ATOPIC DERMATITIS

A Case Study Presented To Level IV Clinical Instructors

INTRODUCTION
‡ Atopic dermatitis is an immune-mediated inflammation of the skin, often with a significant genetic component. Pruritus is the primary symptom; skin lesions range from mild erythema to severe lichenification PREVALENCE/ STATISTICS ‡ Atopic dermatitis is a common condition affecting approximately 17% of the population, with a slight female preponderance (1.3:1 in children). The incidence has increased twofold to threefold since the 1970s

PATIENT¶S PROFILE
‡ General Data ‡ Our case study revolves on an 11 month old female child, Baby Plok. She is a Filipino citizen born in Ilocanos Sur San Fernando City, La Union on September 28, 2008. She is a Roman Catholic. Her parents are Mr. Oink and Mrs. Oink. She is the one and only child of the couple.

PATIENT¶S PROFILE
‡ Immunization Status Baby Plok has completed her dose of DPT,OPV, BCG, Hepa B and measles vaccine. ‡ Past Medical History Baby Plok was first admitted at the Bethany Hospital last April of 2009 because of hypersensitivity reaction due to unknown cause. After two months she again was brought to the hospital with the case of Acute Gastroenteritis

PATIENT¶S PROFILE
‡ History of Present History Five days prior to admission, Baby Plok developed skin rashes that seem to be dry and scaly, and started below her axilla. One day after she received measles vaccine, the rashes worsens and extends to her neck and submandibular area.

PATIENT¶S PROFILE
‡ History of Present History ‡ Baby Plok was admitted at the Bethany Hospital, Pediatric Ward last August 31, 2009 with a chief complaint of skin lesions. Upon assessment in the out Patient Department, Baby Plok have initial vital signs of: Temperature-37.9°C, Pulse rate of 103, respiratory rate of 22 and, a weight of 9 kg. Baby Plok has also manifested erythema, and no ear discharges. He was given initial medications such as Iterax and Inoprisone

PATIENT¶S PROFILE
‡ Family Health History Family of Baby Plok has a history of skin allergies, hypertension, diabetes mellitus and asthma, both from her mother and father.

REVIEW OF THE SYSTEMS

‡ Integument
‡ Baby Plok is fair, has a good skin turgor, with no signs of dehydration noted upon assessment of the skin, but with some lesions over the neck and submandibular areas, and dryness was noted on the neck and submandibular areas.

REVIEW OF THE SYSTEMS
‡ Head and Neck

‡ Head is symmetrical, with no scalp tenderness, or masses present. Hair is black and equally distributed around Baby Plok¶s head. Conjunctivae are pinkish, pupils are equal, round, and reactive to light and accommodation. There are no signs of inflammation, pain, and drainage on both ears

REVIEW OF THE SYSTEMS
‡ Nose is equal and patent, with no signs of nasal congestion and flaring. Mucus membranes are slightly dry and pinkish, tonsils are not inflamed and no signs of decayed teeth. Oral hygiene is well observed and there is no unpleasant odor noted. Jugular vein is not distended and lymph nodes are not swollen. There is no presence of stiffness and pain.

REVIEW OF THE SYSTEMS
‡ Chest & Lungs ‡ Chest is symmetrical. No signs of distress noted, cyanosis is also not present. Baby Plok breathe at a rate of 35 breaths per minute and has a cardiac rate of 110 beats per minute. No tenderness noted. Adventitious sounds are also not present.

REVIEW OF THE SYSTEMS
‡ Abdomen ‡ Skin is fair, abdomen is not distended and there are no signs of herniations and bruising. Bowel tone is normal, (every 1520 sec.). Dullness is heard upon percussion in RUQ where liver is located, and tympany on other quadrants. Masses, tenderness and rigidity are not noted.

REVIEW OF THE SYSTEMS
‡ Extremities ‡ Distal pulses are present. Baby Plok has active motor movement and has a capillary refill of 1.5 seconds. Edema is not present and there is no limitations and pain during movement.

GORDON¶S ASSESSMENT
‡ Health Perception and Health Management Pattern Vision Pupils are equally round and reactive to light and accommodation. Palpebral conjunctivae are normal. Eyebrows are symmetrically aligned; hair is thick, evenly distributed. Eyelashes are equally distributed and curled slightly outward. No discharges present. Cornea is transparent, smooth and shiny. Details of the iris are visible, color brown. Sclera appears white.

‡

GORDON¶S ASSESSMENT
‡ Hearing Patient¶s easily responds to sound. ‡ Tongue Appearance Tongue is positioned at the center and moist. ‡ Touch Patient elicits response upon touching a part of her body. ‡ Smell Nose has no discharges, no lesions, not occlude and with patent airway. Color is same as facial skin.

GORDON¶S ASSESSMENT
‡ Cerebellar exam Milestone to this age is present to the client manifested intact cerebellar function. Patient can crawl, sit alone, creep and can take 2 steps without support. Patient may walk 15 steps with assistance. ‡ Lymph nodes Lymph nodes are not inflamed. ‡ General appearance Client is well dressed but with a stinky odor due to the presence of crusted lesions and unintentionally scratches made by the client.

GORDON¶S ASSESSMENT
‡ Nutritional Metabolic Pattern ‡ Skin exam ‡ Skin has crusted lesions appear on the face and spread to the neck, scalp, extremities and abdomen. Lesions resolve to dry scaly macules that fissure and facilitate exposure to irritants and allergens. ‡ Mucus membranes ‡ Patient¶s mucus membranes are pinkish but partially dry. No lesions noted are noted. ‡ Edema ‡ No presence of edema noted on both upper and lower extremities.

‡ Thyroid ‡ The thyroid is located inferior to the larynx. No presence of mass noted. ‡ Jugular vein ‡ Jugular vein is not distended upon palpation. ‡ Gag reflex ‡ Gag reflex is present. ‡ Ambulation mobility ‡ Patient can crawl, sit alone, creep and can take 2 steps without support. Patient may walk 15 steps with assistance.

GORDON¶S ASSESSMENT
‡ Elimination Pattern ‡ Auscultation The patient had a normal bowel sound ranging from 12-14 bowel sounds. ‡ Palpation There is no presence of any mass or tenderness upon palpation.

GORDON¶S ASSESSMENT
‡ Rectal inspection There is no presence of discharges. Anus is dry. No lesions noted. ‡ Colostomy Patient has no colostomy. ‡ Characteristic of Stool Patient defecated normally more than once in 24 hours. Stool is soft and yellow to brownish in color.

‡ ‡ ‡ ‡ ‡ ‡

Usual voiding pattern Patient usually uses four diapers per day. Activity and Exercise Pattern Cardiovascular Pulses Pulse amplitude is normal upon palpation. Patient has a regular heart rate of 90 to 110 bpm ‡ Extremities ‡ Upper and lower extremities have normal motor strength of 3/5. Peripheral pulses are within normal range. Extremities are not edematous. Both upper and lower extremities have crust formation.

‡ Respiratory ‡ Chest expansion is symmetrical. No presence of rales on both lung fields upon auscultation. Patient has an average respiratory rate of 35 bpm. ‡ Musculoskeletal ‡ No contractures noted. Patient can crawl, sit alone, creep and can take 2 steps without support. Patient may walk 15 steps with assistance. ‡ Sleep and Rest ‡ Mother claims that patient has deprived sleep pattern because patient wakes every now and then due to itchiness of lesions. Scratches lesions add to the disturbance of sleeping.

‡ Theories of Development ‡ Freud¶s Theory of development ‡ Sigmund Freud¶s Psychosexual Stages of Development during this stage, the infant is concerned with self-gratification. The infant is all id, operating in the Pleasure Principle and striving for gratification of needs. When the infant experiences gratification of basic needs a sense of trust and security begins. The ego begins to emerge as the infant begins to see self as separate from the mother; this marks the beginning of the development of a sense of self.

‡ Erickson¶s Theory of development ‡ Integrated to Erik Erickson Stages of Psychosocial Development, patient is 11 months old, belongs to infancy (birth to 18 months), wherein he is under Psychosocial Crisis Trust vs. Mistrust. He is engaged to a task of attachment to the mother. The resolution of crisis develops trust in persons; faith and hope about the environment and the future. ‡ The mother reported immediate action to what the patient demands her to do. By giving prompt feeding, cuddling, singing lullaby and touching when patient is crying.

Piaget¶s Theory of Development ‡ Baby Plok is in the stage called coordination of secondary schema wherein she discovers object permanence, or become aware that an object out of sight still exists. Also, she is capable of reproducing events such as shaking her own feeding bottle.

NORMAL ANATOMY & PHYSIOLOGY

PATHOPHYSIOLOGY
staphylococcus aureus, stress, anxiety, systemic illness

dysregulation of of islets of langerhan cells,epidermal cells,macrophages

predominance of Th2 cells over Th1 cells

increase Th1 cytokines & decrease of Th2 cytokines and IL-2

desaturase activity is deficient

Increase in IgE synthesis

Allergic reaction

decrease linoleic and linoleic acid metabolite colonnization on skin due to deficiencies in endogenous antimicrobial peptides

loss of Essential Fatty Acids
increased in transepidermal water loss

ATOPIC DERMATITIS
xerosis, dry skin, cracking of skin, itchiness,pruritus,& lichenfication
Impaired Skin Integrity r/t inflammatory process, Disturbed Sleep Pattern r/t itchiness, Deficient Knowledge r/t to unrecognized signs & symptoms

DIAGNOSTIC TEST, PROCEDURE AND TREATMENTS
‡ CBC TYPING ‡ WBC differential count ‡ A WBC differential can provide more specific information about a patient¶s immune system. WBC differential aids diagnosis because some disorders affect only one WBC type. Abnormally high levels of WBC¶s are associated with allergic reactions.

RESULTS
Variable WBC Normal Values 4.30-10 4.30-10 xx x 150-450 x 4.0-5.5 4.1 12.6 /L x 10x9 Result 12.6 x 109 / L 46% /L 110 g/dL .34 Interpretation
increased

Neutrophils Lymphocytes Monocytes Eosinophils Basophils RBC HGB HCT MCV MCH MCHC PLT

40% - 74% 19% - 48% 3.4% - 9% 0% - 7% 0.5% - 1% /L 110-150 g/dL .30 -.40 80-96 fl 27-31 pg 32% - 36% /L

Normal Normal Normal Normal -

KOH Examination
‡ The potassium hydroxide examination is a simple technique for microscopic examination of a large sample of stratum corneum. The alkaline KOH solution causes separation and ultimately, destruction of the stratum corneum cells. The so-called ³clearing´ of the stratum corneum sample allows easy identification of exogenous (non protein) materials such as hyphae, spores, and fiberglass fibers, which are unaffected or less rapidly affected by KOH solution.

KOH Examination (Procedure)
‡ Explain procedure to client. ‡ Select the site for specimen collection. Powders, creams and ointments may be removed by wiping the area with cloth sponge containing acetone. Alcohol does not remove ointments effectively. ‡ Collect scales from the border adjacent to normalappearing skin. ‡ When blisters are present, remove their roofs for examination.

KOH Examination (Procedure)
‡ Pustules or rings of scale somewhat separated from the confluent lesions suggest candidiasis, and specimens of these lesions should be examined. ‡ Use scalpel with a curved blade or a curette to scrape the loosely adherent scales onto a microscope slide held so that the scales fall directly onto the slide. ‡ Alternately, the specimen may be scraped onto colored paper and then transferred to the microscope slide. Paper may be preferred for awkward areas such as toe webs

DRUG STUDY

CEFTRIAXONE C-Third Class Generation Cephalosporins H-(-) infection (through inhibiton of cell wall synthesis,promoting osmotic instability E-No specific

CEFTRIAXONE (client teaching)
‡ Instruct patient to report reduced urine output, persistent diarrhea, bruising or bleeding. ‡ Caution patient not to use herbs unless prescriber approves ‡ As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, and herbs mentioned above.

CEFTRIAXONE (nursing consideration)
‡ Monitor for extreme confusion, tonic, clonic seizures, and mild hemiparesis when giving high doses ‡ Assess CBC and kidney and liver function test results ‡ Monitor signs and symptoms of super infection and other serious adverse reactions

PARACETAMOL
C-Analgesics, muscle relaxants, anti pyretics H-The drug may relieve fever through central action in the hypothalamic heat regulating center E-Give with food or milk to decreases gastric symptoms, give 30 mins before or 2 hrs.after meals

PARACETAMOL (client teaching)

‡ Tell patient to consult prescriber before giving drug to children younger than age two ‡ Advise parents that drug is only for short term use; urge them to consult prescriber if giving to children for longer than 5 days or adults for longer than 10 days

PARACETAMOL (nursing consideration)

‡ Assess allergic reactions if these occur, drug may have to be discontinued ‡ Assess for chronic poisoning: rapid , weak pulse; dyspnea, cold, clammy extremities, report immediately to prescriber

BACTROBAN CREAM (client teaching)

C-Anti-infectives, topical H-Negative reaction E-No specific

BACTROBAN CREAM (client teaching)
‡ area with soap and water and dry it thoroughly, then apply small amount of drug to area and rub it gently. If desired, tell him to apply gauze dressing ‡ Advise patient to complete entire course of therapy, even if symptoms disappear. Tell him to try not to miss doses ‡ Advise patient to contact prescriber if skin infection doesn¶t improve within 3 to 5 days or if it worsens ‡ Caution patient not to apply drug to eye or mucous membranes (except nasal form for intranasal use

BACTROBAN CREAM (nursing considerations)

‡ Monitor for drug efficacy

OPTIPRED CORTICOSTEROID
C-Glucocorticoid H-False-negative nitrobluetetrazolium test for bacterial infection negative or resolution of infection E- No specific C- monitor V/S,weight, reflexes and grip strength and blood glucose K-Do not stop taking the drug without consulting the health care provider.

PIPERACILLIN SODIUM & TAZOBACTAM SODIUM

C-extended ±spectrum penicillin; beta- lactamase inhibitor H-negative or resolution of infection E-No specific

PIPERACILLIN SODIUM & TAZOBACTAM SODIUM (client teaching)

‡ Tell patient to report any untoward or unlikely reactions ‡ Inform patient to report discomfort at IV site ‡ Ask the patient about allergy to penicillins

PIPERACILLIN SODIUM & TAZOBACTAM SODIUM (client teaching)
‡ ‡ ‡ ‡ Use drug immediately after reconstitution Stop any primary infusion if possible Change IV site every 48 hours Monitor hematologic and coagulation parameters ‡ Watch out for superinfections especially to elderly and immunocompromised patients.

STIEFEL

C-Skin antiseptics H-Negative or resolution of infection E-Twice a day, as needed

STIEFEL (client teaching)
‡ Instruct patient to wash affected area with soap and water and dry it thoroughly, then apply small amount of drug to area and rub it gently. If desired, tell him to apply gauze dressing ‡ Advise patient to complete entire course of therapy, even if symptoms disappear. Tell him to try not to miss doses ‡ Advise patient to contact prescriber if skin infection doesn¶t improve within 3 to 5 days or if it worsens ‡ Caution patient not to apply drug to eye or mucous membranes (except nasal form for intranasal use.

STIEFEL (nursing considerations)

‡ Monitor for drug efficacy

NURSING CARE PLANS
‡ ‡ ‡ ‡ IMPAIRED SKIN INTEGRITY ASSESSMENT: Subjective: ³lagi siyang nagkakamot, meron na nga siyang mga sugat dahil sa kakakamot niya´ as verbalized by his mother Objective: Disruption of the skin surface. Some lesions noted around the neck cause by frequent scratching Client is crying upon touching the affected areas.

‡ ‡ ‡ ‡

IMPAIRED SKIN INTEGRITY (diagnosis)

‡ Impaired Skin Integrity related to chronic inflammatory condition of the skin possibly evidenced by disruption of the skin surface with dry or moist scales, erythema and fissures

IMPAIRED SKIN INTEGRITY (planning)
STG: ‡ After 8 hours of proper intervention, client demonstrates a relief of itchiness and pain as evidenced by absence of cry when touching affected areas. LTG: ‡ After 3 days of proper nursing intervention, the client will display timely healing of skin without any complication and participate in prevention measures and treatment program.

IMPAIRED SKIN INTEGRITY (intervention & rationale) (independent)

‡ Determine nutritional status and risk for injury because of malnutrition to have a basis for proper intervention. ‡ Inspect the skin for erythema, indurations and maceration for initial assessment to provide prompt intervention.

IMPAIRED SKIN INTEGRITY (intervention & rationale) independent)

‡ Note presence for compromised vision, hearing or speech because skin is a particularly important avenue for communication. ‡ Periodically remeasure affected skin and observe for complications to monitor progress of wound healing.

IMPAIRED SKIN INTEGRITY (intervention & rationale) independent)

‡ Keep the area clean and prevent infection to avoid further complications. ‡ Provide an environment that are free of dust and allergens that may further irritate the client to achieve better outcome

IMPAIRED SKIN INTEGRITY (intervention & rationale) independent

‡ Cut child¶s nails as necessary to avoid further scratching that may cause lesions. ‡ Keep the area clean and dry to assist body¶s natural process of repair.

IMPAIRED SKIN INTEGRITY (intervention & rationale) dependent

‡ Administer prescribed medications (Bactroban Cream) on time to alleviate the condition. ‡ Apply chalamine lotion to decrease itching. ‡ Consult with wound specialist to assist with developing plan of care for potentially serious wounds.
‡

IMPAIRED SKIN INTEGRITY (evaluation)
STG: ‡ Goal met: After 8 hours of proper intervention, client demonstrated a relief of itchiness and pain as evidenced by absence of cry when touching affected areas.. LTG: ‡ Goal met: After 3 days of proper nursing intervention, the client displayed timely healing of skin without any complication and participate

SLEEP DEPRIVATION (assessment)
Subjective: ‡ ³Hindi siya nakakatulog ng maayos dahil sa panganagti ng balat niya´, as verbalized by the mother. Objective: ‡ frequent yawning ‡ disturbed sleep frequently during sleep periods

SLEEP DEPRIVATION (diagnosis)

‡ Sleep Deprivation related to itchiness of the skin secondary to atopic dermatitis.

SLEEP DEPRIVATION (planning)
‡ STG: ‡ After 8 hours of proper nursing intervention, the patient will demonstrate an undisturbed sleep. ‡ LTG: ‡ After 3 days of proper nursing management, the client will maintain an undisturbed sleep pattern.

SLEEP DEPRIVATION (interventions & rationale) independent
‡ Assess causative factors that may interrupt with sleep to provide more effective intervention. ‡ Observe and obtain feedback from guardians regarding usual bedtime, rituals, number of hours of sleep, time of arising and environmental needs to determine usual pattern and to provide comparative baseline.

SLEEP DEPRIVATION (interventions & rationale) independent

‡ Implement effective age appropriate bedtime rituals (lullaby) to enhance client¶s ability to fall asleep and promote sense of security for the child. ‡ Do a chronological chart to determine peak performance rhythm.

SLEEP DEPRIVATION (interventions & rationale) dependent
‡ Apply topical medications such as chalamine lotion and bactroban cream to decrease itching, thus inhibiting factor that affects disturbed sleep

SLEEP DEPRIVATION (evaluation)
STG: ‡ Goal met. After 8 hours of proper nursing intervention, the patient demonstrated an undisturbed sleep LTG: ‡ Goal met. After 3 days of proper nursing management, the client will maintain an undisturbed sleep pattern.

VII. SUMMARY, CONCLUSIONS, & RECOMMENDATIONS
‡ SUMMARY ‡ javascript:void(null);Atopic Dermatitis is a disorder of the upper layers of the skin that usually begins in childhood. It typically affects those in families with a history of atopic dermatitis, allergic conditions or asthma. Scaly, itchy skin rashes are typical symptoms of the disorder, which is the most severe and longest-lasting form of dermatitis. ‡ Atopic conditions occur in people who are overly sensitive to allergens in their environment. Though not technically caused by allergies, and not always triggered by an allergen, atopic dermatitis usually appears in infants and young children who already have allergies, or who are likely to develop them later.

‡ The pattern of rash distribution is a distinguishing feature of atopic dermatitis, which is a common type of eczema (an inflammatory skin disease). Red, itchy patches usually start on the face, particularly the cheeks and chin. Over time, the face heals, but for some the rash will then appear on other parts of the body. ‡ There is no cure for atopic dermatitis, but treatments can reduce symptoms. This is crucial, because much of the damage associated with atopic dermatitis is a result of scratching brought on by intense itchiness. Long-term irritation and scratching can cause the skin to thicken and take on a leathery texture (lichenification). It can also increase the risk of infection to the skin. Atopic dermatitis is not contagious.

CONCLUSIONS
‡ Atopic dermatitis is the most common form of eczema, and the terms are often used interchangeably. It is a skin disorder that primarily afflicts infants and children. The exact nature of the relationship between atopic dermatitis and allergies is unclear. For some children, atopic dermatitis improves or disappears as they get older. Children are more likely to develop atopic dermatitis if one or both parents have a history of allergic conditions or asthma. Environmental factors can also bring on symptoms of atopic dermatitis in those who have inherited the atopic disease trait. People living in dry climates may be more likely to develop the condition. Factors that may trigger atopic dermatitis or make it worse include: emotional stress, temperature changes and humidity extremes, bacterial skin infections, contact with skin irritants, such as wool clothing, soap, laundry detergents and cosmetics, sweating, bathing and dry skin

RECOMMENDATIONS
‡ Because atopic dermatitis is likely an inherited condition, there is no way to prevent it. However, there are many preventative steps that can be taken to reduce symptoms. These include avoiding the following triggers: excessive heat and sweating, emotional stress, bacterial skin infections, cold air or conditions likely to make the skin dry, soaps and detergents, fabrics likely to irritate the skin, especially wool, tight clothing, some skin care products (e.g., astringents, alcohol-containing products), tobacco smoke, certain chemicals (e.g., chlorine), acidic foods, dust and sand ‡ In addition to avoiding triggers, patients can make several behavioral modifications that will help reduce symptoms: Avoid taking long or hot baths or showers. After showers and baths, lightly blot skin with towels rather than rubbing intensely. Regular use of unscented moisturizing creams can keep the skin from drying out. Dry skin is more sensitive to irritants, and also lacks a moisture barrier to protect it from irritants. Avoid scratching as much as possible. Excessive scratching can have a devastating long-term effect on skin conditions.

‡ Use doctor-approved medications to reduce itching. Because atopic dermatitis almost always causes intense itching, it is important to consult a physician about medications that can safely relieve these symptoms. Keep fingernails short and clean to reduce the chance of infecting the skin when scratching. Cover infants¶ hands with mittens or socks to keep them from scratching the area. Learn to manage stress. Patients may benefit from learning stress management techniques and participating in stress-reducing activities such as exercise and meditation. Use detergents that are perfume and color free. Running clothing through a second rinse cycle can also help remove potentially irritating detergent from clothing. ‡ Studies have shown that children who are breastfed are much less likely to get eczema. In addition, some research indicates that mothers who exclude cow's milk from their diets can significantly reduce their breastfed child's likelihood of developing atopic dermatitis. However, this link has not yet been well-established

Thank you!!!!!

‡ Presented by bsn4-1a

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