exam 2 review without pictures

8/14/2019 Exam 2 Review Without Pictures

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Exam 2 ReviewNot all information from review is here


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PEDICULOSIS (LICE)

Head lice (Pediculus humanus capitus)

are about the size of a sesame seed

and can easily be seen, although they

hide quickly in response to light.

Their eggs, called nits, are barely

visible, whitish ovals cemented to hair

shafts.

Head lice are extremely contagious,

especially among school children.

Main symptom: itching

Female louse lives about 1 month andlays eggs which hatch in 7-10 days whichare found in the hair shafts close to thescalp

Child commonly ridiculed/embarrasedLice visible to eye, as are nits (eggs)


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HEAD LICE

They afflict an estimated 6 to 12

million children in the United

States.

Twice as many girls as boys get

head lice, not because of greater

hair length, but because girls

have more physical contact withone another and share more

personal articles (hats, clothing,

combs, headphones) that can

transmit head lice.Head lice are rare among African-

Americans, possibly because the

shafts of hair have a shape that

lice cannot grasp easily.


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TREATMENT

Pediculcide (Nix) a shampooApplied twice a week

apart

Daily combing with ametal nit comb for manualremoval

No need to cut childs hair

because of liceLice easily spread in schoolsettingprevention incommunity setting

important


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Machine wash all bedding, clothing,etc. and then dry in hot dryer

Vacuum rugs, furniture, mattressesSoak combs, brushes, hairaccessories for 1 hour inpediculacide

In group settings, store each childsthings separately

Discourage sharing of clothing

items, i.e hats


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Avoid physical contactwith infested child

Inspect group of children

regularly for infestationProvide educationalprograms ontransmission, treatment,and prevention of

pediculosis


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BURNS IN CHILDREN

Deaths and InjuriesDeaths andInjuries

In 2001, more than 500 children age 14and under died and 40,000 were injuredin residential fires. Of these,

40 children were under 1 year old

226 children were aged 1-4 years




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In 2001, nearly 4,500 childrenvisited the emergency room due toresidential fire injures. Of these,

1,555 children were aged 0-4years1,135 children were aged 5-9years

1,765 children were aged 10-14yearsIt is estimated that flames and burnsare responsible for one-fourth of all

fire-related deaths and injuries.


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Approximately 75,000 children ages 14 and

under are treated in hospital emergency roomsfor thermal burn-related injuries, includingflames and contact burns. Children age 14 andunder account for nearly half of all emergencyroom treated thermal burns.

An average of 16 children ages 14 and underdie and nearly 31,500 children are treated inhospital emergency rooms for scald burn-related injuries each year. Children ages 4 and

under account for nearly all of these deathsand the majority of these injuries.

Children ages 4 and under are especially atrisk for scald and contact burns and are at the

greatest risk for fire related deaths.


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BURNS: BACKGROUND

Common injury in

pediatricsFour types of burns

Thermal

Chemical

Electrical

Radioactive


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Thermal Caused by open flames, steam hot liquid

Flush with cool water

Chemical Acids

Neutralize or dilute the chemical

consult poison control

Electrical Direct current, alternating current, lightening

Disconnect source of current; move to area of safety

Radiation Solar, x-rays, radioactive agents

shield skin, limit exposure, move person from source


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BURN RISK: DEVELOPMENTAL

CONSIDERATIONS

Infants: Scalds, house firesToddlers: Pull hot liquids onthemselvesPreschool: Scalds, contact with

hot appliancesSchool-age: Playing with matches,combustion experimentsAdolescents: Accidental or risk-

taking behaviors


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PATHOPHYSIOLOGY

Local response:

Edema increased capillarypermeability and vasodilation increasedhydrostatic pressure within capillariesloss of water, lytes, protein into interstitial

spacesnot a big deal with minor injuryYoung children have larger body surfaceareas than adults and greater insensiblewater loss. The relevance?


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Minor burns usually heal 3-6days and leave no scarringMore severe burns takelonger and have increased

risk for infectionFirst aid for minor burns: stopthe burning process and put

injured area under coolrunning waterWhy would you not use ice?


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DEPTH OF INJURY

Superficial: first degree burns

Partial thickness: second degree burnsFull thickness: third degree burns

Fourth degree burns: include muscle,

fascia and bone

Which type might be most painful?

Least painful?


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Scalds hot

waterSevere sunburns


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FIRST DEGREE

BURNS

Sunburns

Low intensity flash burns

Cooking burns


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DEEP PARTIAL THICKNESS

SECOND DEGREE BURN

Epidermal, upper dermis,

portions of deep dermis

Pain, hyperesthesia,

sensitive to cold air

Blistered mottled red,

weeping, edema

Recover in 2 to 4 weeks,some scars, depigmentation,

contractures

Infection may convert to full thickness


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SYSTEMIC RESPONSE

TO SEVERE BURNSCardiovascular:

Burn shock r/t decreased cardiacoutput associated with myocardialdepressant factor (enzyme) whichdecreases cardiac contractility

Fluid/electrolyte loss compoundproblem further

Adequate fluid replacement =

normal CO


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INDICATIONS OF

ADEQUATE FLUID RESUSCITATION

Urine Output:

2 ml/kg/hr children

30 50 ml/hr adults 30-

Sensorium Conscious/alert Sensorium:

Pulse: Increased

BP: Normal/Increased

Temperature: Increased

N/V: Absent

Serum Electrolytes: Normal range


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Renal: increased fluid loss incirculationdecreased renal plasmablood flowdecreased glomerular

filtrationBUN and Creatinine increased d/ttissue breakdownMay have hematuria from RBC

hemolysisMyoglobinuria can occlude renal

tubulesincreased risk of renal

failure


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GI: perfusion reduced d/taltered blood flowileus of gut

Metabolism: accelerated ratewith burns. Children havereduced glycogen storesincreased breakdown of fatsand proteinsprolongedstarvation state

AnemiaMetabolic acidosis d/t fluid

shifts & loss


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BURN SHOCK

Burn Damage increases capillarypermeability

Water, electrolytes, and albuminmolecules are smaller and are moreeasily lost from vascular space

This increase permeability andinflammatory process causes leakageinto the interstitial space, which causesedema formation

IMPORTANT: Must fluid resuscitate atthe same rate of fluid leakage


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GOAL OF FLUID

REPLACEMENT

Maintain vital organfunction whileavoiding

complications ofinadequate orexcessive fluids


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RULE OF NINE


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FLUID REPLACEMENT

Large Bore IV

Isotonic SolutionRingers Lactated, NormalSaline

Begin as soon as possibleBurns > 40% TBSA shouldhave 1 amp Bicarbonate is

added to each liter of fluid


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ASSESSMENT

Airway, breathing, circulation

History and type of burn - 10%

of burns are due to childabuse

Other injuries (example: falls,

explosion)Pain assessment

Fluid status

PREVENTION OF INSECT


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PREVENTION OF INSECT

BITES AND STINGS

Know the insects common

in your localeTeach children to avoiddangerous insects

Apply a commercial insectrepellant - DEET:

Precautions


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PREVENTION STRATEGIES

Inspect skin for ticks afterplaying outside

Wear long pants and sleeves to

avoid tick bitesStay calm when near stinginginsets

Avoid eating sweetened foodsand beverages when outside

Treat pets for fleas and ticks


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Bacterial Meningitis

Inflammation of the meninges

Newborns and infants at greatest risk

Higher morbidity and mortality than viral

meningitis Common bacterial causes

Haemophilus influenzae type B

Neisseria meningitidesStreptococcus pneumoniae

Group B Streptococcus


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Bacterial Meningitis: Signs andSymptoms (Infants)

Fever

Changes in feeding pattern

Vomiting, diarrhea

Anterior fontanelle bulging or flat

Alert, restless, lethargic, or irritable

Difficult to console High-pitched, moaning cry


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Bacterial Meningitis: Signs andSymptoms (Children)

Fever

Confusion, delirium, irritable, lethargic

Vomiting

Muscle or joint pain


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Bacterial Meningitis: Signs andSymptoms (Children) (contd)

Hemorrhagic rash (meningococcal meningitis)-Hemorrhagic rash

The rashes appear in about 75% of the patients and

may be quite variable. They can be as small as 1-2mm and appear as tiny red, purple-black spots orthey may be much larger resembling bruises. Theirmost common location is armpits, groin and ankles,

and areas where pressure may be applied (e.g.underwear and socks).


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Bacterial Meningitis: Signs andSymptoms (Children) (contd)

Meningeal irritationHeadache

Photophobia

Nuchal rigidity


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The child with bacterial meningitis assumes an opisthotonicposition, with the neck andthe head hyperextended, to

relieve discomfort.


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To test Brudzinski sign, flex the childs head while in a supine


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To test Brudzinski sign, flex the child s head while in a supineposition. If this action makesthe knees or hips flex involuntarily, a

positive Brudzinski sign is present. This is a commonfinding inmeningitis.


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Progression of Symptoms

Seizures

Apnea

Cerebral edema

Subdural effusion Hydrocephalus

Disseminated intravascular coagulation (DIC)

Shock Increased intracranial pressure


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Bacterial Meningitis: Treatment

Labs and cultures (blood, urine,cerebrospinal fluid)

Intravenous antibiotics

Steroids, anticonvulsants, antipyretics

IV fluids, fluid resuscitation

May be left with severe Neurologic deficits


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Viral (Aseptic) Meningitis

Inflammatory response of meninges

Most common cause: Enterovirus

Child not as ill-appearing as child withbacterial meningitis


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Viral Meningitis: Signs andSymptoms

Irritable or lethargic - general malaise Fever

Headache

Photophobia Upper respiratory symptoms

Positive Kernig and Brudzinski signs -

indicate meningeal irritation Seizures are rare


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Viral Meningitis: Treatment

Labs and cultures (blood, urine,cerebrospinal fluid)

Intravenous antibiotics until cultures are

negative - treat as bacterial meningitis untilproven otherwise

Treatment of symptoms is supportive

Symptoms usually resolve in 3 to 10 days Neurologic deficits are uncommon


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Reye Syndrome

Acute encephalopathy

Associated with use of aspirin and a mildviral illness

With decreased aspirin use, condition is nowrare

Condition develops over five stages


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Reye Syndrome: Treatment

Diagnosis by history, lab findings

Treatment is supportive

Often require treatment for increasedintracranial pressure

Mortality is high

T t t


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Treatment Reye's syndrome is usually treated in the hospital. Severe

cases may be treated in the intensive care unit. The

hospital staff will closely monitor your child's bloodpressure and other vital signs. Specific treatment mayinclude:

Intravenous fluids. Your child may be fed through anintravenous (IV) line. Glucose and an electrolyte solution

containing sodium, potassium and chloride may be giventhrough the IV, too. Insulin. Small amounts of insulin may be used to

increase sugar metabolism. Corticosteroids. These medications may be used to

reduce swelling in the brain. Diuretics. These medications may be used to increase

fluid loss through urination. If your child has trouble breathing, he or she may need

assistance from a breathing machine (ventilator).


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Myelomeningocele

Babies who are born with myelomeningocelealso have a sac-like mass that bulges fromthe back, but a layer of skin may not always

cover it. In some cases, the nerves of thespinal cord may be exposed. A baby whoalso has hydrocephalus will have an

enlarged head, the result of excess fluid andpressure inside the skull.


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T t t


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Treatment

The treatment largely depends on the type

of spina bifida a child has and how severe itis.

meningocele form of the disease usually hasan operation during infancy in which doctorspush the meninges back and close the hole

in the vertebrae. Many children with this typeof spina bifida have no other healthproblems down the road, unless there isnerve tissue involved with the sac.

Treatment cont


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Treatment cont Babies born with the myelomeningocele form of the

disease need more immediate attention and

typically have surgery within the first 1 to 2 days oftheir lives. During this first surgery, doctors typicallypush the spine back into the vertebrae and closethe hole to prevent infection and protect the spine.

A baby who also has hydrocephalus will need anoperation to place a shunt in the brain. The shunt isa thin tube that helps to relieve pressure on thebrain by draining and diverting extra fluid.

In addition, some children need subsequentsurgeries to manage problems with the feet, hips,or spine.


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Preventative Measures

The U.S. Public Health Service recommended inSeptember 1992 that all women of childbearing ageconsume 400 micrograms (ug) of folic acid daily toreduce their risk of having a pregnancy affectedwith spina bifida or other neural tube defects. Folicacid is a B vitamin. For women, this amount of folicacid on a daily basis spina bifida or anencephaly,both of which are neural tube defects (NTDs) in thebaby.

M l d l i P N i


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Myelodysplasia: Pre-op NursingCare

Cover sac with sterile dressing (warm saline)

Monitor for CSF leakage

Place infant in prone position with kneesslightly flexed

Assess bowel, bladder function

Monitor for signs of infection

Feed with head turned to one side

M l d l i P t N i


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Myelodysplasia: Post-op NursingCare

Monitor for wound healing Monitor for signs of infection

Monitor for signs of hydrocephalus,

increased ICP Place in prone or side-lying position

Measure head circumference daily

Assess intake and output Avoid latex products

Cerebral Palsy (CP): Background


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Cerebral Palsy (CP): BackgroundInformation

Cerebral palsy caused by insult to centralnervous systemCongenital

HypoxicIschemic

Infectious

Very premature infants at high risk

Birth asphyxia accounts for only 9% of cases

Even though cerebral palsy affects muscle


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Even though cerebral palsy affects musclemovement, it isnt caused by problems in themuscles or nerves. It is caused by abnormalities

in parts of the brain that control musclemovements.

The majority of children with cerebral palsy are born

with it, although it may not be detected until monthsor years later.

A small number of children have cerebral palsy as

the result of brain damage in the first few months oryears of life, brain infections such as bacterialmeningitis or viral encephalitis, or head injury froma motor vehicle accident, a fall, or child abuse.

Early signs of cerebral palsy


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Early signs of cerebral palsy

usually appear before a child reaches 3

years of age. The most common are a lack of muscle

coordination when performing voluntarymovements (ataxia);stiff or tight muscles and exaggerated reflexes

(spasticity);

walking with one foot or leg dragging;

walking on the toes, a crouched gait, or ascissored gait;

muscle tone that is either too stiff or too floppy.

At birth a baby with


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At birth a baby withcerebral palsy is oftenlimp and floppy, or may

even seem normal.


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Types of Cerebral Palsy

Spastic hypertonia, exag. DTR,contractures, abnorm spinal curve

Dsykinetic impair vol muscle, tremors,

inconsistent muscle tone Ataxic abnor vol muscle mov, wide based

gait

Mixed no dominant pattern

Nurses in the Community: Care of


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Nurses in the Community: Care ofthe Child with CP

Continuous support

Coordination of care - referrals

Working with schools to individualizeeducation plan

Adaptive devices

Transition to adult living

Coarctation of the aorta


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a birth defect in which the aorta, the

major artery from the heart, is narrowed. The narrowing results in high blood

pressure before the point of coarctationand low blood pressure beyond the point

of coarctation. Most commonly, coarctation is locatedso that there is high blood pressure inthe upper body and arms and low bloodpressure in the lower body and legs.Symptoms can include localizedhypertension, cold feet or legs,decreased exercise performance, andheart failure.

Coarctation of the aorta


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RHEUMATIC HEART DISEASE

Rheumatic heart disease is the result ofrheumatic fever caused by streptococcalbacteria. Most likely to strike childrenbetween 5 and 15 years old, rheumatic

fever can scar heart valves to the pointwhere they may not function properly Cause: group A streptococcus

Heart damage can occur: carditis or inflammationof the heart muscle

Also can affect any of the valves, giving symptomsof the particular valve dysfunction


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Treatment

The best defense against rheumatic heart

disease is to prevent rheumatic fever fromever occurring. By treating strep throat withpenicillin or other antibiotics, doctors canusually stop acute rheumatic fever from

developing. People who've already had rheumatic feverare more susceptible to attacks and heartdamage. That's why they're givencontinuous monthly or daily antibiotictreatment, maybe for life. If their heart hasbeen damaged by rheumatic fever, they'realso at increased risk fordeveloping bacterial endocarditis, an

infection of the heart's lining or valves.

In April 2007, the American Heart Association updated


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p 00 , t e e ca ea t ssoc at o updatedits guidelines for prevention of endocarditis andconcluded that there is no convincing evidence linkingdental, gastrointestinal or genitourinary tract

procedures with the development of endocarditis. Theprophylactic use of antibiotics prior to a dentalprocedure is now recommended ONLY for thosepatients with the highest risk of adverse outcomeresulting from endocarditis, such as patients with aprosthetic cardiac valve, previous endocarditis, orthose with specific forms of congenital heartdisease. The guidelines no longer recommendprophylaxis prior to a dental procedure for patientswith rheumatic heart disease unless they also haveone of the underlying cardiac conditions listed above.


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DRUG THERAPY

Digoxin (Lanoxin) increases contractility May be given PO in liquid or tablet form, IV

Infant: change in behavior

fussiness

Irritability

intolerance to feedings,


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Signs of Toxicity

CNS Lethargy or drowsiness

Confusion

HA

Hallucinations Visual changes

syncope

GI system

N/V Diarrhea

Anorexia, weight loss, failure to thrive

ABD pain


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When to hold Digoxin

When pulse is Infant less than 90-100

Children- less than 70

Always check potassium level before administerdigoxin

digoxin normally competes with K+ ions for the

same binding site on the Na+/K+ ATPase pump.


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Furosemide (Lasix) diuretic given

IV or PO as liquid or tablet Assessing for effectivenessUO or

number of wet diapers

Spironolactone (aldactone) milddiuretic which spares potassium(why is that desirable?)


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Comes PO only, as tablet or can be madeinto a liquid suspension

Captopril (Capoten) ACE inhibitorpulmonary and systemic vasodilatorwhich helps reduce the workload of theheart

BP important to determine tolerance todrug

Comes PO in tablet or can be crushedand mixed with liquid


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TETRALOGY OF FALLOT

Tetralogy of Fallot has four key features. A ventricular septal defect (a hole between the

ventricles)

many levels of obstruction from the right ventricleto the lungs (pulmonary stenosis) are the mostimportant.

Also, the aorta (major artery from the heart to thebody) lies directly over the ventricular septaldefect, and the right ventricle develops thickenedmuscle.


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TET Spell


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What is it? It is a hypercyanotic spell It occurs when the infundibulum spasms

Infundibulum is the area below the valve,also called the outflow tract

Blood is shuntedL due to spasm

The hypoxia acidosis, which increasespulmonary vascular resistance

TET Spell


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Knee chest position for infants Squatting in children

Both reduce venous blood return, increasessystemic vascular resistanceshunts

more blood to the right O2 100%

Morphine IV or IM

Treatment


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Call for assistance

Inderal PO q6h or q8h beta blocker

to help prevent the spasms fromoccurring

If infant is having frequent tet spells, it

is time for surgical intervention


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S & SMost infants with tetralogy of Fallot developcyanosis in the first year of life.

The skin, lips, and mucous membranes inside themouth and nose take on a noticeably dusky bluecolor.

Only some infants with very severe obstruction ofthe right ventricle outflow turn blue at birth.

A small number of children with tetralogy of Fallotnever turn blue at all, especially if the pulmonarystenosis is mild, the ventricular septal defect is

small, or both.

In some children, the cyanosis is quite subtle andmay go undetected for some time.


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Treatment

Tetralogy of Fallot is treated surgically. Atemporary operation may be done at first ifthe baby is small. Complete repair comeslater. Sometimes, the first operation is a

complete intracardiac repair.


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Surgical Treatment

Temporary OperationIn small and very blue infants, a shuntoperation may be done first to provideadequate blood flow to the lungs. This lets

the baby grow big enough to have a fullrepair. The shunt is built between the aortaand the pulmonary artery. The shunt isremoved when a complete intracardiacrepair is done later.

Surgical Treatment


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Surgical TreatmentComplete repair tends to be done early inlife. Once it was more common to do a

temporary operation first and a completerepair later in childhood.

To do a complete repair, the surgeoncloses the ventricular septal defect with apatch and opens the right ventricularoutflow tract by removing some thickenedmuscle below the pulmonary valve,repairing or removing the pulmonary valveand enlarging the peripheral pulmonaryarteries that go to both lungs. Sometimesa tube is placed between the right ventricleand the pulmonary artery. This issometimes called a Rastelli repair.


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POST OP CARE

Observe VS may have arterial and centrallines in place

Maintain respiratory statusmay bemechanically ventilated at first, then try to

get patient to cough Monitor I & O, meaning all drainage tubes.

Also, be aware of all IV fluids patient isgetting

Ob f li ti f h t


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Observe for complications of heartsurgery:

CHF, respiratory distress, bleeding,neurologic changes, tamponade,infection

Pain management

Support for familykeeping theminformed of childs progress andallowing them to stay at the bedside asmuch as possible


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OTITIS MEDIA

Common in infants and children Causes: URI, being flat when feeding, flat in

crib with bottle propped, smoking &/orodors on clothes from smoking

S & S: crying, fussiness, change in feeding,fever, vomiting, tugging on ear or rubbingaffected ear


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Croup

Broad term of upper airway illnesses -examples

Affect large numbers of children between 3months and 3-5 years

Inflammation of the larynx, trachea, bronchi Usually viral

Croup is most likely to occur during the fall,winter, and early spring, and symptoms are

most severe in kids younger than 3 years ofage

Croup Characteristics


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p

Barking cough fast or difficult breathing

grunting noise or wheezing while breathing.

Occurs most often at night

Last 3-5 days


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Treatment

Humidified oxygen or cool mist This treatment helps to moisten secretions and

inflamed tissues to open the airway and sootheirritation.

Children who are not responding to mist willreceive nebulizer treatments to breathe

Corticosteriod

Racemic epinephrine aerosols


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Epiglottitis

Inflammation of the epiglottis Potentially life-threatening

Usually caused by H. influenzae type B(Hib) - Hib vaccination now required for

children Signs and symptoms: Fever, drooling,

difficulty swallowing


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Epiglottitis: Interventions

Avoid inspecting mouth or throat Allow child to maintain position of comfort

CBC, blood cultures,

Treatment


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Antibiotics IV You may wear a mask that delivers oxygen

to your lungs Possible intubation


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Bronchiolitis (RSV)

RSV accounts for the majority o cases Pathophysiology

Symptoms: Nasal symptoms, cough, fever,wheezing, tachypnea, retractions,

decreased activity level, decreased oralintake, dehydration


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Signs and Symptoms

Tachypnea Significant retractions

Poor oral intake

Lethargy

KNOW AND READ THE PATHO


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RSV

Occurs most often in infants and toddlers Treatment

O2

IV hydration

Suctioning Bronchodilator therapy


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Bronchitis

Bronchitis is an inflammation of the largebreathing tubes (airways) that are calledbronchi, which causes increased productionof mucus and other changes. Although

there are several different types ofbronchitis, the two most common are acuteand chronic (primarily affects adults).


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Bronchitis Symptoms

runny nose, usually before a cough starts malaise (an overall body discomfort or not

feeling well)

chills

slight fever back and muscle pain

sore throat


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Symptoms

In the earlier stages of the condition,children may experience a dry, non-productive cough which progresses later toan abundant mucus-filled cough. Younger

children may have some vomiting orgagging with the cough. The symptoms ofbronchitis usually last seven to 14 days, butmay also persist for three to four weeks.


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Treatment

Medications to help suppress the cough orloosen and clear secretions may be helpful

Bronchodilator inhalers will help openairways and decrease wheezing

antibiotics play a limited role in treatingbronchitis, they become necessary in somesituations.

In particular, if the doctor suspects a bacterialinfection, antibiotics will be prescribed.

People with chronic lung problems also usuallyare treated with antibiotics

Asthma Approximately 17.3 million Americans

have asthma


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The cost of illness related to asthmais around $6.2 billion per year in theUnited States.

Each year, an estimated 1.81 millionpeople with asthma require treatment

in the emergency department withapproximately 500,000hospitalizations.

Children younger than the age of 18

years account for 47.8% of theemergency department visits and34.6% of the hospitalizations due toasthma exacerbations.


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Asthma

Asthma is a disorder caused byinflammation in the airways (calledbronchi) that lead to the lungs.

This inflammation causes airways totighten and narrow, which blocks airfrom flowing freely into the lungs,making it hard to breathe.

The inflammation may be completelyor partially reversed with or withoutmedicines.


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Pathophysiology


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Inflammation of the airways is linked tobronchial hyperresponsiveness, whichmeans that the airways leading to the lungscan narrow when they are exposed to

anything to which they are sensitive,making it hard to breathe.


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So an asthma flare is caused by 3 important changes inthe airways that make breathing more difficult:


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y g Inflammation of the airways

Excess mucus that results in congestion and mucus "plugs"that get caught in the narrowed airways

Bronchoconstriction (bands of muscle lining the airwaystighten up)


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Triggers

Many things can cause asthma, including Allergens - mold, pollen, animals

Irritants - cigarette smoke, air pollution

Weather - cold air, changes in weather

Exercise Infections - flu, common cold


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Asthma (contd)

Symptoms includewheezing,breathlessness,chest tightness,

cough, particularly at night or afterexercise/activity.

Labs/diagnostics


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Pulse ox Chest x-ray-hyperexpansion, atelectasis

and flattened diaphragm, hyperinflation

Pulmonary function test

Peak expiratory flow CBC, CMP, if fever blood cultures


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Acute treatment

Short-acting beta-2 agonists. Thesebronchodilators begin working withinminutes and last four to six hours

corticosteroids

prednisone, methylprednisolone, hydrocortisoneand others


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Chronic Treatment

Respiratory treatments Inhaled corticosteroids

fluticasone (Flovent), budesonide (Pulmicort),

triamcinolone (Azmacort), flunisolide (Aerobid)and beclomethasone (Qvar). Advair Diskus


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Allergic Rhinitis

Common childhood illness Affects up to 40% of children

Associated with atopic dermatitis (form ofeczema) and asthma

80% of asthmatic children suffer fromallergic rhinitis


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Dehydration: Three Types

Isotonic Loss of sodium and water is equal

Serum sodium is normal

Hypotonic

More sodium is lost than water Serum sodium is low

Hypertonic

More water is lost than sodium

Serum sodium is high


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Etiology of Dehydration in Children

Diarrhea (5 million deaths from dehydrationworldwide)

Vomiting - nasogastric tubes

Hemorrhage

Burns


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Pathophysiology of Dehydration

Initial dehydration (First 3 days) Most of fluid loss (80%) is from

extracellular fluid compartment

20% is from intracellular fluid

compartment

Symptoms of Severe

D h d i


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Dehydration

Severe dehydration is a medical emergencyand parents should seek immediatemedical attention. These children appearlethargic (meaning they are difficult to keep

awake) or may be unconscious. They alsomay have: poor drinking or may be unable to drink

a parched mouth and tongue

minimal or no urine output

greater than 9 percent weight loss

increased heart rate, weak pulses, deep breathing, and cool,mottled extremities

capillary refill that is very prolonged or minimal

recoil on skin turgor test in more than 2 seconds

deeply sunken eyes (and/or fontanel in a baby)

Symptoms of Minimal Dehydration


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Sy pto s o a e yd at o

Most children who are sick, either with a cold or

mild stomach bug, will have minimal or nodehydration. These children are alert andappear well and have: normal thirst or mayrefuse some liquids

a moist mouth and tongue

normal to slightly decreased urine output

less than 3 percent weight loss

normal heart rate, pulses, breathing, and warmextremities

capillary refill less than 2 seconds instant recoil on skin turgor test

eyes not sunken (and/or fontanel in a baby)

Symptoms of Mild to Moderate

D h d ti


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Dehydration

Once dehydration worsens, children maybegin to feel tired, restless, and irritable,which makes it difficult to get them to drinkmore fluids. Other signs and symptoms of

mild to moderate dehydration,include: increased thirst a dry mouth and tongue

decreased urine output

3 to 9 percent weight loss

normal to increased heart rate and pulses, normal to fastbreathing, and cool extremities

capillary refill greater than 2 seconds

recoil on skin turgor test in less than 2 seconds

slightly sunken eyes (and/or fontanel in a baby)

T t t f D h d ti


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Treatment of Dehydration

Oral rehydration solutions Intravenous fluid replacement

Choice of fluid

Amount of fluid

Frequent monitoring and reassessment

Weight

Labs

N i I t ti D h d ti


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Nursing Interventions: Dehydration

Prevent dehydration Provide oral rehydration fluids

Monitor intravenous fluid administration

Monitor response to therapy

Teaching

El t l t Ab liti


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Electrolyte Abnormalities

Electrolytes in usually equals electrolytesout

Body maintains balance unless diseasestate occurs

Blood levels measure serum electrolytesonly - may vary in other fluid compartments

S di


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Sodium

Reflect osmolality of body fluids Sodium balance and water balance are

closely tied

Most abundant extracellular ion

H t i


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Hypernatremia

Body fluids are too concentrated - moresodium than water

Causes: Decreased water intake orincreased solute intake - diabetes insipidus

Treatment Fluid replacement

Treat underlying cause

H t i


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Hyponatremia

Body fluids are too dilute - more water thansodium

Causes: Water intoxication, diluted formula,SIADH

Complications: Cerebral edema, seizures Treatment: Replace sodium

Potassium


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Potassium

Most abundant intracellular ion Essential electrolyte

Can shift in and out of cells

Excreted primarily by urine, but also in

sweat, feces


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Hyperkalemia


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Hyperkalemia

Excess potassium in the blood Causes

Increased potassium intake (oral, IV)

Shift of potassium out of cells into

interstitial fluid (massive cell death, oldtransfused blood, acidosis)

Decreased potassium excretion (renalfailure)

Treatment Treat underlying cause

Cation exchange resin (Kayexalate)

Dialysis

Hypokalemia


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Hypokalemia

Decreased potassium in the blood Causes

Decreased potassium intake (NPOstatus, IV fluids)

Shift of potassium into cells (alkalosis,insulin therapy)

Increased potassium excretion (diuretics,diarrhea, others)

Treatment Replacement (IV or oral)


Calcium


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Calcium

Most abundant mineral in the body Involved in

Muscle and nerve function

Bone strength

Hormone secretion

Blood clotting

Hypercalcemia


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Hypercalcemia

Excess of calcium in the plasma Most of calcium is stored in bones

Causes

Increased calcium intake

Shift of calcium from bones toextracellular fluid (hyperparathyroidism,prolonged immobility)

Hypercalcemia (contd)


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Hypercalcemia (cont d)

Treatment: Furosemide (Lasix) increases calcium

excretion

Glucocorticoids decrease absorption

Phosphate (binds with calcium) Dialysis

Hypocalcemia


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Hypocalcemia

Serum deficit of calcium Most of calcium stored in bones Causes

Decreased intake of vitamin D and/or

calcium Hyperphosphatemia

DiGeorge syndrome

Treatment

Treat underlying cause Replace calcium (oral or IV)

Vitamin D

Magnesium


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Magnesium

Necessary for enzyme function, nervefunction

Absorbed in ileum

Present mostly in the cells and bones -

small amount in extracellular fluid Excreted in urine, sweat, and feces

Hypermagnesemia


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Hypermagnesemia

Excess magnesium in blood Causes

Renal failure

Excess magnesium intake (IV)

Treatment: Diuresis

Dialysis

Hypomagnesemia


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Hypomagnesemia

Decreased magnesium in blood Causes

Malnutrition, decreased intake

Chronic diarrhea

Prolonged suctioning Treatment


Replacement

Acid-Base Balance


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Acid-Base Balance

Tightly regulated Balance of acids (hydrogen) and bases

(bicarbonate)

Enzymes and cells operate in a very narrow

range of pH

Normal pH Varies by Age


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Normal pH Varies by Age

Slightly basic Infants: 7.36 to 7.42

Children: 7.37 to 7.43

Adolescents: 7.35 to 7.41

Types of Acids in the Body


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Types of Acids in the Body

Carbonic acid Carbon dioxide and water

Lungs excrete carbon dioxide

Metabolic (noncarbonic) acids

Pyruvic acid Sulfuric acid

Lactic acid

Hydrochloric acid

Can be neutralized by buffers in bodyfluids

Can be excreted by the kidneys

Buffers


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Buffers

Binds hydrogen ions when there aretoo many

Releases hydrogen ions when thereare not enough

Types of buffers Bicarbonate

Protein

Hemoglobin Phosphate

Once buffers are saturated, kidneyexcretes acids


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Nursing Interventions:Hypernatremia


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Hypernatremia

Monitor sodium level, intake and output,urine specific gravity

Assess level of consciousness

Consider underlying cause

Teaching Prevention in the hospital setting - free

water with tube feedings

Nursing Interventions:Hyponatremia


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Hyponatremia

Monitor sodium level, intake andoutput

ADH levels

Formula preparation - dilution?

Monitor level of consciousness

Seizure precautions

Prevention in the hospital setting

Use normal saline rather than sterilewater for irrigations

Avoid tap water enemas

Nursing Interventions:Hyperkalemia


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Hyperkalemia

Stop any potassium-containing fluids frominfusing

Administer medications

Glucose and insulin

Bicarbonate Calcium

Kayexalate

Nursing Interventions:Hyperkalemia (contd)


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Hyperkalemia (cont d)

Monitor cardiopulmonary status Prevention in the hospital setting

Risk increases with use of old blood fortransfusion

IV fluids that contain potassium

Dont give potassium-containing fluids toa child who has oliguria or anuria

Nursing Interventions:Hypokalemia


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Hypokalemia

Ensure adequate potassium intake If child is taking digitalis, hypokalemia

potentiates digitalis toxicity - assess fornausea, vomiting, bradycardia

Cardiac monitoring Potassium replacement (oral or IV)

Nursing Interventions:Hypercalcemia


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Hypercalcemia

Encourage fluid intake Increase mobility

Avoid calcium-rich foods, calciumsupplements

Avoid vitamin D supplements

Nursing Interventions:Hypocalcemia


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Hypocalcemia

Calcium replacement (oral or IV) - nevergiven IM: Causes tissue necrosis

Calcium supplementation

Teaching

Nursing Interventions:Hypermagnesemia


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Hypermagnesemia

Monitor serum levels, blood pressure,reflexes

Monitor for cardiac arrhythmias

Avoid magnesium-containing

substances Dietary sources

Medication (milk of magnesia)

Sea salt

Diuresis

Dialysis

Nursing Interventions:Hypomagnesemia


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yp g

Monitor reflexes, cardiac functioning,muscle cramps

Replace magnesium (oral, IM, or IV)

Increase magnesium in diet - food choices

Teaching


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Developmental Dysplasia of the

Hip (DDH)


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p ( )

Femoral head and acetabulum improperlyaligned

May include hip instability, dislocation,subluxation, or dysplasia

Occurs in girls more than boys - unilateralin 80% of cases

Cause: Unknown - genetic factors likely

Hip dysplasias

Acetabular dysplasia: mildest form


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Acetabular dysplasia: mildest form

Subluxation: largest percent ofcongenital

hip dysplasias

Dislocation:

(the following slide demonstrates thethree types)


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The asymmetry of the gluteal and thigh fat folds is easy

to see in this child with developmental dysplasia of the

hip

Diagnosing:

Ortolanis test: hear the click


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Ortolani s test: hear the click

Barlows test: feel the slipping in andout of the femur head from theacetabulum

Will see uneven gluteal folds in infant

Limping, toe walking in older children

Trendelenberg sign: pelvis tiltsdownward on normal side instead ofupward

Treatment:

Begun as early as possible to


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Begun as early as possible toprevent deformity

Pavlik harness: keeps femurcentered in acetabulum withflexion, prevents hip extension

Harness can be very effective if

there are no other complications Older infants and toddlers may

require traction

Delay in treatment may end inrequiring surgery, which is not always


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effective due to adaptive changes

over time Care required during treatment?

Osteogenesis Imperfecta


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Brittle bone disease Genetic condition affecting collagen

production

Manifestations

Frequent fractures Blue sclerae

Thin, soft skin

Short stature

Muscular Dystrophy


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Group of inherited diseases - Duchennemost common

Muscle fibers degenerate

Onset varies (birth to late in life)

Progression varies (few years to manyyears)

All are terminal


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Duchenne


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Duchenne muscular dystrophyis the mostcommon childhood form of musculardystrophy, with symptoms beginning usuallybetween 2 to 6 years of age in boys.Children who are affected start out by

falling frequently, having trouble getting upfrom sitting or lying down, and may waddlewhen they walk.

Treatment:

No known cure


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Treatment mainly symptomatic to achieve the highestlevel of function possible

Complications:

Contracture deformities immobility

Disuse atrophyInfections

Obesitywhy?

Respiratory problemsinfections

Cardiac problemsCHF


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p

Primary cause of death is fromrespiratory failureinfection orweakness of diaphragm

Guillain-Barre Syndrome

Infectious polyneuritis


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y

Uncommon in children

Is a progressive demyelinatingpolyneuropathyprogressiveascending paralysis

Immune mediated disease associatedwith viral infection

Most common ages are 4-10 years

Treatment: primarilysupportive


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Earlier diagnosis made,

better the outcome Earlier the age, the better

outcome

Use of plasmapharesis, no

respiratory complicationsbetter outcome

Full recovery usually occursmay take up to 1 year or

more Nurses role: preventing

complications of immobility

Multidisciplinary team approach isused, for both the acute phase andh h b h


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the rehab phase

In summary: CP, MD and Guillain-Barre all have immobility issues asmajor components which is the

nurses role to address. Think how immobility affects each

age groupability to socialize, growphysically and cognitively

Pauciarticular Juvenile

Rheumatoid Arthritis


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Pauciarticular JRA refers to a form ofjuvenile rheumatoid arthritis which affectsfour or fewer joints.

Pauciarticular is the most common form ofJRA; about half of all children with JRAhave this type.

This type of JRA affects mostly girls. Girlsunder age 8 are most likely to develop thistype of JRA.

Girls are more commonly affected 3-5:1(CDC)


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Polyarticular Juvenile

Rheumatoid Arthritis


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Polyarticular JRA refers to a form of juvenilerheumatoid arthritis which affects five ormore joints.

a disease of many joints.

This is the type of juvenile arthritis whichdoctors consider to be most similar to adultrheumatoid arthritis.

About 30 percent of all children with JRAhave polyarticular disease.

Girls are two times more likely to have thisdisease than boys.

polyarticular disease

The joints are usually affected symmetrically


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The joints are usually affected symmetrically

(on both sides). Often the small joints of the hands are

affected, as well as other joints.

Low grade fever, weight loss, and anemia may

occur, and in severe cases growth problems. Most children with polyarticular disease test

negative for rheumatoid factor and theirprognosis is usually good.

A minority of children test positive forrheumatoid factor and seemingly are at morerisk for chronic, progressive destruction and

joint damage.

Treatment:

No cure


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Goal: manage pain

preserve joint ROM

minimize effects ofinflammation

(joint deformity)

Promote normal growth and

development

Treatment plan involves multidisciplinaryteam


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NSAIDs are the first drugs used

SAARDs: slower acting antirheumaticdrugs such as methotrexate (which is anantineoplastic drug)

Corticosteroids: have many adverse

effects one major one is decreasedphysical growth

Biologic agent: Etanercept is newlyapproved

Cytotoxic agents:cyclophosphamide, azathiopine,cyclosporine chlorambucil


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cyclosporine, chlorambucil

Have risk of toxicity, these drugsare used in transplants and aschemo agents

Physical management: PT topreserve joint function

Synovectomy not recommended inchildren

Cortisone shot into affected jointcan be tried first

Joint replacement may be seen inolder child


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This is a life long chronic conditionand families should be informedabout community support available;I.e. the Arthritis Foundation and the

American Juvenile ArthritisFoundation

Osteomyelitis

Infection of the bone usually a long bone in


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Infection of the bone, usually a long bone in

lower extremity Acute or chronic

Occurs at any age - boys more than girls(due to trauma)

Cause: Microorganism, usually bacterial Symptoms: Pain, swelling, decreasedmobility, fever

Treatment: Antimicrobials (oral or IV) for 3to 6 weeks

Osteomyelitis: Nursing Care


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Immunization status (tetanus) Obtain cultures and blood work

Administer fluids and medications

Protect from spread of infection

Encourage well-balanced diet Home care teaching - considerations for

home IV therapy


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exam 2 review without pictures

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