PEDS Flashcards
In teenage girls: if they have pendulous breasts (really large breasts; hangs down loosely) → we will see darkening of skin right in the middle of the chest
◦ In really young children: looking for stretch marks → in front of the armpit, under the armpit
◦ Inspect abdomen: large bellies, stretch marks on their belly
◦ stretch marks on the sacrum
Metabolic Resistance
= tells average blood sugar over the past 90 days
Hemoglobin A1C (HgbA1c)
= a BMI (Body Mass Index) that is greater than the 95th percentile for children of the same age & the same gender
Childhood Obesity
• Congenital anomalies
• Baby with low birth weight = 5.5 lbs or
• SIDS = Sudden Infant Death Syndrome
African-American race
Male gender
Mother who have had a Short or long gestation time
Maternal age – really young or old mothers
Maternal education – lower levels of education of mother
Risk Factors of infant mortality
1 - ENABLING:
• When nurse teaches something to a child or parent → we always want a return demonstration
• Ex: a child is just diagnosed with asthma, we teach the child & parent how to use an inhaler → we want them to show us a return demonstration of using an inhaler after the teaching
2 - EMPOWERMENT:
• We give the child & parent a sense of control
• Ex: we encourage the parents to hold, feed, dress their newborn baby
Family-Centered Care
Is based on the premise of doing no harm, by:
1 - Goal: to minimize the child’s separation from the family
• Ex: in pediatrics setting there are no visiting hours, parents come come 24-7 anytime
2 - Minimize bodily injury or pain
• Goal: to keep the stress level down
Atraumatic Care
the child is not sick, we want to prevent the child from getting sick
Interventions that protect from disease or injury –
• Immunization injections
• Well-child check-ups
◦ Newborn baby leaves the hospital with a Hepatitis B vaccine injection
◦ Baby comes back at 6 weeks and at 2, 4, 6 [and 9, 12] months = Well-child visits
◦ We are doing: head-to-toe assessments, measuring head & chest circumference, their length
• Community safety programs – teaching parents about:
◦ helmet safety
◦ car seat safety
◦ as child gets older: using seat belts, kids cannot sit in the front seat
◦ poision safety – 3 key poisons that we teach about:
1. Lead poisoning
2. Medication poisoning
3. Cleaning products poisoning
Primary Prevention
Screening tests
Promotes early detection and treatment of illness
Efforts are made to prevent the spread of contagious diseases
Screening for diseases (secondary screening):
• Screening for Scoliosis (sideways curvature of the spine – occurs most often during the growth spurt before puberty)
• Tuberculosis test = is not a definitive test, is only a suggestive test, is a screening test
◦ we screen someone for Tuberculosis:
◦ when they have had exposure
◦ if they just came from a third-world country
◦ if they are living in a shelter; if the child is moving from one shelter to another, where it is very crowded
• Hearing screening
• Vision screening
• WIC Program (Women, Infant & Children):
Secondary Prevention
the child already has a disease (chronic disease); is already sick
• already has a chronic disability
• the child already has a diagnosis
Goal is to help manage the disease
Interventions that optimize function for children with a disability or chronic disease
Ex: child has a diagnosis for Asthma • we will teach how to use a nebulizer Ex: camps for obese children • they teach children: ◦ how to read labels ◦ making healthy food choices ◦ drinking lots of water ◦ increasing physical activity
Tertiary Prevention
Hyperactivity • very short attention span • difficulty concentrating Developmental delays • speech, language delays Reading deficits Learning disabilities • very low IQ test scores • doing poorly in school Visual problems Motor problems Headaches – lots of headaches Metallic taste in mouth – tastes like they have a penny in their mouth
Clinical manifestations of lead poisoning
• GI symptoms:
◦ severe abdominal pain
◦ nausea
◦ vomiting
S/S of Acute Lead Poisoning:
• 45-69
◦ Treatment: Chelation Therapy
Acute Lead Poisoning
• Calcium rich diet
◦ child will need almost double the amount
◦ b/c lead exposure interferes with Calcium absorption
• Foods high in Iron
◦ b/c lead exposure, high lead blood levels can cause anemia
• Increased Vitamin C
◦ b/c Vit C increases iron absorption
◦ increase juices with Vitamin C
Lead exposure diet
Start screening at ages 1-2 years old
Lead exposure
·old pipes
·paint
·toys
·old homes
Sources of lead: ·old pipes ·paint ·toys ·old homes
- no money, no material resouces
- not enough food, not enough clothes
- no home
- lacking in tangible things; ie lacking in visible things – we can see it
Visible Poverty:
An infant develops a sense of trust or mistrust on the reliability of caregivers providing for his basic needs such as food, physical contact, and attention. The child’s experiences in these months form the earliest sense of self
Birth-18 months
Trust vs mistrust
A young child learns self control, like toilet training without loss of self esteem and so develops a lasting sense of good will and pride, or the child experiences a sense of loss of control or is over controlled from outside
Autonomy vs. shame, doubt
18 months- 3 yrs
The child takes initiative and begins to develop a moral sense of sense of guilt over her goals. St this stage a youngster begins learning his to cooperate and hide to cope with jealousy
Initiative vs. guilt
3-6 yrs
School life prepares the child for productivity in her culture. She may adapt to the world of skills and tools handled by big people or become discouraged and feel inadequate
Industry vs inferiority
6-11 yrs
Adolescents try to discover who they are, how they fit in their peer groups and in society and how to relate to the opposite sex. Intense confusion may result
Identity vs role confusion
12-17 yrs
Inappropriate degrees of inattention, impulsiveness and hyperactivity
ADHD
Inattentive:
• child has trouble focusing in the classroom
• they have scattered thoughts
- Impulsive:
• ex: while teacher is teaching:
◦ the child interrupts the teacher & they dont see anything wrong with it
◦ they start having conservations with kids next to them - Hyperactive:
• child can’t sit still for too long
• theyre constantly running around, getting up
ADHD
Child does not pay attention in class
• They dont pay attention to detail
• They will go home → and they will lose their homework – they have no idea where it went
• NI’s:
◦ Give child written instructions for homework & you have to say it to them
Inattentive type
- they’re squirming in their seat, they cant sit still for too long
- they like to interrupt people
- if teacher asks a question in class → the kid will just blurt out the answer
Hyperactive-Impulsive Type:
assess IQ level • assess hand & eye coordination • visual & auditory perception ◦ vision screening ◦ hearing screening • comprehension skills • memory recall
Screening for ADHD
◦ when kid comes home from school → turn off the tv, decreased the stimulation for the child
◦ make sure all of their homework supplies are near – so theyre not running back-and-forth
• Appropriate classroom placement
• child may have a one-on-one
• may have someone to give them extra help, to go with them from class to class
• oral toothbrush/ care
Pt teaching ADHD
Palate surgery:
• child will not eat for several days
• they will be on TPN (total parenteral nutrition)
• once we start re-introducing foods into the diet – milk, give using needle-less syringe
• • No suctioning in mouth post op
Do not put in their mouth post-operative surgery:
Post-operative Cleft Lip, Cleft
chronic diarrhea
• malabsorption of nutrients
• May result in failure to thri
Celiac disease
- steatorrhea = very fatty, frothy, foul-smelling, bulky feces, stool
- child looks malnourished – over time
- big belly, abdominal distention
- seconary vitamin deficiency
• Young children:
• abdominal distention, big belly
• eating foods with wheat causes Pain
◦ once they eat → will have abdominal pain, will be irritable, moody
- Older children and adults:
- eating foods with wheat causes Pain
- alternating Diarrhea & Constipation
- Malabsorption
Celiac disease
Antigliadin antibody of both IgA and IgG – will test Positive for both
Blood tests: celiac disease
- wheat, wheat products
- rye
- barley
- oats
• Foods that we remove from diet: celiac disease
• Grains: ◦ rice ◦ corn ◦ millet • Vegetables: ◦ all vegetables; all vegetables are gluten-free • Fruits: ◦ all fruits; all fruits are gluten-free • Meat: ◦ any type of meat ◦ Except meats with wheat-based fillers: ▪ hot dogs ▪ sausages ▪ luncheon meats
Celiac disease foods can eat
striae – on armpit area, front & back of arms, breasts, abdomen, sacrum, buttocks, thighs
Stretch marks
- obstruction of lumen of appendix by hardened fecal matter – fecal matter made its way to the appendix & is stuck in there = bacteria grows = causes inflammation = swelling of appendix, pressure
- viral infection; child has a viral infection to the abdomen
Appendicitis
• belly pain
• dull pain
◦ pain starts in the periumbilical area (around the umbilicus on abdomen, stomach)
◦ pain will radiate → to the Right Lower Quadrant → pain then becomes severe, acute pain
▪ when driving to hospital & if car hits potholes → child will scream in pain = is a clue that it is appendicitis; is a Positive sign for appendicitis
• if pain goes away = rupture; perforation of appendix
• One examination – assess child for rebound tenderness at McBurney’s Point = is a Positive sign for appendicitis
◦ rebound tenderness = no pain when you press/push down on the abdomen, pain when you release pressure
S/S Appendicitis:
◦ give IV Fluids
◦ start on broad-spectrum Antibiotics
Before Appendicitis surgery
• IV Fluids
• Antibiotics
• insert Nasogastric Tube – for continuous low Suctioning
◦ to decompress the bowel; we need the bowel to rest
◦ the NG tube is removed when peristalsis has returned
After perforation: appendicitis
- 3 hours per day
- more than 3 days per week
- for more than 3 weeks
Usually occurs by 3 weeks old
Usually goes away by itself (by 4-5 months old)
Colic
If mother is breastfeeding – we do a trial supplementation phase
• tell her to stop dairy for 1 week = to see if the child will improve
For bottle-fed baby:
• switch the formula to a lactose free formula for 1 week = to see if the child will improve
Colic management
- smoking = can trigger Colic
- teach mother – avoid spicy foods, highly seasoned foods = baby will taste in breastmilk & can trigger Colic, abdominal/stomach pain
- feed baby little bits at at time; burp baby in between feedings = gas can trigger Colic
Pt teaching Colic
• series of 2 shots:
◦ first injection = 12-18 months old
◦ second injection = 4-6 years old
MMR/Varicella
is a virus - Agent is paramyxovirus
is spread via:
1. droplet transmission – cough, sneeze – is inhaled
2. direct contact – kids drinking from same straw, sharing foods back and forth
Mumps
Incubation period is 14-21 days
• once virus enter your body → it will incubate for 2-3 weeks
Mumps
• Fever – starts with a high fever; 100.3 – 100.4 degree fever
• headache
• malaise – fatigue, tired, not active, just wants to lie down
• followed by Parotitis = inflammation of parotid gland (on the jaw line; under the ear)
◦ looks like they have swollen cheeks
◦ unilateral or bilateral
• self-induced anorexia
◦ they dont eat b/c it hurts to chew; pain when chewing food
◦ NI: Drink from a straw
• Pain:
◦ ear pain; ears hurt
◦ jaw pain; jaws hurt
◦ the side of their face hurts
S/S – Mumps
- start IV line right away
- IV fluids – b/c theyre not eating
- Contact precautions – contact isolation
- PO fluids, soft, bland foods – foods that they dont have to chew much
- Hot or cold compress
for Adolescent males only → can develop Orchitis = inflammation of testacle, caused by mumps virus
• testacle will be swollen, tender to touch
• Treatment = warm compress to area
• reassure kid that it will go away in 7-10 days
Mumps
first injection: 11-12 years old
◦ second injection: 16-18 years old
Meningococcal Vaccine
Acute inflammation of the Central Nervous System
• Can be caused by various bacterial agents
– Streptococcus pneumoniae
– Neisseria meningitidis
– β-Hemolytic streptococci
– Listeria monocytogenes
– Escherichia coli
Meningitis
- Droplet infection from nasopharyngeal secretions
- Appears as an extension of other bacterial infections through vascular dissemination
- Organisms then spread through the cerebrospina
Transmission of Bacterial Meningitis
Head and neck symptoms: • headache • neck pain; severe neck pain • nuchal rigidity = stiff neck • they cannot flex their neck • back pain • confusion • photophobia = cant stand bright lights ◦ keep lights dim • high Fever = risk of seizure in children • symptoms of increased intracranial pressure •Opisthotonos = arching their head behind the body; arching their head backwards • occurs b/c of meningial irritation
Signs/Symptoms - Bacterial Meningitis:
• put child in supine position
• lift the leg & try to bend knee forward → cant do it
◦ when hip is flexed 90 degrees → cannot straighten the leg
Positive Kernig’s Sign:
• put child in supine position
• lift head & bring chin to the chest → their knees automatically flex
◦ when the head is flexed → hips & knees automatically flex
Positive Brudzinski’s Sign:
there will be low, decreased amounts of glucose in CSF
▪ there will be high, elevated protein levels in CSF
▪ there will be high, elevated protein levels in CSF
elevated white blood cell levels in CSF
Bacterial Meningitis
• ISOLATION precautions ◦ room by themselves • start IV lines • Medications: ◦ Antibiotics – b/c bacterial infection ◦ antipyretics – for high fever ◦ Seizure precautions: ▪ anti-seizure meds – b/c high fever can cause seizure ▪ pad side rails ◦ steroids – for brain swelling ▪ mannitol = decreases intracranial pressure, decreases brain swelling • Maintain hydration • Quiet environment ◦ dim lights – b/c of photophobia
Bacterial Meningitis
Onset is abrupt or gradual • Great prognosis Same S/S as Bacterial Meningitis • Except = theyre not as acutely ill Definitive Diagnosis = Lumbar Puncture: • will have clear CSF • will have normal glucose levels in CSF • will have normal protein levels in CSF • will have mildly elevated white blood cell count in CSF
Viral meningitis
• IV Fluids, IV Hydration • bedrest • Medications: ◦ Antipyretics ◦ Analgesics
Viral meningitis treatment
superficial burns • intact skin – skin is not open • only involves 1 layer of the skin: ◦ epidermal layer • skin can get red – goes away • pain – but it goes away • goes away in a few days • No scarring
1st Degree Burn
– partial thickness burns • involves 2 layers of skin: ◦ epidermal layer ◦ dermal layer • skin is open • skin is moist, red, blisters • heals in 2-3 weeks • There is scarring
2nd Degree Burn
– full thickness burns • involves more layers: ◦ epidermis ◦ dermis ◦ nerve endings ◦ sweat glands ◦ hair follicles
3rd Degree Burn
– full thickness burns
• same as 3rd degree burn, but also involves:
◦ muscles
◦ bone
• when you look at the burn area – you can see ligaments, tendons
4th Degree Burn
- keep child at a horizontal position
- roll the child
- remove clothing
- remove jewelry
- dont cover their face
Patient Teaching for Burns
- Airway compromise and shock
- Local and systemic infection
- Respiratory problems
Complications - Burns
less than 10% of body surface area burned
• treated at home – dont need to go to hospital/ER
◦ wash the area
◦ antibiotic cream, neosporin
• is like a first degree burn
◦ no open wound
◦ there will be no scarring
Minor Burn
= 10-20% of body surface area burned
• bring child to hospital/ER – need to be treated in hospital
Moderate Burn
more than 20% of body surface area burned
• child will be transferred to a burn trauma center, burn trauma unit
The more extensive the burn → the more rapid fluid loss
• fluid shift
• increase in heat loss = will get Hypothermia
◦ we have to keep them warm
Major Burn
bacterial infections
• prone to Pneumonia
Prone to Pulmonary Embolism
Prone to Atelectasis
Cause of death in Burns
give Tetanus Vaccine
• Mild analgesics
• Antipyretics
• Airway maintenance
• Fluid replacement
• High protein, high calorie diet
• Vitamin A and C, Zinc
• promotes healing – increases healing time
• Morphine Sulfate – for major burn pain, we have to sedate them
• Debridement – medicate before b/c painful procedure
• Hydrotherapy – medicate before b/c painful procedure
Treatment of Burns
• ex: Intergra – good b/c cannot be allergic to it
◦ it lacks antigenicity – body cannot reject it
◦ also has a long shelf life
◦ is soft so can mold it to body
◦ it has collagen so body absorbs it once its applied to skin, your own skin will grow into it
Artificial skin
- stress
- premenstrual, girls starting to have their periods; hormone-related
- cosmetics
- improper hygiene – not washing their face
Acne Triggers
- Cystic Acne:
• very pus-likle
• very painful - White Head = closed comedone
- Black Head = open comedone
Types of Acne
• Adequate sleep
Balanced diet = cut back (not stop eating a type of food) on high-fat, greasy foods, fatty foods
Girls with bangs or long hair = pony their hair, specially when they goto bed at night
• Cleansing = wash face BID, twice a day with mild cleanser – in morning & at night
• we encourage them to buy a neutrogena mild face wash
Acne management
Wash face BID
Mild cleanser such as neutrogena
• no manual extraction, no squeezing – leads to ice pick scars & spreads the acne, bacteria
Acne teaching Acne
–African Americans
–Mediterranean descent
–South American, Arabian, and East Indian descent
Ethnicity affected by Sickle Cell
• Cerebrum symptoms – S/S of TIA, stroke
◦ child will be staring; will have a black stare; will be unresponsive
◦ facial drooping
◦ slurred speech
◦ muscle weakness – arm weakness, leg weakness
◦ but they recover from these symptoms right away
Head symptoms of sickle cell
- Double Vision, Diplopia
* Blurred Vision
Eye symptoms of Sickle Cell
- mimics a Heart Attack
- Angina, Chest Pain; severe Abdominal Pain
- Cough
- Shortness of Breath
- Difficulty Breathing
- Nasal Flaring
- Tachypnea – increased Respirations
Chest syndrome of Sickle Cell
- happens when children are going through a rapid growth spurt – b/c the bones of extremities are growing
- Joint Pain
- Joint Swelling
- Joint Inflammation
Hand foot syndrome
- can last from a few hours, to days, up to 2 weeks
- severe Pain
- there will be tissue swelling
- there will be internal inflammation
- TIA (transient ischemic attack) = the child will have a ‘little stroke, mini-stroke’
- there will be tissue ischemia, tissue infarction
Vaso-occlusive Crisis
Anything that increases the body’s need for oxygen:
• Trauma, Traumatic events
• Fever, fighting infections
• Physical and emotional stress
• Increased blood viscosity (sickle cells clump together) – due to Dehydration
◦ ex: child playing outside in the summer on a hot day, theyre not interested in drinking → they become Dehydrated → they will suddenly go into Vaso-occlusive Crisis
• Extremes in Temperature:
◦ really hot – being too hot, over-heated
◦ really cold – being too cold
• Hypoxia
◦ ex: child flying in a poorly pressurized airplane → can cause a Vaso-occlusive Crisis
Causes of Sickle Cell crisis
- Pneumococcal Vaccine – for Pneumonia
2. Influenzae Type b Vaccine
Protect against Sickle Cell
• Tick bite
• Rash – occurs within 30 days of the tick bite (within 1 month)
◦ not everyone will have a rash
◦ “erythema migrans” = bulls-eye rash
Stage 1 Lyme disease
• Rash – all over the body • Symptoms appear • Neurological symptoms: ◦ Headache ◦ Confusion ◦ Impaired Memory, Forgetfulness, forgetting things • Arthritic symptoms: ◦ Joint Pain • Central Nervous System symptoms • Muskoloskeletal System symptoms
Stage 2 Lyme Disease
- severe Arthritis
- more Headaches, Migraine Headaches
- ‘fogginess’ in the head
Stage 3 Lyme Disease
ELISA test
• screening test – not a definitive diagnostic test
• will do this first
• if this comes back Positive for Lyme antibodies → we will confirm it with a Western Blot test
Wester Blot test
• also looking for Lyme antibodies
Lab Analysis of Tick bite
• 8 years old or younger = oral or IV Amoxicillin (on drug list)
◦ for 3 weeks (21 days)
• older than 8 years old = oral or IV Doxycycline (is stronger than Amoxicillin)
◦ for 3 weeks (21 days)
Medications for Tick bite
• wear light-colored clothing = so can see ticks easier • inspect the child for ticks • wear long-sleeve clohtes, long pants, tuck pants into socks & shoes, tuck shirt into pants • most people get tick bites: ◦ hairline on the head ◦ behind the ears ◦ neck ◦ under breasts ◦ armpits ◦ groin area • use insect repellants
Pt teaching for Lyme Disease
A case of acute encephalopathy
Child will be acutely ill
there is no cure
can cause permanent neurological damage
Reyes Syndrome
Fever • Vomiting • Impaired consciousness – b/c the brain is swelling = Cerebral Edema • change in behavior ◦ personality changes ◦ confusion • Seizures • Hepatic dysfunction – Liver disfunction ◦ Hypoglycemia – low blood glucose
S/S - Reye Syndrome:
Liver Function Test • increased, elevated liver enzymes coagulation study • increased, prolonged bleeding time High Ammonia levels Low blood glucose – child will be Hypoglycemia
Diagnosis & Management - Reye Syndrome
Give lots of Fluids
• IV Fluids, IV Hydration
Assess fluid & electrolyte balance
Monitor I & O
Adjust fluid volume
Medications:
• Diuretics = for the cerebral edema – to decrease brain swelling
• Corticosteroids = b/c there is active inflammation
• Anti-seizure medications = for seizures
Supportive therapy for Reyes
- Teach personal hygiene
- Clean drinking water
- Food preparation
Prevention of Diarrhea
• no food for 24 hours → Clear Liquid Diet
◦ only clear liquids: tea, broth, ginger ale soda
• if child has tolerated Clear Liquids for 24 hours → progress to the BRAT diet
◦ B = Banana
◦ R = Rice
◦ A = Applesauce
◦ T = Toast (dry toast)
• if child has tolerated BRAT diet for 24 hours → progress to regular food, but in small amounts
- clean child’s mouth after Vomiting – b/c vomit has hydrochloric acid = damages teeth enamel
- teach child how to: gargle, spit out, use toothbrush
Pt Teaching: for Nausea, Vomiting, Diarrhea:
Associated with bacterial or viral infections • Associated with: • pneumococcal bacterial infections • streptococcal bacterial infetions • virus, viral infections
• Affects primarily school age children
Acute Glomerulonephritis/Nephritis
• Hypertension • Headaches • Fever • Edema ◦ Facial Edema, facial swelling ◦ Edema on hands ◦ Edema on feet ◦ Edem on stomach, abdominal swelling • Oliguria – little urinary output • Hematuria – blood in urine, dark urine • Proteinuria – protein in urine
Clinical Manifestations - Acute Glomerulonephritis
- blood test
- C3 levels will be very low
- When we start treatment – we monitor levels → levels should rise = good sign, mean the treatments are working, child is getting better
Serum complement (C3)
Chest Xray – b/c of fluid retention
• assessing for: Enlarged Heart – b/c heart is overworked due to fluid retention = Hypertrophy of heart
• assess for: Pulmonary Congestion, Pleural Effusion
Acute Glomerulonephritis
• Dietary restriction • restrict fluids • restrict sodium • assess urinary output daily weights COCAF urine • Blood Pressure monitoring • every 4 hours – b/c they can have high blood pressure, Hypertension • Anti-hypertensives • Diuretics bedrest Goes away in 1-2 weeks
Management - Acute Glomerulonephritis
it is a cancerous tumor that grows in utero
Wilm’s Tumor/Nephroblastoma
- hard mass, lump on abdomen
* vomiting
S/S - Wilm’s Tumor/Nephroblastoma:
- Ultrasonography – done first, then CT / MRI → then Biopsy for definitive diagnosis
- looking at image of kidneys
- Computed tomography & Magnetic resonance imaging (MRI)
- looking for the location of the tumor on the kidney
- looking for spread of cancer
- Biopsy – most definitive diagnosis
- ChestX-rays
- looking for metastases to lungs
Diagnosis - Wilm’s Tumor/Nephroblastoma
• throat pain • pain when swallowing • pain when chewing ◦ so they wont eat, not hungry ◦ they will prefer to drink instead of eating solid foods ◦ prefer to use a straw to drink • bad breath (Halitosis), foul-smelling mouth • Fever
S/S – Tonsilitis:
- Amoxicillin = Antibiotics
* throw out their toothbrush – b/c it will have the bacteria
Bacterial Tonsillitis:
– if child can understand:
◦ there will be a lot of pain when you wake up after the surgery
◦ your throat will hurt
◦ you will have difficulty swallowing
◦ Discourage coughing, clearing throat, blowing nose, sneezing
Pre-operative Teaching of tonsillitis
◦ NPO, nothing by mouth
• When they can start taking things by mouth:
◦ No hot liquids
◦ give cool liquids:
▪ cool water
▪ crushed ice
▪ ice pops – but no purple, red, brown – b/c dark colors will hide blood
◦ give clear liquids - No dark-colored liquids
◦ No ice cream, No dairy products, No milk
▪ b/c it forms a coating in the mouth, throat → they will want to clear their throat – we Dont want that – bc/ can rupture
Post-operative: Tonsillitis
• smoke, second-hand smoke • Upper Respiratory Tract Infections ◦ ex: colds • allergies ◦ ex: food allergies • bottle propping – milk, formula gets pushed up into the middle ear → bacteria grows
Risk factors triggers for otitis media
• Ear Pain – unilateral or bilateral
◦ young children cant talk – so cant tell you their ear hurts
◦ they turn their head from side-to-side all the time = means pain
◦ they tug on their ear, they stick their finger in the ear = means pain
◦ crying
◦ they wont eat – b/c of pain
• Fever
• Lymphadenopathy – swollen lymph nodes
Children with repeated otitis media = can have hearing loss
• hearing loss will cause → speech delays
S/S – Otitis Media:
▪ if they see drainage from the ear → leave it alone
▪ just use a washcloth & warm water to wipe the external ear → Do Not put a q-tip in the ear
▪ Never put any q-tips in ear ever
Pt Teaching: of Tonsillitis
have to meet 1 of these conditions: ◦ 3 ear infections in 6 months ◦ 6 ear infections in 12 months ◦ 6 ear infections by 6 years old • they ventilate the middle ear & keep the pressure open • also facilitates drainage • surgery to install them
• Criteria for child to have Tympanostomy tubes –
• no coughing
• no sneezing
• no blowing nose
• Short-term Tympanostomy tubes:
◦ will stay on ear for 6-12 months
▪ show child & parent what the ear tubes look like
▪ short-term tubes can fall out on its own – its ok
• Long-term Tympanostomy tubes:
◦ will stay on ear for 1-2 years
◦ they will not fall out on its own – Dr will remove them (surgery)
▪ Pt Teaching (pre-op teaching) for Tonsillitis
- Pneumococcal Vaccine
- Haemophilus Influenzae type b (Hib) Vaccine
• Both are series of 4 injections:
◦ 2, 4, 6, 12 months
Prevent Tonsillitis
Transmission:
• Airborne, Droplet:
◦ coughing, sneezing
• Direct contact:
◦ sharing bottles, sharing drinks, sharing spoons
◦ kissing
Is a Virus, Viral Infection - Epstein-Barr Virus
Infectious Mononucleosis
Initially – very mild symptoms: • warm feeling, eyeballs feel warm • fatigue, tired all the time, want to stay in bed all the time ◦ fatigue will be the last symptom to go away ◦ so pt can feel tired for 2-3 weeks • fever • anorexia, poor appetite Then: • Lymphadenopathy – swollen lymph nodes ◦ can be anywhere in the body ◦ on throat, abdomen, under the armpit • Splenomegaly – enlarged spleen ◦ inflammation of spleen → can rupture
S/S - Infectious Mononucleosis:
Monospot test
• sample taken & sent to Lab
• looking for antibodies for Epstein-Barr Virus = Heterophil / Heterophile Antibody
• if Positive for the antibody = Definitive diagnosis
Medications:
• is a Virus = so no cure → it has to run its course; Diseases lasts for 2-3 weeks
• Mild analgesics
• NEVER give Aspirin – b/c its a virus
Rest & Fluids
Management of Infectious Mononucleosis
Is a bacterial infection – caused by:
• Haemophilus Influenzae type b (Hib) bacteria
◦ So Vaccinate – to prevent Acute Epiglottitis
◦ Haemophilus Influenzae Type b (Hib) Vaccine
• also caused by: Streptococcus Pneumoniae bacteria
◦ so vaccinate – to prevent Acute Epiglottitis
◦ Pneumococcal Vaccine
Acute Epiglottitis
- Airway closure
- Increased pulse
- Restlessness
- Retractions – visible retractions on chest wall
- Anxiety – child is very anxious
- Inspiratory Stridor – high-pitched noise when breathing in
- Drooling – child drools b/c it’s painful to swallow
S/S - Acute Epiglottitis:
• Difficulty Swallowing – as child gets worse
◦ cant keep child in supine or semi-reclined position
• Distress – Respiratory Distress = difficulty breathing
• Dysphagia = difficulty swallowing – b/c of pain when swallowing
• Dysphonia = difficulty speaking
◦ cant understand what theyre saying
• Throat Pain, Pain when swallowing
◦ child will wake up in the middle of night screaming in pain
◦ have child sit-up, in a Tripod Position (leaning forward with hands on knees) = makes breathing easier
▪ they will start drooling – b/c of pain when swallowing, theyre not swallowing
S/S - Acute Epiglottitis
Dont put tongue blade in their mouth – b/c can close their Airway
Child may need to be entubated
IV Fluids – b/c they cant take anything by mouth, its too painful swallow
• IV therapy
• Antibiotics
• b/c its a bacterial infection
• start with IV Antibiotics → then oral when they can swallow
• Corticosteroids
• for the inflammation of airway
• Humidified Oxygen
Management - Acute Epiglottitis
Infections of the Lower Airways; Lower Respiratory Tract Infection Is a Virus, Viral Infection of the Lungs • lower airways: ◦ bronchi ◦ bronchioles
- RSV (Respiratory Syncytial Virus)
Transmission: • Airborne, Droplets ◦ coughing, sneezing • Direct contact • Indirect contact ◦ touching infected surfaces, doorknob
RSV
• Rhinorrhea = clear nasal discharge ◦ starts with a runny nose ◦ discharge is clear; not purulent, not discolored • nasal congestion • Tachypnea – rapid breathing • nasal flaring • substernal retractions
S/S - RSV (Respiratory Syncytial Virus):
Isolation = Contact Precautions • gloves, gown • Encourage breast feeding • Teach medication administration • Clear nasal passages • for babies = nasal drops & bulb syringe to clear nosal congestion
Nursing Management - RSV (Respiratory Syncytial Virus)
- DEA or ELISA test
- swab of nose taken
- looking for antibodies against the syncytial virus
Once they are diagnosed = Contact Precautions
• gloves, gown
• hand-washing
• Humidified Oxygen = to make breathing easier
• IV Fluids
• Medications
• Ribavarin = Anti-viral medication – prevent virus from replicating
• Synagis = given prophylactically
Diagnosis & Management - RSV
1st screening at 6-12 months
2nd screening at 2 years old
Lead screening
Cooper piping
Paint
Toys
All run down houses
Sources of lead
- they have very rich fantasies growing up – b/c it is always about them, they got everything, the didnt have to share or borrow anything
- they have a lot of pressure to perform well from their parents
- they are very mature; they mature at a very early age – b/c they didn’t grow up with siblings
- they are very sensitive to the needs of other people
Only child
- they dont care; they just go with the flow
- they are less dependent on anybody in the household
- they do their own thing
- they are very affectionate
- they have a lot of friends; they are very well liked by their friends
Youngest child
- they are praised less by the parents – b/c the praise goes to the oldest child
- they compromise
- they adapt very well in the home setting
Middle Child
- has a lot of pressure on them; parents expect a lot from first-born children
- they tend to be anxious
- they are high achievers; they are very motivated; they are very driven
- they want to please the parents
Oldest child
Double weight
Birth to 6 months
Triple weight
6-12 months
1/2 inch rectal
Birth to 12 months
- These children are having muscle development
- there will be intense activity in the children → they cannot sit still
- they are running, they are jumping
Toddler = 1 – 3 years old
- These children are very chatty – they talk a lot
- they have a large vocabulary
- they are learning to develop social skills
- they are trying to be independent – even though they are still dependent on their parents
Preschool = 3 – 6 years old
- their peers becomes very, very important to them
* they will start to develop a ‘Moral Conscience’ = knowing right from wrong
School age = 6 – 11 years old
• during adolescent years → puberty occurs
◦ their bodies are changing & they dont understand whats going on with them
• they sleep a lot
• they can start to have identity problems
Puberty / adolescent = 11 – 19
- Socialization; socialization skills
• they learn to share, they learn to give, they learn to take
• they are understanding right from wrong - Creativity
• having very rich fantasies
• exploration
• ex: child wants to be a super hero - Self-awareness
• they learn who they are & what their place is in the world - Moral standards
• they develop a sense of fairness, honesty, self-control
• they start to become considerate towards other people
Play enhances:
◦ children in the same room that are doing things together
◦ they are borrowing & lending things with each other
◦ they are passing things with each other
◦ ex: they are sharing crayons with each other
◦ during Associative Play:
▪ there is no group leader
▪ there is no goal in mind
Associative play:
is the most widely used developmental screening tool
• is an early screening tool used by child psychologists, child therapists
is NOT an IQ test
it is only a suggestive test
• this test is administerred in the form of a game
◦ the game has 125 items in it – the child is not expected to finish all of them
• Based on how the child answers or interacts during the screening time → the child may be referred to an Occupational Therapist, Physical Therapist, Speech Therapist
Denver II Screeing Tool
• Explain what, how, and why – b/c these children are very chatty, they want to know everything
• They are very concerned about their bodies
◦ ex: is it normal that I have a penis & you have a vagina?
• Allow the child to touch and “practice” with medical equipment
• Ensure that personal possessions will not be harmed or lost
School-age children: 6 – 12 years old
Head = small head
• Eyes = upward slant of the eyes
• Ears = small ears – very short pinna
• Nose = flat nasal bridge
• Mouth =
◦ they’re mouth breathers
◦ tongue protrusion
• Hands = short, stubby fingers
◦ Simian Crease (is a single line that runs across the palm of the hand. People usually have three creases in their palms)
• Feet = short, stubby toes
• short stature – they dont become tall
• they’re born with a conditon called Hypotonicity = low muscle tone
◦ so they fall over all the time as babies
There are special growth charts for Down Syndrome
• they will meet the targets – but later than usual
Clinical Manifestations – Down Syndrome:
• Congenital
• many born with congenital anomalies – they get surgery to repair the congential anomaly
• They’re prone to Respiratory tract infections – at a very early age
• Hypotonicity
• low muscle tone – on the outside & inside
• weak chest muscles – theyre not getting full chest expansion
◦ so they’re prone to Upper Respiratory Tract Infections
• Constipation
• b/c low muscle tone in their GI tract – weak peristalsis
• Underdeveloped nasal bones
• they always have snot in their noses
• so they are mouth breathers
Problem with Down Syndrome
• Repair congenital anomalies - very early on
• Screen vision and hearing
• most will be wearing glasses from a very young age
• 80% will survive age 60 and beyond
• Provide reading materials and referral to support groups
Genetic counseling if they want to have another child
Once they are in the school setting – they will have in Individualized Education Plan:
• they get extra services in school
Management & Prognosis – Down Syndrome
• Peculiar bizarre behaviors
• repetitive behaviors
◦ ex: they will keep hitting their head on a wall; theyre constantly playing with their fingers
• when you enter their personal space → they will back off
◦ they dont like being touched
◦ they dont want to be hugged
• they can be violent in nature – they have no control over it
◦ they will just lash out at you
- Poor eye contact
- they dont make eye contact
Autism
have an Anticholinergic effect = dries-up secretions:
◦ dry eyes
◦ dry nose
◦ dry mouth = no saliva
▪ saliva has enzymes that neutralizes bacteria going into the mouth
▪ no saliva = can cause growth of bacteria
▪ so child can have lots of Dental Caries
▪ Pt Teaching: Oral Hygiene:
• drink a lot of water
• brush teeth at least twice per day
• floss
• frequent dental check-ups
◦ theyre thirsty all the time
Psychostimulants
Difficulty Swallowing – as child gets worse
◦ cant keep child in supine or semi-reclined position
• Distress – Respiratory Distress = difficulty breathing
• Dysphagia = difficulty swallowing – b/c of pain when swallowing
• Dysphonia = difficulty speaking
◦ cant understand what theyre saying
D’s of Epiglottis
• Throat Pain, Pain when swallowing
◦ child will wake up in the middle of night screaming in pain
◦ have child sit-up, in a Tripod Position (leaning forward with hands on knees) = makes breathing easier
▪ they will start drooling – b/c of pain when swallowing, theyre not swallowing
Epiglottis
Management - Acute Epiglottitis
Dont put tongue blade in their mouth – b/c can close their Airway
Child may need to be entubated
IV Fluids – b/c they cant take anything by mouth, its too painful swallow
• IV therapy
• Antibiotics
• b/c its a bacterial infection
• start with IV Antibiotics → then oral when they can swallow
• Corticosteroids
• for the inflammation of airway
Management of Epiglottis
Affects exocrine glands (glands that produces secretions via ducts): (not endocrine glands) • Salivary glands • Sweat glands • Respiratory glands • Digestive glands
Glands → secretes mucus
Cystic Fibrosis → the glands will produce a lot of thick mucus → will cause obstruction, will clog-up all the exocrine glands
Pathophysiology of Cystic Fibrosis
Lungs Pancreas Intestines Reproductive liver
Cystic fibrosis
Respiratory Tract Infections = main reason these children die
• mucus will settle in the lungs (in the respiratory tract) – in bronchi & in alveoi
◦ bacteria will grow → Respiratory Tract Infection
◦ child can have repeated respiratory tract infections
• the mucus will cause problems getting air out of lungs – they will have air trapping = hard to get air out of the lungs
• Patchy Atelectasis = parts of lung will collapse
• COPD, Emphysema, Obstructive Emphysema
Lungs
• mucus clogs-up pancreatic ducts
• Pancreatic Fibrosis = pancreas becomes hardened (thickened, scarred)
◦ Pancreas produces Insulin
▪ so they cannot make Insulin → they develop Diabetes
Pancreas
Intestines:
• Pancreas also secretes enzymes that goes to the small instestines through the Pancretic Duct
◦ but the pancreatic duct is blocked by the mucus – the enzymes will not get to the small intestines
◦ so the intestines will have problems absorbing:
▪ proteins
▪ carbohydrates
▪ fat-soluble vitamins = Vitamin A, D, E, K
• Pancreas also produces Bile
◦ b/c the duct is blocked by mucus – bile cannot get to the small intestines
Intestines
▪ so their stool will be = clay colored, foul-smelling, fatty, frothy (steatorrhea)
▪ will see undigested food particles in the stool
▪ so child will have failure to thrive (skinny, low weight, weight loss)
▪ child is eating, has good appetite → but does not gain weight
• b/c not absorbing enough proteins, carbohydrates, fat-soluble vitamins from food
• Intestinal Obstruction
• Meconium Ileus – intestinal obstruction in newborns
◦ newborn will strain to have their first bowel movement, stool (meconium) – very hard to get it out b/c the stool becomes very thick, sticky, hard
◦ will cause:
▪ small bowel obstruction
▪ Prolapsed Rectum
Intestines
• girls:
◦ can have problems getting pregnant – b/c the thick mucus secretions acts like a barrier, prevents sperm from getting through
◦ will take longer to hit puberty
• boys: will be sterile – b/c the mucus is clogging their vas deferens → so it prevents sperm transport
◦ so hard to father children
Reproductive
• Portal Hypertension = Hypertension:
◦ Veins that goes to the GI organs become obstructed
◦ blood flow through the liver is blocked → causes an increase in the Blood Pressure in the portal vein (the vein that carries blood from the digestive organs to the liver)
Liver
• Quantitative sweat chloride test
• gold-standard test for cystic fibrosis
• child with Cystic Fibrosis = will sweat large amounts of chloride, salt
• device with a medication (Pilocarpine) is strapped onto childs arm – no pain
◦ Pilocarpine stimulates the area to start sweating → sample of sweat taken & sent to lab
• looking for:
◦ high, elevated Sodium levels
◦ high, elevated Chloride levels
Diagnostic Evaluation of Cystic Fibrosis
40 meq or less
Nml Chloride
40 - 59 → highly suggestive
Cystic Fibrosis
60 or higher → definitive diagnosis
Cystic fibrosis
Vital Capacity (the greatest volume of air that can be exhaled from the lungs)
• will be decreased
2. Tidal Volume (the volume of air inhaled & exhaled in a single breath)
• will be decreased
• the amout of air they breath in & breath out will be decreased
3. Residual Volume (amount of air still in the lungs after breathing out)
• will be increased
Cystic Fibrosis
the greatest volume of air that can be exhaled from the lungs
Vital capacity
the volume of air inhaled & exhaled in a single breath
Tidal Volume
amount of air still in the lungs after breathing out
Residual Volume
Chest x-ray
• will see = Patchy Atelectasis in lungs
• will see Obstructive Emphysema
Stool/enzyme analysis
• steatorrhea = foul-smelling, fat in stool, frothy
• undigested food particles in stool
• Barium enema – Meconium Ileus, Prolapsed Rectum = to see where the obstruction is
Cystic Fibrosis
prevent Respiratory Infections = main reason they die
Nebulizer treatments
• do this first – then do chest physiotherapy after
• CPT – chest physiotherapy
• teach parents how to do Chest Physiotherapy – ACT = Airway Clearance Therapy
• b/c they’re making a lot of mucus – but can’t get it out
◦ do in the morning – when the child wakes up
◦ do periodically during the day
◦ do at night – before child goes to sleep
• Bronchodilator medication
• to open bronchi = so easier to breath
• Forced expiration
• Pulmonary infections – Prone to Infections
Prophylactin Antibiotics given at home:
• Home IV antibiotic therapy
• Aerosolized antibiotics
Prophylactic Corticosteroids give at home
• s/e of long-term corticosteroids use: Osteoporosis
◦ so child can also get Osteoporosis
Respiratory Management of Cystic Fibrosis
• Pancreatic enzymes
• given in pill-form, can sprinkle on foods for young
• give when eating a high-fat meal → to prevent steatorrhea (fat in stool, foul-smelling, frothy)
• if child still has fats in stool → keep adding more pancreatic enzymes
• High-protein, high-calorie diet
Lots of fluids
• Bowel regime
• Reduction of rectal prolapse
Salt supplementation:
• b/c they excrete, sweat a lot of salt
• specially in the summer – b/c they sweat more
• during fever – b/c they will be sweating
Give fat-soluble Vitamins
• Vitamin A, D, E, K – given in a water-soluble form
GERD - Gastroesophageal reflux disease
• stomach acids, stomach contents flows back (reflux) to esophagus
• acid reflux, heartburn
These children prone to Constipation
• Give laxatives, stool softeners, fleet enemas
GI Management in Cystic Fibrosis
start Screening at 10-12 years old
◦ we screen girls earlier b/c they go through puberty first
Girls scoliosis
start Screening at 13-14 years old
continue screening until they are done growing
Boys scoliosis
• Have child bend over & dangle arms down → stand behind them & will see uneven hips, shoulders
Adams forward bending test
◦ we will do “watchful waiting” - we will just keep screening them for scoliosis, come in at least 2 time per year,
Risser scale = 10-15 degree angle:
Risser scale = 20-40 degree angle:
◦ use a Brace
Scoliosis
Risser scale = over 40 degree angle:
◦ surgery
Scoliosis
will still wear a brace for several weeks – dont want them bending, twisting
Post-Op Scoliosis surgery
• “occult” = hidden, cannot see it → so easy to miss in-utero
• the best one to be born with
◦ child will be normal = no neurological problems
• S/S:
◦ hair growing out of newborn’s back
◦ fat pad on back – no pain when you touch it
• some bones in the vertebral column do not fuse
◦ there is an opening in the spinal column = but nothing protrudes
• spinal nerves intact = so good prognosis
Spina Bifida Occulta:
• “meningo” = meninges (the 3 membranes that covers the brain, spinal column = contains cerebrospinal fluid)
• “cele” = fluid-filled sac
• can be detected in-utero
• S/S:
◦ there is a fluid-filled sac, outpoutching on the back
• some bones in the vertebral column do not fuse
◦ there is an opening in the spinal column = allows fluid-filled sac to protrude
◦ the sac contains the meninges & cerebrospinal fluid
• spinal nerves are still intact – are not in the sac = so good prognosis
Meningocele
• the worse one to be born with
• can be detected in-utero
• damage is already done = there is nothing we can do for these children
◦ child will be born with severe neurological deficits:
▪ Paralysis – of lower extremities
▪ may have hip dysplasia, foot deformities, clubbed foot
▪ these children will have bowel, bladder problems for life
◦ The child’s intelligence is intact = does not effect their brain
▪ they just have no control from the Myelomeningocele → down
Myelomeningocele
◦ there is a fluid-filled sac, outpoutching on the back
• some bones in the vertebral column do not fuse
◦ there is an opening in the spinal column = allows fluid-filled sac to protrude
◦ the sac contains the meninges & cerebrospinal fluid
◦ the spinal nerves are also in the sac
Can cause obstruction of the cerebrospinal fluid → the CSF will accumulate in the head = will cause Hydrocephaly (
Myelomeningocele
all dark, green leafy vegetables – spinach
◦ fortified bread, whole-grain bread, fortified cereals
Folic Acid
Is a condition that affects:
- your brain
- motor function
• A group of permanent disorders of the development of movement and posture, causing activity limitation that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain
Cerebral palsy
- can occur in-utero b/c of Hypoglycemia – their brain didnt get glucose
- head trauma = car accidents, Meningitis, Shaken Baby Syndrome
Causes of Cerebral Palsy:
Intellectual Problems
• adult can have mentality of a child
Difficulty Understanding
Speech Problems
Motor Problems
• no fine motor skills – they have gross motor skills
Abnormal Muscle Tone
• Hypertonicity = very tight, rigid muscle tone
◦ affects their ability to walk, may need crutches, wheelchair
◦ will have problems with posture, balance, coordination
can have Seizures of unknown cause
** child will not meet their milestones
Signs/Symptoms - Cerebral Palsy:
It takes a very long time to get a diagnosis of Cerebral Palsy – b/c have to rule out other neuromuscular diseases first
• PE
• MRI/CT
• Motor disorders
• Monitor closely for 1st two years of life
Diagnosis & Management - Cerebral Palsy
• Early recognition
• 5 Goals:
–Establish locomotion, communication
–Gain optimal motor function
–Correct defects asap
–Provide educational opportunities
–Promote socialization skillsManagement - Cerebral Palsy
- Chronic autoimmune inflammatory disease
- Immunogenic susceptibility, environment and or external triggers
- Have chronic inflammation of synovium with joint effusion and erosion, destruction and fibrosis of cartilage
Increase of synovial fluid in the joints.
There is joint space widening.
There is soft tissue swelling.
Juvenile Idiopathic Arthritis (JIA)
Joints: • Joint Pain – very painful • Joint Swelling • Joints warmth • Joint redness
Signs/Symptoms - Juvenile Idiopathic Arthritis:
No definitive tests – based on what the child & parents say Blood Test: ESR – Erythrocyte Sedementation Rate • if high, elevated = means that there is active inflammation in the body – doesnt tell you where • is only a suggestive test Leukocytosis: • high, elevated White Blood Cells • occurs during flare-ups • ANA - Anti Nuclear Antibody • Radiographs – joint Xray
Diagnosis - Juvenile Idiopathic Arthritis
