What changes have occurred overnight in a 2-year-old patient with staphylococcal skin syndrome (SSS), including new skin lesions, fever, signs of distress, fluid intake and output, behavior, appetite, and respiratory status?

Day 2 Assessment Questions for Parents of 2-Year-Old with Staphylococcal Scalded Skin Syndrome

On day 2 of admission for SSSS, systematically assess overnight progression by asking parents about skin changes, systemic symptoms, pain level, fluid intake/output, and signs of complications—focusing specifically on new areas of skin peeling, fever patterns, irritability, oral intake, urine output, and respiratory symptoms.

Skin Progression Assessment

Ask parents to describe any new areas of skin involvement or changes in existing lesions:

• Has the redness spread to new body areas overnight? 1
• Have you noticed new blisters or areas where the skin looks like it's peeling or coming off? 2
• Are there new areas of raw, exposed skin that weren't there yesterday? 3
• Does the skin appear to be separating or peeling with minimal touch or pressure (especially at IV sites, under monitoring leads, or where clothing touches)? 4, 2
• Have you noticed any areas that look infected, with pus or increased drainage? 1

Pain and Comfort Assessment

Determine the child's pain level and overall comfort:

• Does your child seem more or less irritable compared to yesterday? 5
• Is your child crying more when touched or moved? 2
• Does your child appear to be in pain when you try to hold them or change their position? 1
• Is your child able to sleep, or are they waking frequently due to discomfort? 5

Fever and Systemic Symptoms

Assess for signs of worsening systemic illness:

• Has your child had any fever overnight, and if so, what was the highest temperature? 3, 5
• Does your child seem more lethargic or less responsive than yesterday? 6
• Have you noticed any episodes where your child seemed to have difficulty breathing or was breathing faster than usual? 6
• Has your child had any episodes of appearing pale, mottled, or having cold hands/feet? 6

Fluid Intake and Output

Critical assessment for fluid balance and renal function:

• How much has your child been drinking overnight (approximate volume in ounces or mLs)? 6
• Has your child been willing to drink, or are they refusing fluids? 5
• How many wet diapers have you changed since yesterday, and were they as wet as usual? 6
• Have you noticed the urine appearing darker or more concentrated? 6
• Has your child had any vomiting or diarrhea? 1

Oral and Mucosal Involvement

Distinguish SSSS from more serious conditions like SJS/TEN:

• Has your child developed any sores or redness inside the mouth? 1
• Are the lips cracked, bleeding, or crusted? 1
• Have you noticed any redness, discharge, or crusting around the eyes? 1
• Is there any redness or irritation in the genital area? 1

This distinction is critical: SSSS characteristically spares mucous membranes, while SJS/TEN involves them early and prominently. 1

Feeding and Nutrition

Assess nutritional intake and ability to feed:

• Has your child been eating or breastfeeding/bottle-feeding normally? 5
• If eating, approximately how much compared to their usual intake? 5
• Is your child refusing food or showing signs of mouth pain when trying to eat? 1

Respiratory Assessment

Screen for potential complications:

• Have you noticed any coughing, wheezing, or noisy breathing? 1, 6
• Does your child seem to be working harder to breathe (using stomach muscles, flaring nostrils)? 6
• Have you heard any rattling or congestion in the chest? 1

Behavioral Changes

Assess neurological status and overall clinical trajectory:

• Is your child more alert and interactive today compared to yesterday, or less so? 5
• Has your child been able to play or show interest in toys/activities? 5
• Have you noticed any unusual movements, stiffness, or difficulty moving? 6

Response to Treatment

Evaluate antibiotic efficacy and wound care:

• Have you noticed any improvement in the skin appearance since starting antibiotics? 2
• Are the areas of raw skin looking better, worse, or the same? 4
• Has there been any bleeding from the affected skin areas? 1

Critical Pitfalls to Avoid

Do not dismiss parental concerns about mucosal involvement—this could indicate misdiagnosis of SJS/TEN rather than SSSS, which requires entirely different management and has significantly higher mortality. 1

Monitor closely for fluid overload rather than assuming only dehydration risk—hyponatremia and fluid overload are common complications in severe SSSS despite the extensive skin loss. 6

Assess for signs of sepsis including temperature instability, increased work of breathing, and altered mental status, as these indicate potential progression to systemic infection. 4, 6