Chapter 52 - Integumentary Conditions PDF

UNIT 12 Health Conditions of Children 52 Integumentary Conditions Cheryl Sams http://evolve.elsevier.com/Canada/Perry/maternal OBJECTIVES On completion of this chapter the reader will be able to: 1. Describe the distribution and configuration of the various skin lesions. 2. List the benefits of a...

UNIT 12 Health Conditions of Children 52 Integumentary Conditions Cheryl Sams http://evolve.elsevier.com/Canada/Perry/maternal OBJECTIVES On completion of this chapter the reader will be able to: 1. Describe the distribution and configuration of the various skin lesions. 2. List the benefits of a moist environment for wound healing. 3. Contrast the manifestations of and therapies for bacterial, viral, and fungal infections of the skin. 4. Compare the skin manifestations related to age in children. Outline a care plan to prevent and treat diaper dermatitis. Outline a care plan for a child with atopic dermatitis. Formulate a teaching plan for an adolescent with acne. Describe the methods for assessing a burn wound. Discuss the physical and emotional care of a child with a severe burn wound. 10. Describe strategies to reduce the risk of sunburn. INTEGUMENTARY ANATOMY AND PHYSIOLOGY smooth fibre bundles. Nails are composed of hard keratin; modified layers of horny epidermal cells arise from proximal nail folds and adhere to nail beds. Skin glands include sebaceous glands, which produce sebum for skin surface lubrication and minimizes fluid loss; secretion increases at puberty and late in pregnancy and decreases in advancing age. The skin is the largest organ in the body and provides a protective covering. The skin is composed of stratified epithelial cells, which are thickest on the palms and soles. The outer epidermal layer starts with the following stratum: corneum lucidum, granulosum, spinsum, and germinativum (Figure 52.1). The skin is pigmented by melanocytes in the germinativum layer, which darken the skin (in response to sunlight) to varying degrees. Blood vessels are located in the dermis. The dermis, which lies directly beneath the epidermis, consists of connective tissue containing white collagenous and yellow elastic fibres, blood vessels, nerves, lymph vessels, hair follicles, and sweat glands. The skin has four functions: • To provide sensory input—the sensations of pain, temperature, touch, and pressure—and to discriminate between the sensations through a nervous system pattern to the cerebral cortex • For protection—the skin forms an elastic, resistant covering for protection against the external environment, inhibiting excessive water loss and that of essential electrolytes and providing an acid mantle to protect skin from irritants and bacterial invasions. • Thermoregulation and the prevention of heat loss by processes of conduction, convection, radiation, and evaporation (which occurs as either insensible water loss or visual water loss as perspiration) • To act as a warning system for danger by sending information to the brain about the external environment The appendages of the skin are protective and include hair, nails, and glands. Hair is composed of individual units of follicles that contain cuticle, cortex, and medulla with attached arrector pili muscles that are 5. 6. 7. 8. 9. INTEGUMENTARY DYSFUNCTION Skin Lesions Lesions of the skin result from a variety of etiological factors. Skin lesions can involve (1) contact with injurious agents (infective organisms, toxic chemicals, and physical trauma), (2) hereditary factors, (3) external factors such as allergens, or (4) systemic diseases, such as measles, lupus erythematosus, and nutritional deficiency diseases. Responses to these agents or factors are highly individualized. An agent that is harmless to one individual may be damaging to another, and a single agent may produce varying degrees of response. Contact dermatitis, such as poison ivy, is seen only when the noxious agent is found in the environment. An important factor in the etiology of skin manifestations is the child’s age. Infants are subject to “birthmark” malformations and atopic dermatitis (AD) that appear early in life, and acne is a characteristic skin disorder of puberty. Pathophysiology of Dermatitis. More than half of the dermatological conditions in children are forms of dermatitis. This implies a sequence of inflammatory changes in the skin that are grossly and 1407 1408 UNIT 12 Health Conditions of Children Arrector pili muscle Hair shaft Pore of sweat gland Stratum lucidum Stratum granulosum Huxley layer Stratum germinativum Henley layer Papillary layer External sheath Reticular layer Glassy membrane Hair matrix Papilla of hair follicle Subcutaneous tissue Elastic fibres Connective tissue layer Dermis Hair follicle Cuticle Epidermis Stratum corneum Sebaceous gland Artery Vein Sweat gland Fig. 52.1 Anatomical structures of the skin. (From Ball, J. W., Dains, J. E., Flynn, J. A., et al. [2015]. Seidel’s guide to physical examination [8th ed., p. 115]. Mosby [Fig. 8-1]). microscopically similar but diverse in course and causation. Acute responses produce intercellular and intracellular edema, the formation of intradermal vesicles, and an initial infiltration of inflammatory cells into the epidermis. In the dermis there is edema, vascular dilation, and early perivascular cellular infiltration. The location and manner of these reactions produce the lesions characteristic of each disorder. The changes are usually reversible, and the skin ordinarily recovers without blemish unless complicating factors such as ulceration from the primary irritant, scratching, and infection are introduced or underlying vascular disease develops. In chronic conditions, permanent effects are seen that vary according to the disorder, the general condition of the affected individual, and the available therapy. Diagnostic Evaluation. Although the history and subjective symptoms of skin lesions are explored first, the obvious objective characteristics of the lesions are often noted simultaneously. Many skin lesions are easily diagnosed after careful inspection. History and subjective symptoms. Many cutaneous lesions are associated with local symptoms. The most common local symptom is itching (pruritus), which varies in intensity. Pain or tenderness often accompanies some skin lesions. Other skin sensations such as burning, prickling, stinging, or crawling are also described. Alterations in local feeling include absence of sensation (anaesthesia); excessive sensitiveness (hyperesthesia); diminished sensation (hypesthesia or hypoesthesia); or abnormal sensation, such as burning or prickling (paresthesia). These symptoms may remain localized or migrate, may be constant or intermittent, and may be aggravated by a specific activity, such as exposure to sunlight. It is important to determine whether the child has an allergic condition such as asthma or hay fever or history of a previous skin disease. AD, often associated with allergies, frequently begins in infancy. Important questions for the parent include when the lesion or symptom first appeared; whether it occurred with ingestion of a food or other substance, including any medication; and whether the condition was related to activity such as contact with plants, insects, or chemicals. Objective findings. The distribution, size, morphological characteristics, and arrangement of skin lesions provide significant information. Extrinsic causes usually result from physical, chemical, or allergic irritants or from an infectious agent such as bacteria, fungi, viruses, or animal parasites. Skin manifestations are also produced by intrinsic causes such as an infection (measles or chicken pox), medication sensitization, or other allergic phenomena. Types of lesions. Skin lesions assume distinct characteristics that are related to the pathological process. Nurses should become familiar with the common terms used to describe skin lesions because these terms are used in the processes of record keeping and communication. These terms include the following: Erythema—A reddened area caused by increased amounts of oxygenated blood in the dermal vasculature Ecchymoses (bruises)—Localized red or purple discolorations caused by extravasation of blood into dermis and subcutaneous tissues Petechiae—Pinpoint, tiny, and sharp circumscribed spots in the superficial layers of the epidermis Primary lesions—Skin changes produced by a causative factor; primary lesions in pediatric skin disorders include macules, papules, vesicles, patches, bullae, plaque, wheals, nodules, pustules, and cysts (Figure 52.2) Secondary lesions—Changes that result from alteration in the primary lesions, such as those caused by rubbing, scratching, medication, or involution and healing (Figure 52.3) Distribution pattern—The pattern in which lesions are distributed over the body, whether local or generalized, and the specific areas associated with the lesions Configuration and arrangement—The size, shape, and arrangement of a lesion or groups of lesions (e.g., discrete, clustered, diffuse, or confluent) Laboratory studies. If a skin issue is related to a systemic disease such as collagen or immunodeficiency disease, laboratory studies are performed to identify the condition. Diagnostic techniques include microscopic examination, cultures, skin scrapings or biopsy, cytodiagnosis, patch testing, Wood light examination, allergic skin testing, and other laboratory tests, such as blood count and sedimentation rate. CHAPTER 52 Integumentary Conditions Macule—flat; nonpalpable; circumscribed; less than 1 cm in diameter; brown, red, purple, white, or tan in colour Examples: Freckles; flat moles; rubella; rubeola Plaque—elevated; flat topped; firm; rough; superficial papule greater than 1 cm in diameter; may be coalesced papules Examples: Psoriasis; seborrheic and actinic keratoses Patch—flat; nonpalpable; irregular in shape; macule that is greater than 1 cm in diameter Examples: Vitiligo; port-wine marks Wheal—elevated, irregularly shaped area of cutaneous edema; solid, transient, changing, variable diameter; pale pink with lighter centre Examples: Urticaria; insect bites Papule—elevated; palpable; firm; circumscribed; less than 1 cm in diameter; brown, red, pink, tan, or bluish red in colour Examples: Warts; drug-related eruptions; pigmented nevi Nodule—elevated; firm; circumscribed; palpable; deeper in dermis than papule; 1 to 2 cm in diameter Examples: Erythema nodosum; lipomas Vesicle—elevated; circumscribed; superficial; filled with serous fluid; less than 1 cm in diameter Examples: Blister; varicella Pustule—elevated; superficial; similar to vesicle but filled with purulent fluid Examples: Impetigo; acne; variola Bulla—vesicle greater than 1 cm in diameter Examples: Blister; pemphigus vulgaris Cyst—elevated; circumscribed; palpable; encapsulated; filled with liquid or semisolid material Example: Sebaceous cyst 1409 Fig. 52.2 Primary skin lesions. (From Seidel, H. M., et al. [Eds.]. [2006]. Mosby’s guide to physical examination [6th ed., pp. 183–185]. Mosby [Table 8-4].) Wounds Wounds are structural or physiological disruptions of the skin that activate normal or abnormal tissue repair responses. Wounds are classified as acute or chronic. Acute wounds are those that heal uneventfully within 2 to 3 weeks. Chronic wounds are those that do not heal in the expected time frame or are associated with complications. Cofactors that disrupt or delay wound healing include compromised perfusion, malnutrition, and infection. In children, most wounds are acute and can be prevented from becoming chronic wounds through appropriate nursing care. Wounds are also classified as surgical and nonsurgical and then further 1410 UNIT 12 Health Conditions of Children Scale—heaped-up keratinized cells; flaky exfoliation; irregular; thick or thin; dry or oily; varied size; silver, white, or tan in colour Examples: Psoriasis; exfoliative dermatitis Crust—dried serum, blood, or purulent exudate; slightly elevated; size varies; brown, red, black, tan, or straw in colour Examples: Scab on abrasion; eczema Lichenification— rough, thickened epidermis; accentuated skin markings caused by rubbing or irritation; often involves flexor aspect of extremity Example: Chronic dermatitis Scar—thin to thick fibrous tissue replacing injured dermis; irregular; pink, red, or white in colour; may be atrophic or hypertrophic Example: Healed wound or surgical incision Keloid— irregularly shaped, elevated, progressively enlarging scar; grows beyond boundaries of wound; caused by excessive collagen formation during healing Example: Keloid from ear piercing or burn scar Excoriation—loss of epidermis; linear or hollowed-out crusted area; dermis exposed Examples: Abrasion; scratch Fissure—linear crack or break from epidermis to dermis; small; deep; red Examples: Athlete’s foot; cheilosis Erosion—loss of all or part of epidermis; depressed; moist; glistening; follows rupture of vesicle or bulla; larger than fissure Examples: Varicella; variola following rupture Ulcer—loss of epidermis and dermis; concave; varies in size; exudative; red or reddish blue Examples: Decubiti; stasis ulcers Fig. 52.3 Secondary skin lesions. (From Seidel, H. M., et al. [Eds.]. [2006]. Mosby’s guide to physical examination [6th ed., pp. 186–188]. Mosby [Table 8-5].) classified in the same manner as burns: superficial, partial thickness, or full thickness (complex wounds that include muscle or bone). Epidermal Injuries. Abrasions are the most common epidermal wounds in children, usually in the form of a skinned knee or elbow. In most injuries the margins of the abraded area are superficial, involving only the outer layers of epidermis, although the central portion may extend into the dermis. Epithelial tissue is composed of labile cells, which are constantly destroyed and replaced throughout the lifespan. Thus epidermal injuries usually result in rapid, uneventful healing and recovery. CHAPTER 52 Injury to Deeper Tissues. Tissues composed of permanent cells such as muscle and nerve cells are unable to regenerate. These tissues repair themselves by substituting fibrous connective tissue for the injured tissue. This fibrous tissue, or scar, serves as a patch to preserve or restore the continuity of the tissue. Wounds involving permanent cells include surgical incisions, lacerations, pressure injuries, evulsions, and full-thickness burns. Assessment of the wound is important to detect for early signs of pressure injury development. Factors that contribute to pressure injury formation include impaired mobility, protein malnutrition, edema, incontinence, sensory loss, anemia, infection, failure to turn the child, and intubation. Assessment scales such as Braden QD (Chamblee et al., 2018; Liao et al., 2018) help in evaluation of the severity of the pressure injury. (See Chapter 44 for prevention and treatment of pressure injuries; see Additional Resources for the RNAO best practice guidelines on treating pressure injuries and for the Braden QD assessment tool.) General Therapeutic Management. Some wounds demand aggressive therapy but, typically, the major aim of treatment is to prevent further damage, eliminate the cause, prevent complications, and provide relief from discomfort while tissues undergo healing. Factors that contribute to the development of dermatitis and that prolong the course of the disease should be eliminated when possible. For example, the most common causative agents of dermatitis in infants, children, and adolescents are environmental factors (soaps, bubble baths, shampoos, rough or tight clothing, wet diapers, blankets, and toys) and the natural elements (such as dirt, sand, heat, cold, moisture, and wind). Dermatitis may also result from home remedies and medications. Wound care management has shifted from interventions aimed at maintaining a dry environment to those that promote a moist, crustfree environment that enhances the migration of epithelial cells across the wound and facilitates remodelling. An acute full-thickness wound kept in a moist environment usually re-epithelializes in 12 to 15 days; the same wound when kept open to the air heals in about 25 to 30 days. Dressings. Moist wound healing increases the rate of collagen synthesis and re-epithelialization and decreases pain and inflammation. It also creates an environment for autolytic debridement of necrotic tissue, which creates a clean wound bed and enhances granulation. However, a balance must be achieved between creating a moist wound bed and maintaining a dry periwound area that protects the skin and wound from maceration. The dressing type and frequency of dressing changes help to achieve this balance. The frequency of dressing changes is based on the presence of infection, the type of dressing, the location of the wound, and the amount of drainage. Topical therapy. Topical applications may be applied to treat a disorder, reduce itching, decrease external stimuli, or apply external heat or cold. The emollient action of soaks, baths, and lotions provides a soothing film over the skin surface that reduces external stimuli. Ordinarily, lukewarm or cool applications offer the greatest relief. Integumentary Conditions 1411 Topical corticosteroid therapy. Glucocorticoids are the therapeutic medications used most frequently for skin disorders. Corticosteroids are applied directly to the affected area, are essentially nonsensitizing, and have only minor adverse effects. As with the use of any steroids, their use in large amounts may mask signs of infection, and symptoms may be exacerbated after termination of the medication. The concentrations available without prescription are not adequate for stubborn skin conditions such as psoriasis and may further aggravate inflammation caused by fungus or bacteria. Most parents and children should be counselled that it is both effective and economical to apply only a thin film and to massage it into the skin. Parents and children should also be advised to use the application for no more than 5 to 7 days, because these agents may cause depigmentation and other changes in the skin. Other topical therapies. Other topical treatments include chemical cautery (especially useful for warts), cryosurgery, electrodesiccation (chiefly used for warts, granulomas, and nevi), ultraviolet (UV) therapy (primarily used in psoriasis and acne), laser therapy (especially for birthmarks), and acne therapies such as dermabrasion and chemical peels. New medications called topical immunomodulators are effective in reducing the itching of AD (eczema) and preventing “flares.” Systemic therapy. Systemic medications may be used as an adjunct to topical therapy in some dermatological disorders. The medications most frequently used are corticosteroids, antibiotics, and antifungal medications. Corticosteroids are valuable because of their capacity to inhibit inflammatory and allergic reactions. Dosage is carefully adjusted and gradually tapered to the minimum dosage that is effective and tolerated, as prolonged use may temporarily suppress growth. Antibiotics are used in severe or widespread skin infections. However, because these medications tend to produce hypersensitivity in some patients, they are used with caution. Antifungal medications are the only means for treating systemic fungal infections. Nursing Care. It is important for nurses to not only describe but also assess skin lesions and the associated wounds. The colour, shape, and distribution of lesions and wounds are important to note. Individual lesions are described according to standard terminology. Sometimes two descriptors are used for a particular characteristic, such as maculopapular rash. To confirm or amplify the findings made by inspection, the nurse may gently palpate the skin to detect characteristics such as temperature, moisture, texture, elasticity, and edema. Wounds need to be assessed for depth of tissue damage, evidence of healing, and signs of infection. NURSING ALERT Signs of wound infection are as follows: • Increased erythema, especially beyond the wound margin • Edema • Purulent exudate • Pain • Increased temperature NURSING ALERT Application of heat tends to aggravate most conditions, and its use is usually reserved for reducing specific inflammatory processes, such as folliculitis and cellulitis. Ointments in a petrolatum base provide protection from moisture. Therefore, this type of ointment is indicated around gastrostomy tubes, in skin folds, and in the diaper area. Creams are absorbed by the skin and are used for areas where a nongreasy “feel” is desired, such as the face and hands. The frequency of wound assessment depends on the severity and complexity of the wound. The wound bed is assessed for colour, drainage, odour, necrosis, granulation tissue, fibrin slough, undermining and condition of the wound edges, and the colour and condition of the surrounding skin. Therapeutic programs are designed to include general measures such as rest, protection, and relief of discomfort, and specific treatments such as medication and physical techniques. Only a few skin diseases are contagious; thus it is usually not necessary to isolate the affected 1412 UNIT 12 Health Conditions of Children child, except from persons in danger of acquiring a secondary infection, such as a child receiving large doses of corticosteroids or other immunosuppressant medications or a child with an immune deficiency disorder. However, if the skin manifestation is caused by a viral exanthema, such as measles or chicken pox, the child should be prevented from exposing other susceptible children. Wound care. Parents can generally manage small skin lesions or wounds at home. The parents should be instructed to wash their hands and then wash the wound gently with mild soap and water or normal saline. They should be cautioned to avoid povidone-iodine, alcohol, and hydrogen peroxide because these products are toxic to wounds. NURSING ALERT Do not put anything in a wound that you would not put in the eye. The safest solution is normal saline. Open wounds are covered with a dressing, such as a commercial adhesive bandage, although larger wounds may benefit from the use of occlusive dressings. If a dressing needs to be secured, a nonalcohol skin barrier can be applied to protect the skin, or the wound can be “picture framed” with hydrocolloid dressing and dressing tape can be secured to the hydrocolloid. This method of securing the dressing protects the skin when the tape is removed. Montgomery straps or stretch netting can also be used to secure dressings and to avoid the use of tape. NURSING ALERT Advise parents that the yellow gel forming under hydrocolloid dressings may look like pus and has a distinct odour (somewhat fruity) but is normal leakage. Dressings need to be removed carefully to protect intact skin and the epithelial surface of the wound. When removing transparent or hydrocolloid dressings, the nurse or parent should raise one edge of the dressing and pull parallel to the skin to loosen the adhesive. Lacerations present a special challenge. The injured child and family are usually distressed by the bleeding. In particular, scalp lacerations tend to bleed profusely. The initial nursing intervention is to apply pressure to the area and to attempt to calm the child before further examination. Unless there is bleeding from a severed artery, the wound is cleansed with a forced jet of sterile tepid water or saline (via syringe) and examined for extent, depth, and presence of foreign material such as dirt, glass, or fabric fragments. The location of the wound facilitates assessment. Wounds over bony areas may contain bone chips, and clear fluid seeping from severe head wounds may indicate cerebrospinal fluid. A pressure dressing is applied for transfer to medical care. After the child is in a medical facility, the child is prepared for treatment. Puncture wounds that do not require a tetanus booster are soaked in warm water and soap for several minutes. Causing the wound to rebleed may be helpful. An adhesive bandage can be applied if desired. Puncture wounds of the head, chest, or abdomen or those that could still contain a portion of the puncturing object must be evaluated carefully. Parents should be cautioned against opening blisters or kissing a wound “to make it better.” The wound can easily become contaminated from germs in the human mouth. If scabs form, they need to be allowed to slough off without assistance; picking or early removal may cause scarring and secondary infection. Parents should be advised to seek medical help if there is evidence of infection. Relief of symptoms. Most therapeutic regimens for skin lesions are directed toward relief of pruritus, the most common subjective complaint. Cooling the affected area and increasing the skin pH with cool baths or compresses and alkaline applications such as baking soda baths are helpful in reducing the itching. Clothing and bed linen should be soft and lightweight to decrease irritation from friction and stimulation. During treatment, both the affected and unaffected skin should be protected from damage and secondary infection. Preventing scratching is important. Older children can refrain from scratching or rubbing, although they may need to be reminded to do so. Small children may require the use of devices such as mittens (especially during sleep) or special coverings. Keeping fingernails clean, short, and trimmed reduces the risk of secondary infection. Antipruritic medications, such as diphenhydramine (Benadryl) or hydroxyzine (Atarax), may be prescribed for severe itching, especially if it disturbs the child’s rest. Pain and discomfort are usually managed with nonpharmacological measures and mild analgesia. Severe pain requires more potent medication. Occlusive dressings over wounds reduce pain. For suturing wounds a topical anaesthetic or intradermal buffered lidocaine should be used (see Pain Management, Chapter 34). NURSING ALERT Provide written instructions and demonstrate to parents the correct amount of topical medication to apply (e.g., size of a pea; thin film to cover). If more than one preparation is applied, mark the containers with numbers so the parents remember the correct order of application. Stress that more is not necessarily better with some medications, such as steroids. Home care and family support. Dermatological conditions always involve the family; few situations require hospitalization and most care is delivered at home. Because family members must carry out the treatment plan, their assistance is essential. Regimens that are simple to accomplish in the clinic, hospital, or primary health care provider’s office may be frustrating and baffling at home. The family may also need assistance in adapting equipment available for home therapy. It is important that the child and family be given explanations that are as detailed as possible about both the expected and unexpected results of treatment, including any ill effects that might occur. If unexplained reactions develop, the family should be directed to discontinue treatment and report the reactions to the appropriate person. The use of over-the-counter medicines is discouraged unless the preparations have been discussed and approved by the health care provider. INFECTIONS OF THE SKIN Bacterial Infections Normally, the skin harbours a variety of bacterial flora, including the major pathogenic varieties of staphylococci and streptococci. The degree of pathogenicity of the organism depends on its invasiveness and toxicity, the integrity of the skin, and the immune and cellular defences of the host. Children with congenital or acquired immunodeficiency disorders (such as acquired immunodeficiency syndrome [AIDS]), those in a debilitated condition, those receiving immunosuppressant therapy, and those with a generalized malignancy such as leukemia or lymphoma are at risk for developing bacterial infections. Common bacterial skin disorders are outlined in Table 52.1. CHAPTER 52 TABLE 52.1 Integumentary Conditions 1413 Bacterial Infections Disorder and Organism Manifestations Management Comments Impetigo contagiosa— Staphylococcus (Figure 52.4) Begins as a reddish macule Becomes vesicular Ruptures easily, leaving superficial, moist erosion Tends to spread peripherally in sharply marginated irregular outlines Exudate dries to form heavy, honey-coloured crusts Pruritus common Systemic effects—Minimal or asymptomatic Careful removal of undermined skin, crusts, and debris by softening with 1:20 Burow solution compresses Topical application of bactericidal ointment Systemic administration of oral or parenteral antibiotics (penicillin) in severe or extensive lesions Tends to heal without scarring unless secondary infection Autoinoculable and contagious Common in toddlers and preschoolers May be superimposed on eczema Pyoderma—Staphylococcus, streptococcus Deeper extension of infection into dermis Tissue reaction more severe Systemic effects—Fever, lymphangitis Soap and water cleansing Wet compresses Bathing with antibacterial soap as prescribed Washcloths or towels should not be shared Mupirocin to nares and lesions as prescribed Systemic antibiotics Autoinoculable and contagious May heal with or without scarring Folliculitis (pimple), furuncle (boil), carbuncle (multiple boils)—Staphylococcus aureus Folliculitis—Infection of hair follicle Furuncle—Larger lesion with more redness and swelling at a single follicle Carbuncle—More extensive lesion with widespread inflammation and “pointing” at several follicular orifices Systemic effects—Malaise, if severe Skin cleanliness Local warm, moist compresses Topical application of antibiotic medications Systemic antibiotics in severe cases Incision and drainage of severe lesions, followed by wound irrigation with antibiotics or suitable drain implantation Autoinoculable and contagious Furuncle and carbuncle tend to heal with scar formation Never squeeze a lesion Cellulitis—Streptococcus, staphylococcus, Haemophilus influenzae (Figure 52.5) Inflammation of skin and subcutaneous tissues with intense redness, swelling, and firm infiltration Lymphangitis “streaking” frequently seen Involvement of regional lymph nodes common May progress to abscess formation Systemic effects—Fever, malaise Oral or parenteral antibiotics Rest and immobilization of both affected area and child Hot, moist compresses to area Marking the edges of the erythema to determine and track spreading of the infection Hospitalization may be necessary for child with systemic symptoms Otitis media may be associated with facial cellulitis Staphylococcal scalded skin syndrome—S. aureus Macular erythema with “sandpaper” texture of involved skin Epidermis becoming wrinkled (in 2 days or less), and large bullae appearing Systemic administration of antibiotics Gentle cleansing with saline, Burow solution, or 0.25% silver nitrate compresses Infants subject to fluid loss; impaired body temperature regulation; and secondary infection, such as pneumonia, cellulitis, and septicemia Heals without scarring Fig. 52.4 Impetigo contagiosa. (From Weston, W. L., Lane, A. T., & Morelli, J. G. [2002]. Color textbook of pediatric dermatology [3rd ed.]. Mosby.) Fig. 52.5 Cellulitis of cheek from puncture wound. (From Weston, W. L., Lane, A. T., & Morelli, J. G. [2002]. Color textbook of pediatric dermatology [3rd ed.]. Mosby.) 1414 UNIT 12 Health Conditions of Children Because of the characteristic “walling-off” process of the inflammatory reaction (abscess formation), staphylococci are more difficult to treat, and the local infected area is associated with an increase in bacteria all over the skin surface that serves as a source of continuing infection. In recent years, the number of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections has risen. There is also increasing concern about evolving resistant forms of MRSA due to overuse of antibacterials. Outbreaks of MRSA in Canada have been seen among athletes, prisoners, military recruits, children who attend day care centres, injection drug users, and other groups of people who live in crowded settings or routinely share contaminated items. Indigenous populations have high rates of community-acquired MRSA infections that are mostly skin and softtissue infections and are more virulent, resulting in significant morbidity and mortality. This increased prevalence is in part due to household overcrowding and a lack of indoor piped water, which directly affects this community’s ability to maintain adequate personal and environmental hygiene (Irvine & Canadian Paediatric Society [CPS], First Nations, Inuit and Metis Health Committee, 2012/2020). Nursing Care. The major nursing interventions related to bacterial skin infections are to prevent the spread of infection and to prevent complications. Impetigo contagiosa and MRSA infections can easily spread by self-inoculation; as a result the child must be cautioned against touching the involved area. Hand hygiene is mandatory before and after contact with an affected child. Good hand hygiene practice should be emphasized to both the child and family. Many children with AD are colonized with MRSA in the nares and under the fingernails. Thus for many bacterial infections, and for MRSA infection in particular, the child should be provided with washcloths and towels separate from those of other family members. The child’s pyjamas, underwear, and other clothes should be changed daily and washed in hot water. Razors used for shaving should be discarded after each use and not shared. Caregivers should be instructed to seek medical attention if a child develops a fever or other signs of illness, or if a local lesion does not improve within 48 hours of starting treatment. Families also should be instructed to perform regular cleaning of contact surfaces in the home with a standard household cleaner or detergent (Irvine & CPS, First Nations, Inuit and Metis Health Committee, 2012/2020). Children and parents are often tempted to squeeze follicular lesions. They must be warned that squeezing will not hasten the resolution of the infection and that there is a risk for making the lesion worse or spreading the infection. No attempt should be made to puncture the surface of the pustule with a needle or sharp instrument. For example, a child with a stye (an abscess on the inner or outer part of the eyelid caused by a bacterial infection) may waken with the eyelids of the affected eye sealed shut with exudate. The child or parents should be instructed to gently wipe the lid from the inner to the outer edge with warm water and a clean washcloth until the exudate is removed. The child with limited cellulitis of an extremity is usually managed at home on a regimen of oral antibiotics and warm compresses. Children with more extensive cellulitis, especially around a joint with lymphadenitis or on the face, are usually admitted to the hospital for parenteral antibiotics, followed by continued treatment at home. Nurses are responsible for teaching the family to administer the medication and apply compresses. Viral Infections Viruses are intracellular parasites that produce their effect by using the intracellular substances of the host cells. Composed of only a deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) core enclosed in an antigenic protein shell, viruses are unable to provide for their own metabolic needs or to reproduce themselves. After a virus penetrates a cell of the host organism, it sheds the outer shell and disappears within the cell, where the nucleic acid core stimulates the host cell to form more virus material from its intracellular substance. In a viral infection the epidermal cells react with inflammation and vesiculation (as in herpes simplex) or by proliferating to form growths (warts). Many of the communicable viral diseases of childhood are associated with rashes, and each rash is characteristic. The type of lesion and the configuration of rubeola, rubella, and chicken pox are described in Table 35.7. Other common viral disorders of the skin are outlined in Table 52.2. Dermatophytoses (Fungal Infections) The dermatophytoses (ringworm) are infections caused by a group of closely related filamentous fungi that invade primarily the stratum corneum, hair, and nails. These are superficial infections that live on, not in, the skin. Dermatophytoses are designated by the Latin word tinea, with further designation relating to the area of the body where they are found (e.g., tinea capitis [ringworm of the scalp]). Table 52.3 outlines common dermatophytoses. Nursing Care. When teaching families how to care for a child with ringworm, the nurse should emphasize good health and hygiene. Because of the infectious nature of the disease, affected children should not exchange with other children grooming items, headgear, scarves, or other articles of apparel that have been in proximity to the infected area. Affected children should have their own towels and wear a protective cap at night to avoid transmitting the fungus to bedding, especially if they sleep with another person. Because the infection can be acquired by animal-to-human transmission, all household pets should be examined for the disorder. Other sources of infection are seats with headrests (such as theatre seats), seats in public transportation vehicles, helmets, and gymnasium mats. Both 2% ketoconazole and 1% selenium sulphide shampoos may reduce colony counts of dermatophytes. These shampoos can be used in combination with oral therapy to reduce the transmission of disease to others. The shampoo should be applied to the scalp for 5 to 10 minutes twice a week. The child may return to school once the therapy is initiated. If the child is treated with the medication griseofulvin and symptoms subside, the child or parents may be tempted to decrease or discontinue the medication. The nurse should emphasize the importance of maintaining the prescribed dosage schedule and of taking the medication with high-fat foods for best absorption. They should also be informed of possible medication adverse effects, such as headache, gastrointestinal upset, fatigue, insomnia, and photosensitivity. For children who take the medication over many months, periodic testing is required to monitor leukopenia and assess liver and renal function. Systemic Mycotic (Fungal) Infections Mycotic (systemic or deep fungal) infections have the capacity to invade the viscera as well as the skin. The most common infections are the lung diseases, which are usually acquired by inhalation of fungal spores. These fungi produce a variable spectrum of disease, and some are common in certain geographic areas. They are not transmitted from person to person but appear to reside in the soil, from which their spores are airborne. The cutaneous lesions caused by deep fungal infections are granulomatous and appear as ulcers, plaques, nodules, fungating masses, and abscesses. The course of deep fungal diseases is chronic with slow progression that favours sensitization (Table 52.4). CHAPTER 52 TABLE 52.2 Integumentary Conditions 1415 Viral Infections Infection Manifestations Management Comments Verruca (warts) Cause—Human papillomavirus (various types) Usually well-circumscribed, grey or brown, elevated, firm papules with a roughened, finely papillomatous texture Occur anywhere, but usually appear on exposed areas such as fingers, hands, face, and soles May be single or multiple Asymptomatic Not uniformly successful Local destructive therapy, individualized according to location, type, and number—surgical removal, electrocautery, curettage, cryotherapy (liquid nitrogen), caustic solutions (lactic acid and salicylic acid in flexible collodion, retinoic acid, salicylic acid plasters), X-ray treatment, laser Common in children Tend to disappear spontaneously Course unpredictable Most destructive techniques tend to leave scars Autoinoculable Repeated irritation will cause to enlarge Apply topical anaesthetic EMLA Verruca plantaris (plantar wart) Located on plantar surface of feet and, because of pressure, is practically flat; may be surrounded by a collar of hyperkeratosis Apply caustic solution to wart and wear foam insole with hole cut to relieve pressure on wart; Soak 20 minutes after 2–3 days; repeat until wart comes out Destructive techniques tend to leave scars, which may cause difficulties with walking Apply topical anaesthetic EMLA Herpes simplex virus Type I (cold sore, fever blister) Type II (genital) Grouped, burning, and itching vesicles on inflammatory base, usually on or near mucocutaneous junctions (lips, nose, genitalia, buttocks) Vesicles dry, forming a crust, followed by exfoliation and spontaneous healing in 8–10 days May be accompanied by regional lymphadenopathy Avoidance of secondary infection Burow solution compresses during weeping stages Topical therapy (penciclovir) to shorten duration of cold sores Oral antiviral (acyclovir) for initial infection or to reduce severity in recurrence Valacyclovir, an oral antiviral, used for episodic treatment of recurrent genital herpes; reduces pain, stops viral shedding, and has a more convenient administration schedule than acyclovir Heal without scarring unless secondary infection Type I cold sores prevented by using sunscreens protecting against UVA and UVB light to prevent lip blisters Aggravated by corticosteroids Positive psychological effect from treatment May be fatal in children with depressed immunity Varicella-zoster virus (herpes zoster; shingles) Caused by same virus that causes varicella (chicken pox) Virus has affinity for posterior root ganglia, posterior horn of spinal cord, and skin; crops of vesicles usually confined to dermatome following along course of affected nerve Usually preceded by neuralgic pain, hyperesthesias, or itching May be accompanied by constitutional symptoms Symptomatic Analgesics for pain Mild sedation sometimes helpful Local moist compresses Drying lotions sometimes helpful Ophthalmic variety: use systemic corticotropin (adrenocorticotropic hormone) or corticosteroids Acyclovir Lidocaine (Lidoderm) topical anaesthetic Pain in children usually minimal Postherpetic pain does not occur in children Chicken pox may follow exposure; isolate affected child from other children in a hospital or school May occur in children with depressed immunity; can be fatal Molluscum contagiosum Cause—Pox virus Small, benign tumours Flesh-coloured papules with a central caseous plug (umbilicated) Usually asymptomatic Cases in well children resolve spontaneously in about 18 mo Treatment reserved for troublesome cases Apply topical anaesthetic EMLA and remove with curette Use tretinoin gel 0.01% or cantharidin (Cantharone) liquid Curettage or cryotherapy Common in school-age children Spread by skin-to-skin contact, including autoinoculation and fomite-to-skin contact EMLA, Eutectic mix of lidocaine and prilocaine; UVA, ultraviolet A; UVB, ultraviolet B. SKIN DISORDERS RELATED TO CHEMICAL OR PHYSICAL CONTACTS Contact Dermatitis Contact dermatitis is an inflammatory reaction of the skin to chemical substances, natural or synthetic, that evokes a hypersensitivity response or direct irritation. The initial reaction occurs in an exposed region, most commonly the face and neck, backs of the hands, forearms, male genitalia, and lower legs. Early in the reaction, there is usually a sharp delineation between inflamed and normal skin that ranges from a faint, transient erythema to massive bullae on an erythematous swollen base. Itching is a constant symptom. The cause may be a primary irritant or a sensitizing agent. A primary irritant is one that irritates any skin. A sensitizing agent produces an irritation on those individuals who have met the irritant or something chemically related to it, have undergone an immunological 1416 UNIT 12 TABLE 52.3 Health Conditions of Children Dermatophytoses (Fungal Infections) Disease and Organism Manifestations Management Comments Tinea capitis—Trichophyton tonsurans, Microsporum audouinii, Microsporum canis (Figure 52.6, A) Lesions in scalp but may extend to hairline or neck Characteristic configuration of scaly, circumscribed patches or patchy, scaling areas of alopecia Generally asymptomatic, but severe, deep inflammatory reaction may occur that manifests as boggy, encrusted lesions (kerions) Pruritic Microscopic examination of scales is diagnostic Oral griseofulvin Oral ketoconazole for difficult cases Selenium sulphide shampoos Topical antifungal medications (e.g., clotrimazole, haloprogin, miconazole) Person-to-person transmission Animal-to-person transmission Rarely, permanent loss of hair M. audouinii transmitted from one human being to another directly or from personal items; M. canis usually contracted from household pets, especially cats Atopic individuals more susceptible Tinea corporis— Trichophyton rubrum, Trichophyton mentagrophytes, M. canis, Epidermophyton organisms (see Figure 52.6, B) Generally round or oval, erythematous scaling patch that spreads peripherally and clears centrally; may involve nails (tinea unguium) Diagnosis—Direct microscopic examination of scales Usually unilateral Oral griseofulvin Local application of antifungal preparation such as tolnaftate, haloprogin, miconazole, clotrimazole; apply 2.5 cm beyond periphery of lesion; continual application 1–2 wk after no sign of lesion Usually of animal origin from infected pets Majority of infections in children caused by M. canis and M. audouinii Tinea cruris (“jock itch”)— Epidermophyton floccosum, T. rubrum, T. mentagrophytes Skin response similar to that in tinea corporis Localized to medial proximal aspect of thigh and crural fold; may involve scrotum in males Pruritic Diagnosis—Same as for tinea corporis Local application of tolnaftate liquid Wet compresses or sitz baths may be soothing Rare in preadolescent children Health education regarding personal hygiene Tinea pedis (“athlete’s foot”)—T. rubrum, Trichophyton interdigitale, E. floccosum On intertriginous areas between toes or on plantar surface of feet Lesions vary: Maceration and fissuring between toes Patches with pinhead-sized vesicles on plantar surface Pruritic Diagnosis—Direct microscopic examination of scrapings Oral griseofulvin Local applications of tolnaftate liquid and antifungal powder containing tolnaftate Acute infections—Compresses or soaks followed by application of glucocorticoid cream Elimination of conditions of heat and perspiration by clean, light socks and well-ventilated shoes; avoidance of occlusive shoes Most frequent in adolescents and adults; rare in children, but occurrence increases with wearing of plastic shoes Transmission to other individuals rare Ointments not successful Candidiasis (moniliasis)— Candida albicans Grows in moist areas Inflamed areas with white exudate, peeling, and easy bleeding Pruritic Diagnosis—Characteristic appearance Esophagitis: oral or intravenous (IV) fluconazole; IV amphotericin, voriconazole, or micafungin Skin lesions: topical nystatin, miconazole, or clotrimazole Vulvovaginal: topical clotrimazole, miconazole, butoconazole, terconazole, or tioconazole Common form of diaper dermatitis (see Figure 52.12) Oral form common in infants Vaginal form in older females May be disseminated in immunosuppressed children A B Fig. 52.6 A: Tinea capitis. B: Tinea corporis. Both infections are caused by Microsporum canis, the “kitten” or “puppy” fungus. (From Habif, T. P. [2004]. Clinical dermatology: A color guide to diagnosis and therapy [4th ed.]. Mosby.) CHAPTER 52 TABLE 52.4 Integumentary Conditions 1417 Systemic Mycoses Disorder and Organism Skin Manifestations Systemic Manifestations Management Comments North American blastomycosis—Blastomyces dermatitidis Chronic granulomatous lesions and microabscesses in any part of body Initial lesion a papule; undergoes ulceration and peripheral spread Pulmonary symptoms, such as cough, chest pain, weakness, and weight loss May have skeletal involvement, with bone destruction and formation of cutaneous abscesses Intravenous (IV) administration of amphotericin B Usual portal of entry is lungs Source of infection unknown Noninfectious Pulmonary infections may be mild and self-limited and require no treatment Progressive disease often fatal Cryptococcosis—Cryptococcus neoformans (Torula histolytica) Usually on face; acneiform, firm, nodular, painless eruption Central nervous system (CNS) manifestations—Headache, dizziness, stiff neck, and signs of increased intracranial pressure Low-grade fever, mild cough, lung infiltration IV amphotericin B; may be administered intrathecally for CNS involvement 5-Fluorocytosine for meningitis Excision and drainage of local lesions Acquired by inhalation of dust but may enter through skin Prognosis serious Noninfectious Increased incidence in persons receiving corticosteroids with lymphoreticular malignancies, or type 2 diabetes Histoplasmosis—Histoplasma capsulatum Not distinctive or uniform, but most appear as punched-out or granulomatous ulcers General systemic symptoms may include pallor, diarrhea, vomiting, irregular spiking temperature, hepatosplenomegaly, and pulmonary symptoms Any tissue of body may be involved with related symptoms IV amphotericin B for severe cases Oral ketoconazole Organism cultured from soil, especially where contaminated with fowl droppings Fungus enters through skin or mucous membranes of mouth and respiratory tract Endemic in St. Lawrence Valley region where 20 to 30% of the population test positive on a yearly basis Disseminated diseases most common in infants and children change, and have become sensitized. Prior exposure is not necessarily a factor in the reaction. A sensitizer irritates in relatively low concentrations only persons who are allergic to it. In infants, contact dermatitis occurs on the convex surfaces of the diaper area (see Diaper Dermatitis, later in chapter). Other agents that produce contact dermatitis include plants (poison ivy, oak, or sumac), animal irritants (wool, feathers, and furs), metal (nickel found in jewellery and the snaps on sleepers and denim), vegetable irritants (oleoresins, oils, and turpentine), synthetic fabrics (e.g., shoe components), dyes, cosmetics, perfumes, and soaps (including bubble baths). The major goal in treatment is to prevent further exposure of the skin to the offending substance. Provided there is no further irritation, the skin’s normal recuperative powers will often produce healing without treatment. Otherwise, treatment of contact dermatitis is based on severity. Mild cases are treated with topical steroids. Mild to moderately severe cases may require a 2-week course of strong topical corticosteroids. Very severe cases require systemic corticosteroids. Nursing Care. Nurses frequently detect evidence of contact dermatitis during routine physical assessments. Skin manifestations in specific areas suggest limited contact, such as around the eyes (mascara), areas of the body covered by clothing but not protected by undergarments (wool), or areas of the body not covered by clothing (UV injury). Generalized involvement is more likely to be caused by bubble bath or soap. Often nurses can determine the offending agent and counsel families regarding management. However, if the lesions persist, are extensive, or show evidence of infection, medical evaluation is indicated. Poison Ivy, Oak, and Sumac Contact with the dry or succulent portions of any of three poisonous plants (ivy, oak, and sumac) produces localized, streaked or spotty, oozing and painful impetiginous lesions. The offending substance in these plants is an oil, urushiol, that is extremely potent. Sensitivity to urushiol is not inborn but is developed after one or two exposures and may change over a lifetime. All parts of the plants contain the oil, including dried leaves and stems. Even smoke from burning brush piles can produce a reaction. Some people may react to the skin of mango, which contains uroshiol. Animals do not seem to be affected by the oil; however, dogs or other animals that have run or played in the plants may carry the sap on their fur, and animals that eat the plants can transfer the oil in their saliva. Shoes, tools, and toys can transfer the oil. Golf balls that have been in the rough are another source of contact. 1418 UNIT 12 Health Conditions of Children Urushiol takes effect as soon as it touches the skin. It penetrates through the epidermis and bonds with the dermal layer, where it initiates an immune response. The full-blown reaction is evident after about 2 days, with redness, swelling, and itching at the site of contact. Several days later, streaked or spotty blisters oozing serum from damaged cells produce the characteristic impetiginous lesions (Figure 52.7). The lesions dry and heal spontaneously, and itching stops by 10 to 14 days. Nursing Care. As soon as an exposure is realized, there is no time to waste. The earlier the skin is cleansed, the greater the chance of removing the urushiol before it attaches to the skin. The exposed skin can be cleansed with isopropyl alcohol or vinegar followed by water. A shower with soap and warm water should follow. Harsh soap is contraindicated because it removes protective skin oils and dilutes the urushiol, allowing it to spread; hard scrubbing irritates the skin. Clothes, tools, shoes, and any other objects that had contact with the plants should be cleaned with alcohol and then water. Catechol molecules Treatment of the lesions includes calamine lotion, soothing Burow solution compresses, or oatmeal baths to relieve discomfort. Topical corticosteroid gel is effective for prevention or relief of inflammation, especially when applied before blisters form. Oral corticosteroids may be needed for severe reactions, and a sedative such as diphenhydramine may be ordered. Every effort needs to be made to prevent the child from scratching the lesions. Although the lesions do not spread by contact with the blister serum or from scratching, they can become secondarily infected. Medication Reactions Adverse reactions to medications are seen more often in the skin than in any other organ, although any organ of the body can be affected. The reaction may be a result of toxicity related to medication concentration, individual intolerance to the average dosage of the medication, or an allergic or idiosyncratic response. The manifestations Skin protein 7–10 days T cells 1–2 days Memory T cells No dermatitis Primary contact Memory T cells Catechols combined with skin proteins Many active cells Dermatitis Secondary contact A B Fig. 52.7 A: Development of allergic contact dermatitis. B: Poison ivy lesions; note the “streaked” blisters surrounding one large blister. (A, from McCance, K., & Huether, S. [2010]. Pathophysiology: The biological basis for disease in adults and children [6th ed.]. Mosby. B, from Habif, T. P. [2010]. Clinical dermatology: A color guide to diagnosis and therapy [5th ed.]. Mosby.) CHAPTER 52 may be associated with adverse effects or secondary effects of a medication, either of which are unrelated to its primary pharmacological actions. Although any medication is capable of producing a reaction in the susceptible individual, some medications have a tendency to produce a particular reaction consistently, and others are more likely to produce an untoward effect. Many are allergenic responses that occur after a previous administration of the medication, even a topical application. Other factors influence a medication response in a particular individual. For example, the incidence increases with the amount and number of medications given. NURSING ALERT Intravenous (IV) medications are more likely to cause a reaction than oral medications. Stop the medication, but maintain the infusion with normal saline. Manifestations of medication reactions may be delayed or immediate. A period of 7 days is usually required for a child to develop sensitivity to a medication that has never been administered previously. With prior sensitivity the manifestations appear almost immediately. Rashes are the most common manifestation of adverse medication reactions in children. However, individual medication reactions may vary from a single lesion to extensive, generalized epidermal necrosis such as that seen in Stevens-Johnson syndrome. Cutaneous manifestations can resemble almost any skin disease and can appear in almost any degree of severity. With few exceptions, the distribution of a medication eruption is widespread because it results from a circulating agent, appears as an inflammatory response with itching, is sudden in onset, and may be associated with constitutional symptoms such as fever, malaise, gastrointestinal upsets, anemia, or liver and kidney damage. In most cases treatment for simple cutaneous reactions consists of discontinuing the medication. Sometimes a decision is made to continue the medication, such as an antibiotic in an infant or small child, until the cause of the rash is clearly indicated. In urticarial-type eruptions antihistamines may be ordered, and for widespread and severe lesions corticosteroids are beneficial. Severe anaphylactic reactions are a medical emergency (see Anaphylaxis, Chapter 47). Nursing Care. The most effective means of management is prevention. Parents always remember a severe reaction in their child; a careful history will elicit evidence of a previous medication reaction. The history should include the medication’s name, the nature of the reaction, dosage, and how soon after administration the reaction occurred. Nurses who suspect that a rash is caused by a medication should withhold any further dose and report the eruption to the primary health care provider. Frequent offenders in medication reactions are penicillin and sulphonamides, and nurses must be alert to this possibility. However, even commonplace medications, including Aspirin, barbiturates, chemical agents in some foods, flavouring agents, and preservatives, are capable of producing an undesired response. Persons who have severe reactions should wear a medical identification bracelet in case of emergency or inadvertent administration of the offending medication. SKIN DISORDERS RELATED TO ANIMAL CONTACTS Arthropod Bites and Stings Bites and stings account for a significant amount of mild to moderate discomfort in children. Most bites and stings are managed by simple Integumentary Conditions 1419 symptomatic measures, such as compresses, calamine lotion, and prevention of secondary infection. Arthropods include insects and arachnids, such as mites, ticks, and spiders. Most arthropods in Canada, including tarantulas, are relatively harmless. Although all spiders produce venom that is injected via fangs, some are unable to pierce the skin and others produce venom that is insufficiently toxic to be harmful. Only two spiders—the brown recluse and the black widow—inject venom deadly enough to require immediate attention. Children bitten by these arachnids must receive medical attention as soon as possible. The black widow bite causes local, regional, or generalized pain associated with nonspecific symptoms and autonomic effects such as sweating, muscle cramps, and vomiting. Antivenoms are an important treatment for black widow spider bites. Muscle relaxants, analgesics or sedatives, and steroids are also used to treat the manifestations. The brown recluse spider bite causes pain and erythema that can become a necrotic ulcer. Systemic reactions include fever, nausea and vomiting, and joint pain. The