Test #7 Flashcards
What do you assess for when assessing the musculoskeletal?
- Observe infant’s movements in crib
- Inspect for differences in extremity length & size
- Assess muscle tone & symmetry
- Gentle passive ROM to assess joint rotation
- Assess head lag
-Skin folds on thigh (To see their musculature in their long bones,
are they attached how they should be? Are the folds symmetrical)
- Posture, gait, strength, screening
- Comparing left to right extremities, ROM
- Comparing growth & development to normal chart (nutrition, activities)
Promote well child visits, see doctors at scheduled times
Nutritional Status Assessment: HAIR is a good indicator,
height/weight, bowels
-Complaints, history
What do you assess for when pertaining to sleep and how many hours a night do children need by age?
- Infants periods of reactivity
- # of hours of sleep/day/age & growth
Newborn: 15-20 hours a day
Toddler 2-4 years: 12-14 hours a day
Preschool 4-6 years: 10-12 hours a day
School Age 6-12 years: 8-12 hours a day
Adolescent 12-18 years: 9 hours a day (Most only get about 6 hours)
-Sleep Apnea: stop in breathing of greater than 20 seconds
Not going to grow as well
-SIDS Prevention (P. 107)
What is Comparment Syndrome?
occurs when swelling causes pressure within these closed fascial compartments to rise, compromising vascular perfusion to the muscles and nerves
What are some assessments for Compartment Syndrome?
severe pain, often unrelieved by analgesics
signs of neurovascular impairment
If extending the fingers or wiggling the toes produces pain, and/or the quality of the radial or pedal pulse is poor to absent
What are some assessments of Cast Syndrome of a child in a hip spica cast?
Abdominal Cramps
Bloating
Vomiting
How do you prevent cast syndrome with a hip spica cast?
Reposition Q2HR
Inc fluid & dietary fiber
Provider cut a “belly hole” to allow “belly” expansion
Legs abducted
What are all the items we need to teach for home cast care?
Check the Edges of the Cast as Follows:
- If they appear rough or are irritating the skin, “petal” the cast by overlapping moleskin or adhesive tape (1 to 2 inches in width; 3 to 4 inches in length with one rounded edge) around the cast edges.
- Waterproof tape should be used in the perineal area.
To Assist with Drying the Cast, Do the Following:
- Place the child on a firm mattress.
- Support the cast and adjacent joints with pillows.
- For a plaster cast, reposition every 2 to 4 hours to ensure thorough drying.
- Lift the cast with the palms of your hands.
- You may direct a fan toward the cast to facilitate drying.
- Once dry, the cast should sound hollow and be cool to the touch.
Swelling Generally Peaks within 24 to 48 Hours. To Prevent Problems, Do the Following:
- Apply bagged ice to the casted area (be sure to keep melting ice from touching the cast or leaking underneath).
- Elevate the extremity at the level of the heart with pillows.
- Apply pressure to the nail bed of the child’s casted extremity and count how long it takes for the color to return (it should take no longer than 2 seconds). Repeat every 2 hours for the first 24 to 48 hours.
- The casted extremity should be the same color and temperature as the other extremity.
- Check each finger or toe for sensation and movement several times each day for 2 days.
Protect the Cast as Follows:
- If the child is permitted to bathe or shower, be sure to cover the cast with plastic and waterproof tape to keep the cast dry.
- Do not put anything inside the cast. Keep small toys and sharp objects away from the cast. Supervise your child during mealtimes so the child does not get food underneath the cast.
Contact the Physician If Any of the Following Occurs:
- The cast feels warm or hot or has an unusual smell.
- Any drainage or blood suddenly appears on the cast.
- Your child reports pain, burning, numbness, or tingling.
- The extremity changes color or temperature, or any swelling persists.
- Any fever above 101.5° F (40° C) taken by mouth.
- Slipping of cast, inability to visualize toes or fingers.
When Preparing to Remove the Cast, Do the Following:
- Explain the cast removal to your child. The cast remover works by vibration that creates a warm tickling feeling on the skin and sounds like a vacuum cleaner.
- Allow time for the child to adjust to the cast remover. Ask the technician or physician if your child can examine the cast remover and see how it works ahead of time.
- Once the cast is removed, the skin will be dry and flaky. Wash the area with warm water and soap. Discourage the child from scratching.
• The extremity will be stiff for a while and will look smaller because the muscles have not been used. It may need to be supported with a sling. Normal movement will correct the stiffness. (McKinney 1347)
McKinney, Emily, Susan James, Sharon Murray, Kristine Nelson, Jean Ashwill. Maternal-Child Nursing, 4th Edition. W.B. Saunders Company, 2013. VitalBook file.
What are some nursing care items of a child in skin traction?
- Fractures, muscle spasms, spine alignment
- Neuromuscular assessments Q4H
- Traction weights checked, hanging free
Don’t bump, don’t move, monitor the pull of traction that
they are in alignment, don’t set on bed, don’t let touch the floor
- Perform skin care Q4H
- Provide diversional activities
3 Year Old: Painting, iPad, Things that move and keep attention
8 Year Old: Video Games, homework, tutoring, movies, books
Teenage: Phone, friends, electronics
P. 1341 Box For Tractions
What are all the nursing care items for a child in skeletal traction? TONS
- Portal of Entry - RISK for infection!! HUGE!
- Localized infection of the tissue, the bone and can lead to sepsis!
- Neuromuscular assessment Q4H
- Pins going into the bone
- Know signs of compartment syndrome & report them to PCP immediately
Causes decrease in blood flow and the tissues do not receive blood flow thats needed
Causes tissue death
Irretractable pain, delayed cap refill, check peripheral pulses distal, lack of blood flow, pallor, pulselessness, paresthesia (This is when there is already tissue death), pain, paralysis (Tissue death), poikilothermic
Interventions: Elevate extremity, split cast to relieve pressure (Make sure to maintain alignment), may need surgery to restore blood flow
- Maintain Traction
- Assess & care for pin sites with post-op VS for S/S of infection
- Prevent Skin Breakdown
- Manage pain
- Maintain good nutrition & elimination
Inc Fiber, protein, green leafy’s, fruit
-Assess for complications
osteomyelitis, pneumonia, circulatory,
compromise, ischemia, & disuse
PT, OT all come to help keep things working good
- Prepare family for discharge
- Provide psychosocial support
- POST OP CARE: EXTERNAL FIXATOR (P.1343)
Neurovascular checks
Pin care
Drainage
Collaborate with Physical Therapy
Prepare to self/family care at home
We do a neurovascular assessment every 2 hours for the first 48 hours after cast/traction is applied. What are we looking for?
- Done at least every 2 hours during the first 48 hours after the device is applied
- Pain: Does the child complain of pain in the affected limb? Is It relieved by narcotic medication? Does it become worse when fingers or toes are flexed? If yes, notify provider PCP IMMEDIATELY (Compartment Syndrome P.1344)
- Sensation: Can the child feel touch on the extremity? Is two-point discrimination decreased? If yes call PCP IMMEDIATELY (Compartment Syndrome)
- Temperature: Does the affected limb feel warm? Does it feel cool? A cool extremity may change to feeling warm if a blanket is placed over it and the extremity is elevated to heart level. If the extremity is still cool after these interventions, there is poor circulation
- Edema: Compare the size of the extremity with the other extremities
- Capillary refill time: Apply brief pressure to the nail bed and note how quickly pink color returns to the nail bed. <3 seconds is normal. If >3 sec, circulation is poor
- Color: Note the color of the affected limb. Compare it to the color of the unaffected limb. Pink is the norm. If the color is paler than the unaffected limb, circulation is poor
- Motion: Can the child move fingers or toes? Lack of movement may indicate nerve damage
Pulses: Check pulses distal to the injury or cast. If the pulse is difficult to locate, assess with a doppler and mark the spot with an X. If the cast covers the foot or hand, it may not be possible to check the pulse, but the other neurovascular assessment can be implemented
What are the affects of immobility?
-Decreased Muscle Strength
Decreased Venous return
Dec Cardiac Output & Dec Exercise intolerance
-Bone demineralization: Osteoporosis
Fractures (Inc in lab values)
Hypercalcemia:
Cardia irregularity, renal calculi, bone spurs
@ Risk for falls and fractures
-Slowed growth and development
Orthostatic Hypotension
Difficulty expanding chest/pneumonia
Difficulty feeding, anorexia, constipation
Urinary retention/infection
Skin Breakdown
Boredom/Separation from friends & family
Nursing Plan P. 1345 Table 50-2
Promote Health & Safety
What are some consequences of immobility?
Integumentary:
Red or irritated skin, presence of ulceration or drainage
Impaired Skin Integrity
PREVENT: Reposition the child every 2 hr and as needed; encourage the child in traction to use a trapeze to facilitate movement.
Use an egg crate–type or sheepskin mattress for comfort under the back and lower legs. If the child is not capable of any independent repositioning or has decreased sensation, use a pressure relief overlay or mattress. Pay particular attention to the heels to prevent skin breakdown.
Wash and thoroughly dry the areas twice a day; refrain from using lotion, powder, or talc, which can retain moisture.
Change the untrained child’s diapers frequently to prevent skin breakdown.
Examine and record the child’s skin condition once per shift.
Gastrointestinal
Decrease in number or consistency of bowel movements because of decreased gastrointestinal motility
Risk for Constipation
Assess bowel sounds, abdominal distention, elimination pattern; be sure to know the child’s normal pattern, usual stool consistency, and words used for defecation.
Provide a diet high in roughage and fiber and increase fluid intake with foods and fluids the child likes.
Position the child as upright as possible during defecation.
Administer laxatives and/or stool softeners if needed.
Respiratory
Decreased or altered respirations, shortness of breath, decreased breath sounds, adventitious breath sounds
Ineffective Breathing Pattern
Assess respiratory status at least once per shift.
Encourage coughing and deep breathing through the use of games, such as blowing bubbles, pinwheels; older children can use an incentive spirometer.
Reposition every 2 hr and as needed.
Genitourinary
Decreased urinary output from stasis or retention, concentrated or foul-smelling urine
Impaired Urinary Elimination
Maintain hydration levels.
Offer juices (cranberry, apple) and acid-ash foods (cereal, meats) that will acidify the urine.
Monitor the child’s urinary output.
Musculoskeletal
Reduced strength and joint mobility, loss of muscle tone and potential for muscle atrophy, limited range of motion
Impaired Physical Mobility
Test muscle strength and joint mobility every shift and as needed.
Encourage active range-of-motion and stretching exercises of unaffected extremities.
Plan developmentally appropriate activities that require the use of unaffected extremities.
Provide foods high in protein and calcium.
Use elastic stockings or thromboembolic disease hose to promote venous return and decrease circulatory stasis.
Developmental regression, irritability, anxiety, excessive dependence on others, passive behavior
Powerlessness
Recognize the child’s need to regress in response to the immobility; help child regain prior developmental stages when ready.
Explain all routines and procedures to the child and parents and encourage them to participate in care.
Provide the opportunity for therapeutic play: modeling clay, paints, remote-control toys (which give the feeling of mobility and control), puppet play, storytelling, role playing.
Allow the child to use age-appropriate dishes and cups, clothing from home (may have to be adapted to fit over an immobilizing device), transitional object, night-light.
Determine and follow the child’s usual routine.
Encourage the school-age child and adolescent to keep up with schoolwork and keep in contact with peers.
Frequently provide a change in environment: move the bed to take advantage of a different view; move the bed into the playroom; keep side rails up for safety.
Allow and encourage the child’s autonomy in decision making.
What is the first thing we do when there is an Emergency situation with a fracture?
1st: Survey the scene
2nd: Assess extent of injury
What are the 6P’s and T for Neurovascular assessment?
Pain & point of tenderness
Pulses-distal to the fracture site
Pallor
Paresthesia-Sensation distal to fx site
Paralysis-Movement distal to fx site
Pressure-Skin is tense, edema
Temperature distal to fx site compare to the other extremity
What are the steps you take after surveying the scene and assessing injury when there is a fracture?
- Determine mechanism of injury: History
- Immobilize the injury and maintain alignment
- Cover open wounds with sterile or clean dressing (moist)
- Immobilize the limb, including joints above & below the fracture site
- Do not attempt to reduce the fracture or push protruding bone under the skin
- Soft Splint (pillow or folded towel)
- Rigid Splint (Rolled newspaper or magazine)
- Uninjured leg can serve as a splint for leg fx
- Reassess neurovascular status
- Apply traction if circulation compromised
- Elevate injured limb if possible
- Apply cold to injured area (For inflammation and to stop blood flow)
Call emergency medical service or transport to medical facility
What are some assessments if there is a fracture? Open/Closed
-Of a CLOSED fracture:
Generalized swelling
Pain or tenderness
Diminished function/use-Small child refuses to walk/crawl
May include: bruising, severe muscular rigidity, crepitus/grating
Positive X-Ray, MRI, CT scan, fluoroscopy or myelogram
-Additional findings of an OPEN fracture
Bleeding and visible bone possible
What are some fracture complications?
- Compartment syndrome
- Shock
- Fat Emboli - When long bones are broken there are small pieces of fat in the bone marrow. It can escape into the tissue and end up in the blood supply… BAD NEWS
SOB, Cyanosis, Chest Pain, Impending Doom
- Deep Vein Thrombosis
- Pulmonary Embolism
Movement of all the fat and bone getting into the lungs
-Infection
Especially open fracture, surgery with pins
What are some nursing care items for a fracture?
-Obtain Hx
Can be a sign of abuse
- Perform neurovascular assessment
- Prevent infection: ABT, wound cleansing
- Manage Pain
- Care of immobilizers (splints, braces, cases, external fixators, or traction) after closed or open reduction
- Provide Pin care (if applicable)
- Prevent Complications
- Restore function
- Educate Family (Nutrition)
Protein, Calcium (dairy & green leafy)
Care of immobilizers
Provide emotional support
What are some assessments for soft tissue injuries?
Pain, swelling, and ecchymosis
Evaluate neurovascular & ROM
What are some interventions for soft tissue injuries?
RICE (P.1351)
Immobilize the joint
Collaborate with PT
Ibuprofen or acetaminophen
Provide Home care education
Sports Injury
Use protective gear, stretch before
What are some assessments for Osteomyelitis?
Localized tenderness, redness, warmth & dec mobility
Pain on palpitation
Affects the whole body, VS, Fever
Frequently a hx of trauma
Check tetanus immunization
Positive radiography, CT scan
Blood Cultures - Do BEFORE antibiotics
What are some interventions for osteomyelitis?
Contact isolation for open wounds
IV Antibiotics & IV site care
Infiltration, Phlebitis, Allergic reaction, adverse reaction to meds, interactions with IV fluids
Monitor erythrocyte sedimentation rate (ESR), C-Reactive protein, CBC, CMP
Indicates how well the infection is doing and responding (DEC ESR & C-Reactive Protein)
Promote rest & manage pain
Turn gently with limb positioned & supported
Monitor I&O
Nutrition balanced - Inc protein, Vit C & Calories
Diversional activities
Teach parents about antibiotic completion
What are some assessments for tetanus?
Progressive stiffness and tenderness of the muscles in the neck & jaw
Trismus (Difficulty opening the mouth)
Risus Sardonicus (A peculiar Grin)
Opisthotonus Posturing (Neck is pulled back and tight)
Laryngospasm of the respiratory muscles
Tetanus Prophylaxis through immunization is the key to preventing tetanus
What are some interventions for tetanus?
Give tetanus Immuno Globulin (TIG) and antibiotics
Closely monitor and maintain respiratory support
Monitor fluids, electrolytes & calorie intake
Give NG feedings or TPN,
Assist with ET intubation (Laryngospasms)
Eliminate stimulation
Conduct frequent neurological assessments
Assess O2 Saturation and blood gases
Perform oropharyngeal suctioning
Give medications - Neuromuscular blocking agent requires ventillation support
Maintain Hydration
Collaborate with other health team members
Medications
Diazepam
Lorazepam
Baclofen
Dantrolene Sodium
Midazolam
Rocuronium
Vecuronium (Neuromuscular medication that causes muscles to calm and relax) (BE FAMILIAR)
What are some assessments for Scoliosis?
Unequal shoulder heights
Scapulae prominences
Waist angles
Rib prominences
Chest Asymmetry
Leg Length Discrepancy
What are some interventions for scoliosis?
Discuss bracing & exercise
Assess body image & maintain brace use
Less than 25 degrees it will be watched
More than 25 degrees it will go to a brace - Goal is to prevent further curvature
Tight fitting shirt under their brace to prevent breakdown (NOT an option)
PRE-OP CARE (P.1355)
Explain to child and parents what to expect
Tour ICU
Teach ROM exercises
POST-OP CARE
VS, Neuro status
Fluid balance
Pain Control
NG Tube
Advance Diet
Chest Tube
S/S of infection
Logrolling
Preventing constipation
Discharge teaching, Community resources & encourage to be as active as possible
Alternative - Chiropractics for initial treatment
What are some care items for a child in a brace for scoliosis?
Brace should be comfortable
Skin care
Wear fitted t-shirt beneath brace
Check brace daily for rough edges
What are some assessments for developmental dysplasia of the hip?
Asymmetry of hip folds
Limited abduction (Found early)
Allis Sign
Barlow Maneuver
Ortolanie Maneuver (move and you will feel a click)
What are some interventions for developmental dysplasia of the hip?
Pavlik harness (P.1362 50-10) - For less than 6 months most common
Monitor for skin breakdown, know how to secure in carseat
Keep top of femur where it should be
Hip Spica Cast
Prevent complications or injury
Parent education & support
What is LEGG-CALVE-PERTHES DISEASE ?
-Persistent hip pain that worsens with movement. It may initially come and go and be felt in other areas such as the groin, thigh, or knee. Patients typically limp or have limited ROM.
What are some assessments for Legg-calve-perthes?
Hip or knee soreness or stiffness
Painful limp, quadriceps muscle atrophy
What are some interventions for Legg-Calve-Perthes Disease?
Monitor non-weight bearing hip abduction, Bed Rest
Abduction brace may be used if bed rest isn’t workng, Looks like A
Assess ROM, pain & neurovascular status
Toronto brace - Feet are externally rotated
Educate brace
What are some treatments for Legg-Calves-Perthes disease?
Anti-Inflammatory meds, non-weight bearing and ROM exercises, bedrest
If it doesn’t get better in 7-10 days use:
Petrie Cast or abduction braces (Toronto brace)
What is slipped capital femoral epiphysis?
- Stress on the proximal femur at the time when the epiphyseal plate is just about to close – during adolescence. It is more common in obese or overweight boys.
- It is believe to be a combination of stress along with hormonal changes. Typically starts out only affecting one side but is seen bilaterally in 25% of the cases.
What are some assessments for slipped capital femoral epiphysis?
Adolescent growth spurt, obesity
Pain in groin, thigh or knee & limping
Worsens with any activity
Loss of Hip Motion
What are some interventions for slipped capital femoral epiphysis?
Bed rest to prevent further damage
Maintain non-weight bearing, NO ROM!
Post op care-PT, Crutches, walking
Address obesity if present, refer to dietician
Provide emotional support
Home care Teaching
How is slipped capital femoral epiphysis diagnosed?
X-Ray w/pt in frog-leg position
What is Duchenne Muscular Dystrophy?
Appears between 3 & 7
Waddling, wide based gait
The child will have to use the “Gower maneuver” to rise from the floor (described as putting hands on the knees and moving the hands up the legs until standing erect).
Ability to walk is lost between 9 & 12
Death is caused by cardiomyopathy and resp complications
Such as: Heart Failure/Sudden Cardia Arrest
What are some assessments for Duchenne MD?
Progressive symmetrical muscle wasting
Muscle weakness without loss of sensation
Gower maneuver
What are some interventions for Duchenne MD?
Focus on issues with immobility
Preventing contractures
Preventing skin breakdown
Prevent respiratory infections
Monitor skin
Help client maintain independence & self care
Ensure good nutrition
Increased fiber and decreased calories
Assess mobility & safety
Provide emotional support
Facilitate collaboration
Complimentary Care
How to turn, reposition, Do PROM, massage & when to call PCP
What is Juvenile Arthritis?
- JA is the leading cause of childhood disability and blindness. It is an autoimmune inflammatory disease with no known cause.
- It affects the synovial joints – movable joints that contain synovial fluid
How is juvenile arthritis diagnosed?
Child must be less than 16
Have swelling in at least 1 joint for more than 6 weeks that is not the result of trauma
What are some interventions for Juvenile Arthritis?
Medications
Corticosteroids
NSAIDS
DMARDs (Disease modifying antirheumatic drugs
Methotrexate
Prevent injuries and identify exacerbations
Encourage stretching 10 min prior to activity
Especially in am before getting out of bed
Teach family about disease and proper care
Eye Exams
Diet
Collaborate with physical & occupational therapist
Provide age-appropriate activities
Include the child in decision making
Proper nutrition
Increased fiber, protein, calcium & fluids
Monitor for chronic & acute uveitis (Intraocular inflammation)
What is osteosarcoma?
- MC Cancerous tumor affecting skeleton of children
- Usually follows injury to affected bone during rapid growth
- Prognosis good if caught early
What are some assessments for osteosarcoma?
Hx of injury & hx of discomfort
Palpation at site, tenderness, swelling, warmth, erythema
Limp
What are some interventions for osteosarcoma?
Administer chemotherapy P. 1268 Box 48-1
Sugery – limb sparing versus amputation
Manage Pain
Support & Refer client & family
Radiation – Only as palliative tx, doesn’t treat
What is HIV/AID?
- Human Immunodeficiency Virus
- Acquired Immunodeficiency Syndrome
- HIV is viewed as a chronic condition with ongoing challenges
- AIDS is the most advanced manifestation of the HIV infection
- Viral infection infects CD4 lymphocytes
What are the CDC classifications for children under 13 years of age?
Category N - Not symptomatic - Stage 1:
No signs or symptoms considered to be the result of HIV infection are present, or the child has only one of
the conditions listed in the mildly symptomatic section.
Category A - Mildy symptomatic - Stage 2
Two or more of the following conditions are present,
but the child has none of the conditions listed in the
moderately or severely symptomatic sections.
»»Lymphadenopathy
»»Hepatomegaly
»»Splenomegaly
»»Recurrent upper respiratory infections, sinusitis,
or otitis media
»»Dermatitis
»»Parotitis
Category B - Moderately symptomatic - Stage 3
›› Children with the following conditions are
considered moderately symptomatic.
»»Anemia
»»Bacterial meningitis, pneumonia, or
sepsis (single episode)
»»Oropharyngeal candidiasis
»»Cardiomyopathy
»»Cytomegalovirus infection, with onset before
1 month of age
»»Recurrent or chronic diarrhea
»»Hepatitis
»»Herpes simplex virus (HSV), stomatitis,
bronchitis, pneumonitis, or esophagitis
»»Herpes zoster
»»Nephropathy
»»Leiomyosarcoma
»»Lymphoid interstitial pneumonia (LIP) or
pulmonary lymphoid hyperplasia complex
»»Persistent fever (lasting more than 1 month)
»»Toxoplasmosis before 1 month of age
»»Disseminated varicella
Category C - Severely symptomatic - Stage 4
Children with the following conditions are
considered severely symptomatic.
»»Multiple serious bacterial infections (meningitis,
bone or joint, abscesses of internal organ or
body cavity, septicemia, pneumonia)
»»Esophageal or pulmonary candidiasis, (bronchi,
trachea, lungs)
»»Cytomegalovirus disease (greater than 1 month
of age with site other than liver, spleen, or
lymph nodes)
»»HSV stomatitis, bronchitis, pneumonitis, or
esophagitis lasting longer than 1 month
»»Kaposi’s sarcoma
»»Brain or Burkitt’s lymphoma
»»Disseminated or extrapulmonary
mycobacterium tuberculosis
»»Encephalopathy with developmental delays
»»Disseminated coccidioidomycosis
»»Extrapulmonary cryptococcosis
»»Cryptosporidiosis or isosporiasis with diarrhea
longer than 1 month
»»Disseminated histoplasmosis
»»Pneumocystis carinii pneumonia
»»Multifocal leukoencephalopathy
»»Salmonella septicemia
»»Toxoplasmosis of the brain
»»Wasting syndrome
Who gets infected with HIV/AIDS?
Blood, tissue, mom to infant
Infants
During pregnancy
Labor
Birth
After birth if breastfed
Adolescents
Sexual contact
IV drug use
Both contaminated blood exposure
What are some assessments for HIV?
Frequently Present, Highly Indicative Signs
- Repeated or persistent respiratory tract infection
- Repeated or persistent otitis media or sinusitis
- Severe bacterial infections
- Opportunistic infections, such as Pneumocystis jiroveci (PCP) or cryptosporidiosis
- Poor response to appropriate therapy
Frequently Present, Somewhat Suggestive Signs
- Skin lesions
- Failure to thrive or grow
- Chronic diarrhea
- Thrush
- Hepatosplenomegaly
- Anemia, thrombocytopenia, neutropenia
- Small or absent lymph nodes, tonsils, and adenoids
**BIG signs in infants: Persistent Failure to thrive, thrush, cradle **
What are some diagnostics for HIV?
Identifying, treating and educating HIV-positive pregnant women is a must
ELISA or western blot (mom can refuse to test self and baby)
Enzyme Link Immunosuppressive
Not accurate for + or - dx in infants younger than 18 months
Passive maternal antibodies until around 18 months
Virologic testing at:
Immediately following birth in known exposure risk
14-21 days
1-2 months
4-6 months
12-18 months to confirm
2+ on two separate occasions gives + dx
2 - on two separate occasions taken at 1 month and older in non-breastfed infants gives - dx
CD4+ counts & HIV RNA assays assess: (P.629 & 1049 Medications)
Infected children’s immune status
Response to therapy
Risk for disease progression
Need for PCP prophylaxis after age 1
Measured at dx and every 3-4 months after
Stable adolescents may be done less frequently
What are some interventions for HIV?
Infants born to +moms start oral ZDV therapy within 6-12 hours after birth
Prevent infections
Facilitate growth and development
Medications as prescribed (P.629 &1049 Table 1)
Antiretrovirals
ZDV P. 629 in box
Norvir (Look it up! Will be on test)
They will only take meds until - or + dx.
Then depending on viral loads.
If they are above 500-600 they will not need to take medications.
Pain Relief
Small frequent meals, high calorie, high protein
Encourage fluids
Provide play time
Prevention
Immunizations
Table P.1062 42-2
Rotavirus and Varicella maybe not given
Provide Support
Give references
www.aidsinfo.nih.gov
What is sickle cell anemia?
- Genetic Disorder
- Production of sickle hemoglobin (HBs), chronic hemolytic anemia, and ischemic tissue injury
- RBCs become sickle shaped and rigid
- Rigidness obstructs the capillary blood flow and tissue hypoxia
- May result in a crisis
Vaso-Occlusive crisis is a crisis of sickle cell. What are some characteristics, manifestations and treatments for a painful episodes?
—————————-CHARACTERISTICS
Most common type of crisis and reason for hospitalization
Typically produces bone or joint pain, but pain can occur anywhere
Pain may come and go
Frequency of pain is individualized
Pain is precipitated by infection, cold, stress, acidosis, local or generalized hypoxia
—————————-MANIFESTATIONS
Mild: Joint or bone pain lasting a few hours
Severe: Joint or bone pain lasting days
—————————-TREATMENT
Oral analgesics initially and, if ineffective, IV opioids (usually morphine), which may be given by either intermittent or continuous infusion
Oral or IV NSAIDs
Oral and IV hydration
Aggressive incentive spirometry use (10 breaths every 2 hr when awake)
Consistent manner to assess subjective experience of pain is essential
Use of nonpharmacologic pain management strategies in addition to medications (McKinney 1247)
McKinney, Emily, Susan James, Sharon Murray, Kristine Nelson, Jean Ashwill. Maternal-Child Nursing, 4th Edition. W.B. Saunders Company, 2013. VitalBook file.
Vaso-Occlusive crisis is a crisis of sickle cell. What are some characteristics, manifestations and treatments for a Acute Chest Syndrome?
————————-CHARACTERISTICS
Common cause of hospitalization
Sometimes confused with pneumonia
Can recur
————————MANIFESTATIONS
Chest pain, fever, cough, abdominal pain
————————-TREATMENT
IV hydration (1-1½ times maintenance), antibiotics, oxygen, RBC transfusion, analgesics
Vaso-Occlusive crisis is a crisis of sickle cell. What are some characteristics, manifestations and treatments for Dactylitis (hand-and-foot syndrome)?
———————CHARACTERISTICS
Occurs in children ages 6 mo to 4 yr
Self-limiting complication
———————MANIFESTATION
Swelling of hands or feet, pain, warmth in affected area
———————TREATMENT
Oral analgesics, hydration (oral or IV), rest
Vaso-Occlusive crisis is a crisis of sickle cell. What are some characteristics, manifestations and treatments for Priapism (Persistent erection of the penis)?
———————–CHARACTERISTICS
Occurs if penile blood flow becomes obstructed
———————–MANIFESTATION
Persistent, painful erection
———————–TREATMENT
Analgesics; hydration
Avoid hot and cold packs
Vaso-Occlusive crisis is a crisis of sickle cell. What are some characteristics, manifestations and treatments for Cerebrovascular Accident?
——————————-CHARACTERISTIC
Without treatment, mortality rate of 20%; 70% of patients have a recurrence
——————————-MANIFESTATIONS
Hemiparesis or monoparesis, aphasia/dysphasia, seizures, alteration in level of consciousness, vomiting, vision changes, ataxia, headache
——————————-TREATMENT
Long-term RBC transfusion therapy or erythrocytapheresis and possibly chelation therapy
May require extensive rehabilitation
What are some triggers for a sickle cell crisis?
Dehydration
Hypoxia
Acidosis
What are some assessments for sickle cell anemia?
History
Symptoms usually appear after 4-6 months of age
Delayed growth and puberty are common
Pain
Fever of 101.3 or higher
We need to watch CLOSELY bc it can turn bad
Cough
Swelling
Decreased hemoglobin level
Pallor
Lethargy
Headache
What are some diagnostics for sickle cell anemia?
CBC
Isoelectric focusing
Hemoglobin electrophoresis (Dx tool for this disease)
High performance liquid chromatography
Children have elevated reticulocyte counts
Prenatal Dx between 8-10 weeks using chronic villus sampling
15 weeks using amniocentesis
What are some interventions for sickle cell crisis?
Adequate hydration and blood flow
Administer O2
Blood transfusion (1 QUESTION)
Administer analgesics as prescribed
Opiods and NSAIDS
Elevate HOB no more than 30 degrees
Prevent Infection
Administer abx as prescribed
Prevention of crisis
Education
P.1248 - Home care Box
ENCOURAGE FLUID INTAKE
What is the first intervention for sickle cell crisis?
Pain relief then O2 (Usually at the same time)
Make sure blood is warm
What is Hemophilia?
- Lifelong hereditary blood disorder
- No cure
- Different types depending on the coagulation factor deficiency
- X-Linked autosomal recessive disorder
–Carrier females pass on the defect to affected males
-Rare for females to have
What are some assessments for hemophilia?
History
Family
Client
Monitor for bleeding
What are some diagnostics for hemophilia?
Often dx after circumcision
May be delayed until the toddler years
PT
PTT
Bleeding time
Fibrinogen level
Platelet count
Quantitative immunoelectrophoretic assay
Factor VIII and IX assays
What are some interventions for hemophilia?
Individual
Depends on severity of illness
Goal is to prevent excessive bleeding
May require transfusions
Factor replacement therapy
Factor 8 & 9 replaced into blood
Prophylactic therapy
Avoid activities that induce bleeding
No contact sports
Protect joints
Bleeding is treated with RICE
Treat the area that is bleeding, pressure on wound, RICE, watch for level of consciousness if hit head
Make sure when we pull out/put in IV or foley on these kids be aware of excessive bleeding and monitor.
NO ASPIRIN!!!
If you walk in a room and your client is bleeding PUT ON GLOVES then Apply pressure!!
What is Immune thrombocyopenia pupura?
-Acquired bleeding disorder characterized by :
Thrombocytopenia
Purpuric Rash
Normal Bone Marrow
Absence of signs of other identifiable causes of thrombocytopenia
Acute or Chronic
Better in 6 months ACUTE; Lasts longer than 6 months CHRONIC
MC acquired bleeding disorders in children
Whatare some assessments for ITP?
Sudden onset of bruising and petechiae
Bleeding involving mucous
Child is otherwise in good health
What are some diagnostics for ITP?
History
Family (Gumline bleeding)
Medications
CBC
Platelet count might be low but everything else is normal
Physical Examination
Had a febrile illness in the last month
May do bone marrow aspiration to rule out oncology issues
What are some interventions for a child with ITP?
Priority is to prevent rare but lefe-threatening bleeding events
Restore platelet count to above 20,000/mm3
Treatment includes oral steroids and IVIG
Steroids may be 2-4 weeks
IVIG daily for 1-2 days
May need a splenectomy
Can cure children with chronic ITP (P.1257)
What is aplastic anemia?
- Anemia = Decreased iron in the blood
- Food high in iron - Green leafy, raisins
- Bone marrow ceases production of the cells it normally manufactures
- Everything is low!
- Results in peripheral pancytopenia
- Everything is low, RBC, hemoglobin, hematocrit, Etc!
- All formed elements of the blood are simutaneaously depressed
- Can be congenital or acquired
- Most cases in children are idiopathic - without an identifiable cause
What are some assessments for aplastic anemia?
Petechiae
Ecchymosis
Pallor
Epistaxis
Fatigue
Tachycardia
Anorexia
Infection
What are some diagnostics for aplastic anemia?
May be suspected from:
History
CBC
Bone marrow aspiration ONLY if necessary
MC known in posterior illiac crest - Can be done in tibia
Procedure doesn’t hurt but aftermath DOES!
Pain meds after procedure and heat/cold on it!
Watch for infection!
Confirmed by biopsy
What are some interventions for aplastic anemia?
If acquired - discontinue exposure to causitive agent
Treatment is otherwise based on symptoms
Bone marrow or allogeneic hematopoietic stem cell transplantation remains the treatment of choice for children with severe aplastic anemia, with a suitable donor.
Orange Juice helps absorbs iron
What is Leukemia?
- Group of malignancies that affect the bone marrow and lymphatic system
- Causes bone marrow dysfunction that leads to anemaia and neutropenia
- Abnormal uncontrolled proliferation of WBCs
- Most common form of cancer in children under 15
- ALL - Acute Lymphoblastic Leukemia
- Most Common
- Remission with a 5 year disease free survival rate of 85%
- More common in boys
- ANLL - Acure Nonlymphocytic Leukemia
What are some assessments for Leukemia?
Cause is unknown
Genetic factors appear to play a signifigant role
May present with :
Fever
Pallor
Excessive bruising
Bone or joint pain
Lymphadenopathy
Malaise
Hepotosplenomegaly
Abnormal WBC
Mild to profound anemia and thrombocytopenia
EARLY :
Low Grade Temp
Pallor
Chills
petechiae
Increased Bruising
Abnormal Bleeding
Abd, leg and/or joint pain
Headache
Constipation
Vomiting
Unsteady Gait
LATE
Hematuria
Ulcerations in the mouth
Enlarged kidney’s and/or testicles
Signs of Increased ICP
What are some diagnostics for Leukemia?
Strongly suspected from history and clinical presentation
Initial CBC
Confirmatory test is bone marrow aspiration and/or biopsy
BONE MARROW ASPIRATION (1 QUESTION)
May need to do lumbar puncture
Looks for blast cells in spinal fluid
Flow cytometry
What are some interventions for Leukemia?
Chemotherapy/radiation combination:
Ease adverse effects
Increase fluids to flush kidney’s
Help adjust to body image changes
Encourage family to use support group
Prevent Infections
Monitor skin for bruising and breakdown
Pain Relief
High protein, high calorie, bland diet
