Video Case Study - Eczema in the Pediatric Patient

Nurse Lisa works in a primary care clinic and is caring for Jamie, a 2-and-a-half-year-old who was brought in for a rash, by her mother Claire.

After settling Jamie in her room, Nurse Lisa goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Jamie’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Lisa recognizes important cues, including Jamie’s skin assessment, which reveals several clusters of dry, red patches to her wrists and ankles.

She also notes that Jamie is scratching her left wrist, which is eroded and excoriated. Nurse Lisa asks Claire about Jamie’s skin irritation.

Nurse Lisa: I see that Jamie has some dry and reddened skin. When did these symptoms start?

Claire: A few weeks ago, when the weather got colder. Nurse Lisa: Have you tried any treatments or therapies to help relieve the itching?

Claire: Sometimes I put her in a hot bubble bath, but it doesn’t seem to help. I also put lotion on her every day, which helps a little.

Next, Nurse Lisa analyzes these cues. Nurse Lisa understands that Jamie has an itchy inflammatory rash, and that Jamie’s scratching is causing excoriation.

She also knows the breakdown of Jamie’s skin increases the risk for infection. Nurse Lisa recognizes that Jamie needs effective management of her rash.

She reports her assessment findings to the health care provider, who diagnoses Jamie with eczema, or atopic dermatitis, and prescribes oral loratadine and a topical corticosteroid to reduce pruritis and inflammation.

Now, using the information she’s gathered, Nurse Lisa develops a priority hypothesis of impaired skin integrity. Then, Nurse Lisa generates solutions to address Jamie’s impaired skin integrity that will include pharmacologic and nonpharmacologic interventions; and she establishes the expected outcome that after intervening, Jamie’s rash will show improvement in one month.

Nurse Lisa then takes action to implement these solutions and talks with Claire about Jamie’s prescribed medications. Nurse Lisa: Jamie has been prescribed two medications to help with her rash.

The first is an oral antihistamine called loratadine, which will help decrease Jamie’s itching. Claire: Oh, I’ve taken those.

Don’t they make you sleepy? Nurse Lisa: This medication is a non-drowsy type, so it can be taken in the daytime.

The next medication is a topical corticosteroid cream, which reduces inflammation, so her skin can begin to heal. You’ll apply this to the affected areas of Jamie’s skin.

Claire: Okay, I understand. Nurse Lisa then demonstrates how to clean and dry Jamie’s skin and apply the cream.

Next, Nurse Lisa teaches Claire about strategies to promote Jamie’s skin integrity. She explains how bathing in tepid water with mild, unscented soap can relieve itching.

She also encourages applying a moisturizer to Jamie’s skin, after bathing, to promote hydration. Then, Nurse Lisa explains how maintaining clean and short fingernails can prevent skin breakdown from scratching and reduce the risk for infection.

She suggests that Jamie wear gloves if itching and scratching persist. Then, she recommends ways to minimize irritation to the skin, such as laundering all clothing and bedding with mild detergent and avoiding abrasive fabrics, like wool.

Lastly, Nurse Lisa instructs Claire to report signs of skin infection to the health care provider, such as purulent drainage and honey-colored crusts or pustules.

One month later, Jamie and Claire return for a follow-up appointment, and Nurse Lisa evaluates the outcomes of her actions.

She assesses Jamie’s skin and notes that the affected areas are no longer excoriated and that there are no signs of infection.

Claire also reports that Jamie is scratching less following the prescribed therapies. Alright, as a quick recap.

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Nurse Lisa recognized and analyzed cues related to Jamie’s eczema, and prioritized hypotheses and generated solutions to address this problem.

Nurse Lisa then implemented pharmacologic and nonpharmacologic measures to manage Jamie’s impaired skin integrity and evaluated Jamie’s outcomes and compared them to the expected outcome.

Since Jamie’s rash showed improvement at the follow-up appointment, Nurse Lisa determined that the plan of care was successful.