Exam 2: Pediatrics best New Update 2022/2023 with Assured Success GRADED A+, Study Guides, Projects, Research of Nursing

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Exam 2: Pediatrics best New Update 2022/2023 with Assured Success GRADED A+ Chapter 6: Childhood Communicable/Infections Diseases/Immunization Schedule Good way to remember the first 6 months B (Hep B) D (Dtap) R(rotavirus) H (Hib) I(IPV)P (PCV) Birth: B 2 Months: B DR ROTA HIP 4 Months: DR ROTA HIP 6 Months: B (to 18 months) D (then at 15 months) R ROTA (teq) HIP (then at 12 To 15 months) Recommended Schedule (pg 171) • Hepatitis B o Birth, 1 to 2 months, then at 6 to 18 months (3 Doses) o If mother is positive or status is unknown give both hep b and HBIG (immunoglobin) within 12 hours o Do NOT give to infants less than 2000 grams (4.4 lbs) until one month of age o Review: This is spread via sex and blood products, symptoms will be liver dysfunction • Hepatitis A o Give at 1 year of age and then 6 months after [around 19 to 23 months)) (2 Doses) • TdaP (older kids) o Give combination of tetanus and pertussis vaccines) (younger than 11 years of age o This is a booster shot for those who have already completed the DdaP • DdaP (younger kids) o Give at 2, 4, 6 and 15 months (4 Doses) o Combination of tetanus and pertussis vaccines for less than 7 years of age • Pneumococcal (PVC13) o Give at 2, 4, 6 and 12 to 15 months (4 Doses) • Rotavirus o Give at 2, 4, 6 months (3 doses) for RotaTeq ▪ Do not give after 32 weeks o Give at 2 and 4 months (2 Doses) for Rotarix o Both medications are given orally o If infection occurs, still complete series • Polio o Give at 2, 4, 6 to 18 months, and 4 to 6 years of age (4 Doses) Nursing Responsibilities (Pain, contraindications, take MMR/varicella together or wait on month, Chapter 26: Overview of Oxygen and Carbon Dioxide Exchange • Disturbances in acid– base balance are respiratory acidosis, respiratory alkalosis, metabolic acidosis, and metabolic alkalosis. • Defense mechanisms of the respiratory tract include the lymphatic system, mucus secretions, ciliary action, epiglottis (will look like a thumb, prevent aspiration), cough reflex, tracheobronchial dynamics, body position changes, and humoral defenses. • HCO: 22-26 • pH: 7. 35 – 7:45 • PaCO2: 35 – 45 mm Hg • PaO2: 75 – 100 mm Hg • Respiratory assessment should include o Developmental Differences for an infant/child ▪ Diaphragmatic abdominal breathing up to 5 years of age ▪ Smaller airways ▪ Immature lung tissue ▪ Respiratory rate higher ▪ Early infancy, irregular breathing ▪ Infants are nose breathers ▪ High potential for obstruction (due to size of airways) ▪ Decreased surfactant in neonate o Respirations (pg 884) ▪ Associated Observation include retractions, nasal flaring, head bobbing, noisy breathing, stridor (upper airway sound, resistance), grunting, Normal pulse & respiratory rates for children Ag e Pulse Respirati on s Newborn 100 to 160 30 to 60 1 to 11 months 100 to 150 25 to 35 1 to 3 years (toddler) 80 to 130 20 to 30 3 to 5 years (preschooler) 80 to 120 20 to 25 3 wheezing (due to 4 constriction), color changes of the skin, chest pain, clubbing (due to severe hypoxemia), and cough 𝑄 Supraclavicular and suprasternal notch retractions indicated severe airway obstruction o Auscultation of chest to assess ▪ Breath sounds— Presence, intensity, quality, symmetry ▪ Abnormal sounds—Stridor, wheezes, crackles, rubs, increase or decrease in sounds • Diagnostic Procedures for Respiratory Issues o Lung scan o Bronchoscopy o ABGs ▪ Via heel stick in infants, warm site first ▪ First do Allen test ▪ Use heparinized syringe ▪ Do not allow air bubbles to enter sample o Pulmonary Function test ▪ This test is used to determine the severity and course of a disease and to study the effects of treatment o Noninvasive Monitoring (TCM/ETCO2) (see below) • Noninvasive Monitoring of Oxygen o Pulse oximetry o Transcutaneous Monitoring (TCM) which provides continuous monitoring of transcutaneous partial pressure of oxygen in arterial blood (tcPaO2) and, with some devices, of carbon dioxide in arterial blood (tcPaCO2). An electrode is attached to the warmed skin to facilitate arterialization of cutaneous capillaries ▪ The site of the electrode must be changed every 3 to 4 hours (or more frequently according to skin status) to avoid burning the skin, and the machine must be calibrated with every site change o End-tidal carbon dioxide monitoring (ETCO2) measures exhaled carbon dioxide noninvasively. ▪ ETCO2 monitoring is obtained by measuring exhaled CO2 and provides real- time evidence of ventilation ▪ During CPR, a level of > 15 mm Hg is indicative of ineffective chest compression and or too much ventilation ▪ A change in waveform or value, the nurse must assess ABCs immediately • Treatment for Respiratory Issues: supplemental oxygen therapy, positioning for maximum airway opening, humidification, aerosol therapy, and artificial 7 are caused by viruses. o Many have similar signs and symptoms – treatment is often focused on treating the signs and symptoms 8 ▪ Ease respiratory efforts – positioning, HOB elevated, suctioning, warm or cool mist (use shower to produce steam if at home) ▪ Promote rest (hard with active kids – encourage quiet activities) ▪ Promote comfort (suction before feeding infants; hot or cold applications) ▪ Prevent spread of infection (hand washing, cover nose/mouth when sneezing/coughing, proper tissue disposal, don't share items, remove from contact with other children) ▪ Reduce temperature ▪ Promote hydration and nutrition 𝑄 If diet is “PO as tolerated” but RR high, patient will not tolerate 𝑄 Don't force fluids, don't awaken child to drink, consider popsicles, Pedialyte, small amounts of favorite fluids, suction before offering • Signs and symptoms of respiratory tract infections in children (pg 890) o Fever (may be absent in neonates less than 28 days old); greatest at ages 6 months – 3 years); may cause seizures (60 months or less) o Meningismus (meningeal signs without infection of the meninges) – fever, headache, pain, stiffness in back and neck, the symptoms will subside as temperature drops) o Anorexia, vomiting, diarrhea o Abdominal pain (may be referred pain, related to muscle spasms from vomiting, may be caused by mesenteric lymphadenitis) o Nasal blockage o Nasal discharge (thin/watery=rhinorrhea/viral or thick/purulent=bacteria) o Cough, respiratory sounds o Sore throat • Nursing Care for General Respiratory Concerns o Ease respiratory effect (reposition, tapped heel, blow by) o Promote Rest o Promote Comfort o Prevent spread of infection o Reduce temperature (via ibuprophen or acetaminophen) o Promote hydration and nutrition o Provide family support and home care o Droplet precautions for Acute Epiglottis and Mengititis Acute Viral Nasopharyngitis (The Common Cold) (pg 891) • Caused by a number of viruses, so vaccines DO NOT WORK, usually self- limited • Clinical manifestations of Acute Viral Nasopharyngitis: o Young children: fever, irritability, restlessness, decrease in appetite o Older children: dryness, inflammation, irritation of nasal passages (can cause obstruction), sneezing, muscle aches, nasal discharge • Management for Acute Viral Nasopharyngitis: o Rest and fluids at home o Antipyretics 9 o Decongestants if necessary, which can be admin via nose drops or sprays ▪ Are more effective and Safer for 12 years of age but can be given at 6 years of age 1 2 children not return to school or day care until they have been taking antibiotics for a full 24-hour period o Nurses should remind children with a streptococcal throat infection to discard their toothbrush and replace it with a new one after they have been taking antibiotics for 24 hours o Teach patent that this disease is spread via droplets or physical transfer of respiratory secretions Tonsillitis (pg 894) • Viral or bacterial; often occurs with pharyngitis • Signs and symptoms for Tonsillitis o Enlarged tonsils (can cause obstruction if very enlarged), nares blocked, child breathes through mouth which causes mucous membranes to become dry and irritated, cough, muffled voice common, inflammation of cervical nodes (> 2 cm) o Review Tonsil Assessment Image  o Tonsil are typically grade 4 • Treatment for Tonsillitis: o If viral, self-limiting o If GABHS treatment is antibiotics o Tonsillectomy or adenoidectomy if chronic (controversial) ▪ Tonsillectomy (surgical removal of the palatine tonsils) may be indicated for massive hypertrophy that results in difficulty breathing or eating ▪ Adenoidectomy (the surgical removal of the adenoids/pharyngeal tonsils) is recommended for children who have hypertrophied adenoids that obstruct nasal breathing or a history of four or greater episodes of recurrent purulent rhinorrhea in the previous 12 months in a child under 12 years of age ▪ Contraindications to either tonsillectomy or adenoidectomy are (1) cleft palate because both tonsils help minimize escape of air during speech; (2) acute infections due to increase the risk of bleeding; and (3) uncontrolled systemic diseases or blood dyscrasias (4) less than 3 to 4 years of age ▪ Generally, removal of the tonsils should not occur until after 3 or 4 years of age because of the problem of excessive blood loss in young children and the possibility of regrowth or hypertrophy of lymphoid tissue. The tubal and lingual tonsils often enlarge to compensate for the lost lymphoid tissue, resulting in continued pharyngeal and eustachian tube obstruction 1 3 • Nurse Care for Tonsillitis o Preoperative Care for Tonsillitis includes complete history with LAB work especially bleeding tendencies because the surgical site is highly vascular (PT [11- 16 seconds], PTT [25 – 35 seconds]) o Postoperative Care for Tonsillitis ▪ Respiratory status 1 4 ▪ Facilitate drainage (position to the side or on abdomen), careful suctioning and pain management (ice collar to constrict/reduce inflammation or opioids) ▪ Remain in bed for the remainder of day ▪ They are discouraged from coughing frequently, clearing their throat, blowing their nose, or any activities that could aggravate the operative site ▪ Dark blood and blood tinged emesis is normal (prepare parent) ▪ Avoid straws and citrus juice (OJ); milk products (ice cream/pudding) usually not offered until clear fluids retained because they coat the throat and mouth (causes child to clear throat which can cause bleeding) ▪ Popsicles (but not red or brown) so you are able to determine if its blood or not ▪ Nursing Alert: Observe throat directly for evidence of bleeding or other signs and symptoms of hemorrhage (excessive swallowing, tachycardia, pallor, clearing of throat, restlessness, decreasing blood pressure) for 10 days ▪ Drug Alert: Codeine is contraindicated in pediatric patients post tonsillectomy and adenoidectomy (pg 896). OPIODS ONLY. ▪ A cream-colored membrane is often visible on the tonsillar bed postoperatively for 5 to 10 days post-surgery; reassure parents this is an expected finding o Discharge Instructions: Avoid hard foods, teach patient that mouth odor and slight ear pain with a low-grade fever are common for a few days postoperatively. However, persistent severe earache, fever, or cough requires medical evaluation Influenza (pg 897) • Three types include A and B included in vaccine and C which milder NOT included in vaccine • Spread from one individual to another by direct contact (large-droplet infection) or by nasopharyngeal secretions. • Signs and symptoms for Influenza o can be subclinical, mild, moderate, or severe which usually last 4 – 5 days o Dry throat, Dry nasal mucosa, dry cough which result in hoarseness o Fever, chills, myalgia, flushed face, photophobia • Diagnosis for Influenza o Flu A and B can be rapidly detected via direct fluorescent antibody and indirect immunofluorescent antibody staining • Treatment for Influenza o Uncomplicated influenza in children usually requires only symptomatic treatment: acetaminophen or ibuprofen for fever and sufficient fluids to maintain hydration o Oseltamivir, zanamivir, and peramivir (must be sympathetic for less than 2 days) are recommended to treat influenza for patients at high risk of complications from the flu (without/without food) 1 7 ▪ Unilateral or bilateral in child 24 months or older without severe sxs o Supportive care or symptomatic treatment: treating fever and pain ▪ Ibuprofen is best because it last longer o Myringotomy is a surgical incision of eardrum (to alleviate severe pain and drain infected middle ear fluid) 1 8 o Tympanostomy tube is for chronic OM; recommended after 3 to 6 months of effusion with hearing deficits – tube falling out not an emergency ▪ Tympanostomy tubes may be indicated to allow ventilation into the middle ear to equalize middle ear pressure. Most children's hearing improves right after surgery and ear drainage is common up to 1 week after insertion. The tympanostomy tube is eventually pushed out of the eardrum usually 8 to 18 months after tube placement. Parents should be aware of the appearance of a tympanostomy tube (usually a tiny plastic spool- shaped tube) so they can recognize it if it falls out. They are reassured that this is normal and requires no immediate intervention, although they should notify the practitioner. No water precautions needed for this procedure (ie patient can swim) • Complications for Otitis Media: hearing loss which has an adverse effect on development of speech and cognition o Consider hearing tests if OME persists for 3 months or more o Consider hearing test if no within correct cognitive development stage • Management for Otitis Media: analgesics for pain and fever, positioning for best drainage, can clean external canal with sterile cotton swabs, application of heat over the ear (may help sometimes but not always), teach parents ABX therapy compliance, keep water out of ear o Nursing Tip: A child older than 3 can have ear canal pulled up and straighten out and use blow dryer (little to no heat) for 30 seconds three times per day. Hold blow dryer about 18 to 24 inches away from ear canal. o Position them with affected ear DOWN o Prevention of OM ▪ Proper positioning (upright) for feedings ▪ Routine immunization with the pneumococcal vaccine has reduced the incidence of AOM in some infants and children 𝑄 Give at 2, 4, 6 and 12 to 15 months (4 Doses) ▪ Influenza vaccination to children over 6 months is also important ▪ Parents are encouraged to reduce risk factors for AOM by breastfeeding infants for at least the first 6 months of life, avoiding propping the formula bottle (causes fluid pooling in pharyngeal cavity), decreasing or discontinuing pacifier use after 6 months, and preventing exposure to tobacco smoke CROUP A general term applied to a symptom complex characterized by hoarseness, a resonant cough described as “barking” or “brassy” (croupy), varying degrees of inspiratory stridor, and varying degrees of respiratory distress resulting from swelling or obstruction in the region of the larynx. • Occurs primarily in children 6 months to 3 years (rare after 6 years) • Primary goals in the care of children with croup are observation for signs of respiratory distress and relief of laryngeal obstruction • Important to distinguish which type of croup syndrome it is 1 9 • Acute Epiglottit is, Acute LTB, Acute Spasmod ic Laryngiti s and Bacterial Tracheiti s • Table 26.4 – Comparis on of Croup Syndrom es (pg 903) Acute Epiglottitis (Acute Supraglottitis) (pg 803) Acute epiglottitis, or acute supraglottitis, is a medical emergency. It is a serious obstructive inflammatory process that occurs principally in children between 2 and 5 years of age but can occur from infancy to adulthood. The causative agent is usually H. influenzae (bacteria; so, get vaccine at 2 months then 4 months) • Nursing Alert: Three clinical observations that are predictive of epiglottitis are: o Absence of spontaneous cough (not enough airway to cough) o Drooling o Agitation (TOXIC APPERANCE) • Other signs and symptoms include stridor aggravated when supine, high fever, rapid pulse and increased RR o Will often sit in tripod position, lean forward and drool • Treatment for Acute Epiglottitis: o Children with suspected bacterial epiglottitis are given antibiotics intravenously, followed by oral administration to complete a 7- to 10-day course o Ceftriaxone/cefotaxime and vancomycin are generally the first 2 2 breathing. o The most important nursing function in the care of children with LTB is continuous, vigilant observation and accurate assessment of respiratory status. Cardiac, respiratory, and pulse oximetry monitoring supplement visual observations 2 3 o Nursing Alert: Early signs of impending airway obstruction include increased pulse and respiratory rate; retractions; nasal flaring; and increased restlessness. o Teach parent that a blow-by mist can be administered by a parent while the child is being held. Children need the security of the parent's presence. Acute Spasmodic Laryngitis Acute spasmodic laryngitis is distinct from laryngitis and LTB and characterized by paroxysmal attacks of laryngeal obstruction that occur chiefly at night in a child who is typically 1 to 3 years of age. Some children appear to be predisposed to the condition; Viral with an allergic and or psychogenic factors component • Signs and Symptoms of Acute Spasmodic Laryngitis o The child goes to bed well but awakes suddenly with the characteristic barking, metallic cough; hoarseness; noisy inspirations; and restlessness o NO fever is typically present with this condition o The coughing episode subsides in a few hours after waking during the day • Therapeutic and Nursing Care Management for Acute Spasmodic Laryngitis o Children with spasmodic croup are managed at home o Cool mist (and or humidified air) is recommended for the child's room (Warm mist provided o Children with moderately severe symptoms may be hospitalized for observation and therapy with cool mist and racemic epinephrine, as for LTB. Patients may respond to corticosteroid therapy. The disease is usually self-limiting. Acute Bacterial Tracheitis (pg 906) Bacterial tracheitis, an infection of the mucosa and soft tissues of the upper trachea, is a distinct entity with features of both croup and epiglottitis. The disease occurs typically at a mean age between 1 month to 7 years and may cause severe airway obstruction. This is caused by both bacteria and viruses with an allergic component. Many of the manifestations of bacterial tracheitis are similar to those of LTB but are unresponsive to LTB therapy. This condition can be progressive. • Diagnosis of Bacterial Tracheitis o Anteroposterior or lateral neck x-rays show narrowing (Steeple sign) o An endoscopy of the airway performed is usually indicated to remove secretions and obtain cultures • Signs and symptoms of Bacterial Tracheitis similar to LTB (history of URI, stridor), major difference is thick purulent tracheal secretions that create respiratory difficulty • Treatment for Bacterial Tracheitis: Bacterial tracheitis requires vigorous management with antipyretics, fluid status, and antibiotics (10-day course) • Complications for Bacterial Tracheitis: Respiratory difficulties are 2 4 secondary to these copious secretions. If not treated, children with this condition quickly develop a life-threatening respiratory failure and/or acute respiratory distress syndrome INFECTIONS OF THE LOWER AIRWAYS include Bronchiolitis/RSV and Pneumonia 2 7 • Highest incidences of RSV are observed in the winter months; rare in children over 2 years • Diagnosis of Bronchiolitis/RSV o Rapid fluorescent antibody c/s • Therapeutic Management for Bronchiolitis/RSV o RSV is treated symptomatically with cool humidified oxygen, adequate fluid intake, airway maintenance, and possibly bronchodilator medications o Routine chest percussion and drainage is not recommended o Infants with abundant nasal secretions benefit from regular suctioning, especially before feeding o Ribavirin, an inhaled antiviral agent (synthetic nucleoside analog), is the only specific therapy approved for hospitalized children (expensive/high cost) o Prevention of RSV: The only product available in the United States for prevention of RSV is palivizumab (IM/IV), that is given once every 30 days (15 mg/kg/dose) between November through March ▪ Drug Alert for Palivizumab (Synagis)Administration: The lyophilized powder form of palivizumab should be administered within 6 hours of being reconstituted with sterile water because it is preservative free • Nursing Care Management for Bronchiolitis/RSV o Quality Patient Outcomes for Bronchiolitis includes Oxygen saturation 90% or higher, respiratory rate less than 60 breaths/min, and adequate oral fluid intake o Children admitted to the hospital with suspected RSV infection may need separate rooms or may cohort with other RSV-infected children o Make patient assignments so that nurses assigned to children with RSV are not caring for other patients who are considered high risk o Parents should learn how to instill normal saline drops into the nares and suction the mucus with a bulb syringe before feedings and before bedtime so the child may eat and rest better (CT doesn’t work) o The nurse aims additional interventions at monitoring oxygenation with pulse oximetry when clinically indicated, monitoring IV fluids or NG fluids, monitoring for fever and administering antipyretics, and providing information for the parent regarding the infant's status 2 8 o Inform the parents that the infant's cough may persist for a few weeks o Needs N95 mask Pneumonia (pg 909) Atypical Pneumonia 2 9 In the category of atypical pneumonias, M. pneumoniae is the most common bacterial pathogen of community-acquired pneumonia in children 5 years of age or older. Most affected persons recover from acute illness at home in 7 to 10 days with symptomatic treatment, followed by 1 week of convalescence. The incubation period is 2 to 3 weeks, but the cough may last several weeks. Erythromycin, azithromycin, and clarithromycin are the primary agents used for treating atypical pneumonia Bacterial Pneumonia The child with bacterial pneumonia usually appears ill. Symptoms include fever, malaise, rapid and shallow respirations, cough, and chest pain. The older child may complain of headache, chills, abdominal pain, chest pain, or meningeal symptoms (meningism) (Box 26.8). Neonatal Pneumonia Pneumonia in the immediate neonatal period is different from other types of pneumonia described. If infection occurs within 3 to 5 days of birth, the pathogen is usually obtained from the mother transplacentally, or through aspiration of infected amniotic fluid intrauterine, or during or after birth. This can be caused by Group B hemolytic streptococcus, chlamydial pneumonia and herpes. is usually an Radiographs show nonspecific abnormalities. Oral azithromycin given for 3 days is the treatment of choice; alternatively, erythromycin base or ethylsuccinate is administered for 14 days. Viral Pneumonia Classified according to site (lobar, bronchial, or interstitial) or by etiologic agent (viral, bacterial, mycoplasma) or associated with aspiration of foreign material. • Signs and symptoms for Pneumonia: cough, tachypnea, breath sounds (rhonchi or fine crackles), dullness with percussion, chest pain, retractions, nasal flaring, pallor to cyanosis o GI signs (apnea, vomiting, diarrhea, abrupt fever, abdominal distention) o Cough becomes productive (purulent sputum) as infection resolves • Diagnostic Evaluation for Pneumonia o Radiographic examination (infiltrations) o Laboratory studies include Gram stain and culture of sputum o The infant or child with recurrent pneumonia should be further evaluated for CF or an immunodeficiency disease • Therapeutic Management for Pneumonia o Oral high-dose amoxicillin (90 mg/kg/day) in 2 to 3 doses is widely used for outpatient management of infants and children younger than 5 years of age o Erythromycin is the drug of choice for older children and adolescent 3 2 o The tuberculin skin test (TST) is the most common test used to determine whether a child has been infected with the tubercle bacillus. A primary infection initiates a 3 3 hypersensitivity reaction to the protein fraction of the tubercle bacillus, which can be detected 2 to 10 weeks after the infection o Bacille Calmette-Guerin immunization can result in a positive TST. The TST should not take place within 6 weeks of administration of a live vaccine o The standard dose of purified protein derivative (PPD) is 5 tuberculin units in 0.1 ml of solution, which is administered using a 27-gauge needle and a 1-ml syringe intradermally into the volar aspect of the forearm. The tuberculin is injected intradermally with the bevel of the needle pointing upward in the volar or dorsal aspect of the forearm. A wheal 6 to 10 mm in diameter should form between the layers of the skin when the solution is injected properly. If the wheal does not form, the procedure is repeated. The reaction to the skin test is determined in 48 to 72 hours; reactions occurring after 72 hours should be measured and considered to be the result. The size of the transverse diameter of induration, not the erythema, is measured. Once individuals react positively, they will always react positively o Guidelines for interpreting the TST are listed in A clinical examination and a chest x-ray are recommended if the child has a positive TST reaction o A finding of latent tuberculosis infection (LTBI) indicates infection in a person who has a positive TST, no physical findings of disease, and normal chest radiograph findings. • Therapeutic Management for Tuberculosis o Medical management of tuberculous lesions in children consists of adequate nutrition, antimicrobial therapy, general supportive measures, prevention of unnecessary exposure to other infections that further compromise the body's defenses, prevention of reinfection, o A child with LTBI is treated with antimicrobial drugs to decrease the risk of acquiring active TB o The recommended drug regimen for LTBI in children and adolescents includes a daily dose of isoniazid (INH) for 9 months. If the child has isoniazid-resistant disease, rifampin once daily for 4 months can be used o DOT means that a health care worker or other responsible, mutually agreed-on individual is present when medications are administered to 3 4 the patient Asthma (pg 929) Also called Reactive Airway Disease (sometimes used to define in younger children not yet given the diagnosis of asthma). Chronic inflammatory disorder of the airways characterized by recurring symptoms, airway obstruction, and bronchial hyperresponsiveness. The leading cause of chronic illness in children 3 7 ▪ Review – Family Centered Care: Use of Peak Expiratory Flow Meter (pg 934) o Skin testing for allergens o In addition to these tests, other important tests include laboratory tests (complete blood count with differential) and chest radiographs. The complete blood count may show a slight elevation in the white blood cell count during acute asthma o Eosinophilia results greater than 500/mm3 tend to suggest an allergic or inflammatory disorder o Frontal and lateral radiographs show infiltrates and hyperexpansion of the airways, with the anteroposterior diameter on physical examination indicating an increased diameter (suggestive of barrel chest) • Goals of asthma management: maintain normal activity levels and normal pulmonary function, prevent chronic symptoms and recurrent exacerbations, provide optimum drug therapy with minimal or no adverse effects. • General therapeutic management of asthma includes assessment of asthma severity, allergen control (in home environment), drug therapy (stepwise approach; maintenance and rescue meds), symptom management, and sometimes hyposensitization. • Drug therapy for Asthma o Corticosteroids (budesonide and fluticasone) ▪ Corticosteroids are anti-inflammatory drugs used to treat reversible airflow obstruction and control symptoms and reduce bronchial hyperresponsiveness in chronic asthma. Inhaled corticosteroids should be used as first-line therapy in children over 5 years of age ▪ Oral systemic steroids may be given for short periods (e.g., 3- or 10- day “bursts”) to gain prompt control of inadequately controlled persistent asthma ▪ They have few side effects (cough, dysphonia, and oral thrush) ▪ Evidence from clinical trials that monitored children for 6 years indicates that the use of inhaled corticosteroids at recommended dosages does not have long- term significant effects on growth, bone mineral density. However, primary care providers should frequently monitor (at least every 3 to 6 months) the growth of children and adolescents ▪ Although food may not be well tolerated in the acute phase, the child may avoid upset stomach associated with corticosteroids by taking small amounts of a food, such as a few crackers, once the respiratory status has stabilized somewhat ▪ Spacers also help prevent yeast infections in the mouth when corticosteroids are inhaled via an MDI o β-Adrenergic agonists (short acting) (albuterol, levalbuterol [Xopenex] and terbutaline) ▪ β1-adrenergic effects such as increased heart rate and GI disturbances ▪ Albuterol is given orally, via inhaler or via nebulizer, whereas levalbuterol is given via inhaler or nebulizer only o Long-acting β2-agonists (LABAs) (Salmeterol and Foradil) 3 8 ▪ LABAs must be added to anti-inflammatory therapy ▪ Do not take more than 3 to 4 times per day ▪ Drug Alert: Salmeterol and Foradil are never used to treat acute symptoms or exacerbations. 3 9 o Methylxanthines (Methylated xanthine) (Theophylline) ▪ used primarily when the child is not responding to maximal therapy ▪ Therapeutic levels should be monitored closely with this drug because it has a narrow therapeutic window ▪ Theophylline is not recommended for acute asthma exacerbations. ▪ Monitor Trough and Heart rate o Cromolyn sodium ▪ Cromolyn sodium is medication used as maintenance therapy for asthma in children over 2 years of age ▪ It does not result in immediate relief of symptoms and has minimal side effects (occasional cough from inhalation of the powder formulation) ▪ It is only available as an oral preparation or via nebulizer. o Leukotrienes Modifiers (zafirlukast [Accolate] and montelukast sodium)) ▪ Leukotrienes are mediators of inflammation that cause increases in airway hyperresponsiveness ▪ Montelukast is approved to treat asthma in children 12 months old and older, whereas zafirlukast is approved for children 5 years and older o Anticholinergics (atropine and ipratropium) ▪ Anticholinergics (atropine and ipratropium) help relieve acute bronchospasm ▪ These drugs have adverse side effects that include drying of respiratory secretions, blurred vision, and cardiac and CNS stimulation ▪ The primary anticholinergic drug used is ipratropium, which does not cross the blood-brain barrier and therefore elicits no CNS effects (as does atropine) o Omalizumab (Xolair) ▪ Omalizumab (Xolair)is a used for patients with moderate to severe persistent allergic asthma whose asthma symptoms are not controlled by inhaled corticosteroids. It blocks the binding of IgE to mast cells to inhibit the inflammation associated with asthma ▪ It has been approved for use in children 12 years and older ▪ IgE levels are measured before beginning treatment ▪ The drug is administered once or twice a month by subcutaneous injection ▪ Efficacy of omalizumab is not immediate and takes 12 to 16 weeks ▪ Black box warning: Due to anaphylactic reactions. black box warning 60% occurred within 2 hours of administration; therefore, recommendations include observing the recipient for 2 hours after the first three doses are administered and 30 minutes thereafter for subsequent doses. Some children with severe asthma and a history of severe life-threatening episodes may need a prescription for an EpiPen (subcutaneous injectable epinephrine) o Magnesium sulfate ▪ Magnesium sulfate is a potent muscle relaxant that acts to 4 2 trait (must inherit from both parents). Common in Caucasians. • Signs and symptoms of Cystic Fibrosis o The most common symptoms are (1) progressive chronic obstructive lung disease associated with infection; (2) maldigestion from exocrine pancreatic insufficiency; 4 3 (3) growth failure from malabsorption and anorexia; and (4) diabetes symptoms of hyperglycemia, polyuria, glycosuria, and weight loss from pancreatic insufficiency o Respiratory Tract Symptoms for Cystic Fibrosis ▪ Chronic Cough (most consistent feature) ▪ Wheezing respirations and a dry, nonproductive cough, dyspnea, barrel-shaped chest, clubbing, cyanosis ▪ Persistent cases of pneumonia o Gastrointestinal Tract Symptoms for Cystic Fibrosis ▪ The earliest manifestation of CF is meconium ileus (meconium will be thick, putty-like (with signs of intestinal obstruction, including abdominal distention and vomiting) ▪ As the disease progresses, obstruction of pancreatic ducts prevents digestive enzymes (e.g., trypsin, chymotrypsin, amylase, lipase) from being released into the duodenum, which prevents conversion of ingested food into compounds that can be absorbed by the intestinal mucosa (bulky stools) 𝑄 The impaired ability to absorb fats results in a deficiency of the fat- soluble vitamins A, D, E, and K, which may cause bleeding problems if vitamin K deficiency is significant. Anemia is a common complication 𝑄 Replace pancreatic enzymes (give with meals and snacks, sprinkle on food or swallow) Give water-soluble forms of vitamins A, D, E, and K 𝑄 Diet: high-protein, high-caloric diet with unrestricted fat (because of the impaired intestinal absorption). Improved nutrition in children with CF has been associated positively with improved lung function with increased sodium ▪ As solid foods are added to the diet, the excessively large stools become frothy and extremely foul smelling (steatorrhea) ▪ Growth failure (failure to thrive) is common due to decreased absorption of nutrients, vitamins, and fat; increased oxygen demands for pulmonary function; and delayed bone growth (with hypoalbuminemia and edema as a result) ▪ Another common GI complication is prolapsed of the rectum, which occurs in infancy and early childhood and is related to large, bulky stools; malnutrition; and increased intraabdominal pressure secondary to paroxysmal cough ▪ Diabetes symptoms of hyperglycemia, polyuria, glycosuria, and weight loss from pancreatic insufficiency o Reproductive Symptoms for Cystic Fibrosis ▪ Delayed puberty in girls with CF is common even when their nutritional and clinical status is good. Women with CF who become pregnant have an increased incidence of premature labor and delivery and low birth weight in the infant ▪ Males can be sterile o Integumentary System Symptoms for Cystic Fibrosis ▪ The consistent finding of abnormally high sodium and chloride 4 4 concentrations in the sweat is a unique characteristic of CF. Parents frequently observe that their infants’ taste “salty” when they kiss them ▪ This leaves the affected person at risk for abnormal salt loss, dehydration, and hypochloremic and hyponatremic alkalosis during hyperthermic conditions • Diagnostic Evaluation for Cystic Fibrosis 4 7 o Assessment of bone health by history and bone mass density evaluation should be considered in assessing the child's (≤8 years old) health status to detect and prevent osteoporosis or osteopenia • Nursing Care Management for Cystic Fibrosis o Assessment of the child with CF involves comprehensive assessment of all affected systems, with special focus on pulmonary and GI systems o Monitor Growth and development o Monitor for Complications for Cystic Fibrosis: hemoptysis, pneumothorax, CHF, respiratory failure o Hospital Care: All patients with CF require contact isolation for their own protection and wear a mask in communal areas of the hospital. Must have private room. o Home Care for Cystic Fibrosis ▪ Most children and adolescents with CF can be managed at home ▪ Resp. status determines prognosis. Often pts become ventilator dependent. Lung transplant sometimes needed ▪ Normal sexual relationships can be expected. Female patients may be able to bear children but should be informed of the possible harmful effects on the respiratory system created by the burden of pregnancy. They also need to know that their children will be carriers of the CF gene; therefore, genetic counseling for those planning on having children is essential SIDS (pg) Sudden death of an infant younger than 1 year of age that remains unexplained after postmortem • SIDS is the leading cause of post neonatal deaths (1 month to 12 months). • Risk factors for SIDS o prone sleeping position (or side-lying) o soft bedding o co-sleeping o maternal prenatal smoking & maternal alcohol use o family Hx of SIDS (two or more siblings) o male gender o low birth weight or preemie; low Apgar scores o recent viral illness o Native American or AA ethnicity • Protective factors for SIDS: o breastfeeding for the first 6 months of life o pacifier use at bedtime and naptime o supine sleep position • Nursing responsibility for SIDS: educating the family of newborns about the risks for SIDS, modeling appropriate behaviors in the hospital such as placing the infant in a supine sleep position, and providing emotional support to the family who has experienced a SIDS loss. Autopsy will be required. Review Respiratory emergency including CPR (LEADDD drugs) 4 8 Aspirated Foreign Body (pg 917) Round foods the most frequent offenders – more likely to occlude airway. Small lithium or cadmium batters may cause esophageal or tracheal corrosion, and Sharp object produces irritation and edema. The Sudden onset of signs and symptoms is common. The right bronchus (shorter, straighter angle) most usual site of obstruction • Diagnosis of Aspirated of Foreign Body o Bronchoscopy (and or endoscopy) is required for a definitive diagnosis and removal of objects in the larynx and trachea o Fluoroscopic examination is valuable in detecting FBs in the bronchi o The mainstay of diagnosis and management of foreign bodies is endoscopy and bronchoscopy • Therapeutic Management for Aspirated of Foreign Body o Current recommendations for the emergency treatment of the choking child include the use of abdominal thrusts for children over 1 year old and back blows and chest thrusts for children less than 1 year old o Can be removed by endoscopy or bronchoscopy • Nursing Care Management for Aspirated of Foreign Body o Choking on food or other material should not be fatal o Two simple procedures—back blows and the abdominal thrust, which can be used by both health professionals and lay persons—can save lives o Nursing Alert: The child in distress (1) cannot speak, (2) becomes cyanotic, and (3) collapses. These three signs indicate that the child is truly choking and requires immediate and quick action. The child can die within 4 minutes. o Small children should not be allowed access to small objects that they might place in their nose or mouth. Foreign Body in the Nose Children sometimes place foreign objects, such as food (peanuts are a favorite), crayons, small plastic toys, pieces of plastic, beans, beads, erasers, wads of paper, peas, and small stones, into their nose. An FB is suspected when there is unilateral nasal discharge that is foul smelling, local obstruction with sneezing, mild discomfort, and (rarely) pain. The irritation produces local mucosal swelling if the items increase in size as they absorb moisture (hygroscopic). Signs of obstruction and discomfort may increase with time. Infection usually follows, as evidenced by foul breath and a purulent or bloody discharge from one nostril. Removal should occur as soon as possible to prevent the risk of aspiration and local tissue necrosis. Removal usually occurs easily with either forceps, suction or inflation of a balloon catheter behind the obstruction. In some cases, mild sedation may be necessary. Carbon Monoxide Poisoning (pg 923) • Affinity for Hgb; O2 saturation not accurate because CO binds to all receptor sites; pulse ox will show at 100% but it is saturated with CO, not O2. This O2 4 9 status must be checked via ABGs • Signs and symptoms (mild): H/A, visual disturbances, irritability, nausea • Signs and symptoms (severe): confusion, hallucinations, ataxia, coma, cherry red lips and skin • Treatment is immediate humidified 100% O2 as quickly as possible or intubation 5 2 ▪ Plantar should discontinue after 8 months of age ▪ Palmar Grasp should discontinue after 3 months of age ▪ Hyperreflexia, Ankle Clonus and stretch reflexes during passive movements ▪ Tonic neck reflex beyond 4 to 6 months of age 𝑄 This is elicited by turning the infant's head to one side and holding it there for 20 seconds o Associated disabilities such as Seizures and Sensory (visual, hearing impairment, other problems) ▪ Poor control of oral muscles (oral hygiene will be difficult; high risk for cavities, this is especially true due to seizure medications that cause gum hyperplasia) ▪ Constipation due to decreased motility ▪ WILL NOT NECESSARILLY HAVE intelligent disabilities BUT POSSIBLE. • Diagnosis for Cerebral Palsy o Neuro exam, neuroimaging studies will possible show white matter (CT, MRI) o Children with known etiology should be monitored during first 2 years of life o Perinatal History – Box 34.1 (Perinatal Risk Factors) (pg1300) o Persistent reflexes beyond normal age can also be used for diagnosis • The goals of therapy are to recognize CP early and to help patient attain their full potential o Establish locomotion, communication, and self-help via PT therapy, occupational therapy and speech therapy ▪ Mobilizing devices – orthotics (ankle, AFO), splints, scooter boards, wheelchairs and other devices ▪ Gain optimum appearance and integration of motor functions o Correct associated defects as early and effectively as possible ▪ Surgery – primarily to improve function, not correct cosmetic defects – usually after age 6 o Provide educational opportunities adapted to the individual child’s needs and capabilities ▪ Technical aids, microcomputers o Promote socialization experiences with other affected and unaffected children • Medication Therapy o Dantrolene Sodium, Baclofen (administered via pump continuously; less adverse effects), diazepam ▪ The most common side effects of these agents include hepatotoxicity (dantrolene), drowsiness, fatigue, and muscle weakness. Less commonly, diaphoresis and constipation may occur with oral baclofen o Botulinum toxin A is also used to reduce spasticity in targeted muscles of the upper and lower extremities ▪ Side effects include pain at injection site and temporary muscle weakness ▪ Can last up to 6 months 5 3 o Secondary conditions (e.g., seizure disorder, chronic constipation, urinary tract infections, gastroesophageal reflux) • Nursing Care for Cerebral Palsy o Risk identification of infants, parent teaching, nutritional needs, assessment of skin status o LFT due to baclofen and seizure medications 5 4 o Quality outcome is to prevent seizures activity o Pain scales less than 4 on the Wong baker faces pain rating scale Conditio n Cause Onset Age Diagnos i s Treatment Prognos i s Duchenn e Missing 3 to 7 EMG, Corticosteroid Bad, Muscular protein in years muscle s, no real cure eventually Dystroph y muscles biopsy, CM, DNA respirator y and heart analysis failure before age 30. No nuero impairme n t Cerebral Due to Typically, CM PT, Baclofen, Good, the Palsy perinatal before the (persisten Botox A, condition factors age of 2 t reflexes), MRI, Seizure Meds will not get worse (white but may matter have may be neuro present) impairme n t Duchenne Muscular Dystrophy (pg 1338) The most severe and the most common muscular dystrophy of childhood. They are missing a protein in their muscles called Dystrophin (heart and respiratory system are dependent on muscle). They child may appear normal then decline. These children will become worse as time progresses. Evidence of muscle weakness usually appears during the third to seventh year, although there may have been a history of delay in motor development, particularly walking. • Inherited as an x-linked recessive trait (almost exclusively affects males) • Signs and Symptoms of Duchenne Muscular Dystrophy o Progression: child born normal presents with sxs around 4 to 7 years of 5 7 • Initial sxs related to the site of the tumor and compression of adjacent organs – often sxs vague and resemble other common childhood illnesses (earache, runny nose) o Often not detected until large tumors become problematic • Diagnosis of Rhabdomyosarcoma: H/P, scans (x-ray, MRI, CT), LP done if head and neck (often site of primary tumor) 5 8 • All rhabdomyosarcomas are high-grade tumors with the potential for metastases. Multimodal therapy recommended for all patients (surgery, chemo, radiation). Poor prognosis. • Nursing care similar to care for other types of cancer Neural Tube Defects (pg 1310) Congenital malformations involving the embryonic neural tube. Normally the spinal cord and cauda equina are encased in a protective sheath of bone and meninges. Failure of neural tube closure produces defects of varying degrees. • Folic acid supplements during pregnancy can decrease likelihood Types: • Anencephaly occurs when the brain absent; with brain stem infant can maintain vital functions for short while but eventually fatal) – palliative care, family support • Encephalocele occurs when brain is outside of skull in a sac – if whole brain is outside, prognosis poor. If only part of brain, can sometimes be repaired with surgery • Spina bifida (open in spine; two types) o Spina bifida occulta (defect not visible externally, occurs most often in lumbosacral area – sometimes “dimple” in lower back is visible on inspection) o Spina bifida cystica (visible defect with external sac-like protrusion) ▪ Meningocele (meninges and spinal fluid but no neural or nerve elements) ▪ Myelomeningocele (sac on the spine compose of spinal fluid and nerves) Can be anywhere on spine, most occur in lumbar or lumbosacral area 𝑄 Location and magnitude of defect determine degree of neuro impairment – paralysis of lower extremities or sensory deficit • Associated problems include hydrocephalus, infection, impaired genitourinary and Bowel function, musculoskeletal impairment (joint deformities, clubfoot, DDH), and Latex allergy • Care of infants and children with myelomeningocele is directed toward o Protecting the meningeal sac ▪ Prone position (nerve can be impaired when supine) ▪ Surgery usually done immediately ▪ Call physician if any leakage occurs from the myelomeningocele (infection) o Preventing infection and skin breakdown 5 9 ▪ Diapering may be contraindicated until surgery done ▪ Often continual passage of stool (misinterpreted as diarrhea in neonates). This frequent passage of stool is a constant skin irritant and source of infection ▪ Foot and ankle most common site of skin breakdown then buttocks (pg 1314) o Observing for signs of urologic and bowel complications 6 2 o Recovery usually begins within 2 to 3 weeks, and most patients regain full muscle strength. The recovery of muscle strength progresses in the reverse order of onset of paralysis, with lower extremity strength being the last to recover CSF Analysis WBC Protein Glucose Mengititis Increased Increased Decreased Gullian Barre Decreased Increased Normal Tetanus (pg 1324) Occurs when tetanus spores or vegetative bacilli enter a wound (esp. puncture wound) and multiply in a susceptible host due to clostridium tetani. • Incubation period 3 days to 3 weeks (average 8 days) • Clinical manifestations of Tetanus o Infants: The first symptom is difficulty in sucking, progressing to total inability to suck, excessive crying, irritability, and nuchal rigidity o Stiffness and tenderness in jaw or neck (respiratory issues) with difficulty in opening the mouth (trismus/lockjaw), spasm of facial muscles produces the so- called sardonic smile (risus sardonicus), progressive involvement of the trunk muscles causes opisthotonos and a board like rigidity of abdominal and limb muscles, difficulty swallowing, highly sensitive to external stimuli (noise, a gentle touch, or bright light triggers convulsive muscular contractions that last seconds to minutes), and mentation is unaffected • Prevention of Tetanus o A dose of tetanus toxoid is not necessary for clean, minor wounds in children who have completed the immunization series or receive series within 10 years o Children with more serious wounds (e.g., contaminated, puncture, crush, or burn wounds) are given a tetanus toxoid booster prophylactically as soon as possible after injury o The unprotected or inadequately immunized child who sustains a “tetanus- prone” wound (including wounds contaminated with dirt, feces, soil, and saliva; puncture wounds; avulsions; and wounds resulting from missiles, crushing, burns, and frostbite) should receive tetanus immunoglobulin (TIG) and tetanus toxoid at separate sites • Management for Tetanus (primary prevention key) (immunization and boosters) o Specific treatment to prevent tetanus after trauma: tetanus immunoglobulin, tetanus toxoid (increases resistance for another 10 years) IM at separate site; proper cleaning of wounds o Antibiotic treatment with penicillin G (or erythromycin or tetracycline in older children with allergy to penicillin) o Diazepam for seizure control and muscle relaxation o Monitor respiratory status o Control or eliminate stimulation from sound, light, touch o When child recovers, immunization should occur because disease does 6 3 not confer permanent immunity (tetanus toxoid) q10years 6 4 Spinal Cord Injury (pg 1328) Etiology of cord damage: trauma (auto, falling, sports, birth injuries, shaken baby, violence), myelitis (inflammation of spinal cord), congenital defects • Spinal cord injury can affect any of the spinal nerves, and the higher the injury, the more extensive the damage. A child can be left with complete or partial paralysis of the lower extremities (paraplegia; t1-l4) or with damage at a higher level and without functional use of any of the four extremities (tetraplegia; c3-c7). We may not know severity of injury for weeks/months • Clinical Manifestations of SCI o Spinal Shock ▪ This occurs after acute injury. AUTONOMIC effects primarily. Box 34.10 (pg 1329) ▪ Manifestations include the absence of reflexes at or below the cord lesion, with flaccidity or limpness of the involved muscles, loss of sensation and motor function, and autonomic dysfunction (i.e., symptoms of hypotension, low or high body temperature, loss of bladder and bowel control, and autonomic dysreflexia) o Autonomic Dysreflexia ▪ This autonomic phenomenon is caused by distention or irritation, particularly of the bowel or bladder ▪ Manifestations include flushing face, sweating forehead, pupillary constriction, marked hypertension, headache, and bradycardia o Neurogenic Shock ▪ Neurogenic shock occurs as a result of a disruption in the descending sympathetic pathways with loss of vasomotor tone and sympathetic innervations to the cardiovascular system ▪ Manifestations include Hypotension, bradycardia, and peripheral vasodilation ▪ Treatment is inotropic drug such as digoxin o Scoliosis will development (especially in adolescent years of growth) • Therapeutic Care for SPI o ABCs (use jaw thrust technique, and this is priority) o Nuero Assessment (have spine immobilized during this assessment) o ABCs (use jaw thrust technique) o The child is monitored for cardiovascular instability, and measures are taken to support systemic blood pressure and maintain optimal 6 7 Chapter 30: The Child with Cerebral Dysfunction The purpose of the neurologic examination is to establish an accurate, objective baseline of neurologic information. Complete neurologic examination includes level of consciousness; posture; motor, sensory, cranial nerve, and reflex testing; and vital signs. • Development of Neurologic System • Cerebral Blood Flow o CBF remains constant at a cerebral blood pressure between 50- and 150-mm Hg. Because cerebral venous pressure is usually very low and relatively constant, cerebral blood pressure is determined mainly by systemic arterial pressure • Autoregulation of Cerebral Blood Flow o One of the most important factors in the control of CBF is autoregulation, the unique ability of cerebral arterial vessels to change their diameter in response to fluctuating cerebral perfusion pressure (CPP). The CPP is the mean arterial pressure (MAP) minus the intracranial pressure (ICP) or (CPP = MAP – ICP) o When CBF decreases, causing clinical symptoms of ischemia (nausea, fainting, dizziness, dim vision) o Conversely, increased MAP leads to “breakthrough of autoregulation,” with increased CBF leading to microhemorrhages and cerebral edema. Autoregulation may be impaired locally or globally as a result of trauma or ischemia • Increased ICP • Assessment for Neurologic System o General aspects o History (maternal infections and conditions) o Physical exam ▪ LOC 6 8 ▪ Size and shape of head (fontanels) Posterior fontanel closes at 6-8 weeks; anterior at 12-18 months Head should be between 5th to 95 percentiles ▪ Activity (Lethargic, Playing) 6 9 ▪ Facial features (ocular movements/PERRLA, smiling) (pg 1115) ▪ Cry (neuro cry has a unique sound – loud, high pitched) ▪ Glasgow coma scale (variation for pediatrics) 𝑄 Glasgow Coma Scale (GCS), which consists of a three-part assessment: eye opening, verbal response, and motor response 𝑄 A person with an unaltered LOC would score the highest, 15; a score of 8 or below is a definition of coma; the lowest score, 3, indicates deep coma or death o Motor function o Posturing ▪ Flexion ▪ Extension o Reflexes (show neurologic health/ should disappear at a certain age) ▪ Babinski Reflex ▪ Moro Reflex o Vital signs (baseline) • Diagnosis is EEG for seizure activity (can do 24-hour observation test), CT, MRI, Lumbar puncture, US • Increased ICP o Signs and symptoms of ICP ▪ Infants: tense, bulging fontanel (normal when crying), increase in head circumference, high-pitched cry, distended scalp veins , poor feeding ▪ Children: H/A (especially when lying flat or coughing, sneezing, bending over), nausea and vomiting, inability to follow commands , decline in school performance; double or blurred vision with movement of head, headache on awakening ▪ Signs of ICP: increased BP and decreased HR • CO2 (effects of hypercapnia and hypoxemia) on ICP o Hypercapnia (PaCO2 >45 mm Hg) increased cerebral blood flow (ICP increases) o Hypocapnia (PaCO2 <35 mm Hg) constricts cerebral arterioles and decreases CBF o Profound hypoxia (PaO2 50 mm Hg) dramatically increases CBF (ICP increases) o Meds (sedation, osmotic diuretic (mannitol)) • TABLE 30.1: Neurologic Diagnostic Procedures (pg 1117) Nursing Management for the Unconscious Child • Ensuring circulation, airway, and breathing (CAB) o Position at 15 – 30 degrees • Continual observation of the LOC (pupillary reaction) • Pain assessment/management (can cause an increase in ICP) • ICP (Treatment and Nursing Activities) o Interventricular Catheter Insertion o Mannitol ▪ The nurse must ensure Foley catheter insertion to monitor input and 7 2 vasoconstriction, which reduces CBF, thereby decreasing ICP • Nursing Activities for Intracranial Pressure Monitoring 7 3 o Take particular care in positioning these patients to avoid neck vein compression that may further increase ICP by interfering with venous return o Nursing Alert: Elevate the head of the bed 15–30 degrees and position the child so that the head is maintained in midline to facilitate venous drainage and avoid jugular compression. Turning side to side is contraindicated because of the risk of jugular compression o Monitor pain and emotional status o NO vigorous ROM o Suctioning and percussion are poorly tolerated; therefore, these procedures are contraindicated unless the child has concurrent respiratory problems o Vibration, which does not increase ICP, accomplishes excellent results and should be tried first if treatment is needed. If suctioning is necessary, it should be used judiciously and preceded by hyperventilation with 100% oxygen, which can be monitored during suctioning with a pulse oxygen sensor reading to determine oxygen saturation. Cranial Deformities • General measurements (pg 204) o The head is typically 33 – 35 cm (can be less right after birth due to molding) o Crown-to-rump measurements are usually 31 to 35 cm (12.5 to 14 inches). ▪ Head circumference may be compared with crown-to-rump length provides a means for identifying infants at risk, as head circumference is generally equal to or up to 2 cm (0.8 inches) ▪ Increased crown to rump (more than 4 cm) expects bleeding • Microcephalus is an abnormal small head. There is not enough space for the brain to develop correctly. This can be due to congenital factors and or secondary factors (zika virus, tobacco/alcohol exposure, maternal DM). o No specific treatment; nursing care is supportive o Neurologic manifestations range from decerebration, complete unresponsiveness, and autistic behavior to mild motor impairment, educable neurocognitive impairment, and mild hyperkinesis. • Craniostenosis/craniosyostosis are premature closure of cranial sutures o The condition may be divided according to the number of sutures involved; primary Craniostenosis involves one or more sutures as a result of abnormalities of skull development o Treatment is strip craniectomy (before 6 months for best cosmetic outcome) ▪ This procedure can cause lots of blood lost (monitor hct/hgb) ▪ With endoscopic surgery, blood loss is minimized, but the child must wear a cranial molding helmet for 3 to 4 months for 23 hours per day (skin care; eyelids may be puffy and closed post op) o Potential risk factors for Craniostenosis include maternal Caucasian race, advanced maternal age, male infant, use of nitrosatable drugs, fertility treatments, and certain paternal occupations (e.g., agriculture, repairmen, 7 4 mechanics, forestry) o Diagnosis is established with CT scan, and MRI is useful in identifying accompanying brain abnormalities. • Pierre Robin Sequence (PRS) is a defect characterized by retroposition of the tongue and mandible, which often results in neonatal respiratory and feeding problems. 7 7 o Epidural hematoma is a hemorrhage into the space between the dura and the skull. As the hematoma enlarges, the dura is stripped from the skull; this accumulation of blood forces the underlying brain contents downward and inward as it expands ▪ Arterial and or venous in origin ▪ Rapid onset of clinical manifestations ▪ CT configuration is usually lenticular ▪ Mortality High ▪ Unilateral ▪ Fracture typically present, usually >2 years (epidural doesn’t fully develop until) ▪ Common symptoms include change in LOC and Cushing Triad (systemic hypertension, bradycardia, and respiratory depression is a late sign of impending brainstem herniation o Subdural hematoma crosses the suture lines (slowly progression) and is fairly common in infants. Most often it is the result of assaults or violent shaking (SBS) ▪ Venous in origin ▪ Slow onset of clinical manifestations ▪ CT configuration Curvilinear or crescentic ▪ Mortality Low ▪ Bilateral ▪ Nursing Alert: Children with a subdural hematoma and retinal hemorrhages should be evaluated for the possibility of child abuse, especially shaken baby syndrome ▪ Closely observe older children for signs of neurologic deterioration, including altered mental status, vomiting, lethargy, and signs of increased ICP. Hemiparesis, hemiplegia, and anisocoria (unequal pupils) are signs of brainstem compression and require emergency treatment targeted at decreasing ICP o Infection o Edema ▪ Some degree of cerebral edema is expected after craniocerebral trauma. Cerebral edema peaks at 24 to 72 hours after injury and may account for changes in a child’s neurologic status ▪ Cytotoxic edema is a result of direct cell injury and is caused by intracellular swelling. In many cases the brain cells are irreversibly damaged ▪ Vasogenic edema is due to increased permeability of capillary endothelial cells, resulting in increased intracellular fluid. In vasogenic edema the nerve cells are not primarily injured • Sequelae of Traumatic Brain Injury includes Postconcussion syndrome, posttraumatic syndrome, posttraumatic seizures hydrocephalus • Nursing Management for Head Injury o Teach parent sxs of increased ICP 7 8 Hydrocephalus (pg 1159) 7 9 Hydrocephalus is a condition caused by an imbalance in the production and absorption of CSF in the ventricular system due to obstruction and or impaired absorption. Surgical treatment is the therapy of choice in almost all cases of hydrocephalus; however, most children require a shunt to promote CSF drainage. • Etiology of Hydrocephalus: congenital (most cases), infection, or acquired (brain injury, trauma) o Preemies at high risk for brain bleed (increases the fluid) o Very often associated with myelomeningocele (is a birth defect in which the backbone and spinal canal do not close before birth) • Signs and symptoms of Hydrocephalus o In infancy: before closure of the cranial sutures, head enlargement is the predominant sign o Other signs include bulging fontanels, anterior fontanel is tense, scalp veins are DILATED, the bones of the skull become thin and the sutures become palpably separated to produce the cracked-pot sound (Macewen sign), severe cases frontal protrusion (with pupils sluggish/PERLA absent, depressed eyes, and the eyes may be rotated downward, producing a setting-sun sign o FTT symptoms (decreased LOC, poor feeding, irritable/lethargic) o The infant cries when picked up or rocked and quiets when allowed to lie still o Early infantile reflexes may persist, and normally expected responses may not appear, indicating failure in the development of normal cortical inhibition with opisthonos (muscle spasms) o The signs and symptoms in early to late childhood: caused by increased ICP, headache upon awakening, strabismus, lethargy, n/v • Diagnosis for Hydrocephalus o In infancy the diagnosis of hydrocephalus is based on head circumference that crosses one or more percentile lines on the head measurement chart within a period of 2 to 4 weeks o The primary diagnostic tools for detecting hydrocephalus in older infants and children are CT and MRI (provide Mild sedation for children under age 8 or with neurodevelopmental disabilities because the child must remain absolutely still for an accurate study) • Treatment for Hydrocephalus is surgery (direct removal of obstruction), placement of shunt (usually ventriculoperitoneal shunt; VP [neonates], VA [older children) to drain CSF, EVD [closed system]) 8 2 which aggravates hypoxia. Also, nuero and cardiovascular organs. • Nursing Alert: All children who have a submersion injury should be admitted to the hospital for observation. Although many patients do not appear to have sustained 8 3 adverse effects from the event, complications (e.g., respiratory compromise, cerebral edema) may occur 24 hours after the incident. • Factors are hypothermia, aspiration, hypoxia • Affects most organs (especially pulmonary, cardiovascular, neuro) o permanent brain injury can occur after 4 to 6 minutes of submersion, while heart and lungs can survive up to 30 min • Management for Submersion Injury o Resuscitate at scene (CPR) ▪ Pediatric CPR includes 5 cycles (about 2 mins) of 30 compressions to 2 breaths o The first priority is to restore oxygen delivery to the cells and prevent further hypoxic damage (mechanical ventilation may be need) o Blood gases and pH are monitored at frequent intervals as a guide to oxygen, fluid, and electrolyte therapies. o Monitor for hypothermia (rewarm) o Correct acidosis (bicarbonates) o Chest PT o Monitor for Seizures, hypoglycemia and hyperglycemia, Aspiration pneumonia o Teach (prevention) o Monitor for neglect Bacterial Meningitis (pg 1133) An acute inflammation of the meninges and cerebrospinal fluid. Strep pneumoniae and viruses most common cause. This is a medical emergency. More common in school age children. This condition is Contagious. The nurse must ensure that standard, contact and droplet precautions for at least 24 hours after initiation of antibiotics • Signs and Symptoms of Bacterial Meningitis (purple rash is very common) (pg 1135) o Infants and young children: changes in temperature (both), poor feeding, vomiting, irritability, seizures (often with neuro cry that is high pitched), bulging or tense fontanel, nuchal rigidity (doesn’t want to flex head) o Older children and adolescents: seizures (often the initial sign), stiff neck (positive Brudzinski sign), H/A, irritable, agitated, seizures, photophobia, confusion, hallucinations, aggressive behavior, change in LOC ▪ Purpuric rash (50% of cases), especially when in septic, shock like state ▪ Joint involvement sometimes seen; chronically draining ear o Neonates: Child well at birth but within a few days begins to look and behave poorly then FTT symptoms refuses feedings, poor sucking ability, vomiting or diarrhea, poor tone, lack of movement, weak cry, full, tense, and bulging fontanel may appear late in course of illness, Neck usually 8 4 supple • Diagnosis for Bacterial Meningitis o A lumbar puncture is the definitive diagnostic test. The fluid pressure is measured, and samples are obtained for culture, blood culture Gram stain, blood cell count (WBC increased), and determination of glucose (will be decreased) and protein levels (increased). HESI HINT: This is because the bacteria eat the glucose and defecate the protein ▪ Measure glucose 30 mins before lumbar puncture ▪ Culture and sensitivity are needed to identify the causative organism 4 7 o Liver biopsy is contraindicated for prolonged bleeding times, infection and obstructive jaundice • Signs and symptoms for Reye Syndrome: fever, impaired consciousness, and disordered hepatic function (look for an increase in ammonia and or increased in LFT). o Onset of RS notable for profuse vomiting and neurologic impairment (personality changes, seizures, coma) o Cerebral edema with increased ICP • Nursing Care Management for Reye Syndrome o Mannitol and or Lasix can be prescribed ▪ Hesi Hint: monitor for hyponatremia and hypokalemia o LOC (ICP) o Accurate and frequent monitoring of intake and output is essential for adjusting fluid volumes to prevent both dehydration and cerebral edema o Because of related liver dysfunction, monitor laboratory studies to determine impaired coagulation, such as prolonged bleeding time o Monitor hydration due to fever o Patients who survive have full liver function recovery o Drug Alert for Salicylates: Families need to be aware that salicylates, the alleged offending ingredient in aspirin, are contained in other products (e.g., Pepto-Bismol). They should refrain from administering any product for influenza-like symptoms without first checking the label for “hidden” salicylates Seizures (pg 1141) Caused by excessive and disorderly neuronal discharges in the brain. Manifestation depends on the region of the brain in which they originate and may include unconsciousness or altered consciousness; involuntary movements; and changes in perception, behaviors, sensations, and posture. • Epilepsy: two or more unprovoked seizures (recurring) • Types of seizures (Box 30.10; pg 1144) o Focal Seizures ▪ Aura ▪ Loss of LOC ▪ Repetitive movements are noted (no tonic or clonic present) o Generalized seizures are categorized as tonic-clonic, absence, myoclonic, and West syndrome (infantile spasms). They involve the typically NO aura, loss of consciousness and involves both hemispheres. This type of seizures has a rapid onset (no aura) ▪ Generalized tonic-clonic seizure (aka grand mal) - most dramatic. Occurs w/out warning and consists of two distinct phases, tonic (20 seconds) and clonic (30 seconds). This patient will fall to the floor (focal seizures this does not occur) ▪ Absence seizures , formerly called petit mal or lapses, are generalized seizures. They have a sudden onset and are characterized by a brief loss of consciousness, a blank stare, and automatisms. Usually last 4 8 about 5 to 10 seconds. The child may appear as though daydreaming ▪ Atonic seizures, loss of muscle tone (wear helmet) ▪ M yo cl o ni c s e i zu r e s , jerks/twitching (lip smacking, bicycling of legs) • Diagnosis for Seizures: EEG (typically done for 24 hours), MRI, and spinal tap, CBC (glucose) 4 9 • Management for Seizures o TABLE 30.6: Common Antiepileptic Medications (pg 1147) o The goal of treatment of seizure disorders is to control the seizures or to reduce their frequency and severity, discover and correct the cause when possible, and help the child live as normal a life as possible o Management of epilepsy has four treatment options: drug therapy, the ketogenic diet, vagus nerve stimulation, and epilepsy surgery ▪ The ketogenic diet is a high-fat, very-low-carbohydrate, and adequate- protein diet that has shown effectiveness for treatment of epilepsy. The diet is deficient in vitamins and minerals; therefore, vitamin and mineral supplementation is necessary. Potential adverse side effects of the diet include constipation, hypoglycemia during initiation of the diet, acidosis, and lethargy ▪ Vagus Stimulation in which a programmable signal generator is implanted subcutaneously in the chest. Electrodes tunneled underneath the skin deliver electrical impulses to the left vagus nerve (CN X). Throat pain and cough can occur after administration ▪ When seizures are caused by a hematoma, vascular malformation, tumor, or other cerebral lesion, surgical removal is usually recommended. Epilepsy surgery does not always eliminate the need for antiepileptic drug therapy • Status epilepticus is a continuous seizure that lasts more than 30 minutes or a series of seizures from which the child does not regain a premorbid level of consciousness. The initial treatment is directed toward support and maintenance of vital functions including the ABCs (airway, breathing, and circulation) of life support, administering oxygen, and gaining IV access followed by administration of antiepileptic agents. Treatment should begin in 5 minutes and contact medical emergency department. o Benzodiazepine (diazepam or lorazepam) first line ▪ Drug Alert: Diazepam is incompatible with many drugs. To give intravenously, inject slowly and directly into the vein or through tubing as close as possible to the vein insertion site. o IV phenytoin or fosphenytoin followed by phenobarbital is given as the next line of treatment. Fosphenytoin is preferred over phenytoin because of better tolerability second line ▪ BBW: Severe hypotension can result if given medication to rapid (> 3mg/kg/min) ▪ DO not give with milk ▪ Therapeutic range is 10-20 mcg/mL (monitor CBC and through) ▪ Drug Alert: Do not exceed 50 mg/min o Phenobarbital third line ▪ The medication should not be taken with milk, and fluids should be encouraged o Calcium and Vitamin D supplements for ALL seizure meds is needed • Nursing Care Management for Seizures 5 2 • Majority arises from adrenal gland (abdomen) • Primary site is abdomen; other sites are head, neck, chest, pelvis o If in abdomen, often crosses midline (in contrast to Wilms’s, which is usually confined to one side) o Do not palpate • Signs and symptoms for Neuroblastoma o Depend on location and stage (watch for increase abdominal pressure, nerve damage depending onsite) • Neuroblastoma is a “silent” tumor and in more than 70% of cases diagnosis is made after metastasis occurs, with the first signs caused by involvement in the nonprimary site. So, this cancer is aggressive, often poor prognosis for the patient • Treatment for Neuroblastoma o Surgical removal for stages 1 and 2 (radiation has NO benefit during these stages) o Extensive local and or disseminated diseases chemotherapy (mainstay treatment), radiation and other treatments are also available o Biopsy only for stages 3 and 4 (NO SURGERY) Chapter 33: The Child with Musculoskeletal Dysfunction Focus on Nursing Care for Child • Developmental Differences o Healing time (children heal faster) o Development (if anomalies not corrected early, child may develop incorrectly) o Safety • Child Assessment o Alignment, symmetry o Look at spine (curvature, a spot of hair) o Check for anomalies o Developmental milestones o Assessment of the 5 P’s (pulse, pain, paraesthia, pallor, paralysis) • Immobilization Hazards o If hospitalized or immobilized for long time: skin breakdown (prolonged redness > 30 mins indicates pressure area), traction, kidney stones, hypercalcemia, developmental difficulties, clots, respiratory (teach deep breathing excersies) • Table 33.1 – Summary of Physical Effect of Immobilization with Nursing Interventions (pg1248) BONE and SOFT TISSUE TUMORS 50