decibels 4) Severe hearing impairment- 65-95 decibels 5) Profound hearing impairment- 95 or more decibels Types Hearing deficits can be classified as follows;  Conductive hearing deficit  Sensorineural hearing deficit  Mixed type  Central hearing deficit  Peripheral hearing deficit Conductive hearing loss Definition It is dysfunction of sound transmission or conduction of sound wave through the external ear and middle ear. The conduction of sound to the cochlea is impaired. Causes Can be caused by external and middle ear disease include;  Impacted wax, foreign body  Tympanic perforation  Otosclerosis  Cholesteatoma and several congenital syndromes like aperts syndrome.  Common type of hearing deficit sensorineural hearing loss Due to a defect in the conversion of sound into neural signals or in the transmission of those signals to the cortex. Causes  Can be caused by disease of the cochlea, acoustic nerve (CNVlll), brainstem, or cortex  Prevention of injury and accidents with environmental modification Nursing management Nursing diagnosis  Disturbed Sensory Perception  Impaired Verbal Communication  Impaired Social Interaction  Disturbed Body Image  Ineffective Coping  Deficient Knowledge Disorders of Eye strabismus Strabismus is a condition of mal alignment of the eyes where the visual lines of each eye do not simultaneously focus on the same object in space because of lack of muscle coordination which results in a crossed eye appearance. Etiology  Hereditary – positive family history  Tumors, e.g., Retinoblastoma  Damage to muscles or cranial nerves (3rd,4th and 6th)  Associated with syndromes, e.g. klippel feil syndrome. clinical features  Crossed –eye appearance  Diplopia (double vision)  Potential loss of vision  It may be either congenital or acquired. Classification  Paralytic strabismus: - It occurs when one or more of the extraocular muscles have weakness or paralysis and is unable to move the eye. It may be caused by damage to muscles and cranial nerves or due to some tumors. Manifestations are limitation of movement, dizziness, diplopia, false orientation to visual fields.  Non – paralytic strabismus: - It is the defective positioning of the two eyes relative to each other. Alternating strabismus occurs when the child fixes on an object with one eye first and then the other. No diplopia occurs. Diagnosis  Hirschberg corneal light reflex test  Cover test.  Hischberg corneal light reflex test This test is carried out by shining a light on the patient’s face and then observing the reflection. in normal eyes, reflections are symmetric and well – centered, but if there is strabismus, the reflex is not symmetric and not well centered. the eye appears deviated.  Cover test It can be performed only with child’s cooperation. Child is asked to look at distant toy. The first eye is covered for approximately 1-2 seconds. As this eye is covered, the uncovered eye is observed for any shift in fixation. The misaligned eye will deviate inward or outward. Management Medical treatment  Occlusion therapy (eye patching)  Use of glasses with covered lenses  Pharmacologic therapy: Use of miotics (drugs that act on ciliary muscles) to make accommodation easier.  Eye exercises for improvement of vision 1) Eye patching/ occlusion therapy: - stronger eye is covered to allow weaker eye to work alone so that it may become stronger. Duration of therapy is determined by ophthalmologist. Using glasses with covered lenses is also another method of occlusion. 2) Botullinum toxin therapy: - Toxin is injected into the stronger extra ocular eye muscle to produce temporary paralysis in the normal eye to relax it, giving the weaker muscle to chance to recover. 3) Surgical management Extraocular muscles may be cut (shortening), tucked (lengthening) or reattached to the eyeball (repositioning) in a different position to correct the position of the eye ball. childhood cataract Definition Cataract is an opacification or milk white appearance of the normally clear transparent crystalline lens that impairs the vision. It may be congenital or acquired. Congenital cataract is usually bilateral. The child presents with visible clouding of lens, varying impairment of vision and may found with amblyopia. Etiology Congenital cataract:  Prematurity  Maternal infections ( toxoplasmosis, rubella, CMV, herpes simplex, measles)  Chromosomal disorders (turner’s syndrome, trisomy 21)  Metabolic disorders (galactosemia, PKU, cretinism) Acquired cataract  Eye trauma (foreign body, penetrating injury, contusion)  Child abuse  Steroid induced  Radiation  Drug effects (tetracyclines, chlorpromazines)  Hypoglycaemia  Diabetes mellitus  Hypo and hyper vitaminosis “D”  Hypocalcaemia Clinical features Informant – usually parents  History of white spot in pupillary area  High IOP can damage the optic nerve and visual field. Types 1) Open-angle glaucoma: It caused by partial blockage of the drainage canal. The angle between the cornea and the iris is "open", meaning the entrance to the drain is clear, but the flow of aqueous humor is somewhat slow. 2) Closed -angle glaucoma: Caused by a sudden and complete blockage of aqueous humor drainage. The IOP rises rapidly and may lead to total vision loss quickly. Demands immediate medical attention Narrow Angle. 3) Primary congenital glaucoma (PCG)- PCG refers to glaucoma resulting from maldevelopment of the aqueous outflow system. Which has an isolated poor development of the trabecular meshwork that is called: Isolated trabeculodysgenesis. Clinical features ϙ Photophobia ϙ Blepharospasm ϙ Lacrimation/watering Signs: ϙ Enlargement of the globe (Buphthalmos) is a result of elevated intraocular pressure. ϙ Bluish discoloration patches over sclera [due to thinning of sclera underlying uveal tissue becomes visible] ϙ Optic disc may show variable cupping and thus damage to optic nerve in the form of atrophy Corneal signs. ϙ Corneal edema. ϙ Corneal enlargement. (corneal diameter > 13mm) ϙ Tears and breaks in Descemet’s membrane (Haab’s striae). ϙ Epiphora: overflow of tears Diagnosis  Clinical clues- Enlarged eyes; tearing, and photophobia (avoidance of light) Often, babies also rub their eyes.  Measurement of IOP with Schiotz or preferably hand held Perkin’s applanation tonometer.  Measurement of corneal diameter by callipers.  Ophthalmoscopy to evaluate optic disc.  Gonioscopic examination of angle of anterior chamber reveals trabeculodysgenesis. Medical management Drug therapy  Beta-blockers (beta-adrenergic antagonists): Topical beta-blockers include timolol (non-selective beta-1 and beta-2 blocker. beta-blockers typically reduce IOP by 20-30%.  Carbonic anhydrase inhibitors: Oral carbonic anhydrase inhibitors include acetazolamide (Diamox, dose 10-20 mg/kg/day divided into 3 or 4 doses) and methazolamide  Prostaglandin analogs: Latanoprost 0.005% (Xalatan)  Miotic agents: pilocarpine surgical management ϙ Goniotomy: is a surgical procedure in which the doctor uses a lens called a goniolens to see the structures of the front part of the eye. An opening is made in the trabecular meshwork; the new opening provides a way for fluid to flow out of the eye. ϙ Trabeculotomy: A piece of tissue in the eye's drainage angle is removed to create an opening. This new opening allows fluid (aqueous humor) to drain out of the eye. Trabeculotomy performed when cornea is cloudy. ϙ Trabeculectomy Nursing management nursing assessment • Collect proper history regarding the disease • Assess visual acuity, visual fields, IOP • Assess family for patient care Nursing diagnosis • Acute pain • Self-care deficits • Risk for injury • Non- compliance Nursing interventions • Administer medication to lower IOP • Darken the environment • Apply cool compress • Provide quiet space • Teach patient and family risks of glaucoma • Ophthalmologic examination • Stress importance of early detection Refractive errors Definition Refractive error also known as refraction error is problem with focusing of light on the retina. Refractive error means that the shape of the eye does not bend light proper and correct resulting in a blurred image. Types Myopia Myopia - near-sightedness also known as short – sightedness and myopia is a condition of the eye where light focuses in front of the retina instead of on the retina this causes distant objects to be blurred while close objects appear normal. Corrected with concave lens. Hyperopia Far-sightedness also known as long sightedness.