Diaper Rash

A case study presented to the Faculty of Nursing Capitol Medical Center Colleges In partial fulfillment of the requirements in NCM-102 Lecture

I. Introduction
Background of the Study
Diaper rash or diaper dermatitis is a general term describing any of a number of inflammatory skin conditions that can occur in the diaper area. It is caused by over hydration of the skin, maceration, prolonged contact with urine and feces, retained diaper soaps, and topical preparations

Diaper dermatitis commonly affects infants, with peak

incidence occurring when the individual is aged 9-12 months and persons of any age who wear diapers, in particular, elderly people. Patients with diaper dermatitis present with an erythematous scaly diaper area often with lesions, fissures, and erosions. The eruption may be patchy or confluent, affecting the abdomen from the umbilicus down to the thighs and encompassing the genitalia, perineum, and buttocks. Genitocrural folds are spared in irritant dermatitis, but often involved in primary candidal dermatitis. Children with diaper dermatitis have marked discomfort from intense inflammation.

Symptoms


Red, itchy, scaly rash patches in the diaper area and legs

 Redness around the anus and genitalia  Bright red and tender rash and/or spots in the

folds between the thighs and abdomen

 Deep red rash with yellowish scales

Objectives of the study

General Objective:

At the end of this case study, the students will be able to accurately assess signs and symptoms of diaper rash and will appropriately discuss reduction of risk factors for diaper rash with other health care providers and people who are directly taking care of the infants.

Specific objectives:
Students will be able to: Explain indicators of risk and complications of diaper rash to their health provider of patients. Describe the risks of diaper rash complications, including Intertrigo, psoriasis and the goals of management. Discuss with patients and families the importance of good hygiene in the prevention and management of diaper rash. Develop treatment plans in the context of each patient's life and environment.

Theoretical Framework
Self-Care

Deficit

Dorothea E. Orem

Dorothea

E. Orem, M.S.N.Ed., D.sc., R.N., was born in 1914 in

Baltimore, Maryland. She began her nursing education at Providence Hospital School of Nursing in Washington DC. She earned her Bachelor of Science in Nursing Education in 1939 and her Master of Science in Nursing Education in 1945 from the Catholic University of America. She has received several honorary degrees including a Doctor of Science.

Defined Nursing: The act of assisting others in the provision and management of self-care to maintain/improve human functioning at home level of effectiveness .

Identified 3 related concepts:

activities an Individual performs independently throughout life to promote and maintain personal well-being. Self Care Agency aquired ability or power to engage in self-care. Self Care Demand totality of care measures necessary at specific at specific times Self Care Requisites defined as the reason for which self-care is undertaken. Self-care deficit results when self-care agency (Individuals ability) is not adequate to meet the known self-care needs.
Self-care

Nursing

System nursing interventions needed when Individual

is unable to perform the necessary self-care activities:

Wholly compensatory nurse provides entire self-care for

the client. Example: care of a new born, care of client recovering from surgery in a post-anesthesia care unit
Partial compensatory nurse and client perform care;

client can perform selected self-care activities, but also accepts care done by the nurse for needs the client cannot meet independently. Example: Nurse can assist post operative client to ambulate, Nurse can bring a meal tray for client who can feed himself

Supportive-educative nurses actions are to help the

client develop/learn their own self-care abilities through knowledge, support and encouragement. Example: Nurse guides a mother how to breastfeed her baby, nurse educates mother in prevention and treatment of diaper rash

Self Care R R

Self-Care Agency DEFICIT R Nursing Agency R

Self-Care Demand

II. Patients Data Base

Personal data Patient Baby zelle is a 1 and 1/2 month old, female, single and living in Nayon Quezon City. She was born in the 30th of January 2011. She is a Filipino citizen and a member of Roman Catholic Church.

Immunization History:
BCG Hepa B1 DPT1 OPV1 Hepa B2 January 30, 2011 January 30, 2011 March 15, 2011 March 15, 2011 March 15, 2011

Family History: History:

Mother Allergies (-) (-) Father

Hypertension (+) (-)

Mother Diabetes Mellitus (+)

Father (-)

Convulsion (-) (-)

Physical Examination
Body Part Head Normal Finding Symmetrical, normocephalic Actual Finding Symmetrical, normocephalic Clear scalp with hair intact Hair is black and equally distributed Symmetrical, pinkish conjunctiva Anicteric sclera Shoulder is at the same height Nipple is symmetrically aligned Symmetrical chest expansion

Eyes

Pinkish conjunctiva Clear sclera Shoulder is at the same height Nipples is symmetrically aligned

Chest

Body Part Abdomen

Normal Finding No lesions Flat or rounded Uniform in colour No inflammation of lymph nodes No nodules Skin is uniform, whitish pink in colour, no lesions, moist

Actual Finding Soft and Rounded No lesions, rashes and no mass No inflammation of lymph nodes No mass Skin is uniform, warm and moist, fair white in color. With rashes in buttocks to genitalia No lesion and edema (-) cyanosis

Neck

Skin

Extremities

No lesion and No edema

III. Clinical Discussions

Anatomy and Physiology INTEGUMENTARY SYSTEM

Integumentary System is the organ system that

protects the body from damage, comprising the skin. The integumentary system has a variety of functions; it may serve to waterproof, cushion, and protect the deeper tissues, excrete wastes, and regulate temperature, and is the attachment site for sensory receptors to detect pain, sensation, pressure, and temperature. In humans the integumentary system also provides vitamin D synthesis.

Epidermis This is the top layer of skin made up of epithelial cells. It does not contain blood vessels. Its main function is protection, absorption of nutrients, and homeostasis. In structure, it consists of a keratinized stratified squamous epithelium comprising four types of cell: keratinocytes, melanocytes, Merkel cells, and Langerhans cell. The major cell of the epidermis is the keratinocyte, which produces keratin. Keratin is a fibrous protein that aids in protection. The majority of the skin on the body is keratinized, meaning waterproofed.

The only skin on the body that is nonkeratinized is the lining of skin on the inside of the mouth. The epidermis also contains Langerhans cell, which are formed in the bone marrow and then migrate to the epidermis. They work in conjunction with other cells to fight foreign bodies as part of the body's immune defense system. Melanocytes create melanin, the substance that gives skin its colour.

Dermis The dermis is the middle layer of skin, composed of dense irregular connective tissues. Its major parts are collagen (a protein that adds strength), reticular fibers (thin protein fibers that add support), and elastic fibers (a protein that adds flexibility) allowing stretching and conferring flexibility, while also resisting distortions, wrinkling, and sagging. The dermal layer provides a site for the endings of blood vessels and nerves. The dermis has two layers: the papillary layer, which has loose connective tissue, and the reticular layer, which has dense connective tissue.

The papillary layer lies directly beneath the epidermis and connects to it via papillae (finger-like projections). Some papillae contain capillaries that nourish the epidermis; others contain Meissner's corpuscles, sensory touch receptors.

The reticular layer also contains Pacinian corpuscles, sensory receptors for deep pressure. This layer contains sweat glands, lymph vessels, smooth muscle, and hair follicles and cells that aid in healing.

Subdermis It is composed mainly of connective and adipose tissue. Skin produces associated structures such as sudoriferous glands and sebaceous glands. Its physiological functions include insulation, storage of energy.

Patterns of Functioning Health PerceptionHealth Management Pattern

Before infection

During infection

Analysis / Interpretation Health provider has good management in developing condition.

Health provider Health provider has a good followed the therapeutic health doctors order for management and her childs seeks for health immediate consultation. recovery. Patient breastfeeds 7-8 times Patient still breastfeeds 7-8 times

NutritionalMetabolic Pattern

ActivityExercise Pattern

Patient has limited activities.

Patient has limited activities.

Patients nutrition is still the same and essential in the recovery of her condition. The patient is asleep most of the time.

Patterns of Functioning Elimination Pattern

Before infection

During infection

Analysis / Interpretation Patients elimination pattern was not affected by his condition.

Patient has three to four times of bowel movements per day

Patient still voids and eliminates bowel regularly.

Sleep- Rest Pattern

Patient is asleep for 12 hours in a day with three naps and at night patient can go back to sleep when she wake up periodically

Patient sleeps Patient is unable less than 12 to get enough hours and she sleep in a day could not sleep due to discomfort. well because she feels irritated by the discomfort of her condition..

Patterns of Functioning CognitivePerceptual Pattern

Before infection During infection

Analysis / Interpretation Patients sensorimotor becomes more functional

She is attracted to anything with color and music

Patient is awake and attracted to music

SelfPerception Pattern

She only cries when she is hungry or if she feels sleepy and uncomfortable.

Her cries and Her cries and grimaces show grimaces show that that she feels she feels uncomfortable uncomfortable due due to her diaper to her diaper rash rash

Patterns of Functioning

Before infection During infection

Analysis / Interpretation

RoleRelationship Pattern

Patient has a good relationship towards people and his significant others.

Patients relationship to people around her was not affected by her condition.

Patient maintained close relationship to the people around her.

Values-Belief Pattern

Patient and her Patient and her Patients family kept family attends family still attends their faith to God mass every mass every Sunday morning Sunday morning

Pathophysiology
Precipitating: Environment Irritants Overhydration of Stratum corneum And increase skin pH Disruption of lipid bilayer Damage of Stratum corneum Microorganism/Irritants penetrates And reach Langerhans cells and Epidermis Predisposing: Age

Fecal enzymes degrade Stratum corneum Proteins and disrupt ingetrity Penetrants interact with the keratinocytes And fibroblasts Penetrants stimulate cytokine release By keratinocytes Cytokines act on the vasculature of the Dermis resulting in inflammation

Drug Study
Generic Name: Zinc Oxide Brand Name: Calmoseptine Classification: Skin protectant Dosage: Every change of diaper Action: Skin protectant, soothes irritating skin Indication: Protects skin, soothes irritating skin. It works by temporarily relieving itching and pain. It also decreases moisture in the affected skin

Drug Study
Contraindication: Contraindicated to patient with hypersensitive to drug Contraindicated to treat a deep wound or punctured wound Adverse reaction: Skin: rashes, hives, itching Nursing Responsibilities: Dont apply to deep wounds Rinse at once with cool water if medication got into the eyes, nose or mouth.

Assessment

Diagnosis

Planning

Implementation

Evaluation

O: y Disruptio n and redness of skin area y With rashes on the buttocks to genitalia

Impaired skin integrity related to humidity as evidenced by rashes on the buttocks to genitalia

Short term: After 8hours of nursing intervention health provider will be able to: Demonstrate preventive measures verbalize feelings and ability to manage situation Long term: After 1day of nursing intervertion health provider will be able to: maintain optimal nutrition needed for wound healing and skin repair display timely healing of skin lesions

y y

Assess the etiology Periodically remeasure wound & observe for complication Keep the area clean and dry to prevent infection Inspect skin on a daily basis, describing wound characteristics and changes Use appropriate barrier dressing, skin protective agent Administer medication as prescribed

After 8hours of nursing intervention health provider was able to demonstrate preventive measures and verbalized feelings and ability to manage situation After 1day of nursing intervention health provider was able to maintain optimal nutrition and displayed timely healing