Chapter 22 Notes

Bacterial Infections
^^^^
Acne
• Mild
• Comedones
• Open = blackhead
• Closed = white head and pustule
• Moderate
• Comedones
• In ammatory pustules and papules
• Severe
• In ammatory papules, pustules, nodules
• Scarring
Acne
Acne vulgaris is the most common bacterial skin disorder treated by physicians in adolescents
(Fig. 22-3). Although acne can occur during any age and could be a clinical manifestation of
other conditions, generally it begins in the teen years.
SIGNS AND SYMPTOMS
Signs and symptoms of acne can be mild, moderate, or severe and progress in the following
pattern:
▪ Increased sebum production
▪ Follicular hyperkeratinization
▪ Propionibacterium acnes (P acnes) within the follicl
▪ n ammation with papules, pustules, nodules, or cysts
Signs and symptoms of mild acne include open comedones, closed comedones, and no
in ammatory lesions. An open comedo, often called a blackhead, has an open follicular ori ce
with oxidized lipids, keratinocytes, and melanocytes. A closed comedo, which has a white head
and pustule, has a closed follicular ori ce with sebum and keratinous substances.
Moderate acne will have a mix of nonin ammatory comedones and in ammatory pustules and
papules, while severe acne will have an increased number of in ammatory papules, pustules, and
nodules with evidence of scarring. Severe acne is a signi cant progression of the signs and
symptoms listed.
DIAGNOSIS
A thorough skin assessment and a complete health history is the method of diagnosis for acne.
The nurse can prepare the teen for an assessment by making sure their face, scalp, chest, and
back are exposed and cleansed of all makeup and powders. Laboratory tests are ordered when an
underlying endocrine disorder is suspected.

Acne (continued)
Treatment
• Tetracycline
• Doxycycline

1
fl
fl
fl
fl

fi
fl

fi
fl
fl

fi
 • Topical and oral antibacterial agents (inhibits growth)
• Isotretinoin – TERATOGENIC
• Oral contraception (decreases hormone production)
• OTC salicylic acid, benzoyl peroxide, sulfur, and alpha hydroxyl acids
Prevention/Education
• Proper skin care/cleansing
• Avoid using oil-based cleansers and moisturizers in areas of breakout
• Avoid oil-based make-up
• Reduce stress
• OTC salicylic acid, benzoyl peroxide, sulfur, and alpha hydroxyl acids
• Use sunscreen; limit sun exposure
Collaboration in Caring
Both nursing care and medical care play an important role in treating adolescent acne. The nurse
must teach the adolescent about proper treatment of the acne. Prior to any type of acne care,
assist the adolescent in gently cleansing the affected area. Be sure to assess the acne area
including the face, chest, and back in good light. Post-treatment measures include gently
cleansing or using a cool cloth to soothe the immediate in ammatory effects of tissue disruption
and provide comfort.
Nursing care also includes teaching the adolescent about medications used in the treatment of
acne including antimicrobials (topical or oral antibiotics), retinoids, and/or hormonal therapy.
Antimicrobials include erythromycin (Ery-Tab) (topical or oral), clindamycin (Cleocin) (topical
or oral), tetracycline (Sumycin) (oral), minocycline (Minocin) (oral), and doxycycline
(Vibramycin) (oral). Retinoids include tretinoin (Retin A) (topical), tazar- otene (Tazorac)
(topical), and isotretinoin (Accutane) (oral).
PREVENTION
Acne can be prevented in some adolescents with care in skin cleansing along with decreasing
rubbing and picking of the existing comedones. Avoiding oil-based cleansing and moisturizing
products in the areas where acne breakouts commonly occur, such as the forehead and nose (T-
zone), may also be bene cial. Oil-based makeup does not resolve acne breakouts and may
worsen them. Stress may make acne worse in some adolescents at particularly taxing times.
Over-the-counter medications for acne typically have one or more of the following ingredients:
salicylic acid, benzoyl peroxide, sulfur, and alpha hydroxyl acids. Most adolescent acne
improves with cleansing and proper moisturizing with a water-soluble moisturizer.
EDUCATION/DISCHARGE INSTRUCTIONS
Teaching and reinforcing proper skin care and medication management are essential for the
adolescent with acne. Acne treatment tends to be very drying and must not be covered with
moisturizers or makeup. Teaching the teen how to use the medication at bedtime may increase
adherence to the treatment regimen. Information about common medication for acne is found in
Table 22-2.

Impetigo Contagiosa
• Highly contagious, caused by staph or strep infection
• Spread by direct contact
• Signs and symptoms
• Diagnosis
• Treatment

fi

fl

• Nursing Care
• Education
Impetigo Contagiosa
Impetigo contagiosa is a bacterial staph or strep infection of the skin often found on and around
the mouth and nose of the child or elsewhere on the face (Fig. 22-4). It may also appear on the
hands, neck, trunk, buttocks, or extremities. Infants and children younger than age 5 are at
greatest risk for impetigo. It is generally caused by Staphylococcus aureus. On rare occasions,
other bacteria may be responsible for the skin infection, including methicillin-resistant
Staphylococcus aureus (MRSA).
SIGNS AND SYMPTOMS
The lesions begin as a vesicle or pustule surrounded by edema (swelling) and erythema
(redness). Later these lesions erupt, leaving honey-colored exudate. This exudate becomes crusty
in appearance and sticky to the touch. The child may experience pruritus (itching) that is not
usually painful. Over time, impetigo clears, leaving no residual scarring in the absence of
scratching or picking.
DIAGNOSIS
Impetigo is diagnosed through assessment and rarely requires lab testing. A diagnostic culture is
needed if the health-care provider is unsure of the exact diagnosis and is investigating a
differential diagnosis such as contact dermatitis or herpes virus.
PREVENTION
Impetigo is very contagious and passed by touch from the infected child to others. Good hand
washing and keeping a child at home for 24 hours after the induction of the antibiotic will
decrease the spread of impetigo in the child’s environment.
COLLABORATIVE CARE
Topical antibiotics such as mupirocin (Bactroban) may be used if the skin lesions are limited.
Oral antibiotics are given for widespread infections and may include amoxicillin/clavulanate
(Augmentin), dicloxacillin, or erythromycin (E.S.S.) Other common medications for impetigo
include cephalexin (Ke ex) (oral) and clindamycin (Cleocin) (oral).

Methicillin-Resistant Staphylococcus Aureus

• MRSA is a circular, anaerobic, gram-positive bacterium
• Contagious; direct contact
• Signs and symptoms
• Diagnosis
• Treatment:
• Antibiotic (IV or PO)
• Topical antibiotic cream
• Nursing Care
• Education
Methicillin-Resistant Staphylococcus Aureus (MRSA)
MRSA is a circular, anaerobic, gram-positive bacterium prevalent in the nose and skin of most
individuals. MRSA is resistant to treatment from beta-lactam antibiotics such as methicillin, also
called meticillin, amoxicillin (Amoxil), penicillin G (Bicillin L-A), and oxacillin (Bactocill).
Hospital-acquired MRSA may result in systemic infection, but community-acquired MRSA is
usually limited to the skin and soft tissue.
SIGNS AND SYMPTOMS

fl

 MRSA is most often a skin infection, and signs and symptoms can include vesicles, pustules, and
other bumps that are painful, red, leaking pus, and/or swollen. The lesion may resemble a spider
bite. Skin around a sore is warm or hot to the touch. Upon rupture, the exudate is white to
yellow.
DIAGNOSIS
MRSA is diagnosed through clinical assessment. However, a culture is warranted if the lesion is
one of many, a recurrent lesion, or if the child has impaired immunity or has recently been
released from the hospital.
PREVENTION
MRSA is contagious and is passed skin-to-skin and from inanimate surfaces to the skin. Because
MRSA can live longer on hard surfaces than soft surfaces, it is important to teach parents to
clean surfaces. Children should be taught good hand washing and personal hygienic practices.
Athletes should shower immediately after events and avoid shar- ing personal items. Schools,
day cares, and athletic facilities should cleanse the environment regularly with a good
bactericidal spray or wash. In the home setting, regular unscented bleach is very effective in
killing bacteria and viruses on hard surfaces.
COLLABORATIVE CARE
The rst line of treatment for MRSA is the administration of an oral antibiotic and/or a topical
antibiotic cream:
▪ Vancomycin (Vancocin) (IV)
▪ Clindamycin (Cleocin) (IV/IM/PO), dicloxacillin (PO)
▪ Mupirocin (Bactroban (topical)

Cellulitis
• A bacterial infection that occurs when bacteria enter through a crack or break in the
skin
• Most commonly streptococcus and staphylococcus
• Signs and symptoms
• Diagnosis
• Prevention
• Collaborative care
Cellulitis
Cellulitis is a bacterial infection that occurs when bacteria, most commonly streptococcus and
staphylococcus, enter through a crack or break in the skin. Animal bites can cause cellulitis.
Bacteria can also enter through areas of dry, aky, or swollen skin.
SIGNS AND SYMPTOMS
With cellulitis, skin may be:
▪ Red to purplish-red
▪ Swollen or indurated
▪ Warm or hot to touch
▪ Tender or painful to touch
DIAGNOSIS
A complete history and physical is the usual method of diagnosis. Lab tests, radiological testing,
or surgical biopsy is used only in the presence of severe infection. Complete blood counts and
blood cultures are ordered to rule out septicemia (infection of the blood) if symptoms warrant.
PREVENTION

4
fi

fl

 To help prevent cellulitis, tell the caregiver about these simple care measures when the child has
a skin wound:
▪ Wash the child’s wound daily with soap and water.
▪ Apply an over-the-counter antibiotic cream or ointment.
▪ Watch for signs of infection such as redness, pain, and drainage.
COLLABORATIVE CARE
Nursing Care
Management may vary depending on the location of the cellulitis and the total surface area of the
induration as well as the age of the child. Most cases of cellulitis are handled in the outpatient
arena. Cellulitis that manifests on the face and neck, genitals, or over a joint is more worrisome
as it may cause systemic infection. Orbital cellulitis carries a high risk of morbidity and is treated
aggressively with hospitalization for IV antibiotics (Fig. 22-5). Nursing care of a patient with
cellulitis includes marking the circumference of the reddened area with a marker to distinguish if
the rash is improving or worsening with treatment.
If a child has a severe case of cellulitis, hospitalization and IV antibiotics may be necessary. In
addition, steroids to decrease in ammation such as prednisolone (Pediapred) may be ordered but
are not routine. Another nursing intervention for symptom control is the administration of an
anti-in ammatory medication such as ibuprofen (Children’s Advil) or acetaminophen (Children’s
Tylenol).
Medical Care
Medications are important in the management of cellulitis, and these medications are often
prescribed
▪ Penicillin G (Bicillin) IM
▪ Amoxicillin (Amoxil)
▪ Ceftriaxone (Rocephin)
▪ Cephalexin (Ke ex)
▪ Clindamycin (Cleocin
If MRSA is considered (based on history or suspect abscess), these medications are used:
▪ Vancomycin (Vancocin) (IV)
▪ Clindamycin (Cleocin) (IV/IM/PO)
▪ Dicloxacillin (PO)
Fungal Infections
^^^^
Tinea Infections
• Fungal infections that a ect the skin, scalp, or nails
• May spread from person to person or from animal to person
• Signs and symptoms depends on location and presentation
• Diagnosis on inspection or using Wood’s lamp
Tinea Capitis, Tinea Corporis, Tinea Cruris, and Tinea Pedis
Tinea capitis, tinea corporis, tinea cruris, and tinea pedis (dermatophytosis) are fungal infections
that affect the skin, scalp, or nails (Fig. 22-7). Children of all ages can be affected. This infection
may spread from person-to-person or from animal (especially cats) to person. These infections
may also be spread by contact with inanimate objects such as clothing, furniture, or bed linen of
another infected person. Some children may be colonized but remain asymptomatic.
The major clinical subtypes of dermatophyte infections are:

5
fl
:

fl

ff

fl

 ■ Tinea corporis – Infection of body surfaces other than the feet, groin, face, scalp hair, or beard
hair characterized by a round to oval lesion with maculopapular border with central clearing and
often with scaling, except the scalp, groin, hands, and feet; seen in children and adolescents;
sometimes referred to by the common term ringworm even though no “worm” is involved.
■ Tinea pedis – Infection of the foot, also known as “athlete’s foot,” characterized by red, scaly,
pruritic skin that may develop weeping and involves the kinesthetic webbed areas of the toes and
feet. This infection can occur in children and adolescents.
■ Tinea cruris – Infection of the groin, commonly known as “jock itch,” characterized by red,
scaly skin that involves the inner thighs, inguinal creases, or perineal area (rare before
adolescence).
■ Tinea capitis – Infection of scalp hair characterized by scaly, pruritic patches that can be
associated with breakage of the hair and is usually seen in prepubertal children between ages 1
and 10.
■ Tinea unguium (dermatophyte onychomycosis) – Infection of the nail.
SIGNS AND SYMPTOMS
Other signs and symptoms of these infections include:
• Pruritic rash with round, scaly, pink to red lesions, often with central clearing, creating a
circular lesion
• On the head, hair loss may occur in the area of the rash The nurse must remember that
attempting to remove the oral thrush can cause the lining of the oral mucosa to bleed.
DIAGNOSIS
The diagnosis of tinea is made by visual inspection using a Wood’s lamp that discloses
yellowish-gold uorescent coloration.
PREVENTION
Have family pets checked at the veterinarian if they experience areas of fur loss, excessive
itching, or self-grooming. Encourage good hand washing. Have children and adolescents in
sports activities bathe as soon as they are home from practice or games to remove fungal spores
that may be on the skin. Do not share fomites (objects that can carry infection) like bath and
hand towels, combs and brushes, hats, helmets, and intimate apparel.
COLLABORATIVE CARE
Nursing Care
The nurse must stress that everyone in the family needs to be treated and that it is essential not to
share hairbrushes or bath towels. Speci cally, with tinea capitis, the affected area of hair growth
may take 6 to 12 months to grow or may not grow back at all. The nurse can provide emotional
support and suggest hairstyles to help conceal tinea capitis.
Medical Care
Topical or systemic antifungal drugs are often effective therapies. Most super cial cutaneous
dermatophyte infections can be managed with topical therapy with agents such as azoles,
allylamines, butena ne, ciclopirox, and tolnaftate (Table 22-3). Nystatin, an effective treatment
for Candida infections, is not effective for dermatophytes. Oral treatment with agents such as
terbina ne, itraconazole, uconazole, and griseofulvin is used for extensive or refractory
cutaneous infections, and patients should not be treated with oral ketoconazole because of risk
for severe liver injury, adrenal insuf ciency, and drug interactions.
EDUCATION/DISCHARGE INSTRUCTIONS

6
fi

fl
fi
fl
fi

fi

fi

 The child is checked periodically throughout treatment to be sure a proper response is noted. The
nurse must stress the importance of completing the recommended treatment even after the
lesions appear to be cleared. For treatment of tinea pedis, education should include wearing light-
weight dry socks, well-ventilated shoes, and adequate cleaning of shower areas to prevent spread
of the infection.

Tinea Subtypes
^^^^

Dermatitis
^^^^

Atopic Dermatitis
• Chronic skin condition with no known etiology
• Signs and symptoms:
• Pruritis is classic presentation; may be extreme
• Scaly, aky skin; Dry lesions or weepy papules/vesicles
• < 2 years usually face, scalp wrists, arms, legs
• Older children exor areas or anywhere
• Erythema/warmth may indicate secondary infection
• Diagnosis
• Treatment
• Nursing Care
• Education
Atopic Dermatitis
Atopic dermatitis is often described as “the itch that scratches” with pruritis as a classic clinical
characteristic.
This chronic skin condition has three distinct phases (acute, subacute, and chronic) with no
known etiology. This condition has a genetic basis and is the most common type of eczema.
Atopic dermatitis tends to begin early in life in those with a predisposition to allergies.
Characteristically, rashes occur on the head, face (especially the cheeks), neck, elbow and knee
creases, and ankles in infants (Fig. 22-8). In the older child, the rash presents in the folds of the
arms and legs and occasionally on the eyelids and neck.
This condition is found in children with allergies and/or a family history of allergies, asthma, and
rhinitis. Approximately 50% of persons with atopic dermatitis present in the rst year of life and
an additional 30% in the years between ages 1 and 5 (Weston & Howe, 2019). Although the
etiology may be genetic, the child may also have immunological impairment. It is also possible
for the etiology to be environmental in nature (e.g., pollution, indoor allergens such as cigarette
smoke, or infections).
SIGNS AND SYMPTOMS
The child with atopic dermatitis has a red, raised rash that is pruritic and may cause some
discomfort or pain.
DIAGNOSIS
A complete family history and visual assessment of the child reveals the common signs of this
condition. Blood tests reveal an increase in circulating IgE antibodies.
PREVENTION

7
fl

fl

fi
 The priority preventive measure is stopping a secondary infection, which can be accomplished
with good skin care and close monitoring. When a child has atopic dermatitis, prevention of
secondary infection is very important and requires adhering to good hygiene processes,
following prescribed treatment protocols, and maintaining skin hydration.
NURSING CARE
Close and frequent monitoring and assessment of the rash is an important nursing care measure.
Warm, not hot, bathing water will decrease irritation. Encourage the adolescent to keep the water
a bit cooler, avoid excessive scrubbing with exfoliating scrubs and cloths, and pat dry.
Moisturizing immediately after bathing with emollients, such as Cetaphil Moisturizing Cream®
or Eucerin®, locks in moisture and decreases dry, aky, or itchy skin.
EDUCATION/DISCHARGE INSTRUCTIONS
Nurses need to reinforce gentle cleansing and the use of tepid to slightly warm water for bathing
as well as use of appropriate emollients. Encourage patients to practice itch-scratch avoidance
and to keep ngernails trimmed short with no sharp edges. Teach parents the signs and
symptoms of secondary infection including a fever remaining above 101.5oF (38.6oC) or
evidence of red, painful, pus- lled lesions.

Contact Dermatitis
• Caused by direct contact with chemicals or other irritants
• Signs and symptoms
• Pruritic rash lasts 2-4 weeks
• Maculopapular or erythematous papulovesicular rash
• Weeping or crusty
• Treatment
• Topical corticosteroids
• Severe cases systemic steroids
• Nursing care
• Education
Contact Dermatitis
Contact dermatitis can occur after contact with an allergen or skin irritant. In children, the irritant
agents that cause this type of skin sensitivity are often soaps or detergents with fragrances or
dyes. For infants, the diaper area is especially prone. Diaper dermatitis is one form of irritant
contact dermatitis and can be caused by prolonged exposure to urine and feces. It is characterized
by an erythematous, con uent maculopapular rash that is prominent on convex surfaces and in
the folds. Children playing outdoors may encounter plant life that can cause contact dermatitis,
such as poison oak, ivy, or sumac.
SIGNS AND SYMPTOMS
Signs and symptoms of contact dermatitis include:
▪ Irritated, in amed, and pruritic rash within 48 hours of contact with the offending agent
▪ Vesicles and bullae may be present in the area
▪ Urticaria (hives) when there is contact with an allergen
▪ Vesicles that may weep serous uid

DIAGNOSIS
A complete history of both indoor and outdoor exposures for a child presenting with a rash helps
determine diagnosis. If a differential diagnosis is required because of atypical lesions, a biopsy

8
fl
fi
fl
fi
fl

fl

 may be performed. Vesicular lesions that present in children may also include varicella and
impetigo. These etiologies are ruled out before a diagnosis of contact dermatitis is considered.
PREVENTION
Children entering weedy or wooded areas should wear long sleeves, long pants, and socks to
prevent contact with poisonous plants. Strict avoidance of known allergens in the home,
including soaps and fragrances, will decrease the incidence of allergic contact dermatitis.
Prevention of irritant contact dermatitis is avoidance of known substances that have resulted in
rash and, for infants, frequent diaper changes.
NURSING CARE
Nursing care of diaper dermatitis is aimed at allowing the area to heal in an environment of
minimal moisture. This can be accomplished by frequent diaper changes, allowing the area to air
dry, and the use of barrier ointments that include white petrolatum or zinc oxide.

Diaper Dermatitis
^^^^

Seborrheic Dermatitis
• Erythematous plaques with greasy-looking yellowish scales
• Self-limiting
• Signs and symptoms
• Diagnosis
• Treatment
• Nursing Care
• Education
Seborrheic Dermatitis
Seborrheic dermatitis (Fig. 22-10) is a self-limiting eruption consisting of erythematous plaques
with greasy-looking, yellowish scales distributed on areas rich in sebaceous glands such as the
scalp, the external ear, the center of the face, and the intertriginous areas. While seborrheic
dermatitis can occur in infants, children, and adolescents, it most commonly occurs in infants
between the ages of 3 weeks and 12 months. The prevalence of SD peaks at the age of three
months (about 70%) and decreases steadily in the following months to about 7% of children still
affected by age 2.
SIGNS AND SYMPTOMS
Signs and symptoms of seborrheic dermatitis include:
▪ Red to pink patches
▪ Loose yellow, greasy scales
The rash usually appears on the face, the cheek bones, and the nasolabial folds as well as behind
the ears. It can also be found on the scalp, in the eyebrows, and on the upper chest and upper
back.
DIAGNOSIS
The child who is diagnosed with seborrheic dermatitis has the de ned rash. The nurse
understands that the particular look of the rash differentiates it from other conditions such as
lupus, rosacea, and atopic or contact dermatitis.
PREVENTION
If a child has had seborrheic dermatitis in the past and it clears, it can be prevented by

fi

 preemptive treatment. Daily or at least three times a week, an antiseborrheic shampoo can be
used to cleanse the area of skin that is prone to breakout.
COLLABORATIVE CARE
Nursing Care
The initial treatment of scalp seborrheic dermatitis includes education, reassurance, and
conservative measures (emollients and frequent shampooing) to soften and remove the scales.
Some nonpharmacologic interventions include massaging baby oil or olive oil into the baby’s
scalp to gently loosen and remove the scales.
Medical Care
For more severe cases of seborrheic dermatitis, a healthcare provider may order topical
corticosteroids. If conservative measures fail, we suggest either topical low-potency
corticosteroids or ketoconazole 2% shampoo or cream with the addition of an antifungal cream if
the scales appear fungal in nature. It is important to educate parents that this skin condition (even
with treatment) can recur several times before resolving.
EDUCATION/DISCHARGE INSTRUCTIONS
The nurse communicates to the child and family that it is important to know the offending
allergen and that it can be introduced into the system through ingestion, inhalation, or coming
into direct contact. Reinforcing the signs and symptoms of the allergic response as well as
emergency treatment is essential information for the child and family.

Infestations
^^^^

Pediculosis Capitus
• Transmitted by direct contact with infected persons or indirect contact with
contaminated objects
• Signs and symptoms
• Diagnosis
• Treatment
• Nursing Care
• Education
Pediculosis Capitis
Pediculosis capitis, head lice, is a common childhood condition that can be passed among friends
and family. Approximately 6 to 12 million school-aged children are infested yearly. There are
three kinds of lice: scalp (pediculosis capitis), body (pediculosis corporis), and pubic area
(pediculosis pubis). The lice pierce the skin and suck blood. The bites can cause severe itching
and can predispose the child to a secondary infection.
Signs and Symptoms
Signs and symptoms of pediculosis include:
• Live lic
• Tend to live near the nape of the neck and behind the ears
• Louse eggs (nits
• Can be found anywhere along the shaft of the hair; the older the nits are, the more dista
• Pearlescent teardrop in shape, initially laid at the base of the hair shaf
• Fluoresce blue under a Wood’s lam
Diagnosis

10
e

 For lice, the clinical presentation and identi cation of the louse and/or its eggs is important.
Persistent itching of the head is the classic sign.
Prevention
To prevent lice, all children must avoid the use of one another’s combs, barrettes, hats, and
headbands. Children who are involved in sports may pick up lice in batting helmets and other
protective headgear that is shared. These fomites can easily carry lice from child to child.
In the home or school setting, children with active lice need treatment and the environment
should be treated as well. All associated persons affected by lice are also treated.
Collaborative Care
NURSING CARE
The nurse educates the family about over-the-counter lice treatments that may be helpful in the
care of lice. The nurse can explain to the child and family that anyone can get lice if in close
proximity to others who happen to have it. Lice are common in school-age children, and there is
no need for embarrassment. Guide the parents to resolution through treatment.
MEDICAL CARE
Over-the-counter lice treatments may be helpful. Types of pediculicide treatments include
pyrethroids, such as permethrin (Nix) and malathion (Ovide), and antiparasitics, including benzyl
alcohol (Ules a), lindane (Kwell), spinosad (Natroba), and ivermectin (Stromectol). Ivermectin
is used orally in hard-to-manage cases of head lice. Malathion (Ovide) is recommended for
children older than 2, and benzyl alcohol is not recommended for children younger than 6
months. Permethrin (Nix) is not recommended for infants under 2 months of age, and spinosad
has not been proven safe in children younger than age 4.
Education/Discharge Instructions
The nurse instructs the family to wash the hair according to the product’s instructions. If a child
is unable to tolerate these shampoos, former remedies including the use of asphyxiants like
petrolatum and food oils (e.g., olive oil) can be used. Once the shampoo is rinsed from the hair,
remove nits by backcombing with a ne-tooth comb while the hair is still wet (nits are easier to
remove when the hair is damp).
The nurse stresses to the caregiver to implement house-cleaning (e.g., dust, vacuum, and scrub);
wash clothing and bedding; and wipe off hats, helmets, and toys. If a soft or cloth toy like a
stuffed animal is not washable, it must be bagged in a sealed plastic bag and away from family
members’ rooms for 14 days. Launder all bed linens in hot water. Pillows are washed if possible
or thrown away if used by the child to avoid reinfestation. Antilice sprays can be used for
furniture and other environmental objects that are not disposable, but the most important
cleaning step is vacuuming. Hair care items can be boiled (hot water above 140oF) or soaked in
antilice shampoo and never shared.
The nurse instructs the family member to remove nits from eyelashes by applying petrolatum
jelly to the eyelashes twice a day for 8 days. The family member can check the school’s antilice
policy; children must remain home from school until lice-free. The child may be required to be
checked by the school nurse or day-care provider before returning. Tell the family member that
the child should be rechecked for infestation in 7 to 10 days, sooner if they are scratching
incessantly or the itching is interfering with sleep.

Scabies
• Mite infestation with Scaroptes scabiei
• Transmitted by close personal contact with an infected person

11
fi

fi
fi

 • More common in persons who live in crowded conditions or share a bed

• Signs and symptoms
• Diagnosis
• Treatment
• Nursing care
• Education
Scabies
Scabies results from a mite infestation with Sarcoptes scabiei. Children with a weakened
immune system are at increased risk. Scabies is transmitted by close personal contact with an
infected person and is more common in persons who live in crowded conditions or share a bed.
The scabies mite burrows under the epidermis layer of the skin, laying eggs and fecal matter that
causes irritation and severe itching. The burrows appear as small black lines under the skin on
physical examination. Scabies mite cannot survive for more than 3 days away from the skin.
Mite infestation is highly transferable, and although children of all ages are affected, it is most
commonly seen in children younger than 2. The classic clinical feature of scabies is pruritus. It is
often severe and usually worse at night. Pruritus results from a delayed hypersensitivity reaction
to the mite, mite feces, and mite eggs.
Typical cutaneous ndings are multiple small, erythematous papules, often excoriated (Fig.
22-11). Burrows may be visible as 2 to 15 mm, thin, gray, red, or brown, serpiginous lines.
Burrows are a characteristic nding but often are not visible due to excoriation or secondary
infection. Miniature wheals, vesicles, pustules, and, rarely, bullae also may be present.
Signs and Symptoms
Signs and symptoms of mite infestation may include:
▪ Sides and webs of the ngers
▪ Flexor aspects of the wrists
▪ Extensor aspects of the elbows
▪ Anterior and posterior axillary folds
▪ Periareolar skin (especially in women)
▪ Periumbilical skin
▪ Waist
▪ Male genitalia (scrotum, penile shaft, and glans)
▪ Extensor surface of the knees
▪ Lower buttocks and adjacent thighs
▪ Lateral and posterior aspects of the fee
Prevention
Do not share a bed, clothing, or intimate touch with a person who has scabies. Children should
avoid sleeping in the same bed as a parent or sibling with scabies. Even if only one member of
the family has scabies, the entire family is treated.
Nursing Care
The nurse teaches the family how to use the medication after a bath and what to look for in the
case of minor skin irritation. Furthermore, the nurse reminds the parents that a dishwasher with
no other contents can be used to clean washable toys and hair items. Treating clothing, bedding,
towels, and cloth toys by washing them in hot water and then placing them in the dryer is
necessary to kill scabies. Permethrin 5% cream (Elimite) is approved for infants over 2 months
of age.

12

fi
fi

fi

Bites & Stings

^^^^

Lyme Disease
• Tick-borne infection
• Caused by an in ammatory response to the spirochete Borrelia burgdorferi
• Signs and symptoms
• Presents in 3 stages
• Diagnosis
• Treatment
• Collaborative care
• Education and Prevention
Lyme Disease
Lyme disease, a tick-borne infection caused by an in ammatory response to the spirochete
Borrelia burgdorferi, is the most common vector-borne disease in the United States. Exposure to
Lyme disease can occur in any outdoor setting where ticks are endemic. The tick bite is often
found on the head and neck, back, arms, or legs. Animals such as dogs and cats can also have the
disease. Lyme disease occurs year-round, with the highest incidence of infection in the summer.
Children between 5 and 14 years of age are at highest risk because of outdoor activities.
Infection does not induce immunity. It takes 48 hours after contact with a human to introduce the
spirochete into the feeding site where the tick has buried its head. Any rash that appears before
48 hours is an allergic reaction or infection, not Lyme disease. The infection is not contagious
from person to person.
Signs and Symptoms
Lyme disease presents in three stages:
Early localized disease (3–30 days after bite)
• Red macule at the bite sit
• Bulls-eye rash with a central macule and surrounding clear area, then an expanding rash (5–50
cm in circumference
• Possible systemic symptom
• Fatigue, headache, arthralgia (joint pain), neck pain, fever, and myalgia (muscle pain) (listed in
order of prevalence)
Early disseminated disease (2 weeks after bite until chronic symptoms develop)
• Expands as a red, roundish, at, nonpruritic, and nonvesicular (erythema migrans) rash; this
is the most common manifestation of this stage
• Fatigue, headache, arthralgia (joint pain), and fever become more common
• Possible cranial nerve palsy, especially facial nerve palsy (bilateral facial nerve palsy is
pathognomonic for Lyme [characteristic for speci c disease])
• Meningitis (1% of affected children
• Carditis (less than 1% of affected children
• 90% will have positive serological conversion in this stage
Late disease (weeks to months after the initial bite)
▪ Arthritis, lasting up to many years but not considered chronic
▪ Singular joint at a time, migrates from joint to joint, typically larger joints and
primarily the knee(s)
▪ Swollen and tender, rarely erythematous

13
fl

fl
)

fi
fl

 ▪ Can bear weight but is uncomfortable

Diagnosis
Diagnosis is determined by physical and history; incidence of tick bite may or may not be
reported. Labs can con rm Lyme disease. Lab testing is not appropriate in the child who presents
with erythema migrans and lives in or has just visited an area where Lyme disease is endemic.
That child should be treated presumptively for Lyme disease.
Prevention
Avoiding play in wooded areas or using precautions in such environments will decrease the
incidence of Lyme disease. Children can dress in long sleeves and long pants when in wooded
areas; DEET spray is used when age-appropriate. At the end of the day of play (preferably within
2 hours), a shower or bath should be taken, followed by a tick check from scalp to toes. Clothing
and other worn items are put in the clothes washer to avoid live ticks from roaming into the
home. Pets can be combed and have tick collars or skin treatments as an added protection.
Collaborative Care
NURSING CARE
During the history and physical, the nurse asks the family member if there has been an
occurrence of a tick bite.
MEDICAL CARE
A 2-week course of oral antibiotics is given if infection is suspected. Amoxicillin (Amoxil) or Amox = <8
cefuroxime (Ceftin) are the most often used antibiotics in children 8 or younger; however, the Doxy = >8
American Academy of Pediatrics recommends the use of Doxycycline (Vibramycin) or
Tetracycline (Sumycin) in children less than 8 years of age for up to 21 days of treatment.
Otherwise, use of these antibiotics is reserved for children over 8 years of age due to the risk of
staining teeth enamel. If recurrent arthritis, central nervous system complications, or carditis
occurs, treatment lasts for 4 weeks with IV ceftriaxone (Rocephin), cefotaxime (Claforan), or
penicillin G (Bicillin L-A).
Education/Discharge Instructions
Teaching methods of tick bite prevention is invaluable. If the child is treated for Lyme disease,
whether presumptively or because of positive lab tests, the nurse reinforces the proper use of
antibiotics, including compliance. Furthermore, the nurse reminds the family of follow-up
appointments with the health-care provider.

14
fi

15