Saunders Peds Flashcards
vaccines derived from MO’s or viruses; their virulence has been weakened as a result of passage through another host.
Attenuated vaccine
the sound made by forced expiration, which is the body’s attempt to improve oxygenation when hypoxemia is present
grunting
vaccines that contain killed MO’s
inactivated vaccines
a widening of the nares to enable an infant or child to take in oxygen; a serious indication of air hunger
nasal flaring
a form of acquired immunity that occurs artificially through injection or is acquired naturally as the result of antibody transfer through the placenta to a fetus or through colostrum to an infant; is not permanent and does not last as long as active immunity
passive immunity
pertaining to early symptoms that mark the onset of a disease
prodromal
indicates respiratory difficulty
retractions
movement of blood or body fluid through an abnormal anatomical or surgically created opening
shunt
Eczema (Atopic Dermatitis) major goals of management
the major goals of management are to relieve pruritus, lubricate the skin, reduce inflammation, and prevent or control secondary infections.
assessment of eczema
weeping, oozing, and crusting of lesions
Eczema interventions
avoid irritants (detergents, harsh soaps)
bath not more than once daily in tepid water
apply cool, wet compress
antihistamines and steriods
A child with an integumentary disorder needs to be monitored for signs of:
skin infection or systemic infection
Impetigo
a contagious bacterial infection of the skin caused by beta hemolytic strep or staph and occurs most commonly during hot, humid months: honey-colored crusts with ulcerated bases usually on face. institute contact isolotion
Why dont you use Lindane, an alternative product to kill scabies, in children younger than 2 years old?
risk of neurotoxicity and seizures; use permethrin instead
How do you apply permethrin?
apply at least 30 mins after bathing, massage into ALL skin surfaces (except eyes and mouth). leave on skin 8-14 hours, wash off, a repeat tx may be needed
What is parent teaching assoc with scabies?
tell parents to change infected linens DAILY, washed in hot water, dried in hot dryer, and ironed before reuse
Priority Nursing Actions: Major pediatric burn injury
stop the burning process (smother flames)
assess the ABC’s
resuscitation if not breathing
remove burned clothing and jewelry
cover wound with a clean cloth (prevents contamination, relieves pain, and prevents hypothermia)
transport the child to the ED (keep child warm during transport)
why do lower burn temps and shorter exposure to heat cause a more severe burn in a child vs adult?
children’s skin is thinner
Which burns require fluid resuscitation?
burns involving more than 10% of total body surface area require some form of fluid resuscitation in the first 24 hours bc of the fluid shifts that occur as a result of the injury; cystalloids first, then colloids (albumin, Plasma-Lyte, or FFP) are useful in maintaining plasma volume
Do you use the rule of 9’s when estmiating extent of burn in children?
NO! in a pediatric client, the extent of the burn is expressed as a percentage of the TBSA using age-related charts
How do you determine accuracy of fluid resuscitation r/t burn in pediatrics?
VS (esp HR), urine output, adequacy of cap filling, and sensorium status are assessed
assessment indicating scabies
fine, grayish red, threadlike lines
clusters of fluid filled vescicles
herpesvirus infection
situations that precipitate sickle cell crisis (where HbA is replaced with HbS)
fever, dehydration, emotional or physical stress
treating a sickle cell crisis
hydration, oxygen, pain management (analgesics around the clock-but NOT Demerol->seizures), and bed rest (pain cannot be controlled without adequate hydration), blood transfusions may be necessary
sickle cell vaso-occlusive crisis
caused by stasis of blood with clumping of cells in the microcirculation, ischemia, and infarction (fever, painful swelling of hands, feet, and joints, ABD pain)
sickle cell splenic sequestration
caused by pooling and clumping of blood in the spleen (profound anemia, hypovolemia, and shock)
sickle cell hyperhemolytic crisis
an accelerated rate of RBC destruction (anemia, jaundice, and reticulocytes)
sickle cell aplastic crisis
caused by diminished production and increased destruction of RBC’s, triggered by viral infection or depletion of folic acid (profound anemia and pallor)
iron deficiency anemia
commonly results from blood loss, increased metabolic demands, syndromes or GI malabsorption, and dietary inadequacy (pallor, weakness/fatigue, Low H&H, RBCs are microcytic and hypochromic
how do you administer Iron IM?
using ztrack method
when do you take oral iron supplements?
between meals for max absorption with Vit C
aplastic anemia
deficiency of circulating erythrocytes and all other formed elements of blood (pancytopenia), resulting from the arrested development of cells within the bone marrow. (caused by exposure to myelotoxic agents, viruses, infection, autoimmune d/o’s, and allergic states); diagnosis by bone marrow aspiration-immunosuppressive therapy and bone marrow transplant (petechiae, purpura, bleeding, pallor, weakness, tachycardia, and fatigue)
increased tendency to bleed from mucous membranes
von Willebrand’s disease (and includes excessive menstrual bleeding)
Beta Thalassemia Major
most common in mediterraneans, italians, and greeks
frontal bossing, maxillary prominence, wide-set eyes and flattened nose, greenish yellow skin tone, hepatosplenomegaly, microcytic, hypochromic RBCs
leukemia assessment
infiltration of the bone marrow by malignant cells causes fever, pallor, fatigue, anorexia, hemorrhage (usually petechiae), and bone/joint pain, pathological fractures can occur as a result of bone marrow invasion with leukemic cells; signs of infection occur as a result of neutropenia
How does leukemia affect CNS?
IICP
macewen’s sign
cracked pot sound on percussion indicating IICP in infants
setting sun sign (eyes appear to look only downward, with the sclera prominent over the iris)
indicates IICP in infants
neutropenic precautions
aeseptic technique of course, but remember no fresh flowers, low bacteria foods (no fresh fruits or vegetables or undercooked meats) (Aspergillus and Pseudomonas aeruginosa may live in the soil of the living plants)
chemotherapy
monitor for severe bone marrow suppression, during the period of greatest bone marrow suppression (the nadir), blood cell counts are extremely low.
bleeding precautions: how long do you apply pressure to a needle stick site?
at least 10 mins if on bleeding precautions
Hodgkin’s Disease
often metastasizes to nonnodal or extralymphatic sites, especially the spleen, liver, bone marrow, lungs, and mediastinum
characterized by Reed-Sternberg cells noted in a lymph node biospy
Hodgkin’s Disease: prognosis is excellent
pancytopenia
increases risk for infection, bleeding, and anemia (common with radiation)
most common intraabdominal and kidney tumor in childhood (peak incidence is 3 years old)
Wilm’s Tumor (Nephroblastoma)
Wilms Tumor assessment
swelling or mass within the abdomen that is firm, nontender, confined to one side, and is deep within the flank.
Hematuria, fever, and hypertension are clinical manifestations associated with Wilm’s Tumor
why do we see hypertension with wilms tumor?
tumor releases excess renin
Precautions for Wilm’s Tumor
Place sign over bed DO NOT PALPATE ABDOMEN!!! measure abdominal girth at least once daily. Rupture of the tumor can cause the cancer cells to spread throughout the abdomen, lymph system, and bloodstream
neuroblastoma in general
often before age 10. Most presenting signs are caused by the tumor compressing adjacent normal tissue and organs. Neuroblastoma is a tumor that originates from the embryonic neural crest cells that normally give rise to the adrenal medulla and the sympathetic ganglion
Neuroblastoma prognosis
prognosis is poor bc of the frequency of invasiveness of the tumor, and because in most cases a diagnosis is not made until after metastasis has occurred.
neuroblastoma assessment
firm, nontender irregular mass in the abd that crosses midline.
Osteosarcoma
most common bone cancer in children and is usually found on the metaphysis of long bones, esp in the LE (most tumors in the femur) Peak age of incidence is 10-25 years.
osteosarcoma assessment
local pain that is often relieved by flexed position (pain is often attributed to growing pains)
palpable mass
limping if weight-bearing limb is affected
progressive limited ROM
child may be unable to hold heavy objects bc of their weight and resultant pain in the affected extremity
pathological Fx often occur at the tumor site
sudden fixed dilated pupils (or sluggish or unequal)
emergency! report immediately-may indicate IICP and potential brainstem herniation
lack of response to painful stimuli
report immediately
headache worse upon awakening but gets better throughout the day vomiting unrelated to feeding ataxia seizures behavioral changes clumsiness, awkward gait or diff walking diplopia facial weakness
potential brain tumor
opisthotonos, Kernig’s, Brudizinski’s signs
signs of meningitis
opisthotonos
Opisthotonos is a condition in which the body is held in an abnormal position. The person is usually rigid and arches the back, with the head thrown backward.
kernig’s sign
Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees.
brudizinski’s sign
Severe neck stiffness causes a patient’s hips and knees to flex when the neck is flexed.
Phenylketonuria
a genetic disorder that results in CNS damage from toxic levels of phenylalanine in the blood (>20 mg/dL when norms are 1.2-3.4 mg/dL). All 50 states require routine screening of all newborns, and the infant should have fed before specimen collection.
If high, restrict protein and aspartame
monitor physical, neuro, and intellectual development
Type 1 DM
destruction of pancreatic beta cells, which produce insulin, resulting in an absolute insulin deficiency
polydipsia, polyuria, polyphagia, blurred vision, weakness, weight loss, syncope
hyperglycemia
hyperglycemia progressing to metabilic acidosis
DKA
manifestations of DKA
hyperglycemia, kussmaul’s respirations, fruity breath, increasing lethargy, decreasing LOC
deep, rapid, labored breathing
kussmaul’s respirations
what is important to remember about administering potassium to a diabetic pt?
pt should be voiding adequately prior to administering potassium or hyperkalemia may occur
vomiting and diarrhea major concerns
major concerns are dehydration, loss of fluids and electrolytes, and development of metabolic alkalosis. Additional concerns are aspiration and the development of atelectasis and pneumonia.
projectile vomiting
consider pyloric stenosis or IICP
what are common pediatric causes of acute diarrhea?
acute infectious disorders of the GI tract, antibiotic therapy, rotavirus, and parasitic infection
What are causes of chronic diarrhea in peds?
malabsorption syndromes, ibd, immunodeficiencies, food intolerances, and nonspecific factors.
causes of cleft lip and cleft palate
hereditary and environmental factors-exposure to radiation or rubella virus, chromosome abnormalities, and teratogenic factors
What do you fix first? cleft lip or cleft palate, and when does this initial surgery typically occur?
Closure of a cleft lip defect precedes closures of the cleft palate and is usually performed by age 3 to 6 mos. Cleft palate repair is usually performed between 6 and 24 months of age to allow for the palatal changes that occur with normal growth; a cleft palate is closed as early as possible to facilitate speech development.
What is something to watch for in a child with cleft palate?
frequent otitis media resulting in hearing loss
Interventions associated with cleft lip/palate?
assess the ability to suck, swallow, handle normal secretions, and breathe without distress; keep suction equipment and a bulb syringe at bedside; teach parents ESSR method of feeding (enlarged nipple, stimulate sucking, swallow, and rest); AVOID ORAL SUCTION OR PLACING OBJECTS IN MOUTH (PACIFIER, TONGUE DEPRESSOR, ETC)
How do you position post op patient after cleft lip/palate repair?
NOT ON THE SIDE OF THE REPAIR; position on the back, upright to prevent airway obstruction; elbow restraints should be used to prevent the infant from injuring or traumatizing the surgical site (remove restraints q2h to assess skin integrity and circulation and ROM)
esophageal atresia or tracheoesophageal Fistula
the condition causes oral intake to enter the lungs or a large amount of air to enter the stomach, presenting a risk of coughing and choking; severe abdominal distention can occur; aspiration pneumonia and severe respiratory distress may develop, and death is likely to occur without surgical intervention
Treatment of esophageal atresia or tracheoesophageal fistula
maintain patent airway, prevent aspiration pneumonia (broad spectrum Abx may be prescribed), gastric or blind pouch decompression, supportive therapy, and surgical repair.
frothy saliva in the mouth and nose and excessive drooling
Three C’s (coughing, choking during feeding and unexplained cyanosis)
regurgitation and vomiting
abdominal distention
increased respiratory distress during and after feeding
esophageal atresia or tracheoesophageal fistula
What is important to know about a gastrostomy tube preop for esophageal atresia or tracheoesophageal fistula
If a gastrosomy tube is inserted, it may be left open to that air entering the stomach through the fistula may escape, minimizing regurgitation and distention
following correction of esophageal atresia or tracheoesophageal fistula, when can feeding begin?
before oral feedings and removal of the chest tube, prepare for an esophagogram as prescribed to check the integrity of the esophageal anastomosis
following correction of esophageal atresia or tracheoesophageal fistula, what do you teach parents?
instruct the parents to identify behaviors that indicate the need for suctioning, signs of respiratory distress, and signs of a constricted esophagus (poor feeding, dysphagia, drooling, coughing during feedings, regurgitated undigested food)
passive regurgitation or emesis, poor weight gain, irritability, hematemesis, heartburn, anemia from blood loss
assessment findings for GERD
assess amount and characterics of emesis
assess the relationship of vomiting to the itmes of feedings and infant activity
monitor breath sounds before and after feedings
assess for signs of aspiration, such as drooling, coughing or dyspnea after feeding
Place suction equipment at bedside
monitor intake and output
interventions for GERD
what are complications of GERD?
esophagitis, esophageal strictures, aspiration of gastric contents, and aspiration pneumonia
projectile vomiting, dehydration, metabolic alkalosis, and failure to thrive
hypertrophic pyloric stenosis
peristaltic waves are visible from left to right across the epigastrium during or immediately after a feeding
hypertrophic pyloric stenosis
an olive shaped mass is in the epigastrium just right o the umbilicus
hypertrophic pyloric stenosis
pyloromyotomy
an incision through the muscle fibers of the pylorus, may be performed by laparoscopy; Tx for hypertrophic pyloric stenosis
precipitated by fasting, infection, or ingestion of gluten
celiac crisis
when the appendix becomes inflamed or infected, perforation may occur within a matter of hours, leading to
peritonitis, sepsis, septic shock, and potentially death; abdominal pain is most intense at McBurney’s point; rebound tenderness and abdominal rigidity
increased fever, progressive abd distention, tachycardia and tachypnea, pallor, chills, restlessness and irritability
peritonitis (results from perforated appendix)
what indicates a perforated appendix?
sudden relief of pain and then a subsequent increase in pain accompanied by right guarding of the abd.
How do you position prior to appendectomy?
right side lying or low to semi fowlers to promote comfort
do you apply heat to abd if appendicitis is suspected?
No
the most serious complication is enterocolitis: fever, severe prostration, gastrointestinal bleeding and explosive watery diarrhea
hirschsprung’s disease; a rectal biopsy shows absence of ganglionic cells; newborns may fail to pass meconium and refuse to suck
currant jelly-like stools containing blood and mucus; colicky abd pain that causes the child to scream and draw the knees to the abd
intussusceptions: telescoping of one portion of the bowel into another portion
what does passage of normal, brown stool indicate with regard to intussusception?
the intussusception has reduced itself
omphalocele
herniation of the abdominal contents through the umbilical righ, usually with an intact peritoneal sac. immediately after birth, the sac is covered with sterile gauze soaked in NS to prevent drying of the abdominal contents, a layer of plastic wrap is placed over the gauze to provide additional protection against moisture loss. pay particular attention to the infant’s temp: may lose heat through sac
gastroschisis
herniation of the intestine is lateral to the umbilicus and no membrane covers; cover with NS soaked towel and wrap with plastic wrap
increased thirst, dry, sticky membranes, flushed skin, increased temp, n/v, oliguria, lethargy
hypernatremia
tetany, muscle weakness, dysrhythmias and hypotension
hyperphosphatemia
epiglottitis
bacterial form of croup; Hib vaccine helps reduce risk; considered an emergency situation bc it can progress rapidly to severe respiratory distress syndrome
sore, red, inflamed throat (large, cherry red, edematous epiglottis) and pain with swallowing. High fever, absence of spontaneous cough, DYSPHONIA (muffled voice), dysphagia, dyspnea, drooling; agitation, retractions, INSPIRATORY STRIDOR aggravated by supine position, tachycardia, tachypnea; TRIPOD POSITIONING
epiglottitis assessment-DO NOT MEASURE TEMP VIA PO ROUTE!!! DONT LOOK IN THROAT-MAY CAUSE EPIGLOTTIS TO SPASM AND LEAD TO RESPIRATORY DISTRESS!
dry, hacking non productive cough worse at night and becomes productive in 2-3 days
bronchitis: encourage increased fluid intake
how do you verify RSV infection?
test nasal or nasopharyngeal secretions (Synagis is the expensive vaccine)
how do we prevent pneumonia?
PCV; Prevnar vaccines
how do you position a child with pain associated with pneumonia?
on the affected side or splinting (reduces pleural rubbing)
Priority Nursing Actions: Acute Asthma attack
Assess airway patency and respiratory status (intubate?)
Administer humidified oxygen (NC or mask)
Administer quick-relief meds (albuterol)
IV access
prepare child for chest radiograph if prescribed
prepare to draw blood for ABG’s
quick relief Meds (Rescue meds)
short-acting beta agonists (bronchodilators) Anticholinergic (for relief of bronchospasm) Systemic corticosteriods (for antiinflammatory action to treat reversible airway obstruction)
Leukotriene modifiers
long term control of asthma symptoms by preventing bronchospasm and inflammatory cell infiltration
Monoclonal antibody
long term control of asthma symptoms by blocking IgE from binding to mast cells to inhibit inflammation
why do we promote the use of spacers with MDI in a pediatric settings?
prevents yeast infection in mouth
What is important to remember about long-term use of corticosteriods in peds?
monitor growth patterns-may delay growth
What chloride concentration in 75 mg of sweat confirms CF?
> 60 mEq/L (>40mEq/L is confirmation in infants younger than 3 mos of age) Test results between 40-60 mEq/L are highly indicative of Cf and require repeat testing
CF causes contraction and hypertrophy of the muscle fibers in pulmonary arteries and arterioles, leading to
pulmonary HTN and cor pulmonale (RV Failure)
What is the earliest manifestation suggestive of Cystic Fibrosis?
Meconium Ileus in the newborn
What do stools look like in CF patients?
frothy and foul-smelling
Why do CF patients bruise easily?
deficiency of fat soluable vits (ADEK) (bleeding, bruising, anemia)
besides the sweat test, how else might you diagnose a newborn with CF specifically? What about a stool analysis?
newborn screening may be done in some states and may cnsist of immunoreactive trypsinogen analysis and direct DNA analysis for mutant genes
Stool, fat, enzyme analysis: a 72 hours stool sample is collected to check the fat or enzyme (trypsin) content, or both (food intake is recorded during collection)
Interventions R/T CF
goals of Tx include preventing and treating pulmonary infection by improving aeration, removing secretions, and administering Abx
Chest physiotherapy upon awakening and in evening daily (more frequently with active infection, but not around meal times)
Teach the child how to huff in order to better clear secretions
Physical exercise to stimulate mucus expectoration and est effective breathing pattern
Aerosolized or IV Abx may be administered at home through a CVA
CF diet
high calorie, high protein, multivitamins, and vits ADEK. For those with severe lung disease, energy requirements may be as high as 20-50% above recommended daily allowance.
Pancreatic enzymes often given within 30mins of eating all meals and snacks (but dont give if NPO) capsules can be taken apart and sprinkled on food
high risk conditions for SIDS
prone position
use of soft bedding, sleeping in a noninfant bed such as a sofa
overheating (thermal stress)
cosleeping
mother who smoked cigs or abused substances during pregnancy
exposure to tobacco smoke after birth
what should you know about TB testing and immunizations?
TB testing cannot be done at the same time as measles immunization (viral interference from the measles vaccine may cause a false-negative result)
TB Sputum
obtain specimen in morning before breakfast
the inability of the heart to pump a sufficient amount of blood to meet the metabolical and oxygen needs of the body
Heart Failure
assessment of early signs of HF
tachycardia, esp at rest or with slight exertion tachypnea profuse scalp diaphoresis fatigue and irritability sudden weight gain respiratory distress
when do you withhold digoxin?
<70 beats/min in older children
Be aware that infants rarely receive more than 1 mL of digoxin in one dose
signs of digoxin toxicity
anorexia, poor feedings, n/v, bradycardia, and dysrhythmias
what do you monitor for when giving ACEI’s?
hypotension, renal dysfunction, and cough
hypokalemia
muscle weakness/cramping, irritability, restlessness, confusion, inverted T waves and prominent U waves on ECG. Hypokalemia potentiates dig toxicity, so if hypokalemia present, assess for dig toxicity too
when do you give dig in relation to food?
1 hour before or 2 hours after food
What if you miss a dose of dig?
if it is more than 4 hours late, hold the missed dose and just give the normal dose at next scheduled time. If less than 4 hours late, administer the missed dose
widened pulse pressure and bounding pulses
patent ductus arteriosus
blood pressure is higher in the upper extremities than the lower extremities; bounding pulses in the arms, weak or absent femoral pulses, and cool lower extremities (leading to HA, dizziness, and nose bleeds from HTN)
coarctation of the aorta
VSD, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy
Tetralogy of Fallot: tet spells-> squatting
periorbital edema, dependent edema
signs of HF
Actions to take if a hypercyanotic spell occurs in an infant
place the infant in knee-chest position
administer 100% O2
administer morphine (to reduce infundibular spasm)
fluids
post cardiac catheterization interventions
monitor pulse ox for 4 hours
assess pulses below the catheter site for equality and symmetry
VS q15 mins for one hour, then q30mins for 2hours, then qhour for four hours
signs of sepsis
fever, chills, diaphoresis, lethargy, and altered LOC
home care after cardiac surgery
omit play outside for several weeks
avoid activities such as biking where a fall could occur for at least two weeks
child may return to school usually the third week, but only half days
avoid immunizations, invasive procedures, and dental visits for TWO MONTHS!!
an inflammatory autoimmune disease that affects the connective tissues of the heart, joints, skin, blood vessels, and CNS
Rheumatic fever: most serious complication is rheumatic heart disease, which affects the cardiac valves, particularly the mitral valve
rheumatic fever manifests 2-6 weeks after an untreated Group A beta hemolytic strep infection of the upper respiratory tract–ask about a recent sore throat!**
Jones Criteria for Diagnosis of Rheumatic Fever
carditis arthralgia chorea erythema marginatum subcutaneous nodules elevated ESR or positive C-reactive protein prolonged PR interval on ECG
Rheumatic fever assessment
low grade fever that spikes in early afternoon aschoff bodies (lesions found in the heart, blood vessels, brain and serous surfaces of the joints and pleura)
What to do if a child is demonstrating chorea?
initiate seizure precautions
Kawasaki Disease
is an acute systemic inflammatory illness that may develop aneurysms
assessment of Kawasaki Disease
Irritability that may last for 2 months after the onset of symptoms
Acute: fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of cervical lymph nodes
Sub Acute: cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, thrombocytosis
What med do you give for Kawasaki Disease?
Aspirin! antipyretic and antiplatelet (additional anticoags may be needed if aneurysms present)
Immunoglobulin IV to reduce the duration of the fever and the incidence of coronary artery lesions and aneurysms.
machinery like murmur?
patent ductus arteriosus
antecedent GAS, pharyngitis, or tonsillitis 2-3 weeks before symptoms
Glomerulonephritis: characterized by inflammatory injury in the glomerulus, most of which are caused by immunological reaction. Inflammation of the glomeruli results from an antigen-antibody reaction produced by an infection ELSEWHERE in the body.
periorbital and facial edema that is more prominent in the morning, decreased UOP, cloudy, smoky, brown-colored urine (hematuria), pallor, irritability, lethargy, HA, abd flank pain, dysuria, HTN, proteinuria->foamy urine, Azotemia, Increased BUN/Cr
Glomerulonephritis
massive proteinuria, hypoalbuminemia, and edema
nephrotic syndrome: give corticosteriods
acquired hemolytic anemia, thrombocytopenia, and kidney failure
proteinuria, hematuria, and urinary casts
elevated BUN/Cr
decreased H&H
Hemolytic-Uremic Syndrome: hemodialysis and peritoneal dialysis if anuric. Administer blood products if anemia is severe
cryptorchidism
testes didn’t descend; not palpable
Epispadias and Hypospadias
congenital defects involving abnormal placement of the urethral orifice of the penis.
disorder characterized by impaired movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system
Cerebral Palsy
extreme irriability and crying, feeding difficulties, abnormal motor performance, alterations in muscle tone (stiff and rigid arms or legs), delayed developmental milestones, persistence of primitive infantile reflexes (Moro, tonic neck) after 6 mos (most primitive reflexes disappear by 3-4 mos of age) ABNORMAL POSTURING SUCH AS OPISTHOTONOS, seizures may occur
Cerebral Palsy
Which is more serious, an open head injury or closed head injury?
A closed head injury due to risk of IICP in a closed vault: this can occur in shaken baby
the child’s LOC provides the earliest indication of an improvement of deterioration of the
neurologic condition
Early signs of IICP
slight change in VS
slight change in LOC
irritable, high-pitched cry, bulging fontanel, increased head circumference, dilated scalp veins, Macewen’s sign (cracked pot sound on percussion of the head), setting sun sign (sclera visible above the iris)
HA, n/v, visual disturbances, seizures
Late signs of IICP
significant decrease in LOC
bradycardia
altered pupils
decorticate posturing, decerebrate posturing, Cheyne-Stokes respers, coma
signs of brainstem involvement
deep, rapid, or intermittent and gasping respers
wide fluctuations or noticeable slowing of pulse
widening pulse pressure or extreme fluctuations in BP
sluggish, dilated, or unequal pupils
asymmetrical pupils
may indicate a neurosurgical emergency such as an epidural hematoma
acute encephalopathy that follows a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver. A diagnosis is made via liver biopsy
Reye’s Syndrome: Tx goal is to maintain effective cerebral perfusion and control IICP
viral illness 4-7 days prior to symptom onset, fever, n/v, signs of altered hepatic fxn (lethargy), progressive neuro deterioration, increased ammonia
Reye’s syndrome assessment
What do you ask r/t seizure?
obtain info from parents about the time of seizure onset, precipitating events, behavior before and after the incident, history r/t seizures, and ask the child about the presence of an aura (a warning sign of an impending seizure). Monitor for apnea and cyanosis
associated deficits include sensorimotor disturbance, dislocated hips, talipes equinovarus (clubfoot) and hydrocephalus.
Neural Tube Defects include spina bifida and meningocele and myelomeningocele
gently flexing the infant’s legs, with knees together, resting the soles of the feet on the bed. The height of both knees should be equal
galeazzi’s sign aka Allis’s sign test for hip dysplasia
the examiner abducts the thigh and applies gentle pressure forward over the greater trochanter. A “clicking” sensation indicates a dislocated femoral head moving into the acetabulum
Ortolani’s test for hip dysplasia
the examiner adducts the hips and applies gentle pressure down and back with the thumbs, feeling for the femoral head to move out of the acetabulum
Barlow’s test
intervention for hip dysplasia for birth-6 mos age
splint the hips with a Pavlik harness to maintain flexion and abduction and external rotation
intervention for hip dysplasia 6-18 mos age group
gradual reduction by traction followed by closed reduction or open reduction if necessary under general anesthesia. Child is then placed in a spica cast for 2-4 mos until the hip is stable. Then a flexion-abduction brace is applied for approx 3 mos
club foot Tx
treatment begins as soon after birth as possible. Manipulation and casting are performed weekly for about 8-12 weeks bc of the rapid growth of early infancy; a splint is then applied if casting and manipulation are successful. Monitor for pain and perform neuro checks on the toes
asymmetry of the ribs and flanks is noted when the child bends forward at the waist and hangs the arms down toward the feet
adam’s test for scoliosis
monitor for superior mesenteric artery syndrome
caused by mechanical changes in the positions of the chil’d abd contents during thoracic surgery to correct scoliosis. Notify HCP if it occurs. Signs are emesis and abd distention similar to what you see in intestinal obstruction or paralytic ileus.
methotrexate
CBC and LFT’s monitored closely during therapy
disorder of connective tissue that affects the skeletal system, cardiovascular system, eyes and skin
marfan’s syndrome
If a child is HIV positive, do you still follow the immunization schedule?
yes, but only the inactivated influenza vaccine. No measles, give immunoglobulin after measles exposure, only inactivated IM shot for polio, NO ROTAVIRUS or VARICELLA
Rubeola (Measles)
communicable from 4 days before rash appears to five days after
Source of infection may be respiratory tract secretions, blood, or urine
Airborne, contact precautions necessary; transplacental
coryza, cough, conjunctivitis
Measles (Rubeola) (Coryza is inflammation of MM in nasal cavity)
rash appears as red, erythematous maculopapular eruption starting on the face and spreading downward to the feet. Blanches easily with pressure and gradually turns a brownish color (last 6-7 days) may have desquamination
Measles (Rubeola)
Koplik’s spots
small red spots with a bluish white center and a red base; located on the buccal mucosa and last 3 days; Measles (Rubeola)
Which vitamin do we give to Measles?
vit A; Vitamin A is a necessary substrate for preserving epithelial cell integrity and in addition plays a role in immune modulation.
Roseola (Exanthema Subitum)
Agent is Human herpes virus type 6
incubation 5-15 days
communicable from febrile stage to the time the rash first appears
sudden high fever or 3-5 days’ duration in a child who appears well, followed by a rash (rose-pink macules that blanch with pressure) rash appears several hours to 2 days after the fever subsides and lasts 1-2 days
Roseola (Exanthema Subitum)
Rubella (German Measles)
incubation 14-21 days
communicable from 7 days before to 5 days after rash appears
source is nasopharyngeal secretions, blood, stool, urine
Airborne and contact precautions, fomites, transplacental
pinkish red maculopapular rash that begins on face and spreads to the entire body within 1 to 3 days. Petechiae may occur on the soft palate.
Rubella (German Measles)
mumps
incubation period is 14-21 days
communicable immediately before and after parotid gland swelling begins
source: saliva and urine
Airborne and contact precautions
jaw or ear pain aggravated by chewing, followed by parotid glandular swelling; orchitis (testes swollen) may occur
Mumps
Varicella (Chickenpox)
incubation 13-17 days
communicable from 1-2 days before rash to 6 days after the first crop of vesciles, when crusts have formed
source: respiratory tract secretions and skin lesions (at home, isolate child until the vesicles have dried)
transmitted via airborne, contact, and fomites
macular rash first appears on the trunk and scalp and moves to the face and extremities. lesions become pustules, begin to dry, and develop a crust.
varicella
Pertussis (Whooping Cough)
incubation 5-21 days (usually 10)
communicable greatest during the catarrhal stage (when discharge from respiratory secretions occur)
source: respiratory secretions
transmission: contact or airborne, fomites
symptoms of respiratory infection followed by increased severity of cough, with a loud whooping inspiration; may experience cyanosis, respiratory distress, and tongue protusion
Pertussis (whooping cough)
Do infants receive maternal immunity to pertussis?
no
diptheria
incubation 2-5 days
when is ditheria no longer communicable?
variable, until virulent bacilli are no longer present (three negative cultures of discharge from the nose and nasopharynx, skin, and other lesions) usually 2 weeks, can be 4 weeks
foul-smelling, mucupurlent nasal discharge, dense pseudomembrane formation in the throat that may interfere with eating, drinking, and breathing. Lymphadenitis, neck edema, BULL NECK
diptheria
Diptheria interventions
strict isolation diptheria antitoxin (after a skin or conjunctival test to rule out sensitivity to horse serum) Abx Suction as needed ready for tracheostomy
Poliomyelitis
enterovirus
incubation 7-14 days
oropharyngeal secretions and feces
abdominal pain followed by soreness and stiffness of the trunk, neck, and limbs that may progress to CNS paralysis
poliomyelitis
poliomyelitis interventions
enteric and contact precautions
monitor for respiratory paralysis
Scarlet Fever
GAS
incubation 1-7 days
communicable about 10 days during the incubation period and clinical illness.
contact and airborne precautions, fomites
abrupt high fever, flushed cheeks, vomiting, HA, enlarged lymph nodes in the neck, malaise, abd pain
scarlet fever
red, fine sandpaper like rash develops in the axilla, groin, and neck and spreads to cover the body EXCEPT the face. Rash blanches with pressure except in areas of deep creases and fold of the joints. Desquamination, sheetlike sloughing of the skin on palms and soles of feet by weeks 1-3.
scarlet fever
tonge is initially coated with a white, furry covering with red projecting papillae (white strawberry tongue). By the third to fifth day, this coating sloughs off, leaving a red, swollen tongue (red strawberry tongue)
scarlet fever
tonsils are reddened, edematous, and covered with exudate
scarlet fever
pharynx is edematous and beefy red
scarlet fever
Institute contact and respiratory precautions until 24 hours after Abx
scarlet fever
left upper quadrant pain, left shoulder pain
signs of splenic rupture: Mono
what about preemies and vaccines?
children born preterm should receive the full dose of each vaccine at the appropriate chronological age
a history of an anaphylactic reaction to neomycin is a contraindication to which vaccine?
IPV (polio)
contraindications for Hep B vaccine?
less than 2000g weight
allergy to aluminum hydroxide or yeast protein
