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wvc 2 PEDS acute lec

wvc 2 PEDS acute lec G. McGregor

Growth – Increase in height and weight; physical size
Development – Increase in skill or ability to function
Maturation- used interchangeably with development; Children pass through predictable stages of growth and development
Birth to 1 Year A time of rapid growth; Rapid developmental changes; If there is a deficiency of nutrition or nurturing, it can impact the rest of the child’s life
Toddlers Quest for Autonomy; Rapid developmental growth; Terrible Twos and Truly Awful Threes
Preschool During this period, personality and cognitive growth are the defining development; Can do many ADLs independently; Vocabulary increased; Increased coordination; Has all deciduous teeth
School Age Slower physical growth; Rapid cognitive & developmental growth; Begin to make independent judgments; More influenced by attitudes of their friends than previously
Adolescence Transition between childhood and adulthood; Major physiologic changes; Social and psychological pressures; Begins separating from parents, finding own identity
Levels of Intervention Primary- Preventative interventions, such as immunizations, healthy lifestyle choices; Secondary- Screening, early diagnosis and treatment; Tertiary- Treating disease already established, acute or chronic illness
Barriers to Immunization Compliance…Complicated schedule with many injections; Parents forget to schedule; Child is sick and misses time for injection; Parents are concerned about possible bad side effects from immunization Parents are reluctant to inflict pain of injection; Parents believe their child is not at risk because other children have been immunized; Parents have never seen the diseases and do not view them as life-threatening
Impact of Illness… A child’s illness impacts the whole family; Illness has different meanings to different age groups; Helping and supporting the family during illness is a fundamental nursing role
helpful or negative to their hospitalization: positive affect/attitude, physical comfort, humor, advocacy, basic needs, acknowledgement and reassurance.
Caring for hospitalized children….Enter a child’s room with a smile and establish eye contact; Ask children directly how they feel and what they need; Acknowledge children by name and engage them in conversation Provide age-appropriate diversion and friendly interaction Provide basic needs in a gentle, organized manner; Check frequently, if only briefly, to assure the child’s safety and well being
More on Caring for hospitalized children….Remember, older children continue to need physical comfort, reassurance and conversation, they appreciate advocacy; Children/teens respect professionalism & want respect; Provide reassurance at the time of admission; Provide age-appropriate explanations of treatments, timely care, truthful responses and privacy
Age Specific Care Providing care based on the developmental age of the child; Takes into consideration physical, mental and emotional age; A knowledge of normal child development is necessary to provide this care
Assessing the Sick Child appearance is generally more important than chief complaint: Looks good, looks bad; Keep the developmental age in mind; may revert to earlier behaviors when ill; Know VS parameters; Look at the child; Listen to the parent
Five Hazards of Illness Experiencing harm or injury: physical discomfort, pain, mutilation, death; Separation from parents, peers, routines; Facing the unknown; Facing uncertain limits; Loss of control
How Children Respond to Illness Depends on cognitive development, past experiences and level of knowledge
Meaning of Illness Toddlers & preschoolers may think the cause of illness is magical; Early school age may think all illness and injury is caused by germs; Older school age knows illness is can be caused by injury, germs or other situations
Ability to Communicate Infants and young children cannot communicate what hurts, how it hurts – crying, whining, withdrawn; School age can usually describe where it hurts and other sx;mBe observant for non-verbal cues to symptoms of pain
Infant fears separation from primary caregiver
Toddlers & preschoolers fear separation, the unknown, mutilation of body parts. May believe illness is a punishment.
School age and adolescents may fear loss of body parts, loss of life or change in how they are viewed by peers
Parents experience anxiety & fears when their child is ill; This may manifest itself in anger, resistance, demanding behaviors; Preparing & educating the parents about what to expect & make them partners in care
Preparing the Infant can't understand verbal explanations; Make the environment non-threatening; Let them have familiar objects; Encourage primary caregiver to stay with the child as much as possible; Plan to have a consistent nurse with the hospitalized child when possible
Preparing the Toddler & Preschooler Try to alleviate main fears of separation, the unknown & mutilation; Allow them to keep a familiar personal object; Try to maintain familiar routines; reading books aimed at preparing them for hospital stay; Role playing; Be truthful w/out being scary
Preparing the School Age & Adolescent Can understand explanations or read about surgery or treatment; Be specific about any change in body image – scars, hair loss; May benefit from visiting the hospital unit prior to procedure; Allow them time to ask questions, be factual;
Preparing the Child from a Different Cultural Background Will still have a developmental component; Language may be a barrier, get a translator; Good listening and asking the right questions to determine particular needs or concerns; Accommodate cultural beliefs if possible
Preparing the Chronically Ill Child Frequent hospitalizations may have made the child more anxious; The child will anticipate pain; Listen to the parents or primary caregiver; Child may be developmentally delayed due to illness
How to Make a Hospitalization Positive Minimize the length of the stay; Provide continuity of care; Decrease separation anxiety; Provide opportunity for play; Set limits; Explain all procedures and care; Provide holistic care
Minimizing Length of Stay Kids do better @ home; Most minor surgeries can be done as outpatient; For inpatient admission, make sure diagnostics are done in a timely manner; Appropriate care done well and w/out complications; Get complete HX and information at time of admission
Admission Information Why is the child being admitted? Name, birthday; Primary caregiver and family members in the home; Past illness or hospital experiences; Child’s usual routines; Developmental level; Information that would help make the hospital stay more comfortable
Decreasing Anxiety Infants fear separation from caregiver. Can impact health & recovery; Toddlers & preschoolers may not understand parents will return for them; School age & adolescents can understand that parents will return but may need them for support & reassurance;
Play and Recovery Play is the way children learn and develop; Hospitalized children need opportunity to play to support that development; Games and toys appropriate to age; Play can be used as therapy (TV’s not play)
Sleep There are stages of sleep that promote health; When that sleep is interrupted, it interferes with the body’s ability to repair itself
Sensory Overload… Critically ill children in ICU are constantly barraged with lights, noise and being awakened. Can cause confusion and disorientation; Can interfere with healing
Child Safety Promoting safety for children is a responsibility for all members of the health care team
Safety through containment – cribs, doors or gates, covered windows, etc.
Safety through environment- nothing harmful in the child’s room, electrical safety, no equipment on which the child might injure himself
Safety through precautions – preventing nosocomial infections through standard precautions
Nutrition Children need more nutrients per pound of body weight than adults; An ill child must maintain growth while repairing the tissues; Differences in fluid distribution in children causes them to dehydrate more easily
Nursing Considerations for Providing Nutrition… When illness or treatment interferes with adequate intake, nutritional deficits occur Nurses must be proactive in seeing that their pediatric patient is receiving adequate nutrition;Find out what foods the child likes. Do calorie count; Encourage fluid intake through games, using a straw, giving popsicles
Care of a Child Undergoing Diagnostics…From the child’s perspective: ...Hospitals, Lab and X-ray rooms are big, scary places
Sometimes procedures are painful or uncomfortable The health care team members are strangers; Nothing and no one is familiar or feels safe
Diagnostic Procedures Evaluate the child’s age and development
Nursing Responsibilities in procedures Obtaining consent or making sure consent is signed; Explaining the procedure; Preparing the child and family; Accompanying the child; Providing support; Promoting safety; Providing care post-procedure
Common Procedures Lab draw; Urinalysis; X-Rays; CT scan; MRI; Lumbar puncture
Restraints Restraints are used for safety and to assist in the diagnostic procedure; Children do not like to be restrained; Explain to the parents why the restraint is necessary
Only restrain an older child when all other methods of obtaining cooperation have been tried…. Conscious sedation may be a better choice
Venipuncture Should not be excessively painful, need to use experienced person; Infants often get capillary puncture at the heel for lab tests; Older children are drawn from the antecubital veins most often
Obtaining a UA For infants, use pedi-bags; Older children, those that are potty trained can get clean catch; Straight cath or Femcath can be used to obtain a sterile specimen or if the child cannot void
Obtaining Stool Specimens Instruct the parent in the collection of the specimen; Probably easiest to use a “hat” on the toilet or, for potty training children, can use their potty chair;
Fever Reduction Treat fevers > 101 orally or > 102 rectally; Give sufficient dose of Acetaminophen or Ibuprofen based on weight; Do not use Aspirin for infectious illness; Do not overdress the child; Do not sponge the child with cold water or put ice packs on the child
Medication Administration…The 5 Rights are Critical Correct administration includes giving the medication correctly and teaching the primary caregiver about the medication; Can be given in a variety of routes
Oral Medications Infants & toddlers probably will receive a liquid or syrup form; Preschoolers may receive chewables; School age & Adolescents should be able to swallow capsules. May need to be taught.Check to see if a child is able to take the med in a swallowed form
Subcutaneous Medication Subq meds can be administered as they are for adults. Use small needle; Get help if you need it.
Intramuscular Injection Infants and toddlers should get IM meds in vastus lateralis muscle; Older children can be given in deltoid or gluteal muscle; Always comfort the child after a painful procedure
Intravenous Administration Start IV line using catheter size that will fit well in the vein (22g.or 24 g.); IV fluid should run through tubing with a fluid chamber and microdrip; All IV fluids for children should be on IV pump; IV site should be stabilized to prevent dislodging
Infants pain scale – CRIES pain measurement scale
FLACC – pain scale based on behaviors, can be used when the child is unable to describe pain
FACES – pain scale Younger children, visual representation of pain
Numerical or Visual Analog – A pain scale on a line to rate none to worst possible pain
Adolescent Pediatric Pain Tool – Visual activity and numerical scale
FACES or Oucher Can be used by children as young as 3 years of age; Need to verbalize the words that go with each face
Interventions for Pain Best to anticipate when the child may feel pain & take preventative measures; Anxiety increases amount of pain perceived; Use the pain intervention that will be most effective and cause the least anxiety in the child
Congenital vs. Chronic…Congenital anomalies or conditions are problems that occur during embryonic formation of the child. They can be inherited genetic problems or from unknown cause Chronic means an ongoing condition. Diabetes Type I is an example of a chronic condition that is not congenital.
Neonatal Respiratory System… Lungs begin to form in 4th week of gestation; Week 17-28 the bronchioles develop with multiple saccules; Alveoli develop between 32 and 36 weeks; surfactant forms; At birth, water-breather becomes air-breather
Asthma The most common chronic illness in children; Hypersensitivity reaction that causes inflammation of bronchial mucosa and bronchospasm; Trigger can be allergen, infection or emotional response
Assessment for Asthma Hx of development of sx; Medications given; Focused assessment of respiratory system; Pulmonary function tests
1 & 2 punch for asthma Short acting bronchodiliators and corticiosterids
Cystic Fibrosis Generalized dysfunction of the exocrine glands; Inherited genetic disorder; Thick mucous plugs the lungs and affects function of the pancreas
Treatment of Cystic Fibrosis Pancreatic enzyme can be taken orally; Humidified oxygen, nebulized treatments and chest physiotherapy; Lung transplant in adolescence can improve life expectancy; Goal= treat condition so that child may live as normal a life as possible
Child w/ a tacheostomy…Developmental age will influence plan of care; Young children may want to put foreign objects in this new oriface Practice and teach parents to protect the airway; Suctioning procedure is much the same as for adults except may need restraints or another person to hold hands away from the suction catheter, Need to humidify air
Cardiovascular System…Cardiac development occurs in the 4th through 7th week of gestation; Unlike adults, heart problems with children are most often due to congenital anomalies. Other causes of heart problems are respiratory failure, fluid overload or severe hypovolemia
Acyanotic disorder – Strictures or anomalies that cause left-to-right shunt. Cause heart to be ineffective pump. Predispose the child to heart failure..not used as much as a classification system
Cyanotic disorder – Abnormal communication between oxygenated and unoxygenated blood from right-to-left shunt. not used as much as a classification system
To keep ductus open give prostaglandin
To close the ductus arteriosus endomehticin (indocin)
Atrial septal defect abnomal opening between the atria, increaes right heart volumen and pressures. Surgery to close larger defects is done at age 1 to age 3 (type 1 lower end of septum, type 2 more in the middle) heard as a murmur 2nd intercostal
Ventricular septal defect (most common congentical defect) abnormal opening in the septum between ventricles; SX. Heard from 4-8 weeks; surgical closure may be required & should be done early; once pulmonary hypertension is severe, the VSD is inoperable.
Obstruction to blood flow disorders (3) Pulmonary stenosis; Aortic stenosis; Coarctation of the aorta
Mixed blood flow disorders (with mixing oxygenated and unoxygenated blood) (3) Transposition of the great arteries; Anomalous pulmonary venous return; Truncus arteriosis
Decreased pulmonary blood flow disorders (2) Tricuspid atresia; Tetralogy of Fallot
Increased Pulmonary Blood Flow (Blood flow from the left side to the right side) Left heart pressures are higher, blood will flow in the path of least resistance…An abnormal opening in the septum, either in the atria or ventricles allows blood from the left heart to be pushed to the right side
Patent Ductus Arteriosus..Pre-natal circulation has a passage connecting the pulmonary artery to the aorta; Should close in the first weeks of extra-uterine life; Failure to close causes… blood to recirculate into the pulmonary artery instead of going out the aorta; Right ventricular hypertrophy and increased pulmonary pressures
Atrial Septal Defect Abnormal opening between the right and left atrium...Increases right heart volume and pulmonary pressures; Surgery to close larger defect is done at 1 to 3 years of age
Ventricular Septal Defect Abnormal opening in septum between the ventricles; Most common cardiac defect; Symptoms usually appear at 4 to 8 weeks of age; Surgical closure may be required & should be done early; Once pulmonary hypertension is severe, the VSD is considered inoperable
Grading Ventricular Septal Defects grade 1- grade 4…..grade 1 is few symptoms and grade 4 is high pulmonic sx. (at grade 4 surgery can not occur)
Atrioventricular Canal Defect…Also called endocardial cushion defect A low ASD continuous with a high VSD and distortion of mitral and tricuspid valves; Blood may flow left to right but may flow between all chambers; Once pulmonary hypertension is severe, the VSD is considered inoperable
Obstruction to Blood Flow defect Narrowing of vessel or valve; Pressure is increased before the obstruction and decreased after the obstruction; Increased back pressure in the heart; Decreased circulation to organs
Coarctation of the Aorta (Obstruction to Blood Flow defect) narrowing of the lumen of the aorta; Occurs more frequently in boys; Leading cause of congestive heart failure in the first month of life
Pulmonary Stenosis (Obstruction to Blood Flow defect) Narrowing of the pulmonic valve; Symptoms of right heart failure; Systolic ejection murmur loudest at the upper left sternal border
Aortic Stenosis (Obstruction to Blood Flow defect) Stricture of the aortic valve; Prevents blood from passing from the left ventricle into the aorta; Leads to left ventricular hypertrophy and left ventricular failure; Left atrial pressure increases and subsequent pulmonary edema
Types of cyanotic congenital defects (blue babies): Tetralogy of Fallot; Transposition of the great arteries; Total anomalous pulmonary venous return; Truncus arteriosus; Tricuspid atresia; Hypoplastic Left Heart Syndrome
Best place to check for cyanosis in a baby mucus membranes in the mouth.
Defects with Mixed Blood Flow Involve mixing of blood from the pulmonary and systemic circulation; Results in deoxygenation of systemic blood flow; Cyanosis is not always visible
Transposition of the Great Arteries (Defects with Mixed Blood Flow) aorta arises from the Rt vent; Pulmonary artery arises from the left; Two closed circulatory systems; Not compatible w/ life unless septal or ventricular defect is present (needs to keep PDA open); ASD or VSD makes the heart one mixed circulatory system
Truncus Arteriosus (Defects with Mixed Blood Flow) One major artery originates instead of two; Usually accompanying VSD; Child is cyanotic with VSD murmur; Rare defect (surgery is done to make 2 vessels out of one)Surgery to construct two vessels is the treatment
Anomalous Pulmonary Venous Return (Defects with Mixed Blood Flow)… Pulmonary veins returning from the lungs go back to the right atrium instead of the left; For blood to reach the systemic circulation, there must be a… patent ductus arteriosus or ASD (Tx: keep ductus open, surgery to attach pulmonary veins to left atrium) sometimes these children don’t have spleens)
Hypoplastic Left Heart Syndrome (Defects with Mixed Blood Flow)…. Left ventricle is essentially nonfunctional; May be accompanied by mitral or aortic atresia; Right ventricle hypertrophy and increased pressures; decreased O2 levels help increase pulmonary resistance and allows the right heart to shift more blood to the left; Surgery is of limited benefit at this time; Heart transplant is the viable answer
Decreased Pulmonary Blood Flow defects Obstruction of pulmonary blood flow; Pressure increases in the right heart; Causes right-to-left shunt; Deoxygenated blood goes back to the systemic circulation; Results in poor oxygenation of tissues
Tricuspid Atresia (Decreased Pulmonary Blood Flow defects) Tricuspid valve does not allow blood to flow from the right atrium to the right ventricle; Bypasses the step of oxygenation; Surgery to make a superior vena cava to pulmonary artery shunt
Tetralogy of Fallot … Four anomalies are present: Pulmonary stenosis; Ventricular septal defect; Overriding of the aorta; Right ventricular hypertrophy; Increased right ventricular pressure; Infant may not be cyanotic immediately; Surgical correction is done between 1 to 2 years of age
Interventions for tet fit Morphine, beta blocker and put into knee chest position
Congestive Heart Failure… Heart is an ineffective pump D/T weak myocardium; Blood pools in the heart (preload) or in the pulmonary venous system; Heart muscles lengthen and cause ventricles to enlarge to handle more blood; Increased HR to move the blood out; When compensation is no longer possible, decreased perfusion to organs (kidneys); Kidneys stimulate renin-angiotensin system to retain fluid; Adrenal gland secretes aldosterone and pituitary secretes ADH to retain fluid
Symptoms of CHF in Children…Tachycardia; Tachypnea; Right heart failure causes increased venous pressure in the portal system (abdominal girth); Restless, irritable; Lower extremity edema is a late sign; With left heart failure, blood accumulates in the pulmonary system: dyspnea, crackles, rales, cyanosis, pulmonary edema
Symptoms of CHF in Infants Tachypneic; Easily fatigued; Problems feeding, may become diaphoretic with feeding; Generalized edema, periorbital; Abrupt weight gain; Enlarged liver; Apical HR is displaced laterally & down-ward. CXR shows an enlarged heart
Treatment of CHF… Reduce the workload of the heart; Diuretics – Decrease preload; Vasodilators – decrease afterload; ACE –I, calcium channel blockers, Nipride; Slow heart rate and increase contractility – digoxin; Keep child from getting fatigued – allow periods of rest between procedures; Position with head elevated
Congenital Immune Deficiency…Born without essential immune substances or inadequate amounts…B-lymphocyte deficiency – low levels of immunoglobulins; T-lymphocyte deficiency – inadequate T-lymphocyte function, affects CMI and possibly humoral immunity; Combined B and T-lymphocyte deficiency – absence or reduction of both CMI and humoral immunity, no antibodies develop
Secondary Immunodeficiency…Loss of immune system response that can occur from multiple factors; Severe systemic infection, cancer, renal disease, radiation therapy, extreme stress, malnutrition, TX: immunosuppressive therapy, medications; Stress alters immune response by triggering corticosteroid release that suppresses the inflammatory response
Acquired Immune Deficiency Syndrome (AIDS) Caused by Human Immunodeficiency Virus Can be passed from mother to baby through placenta and possibly during breastfeeding; HIV infected mothers that are given Zidovudine during pregnancy are less likely to infect the baby…kids test positive faster
Allergies in Children Can express itself as rash, hives, bronchospasm, anaphylaxis, rhinitis, tearing eyes, sneezing; Assessment of possible allergies starts with a good history; Skin tests & environmental control; Hyposensitization therapy, avoidance, meds
Types Anemias - acute blood loss, infection, renal disease, cancer; Bone marrow depression; aplastic, hypoplastic Vitamin & mineral ( iron deficiency, folic acid deficiency, pernicious anemia (B-12); Sickle cell ; Thalassemia: defects of the blood cells
Hemophilia Inherited interference with blood coagulation; defect somewhere in the 12 step clotting cascade; Classic hemophilia or type A is caused by a deficiency of factor VIII
Gastrointestinal System…Most GI system disorders are not chronic; Children can develop ulcers from stress; Assessment of the abdomen in young children includes history, palpation, auscultation and observing the child’s responses; Children can have nausea and vomiting in response to illnesses that are not of the GI tract; Any GI disorder can interfere with nutrition since the child needs to have enough nutrients for growth and body maintenance
Cleft Palate/Cleft Lip Cleft lip is more prevalent in boys, cleft palate is more prevalent in girls; Familial tendency, happens more frequently in some racial groups than others (can contribute to malnutrition)
Malnutrition Early identification and treatment of malnutrition is essential for normal development
Kwashiorkor – protein deficiency. Occurs most often in children ages 1 to 3 years of age. Skinny limbs, distended belly, anorexic.
Marasmus – deficiency of all food groups. Seen in developing countries, in the U.S. in neglected or failure to thrive children. Feel hungry all the time. Vitamin & mineral deficiencies – rare in the U.S.
Vit a def. blindness
Vit d def rickets
Constipation Difficulty passing hardened stool; Becomes painful, child resists going; Rectum becomes distended; Urge to defecate comes less frequently; Obstipation; Can be caused by lack of fluids, dietary, stress or emotional reasons
Obstipation Severe constipation caused by intestinal obstruction.
Child with a Feeding Tube… Feeding tubes can be nasogastric or gastrostomy; Can be placed to supplement feeding or to give total nourishment; Infants with feeding tubes do not get the pleasure of sucking, use pacifier; Good education of the primary caregiver includes return demonstrations and caregiver should be comfortable with the procedure prior to discharge
Child with an Ostomy…. Can be placed for a number of conditions like imperforate anus, Hirschsprung’s disease; Ileostomy stoma is on the right and will drain liquid stool; Colostomy is lower on the left and will drain soft or formed stool; Getting a good fit for the appliance and protecting the skin are two nursing considerations; Parents need education and to be able to troubleshoot for problems
Eating Disorders Anorexia nervosa and bulimia are most often seen in adolescents between ages 13 to 20 years of age; Poor self-image, depression, intense fear of becoming obese; Can lead to starvation and death
Obesity/Anorexia can cause health problems that will affect their adult life; Dieting at a time when the body is growing can weaken the body; Obesity in childhood leads to obese adults with concurrent health and emotional issues;
Genitourinary System Formed within the first 8 weeks of gestation; Structural abnormalities may be psychologically difficult for parents; Assessment includes a good history, assessment of general physical appearance and analysis of urine
Polycystic Kidney Disease… Can be hereditary with other anomalies to the liver and facial features; Large, fluid-filled masses formed instead of normal kidney tissue; If bilateral, there will be no urine; If unilateral, decreased amount of urine; Systemic HTN develops; Treatment is removal of affected kidney (unilateral) or kidney transplant.
Enuresis (Commonly called “bedwetting”) Can be a problem for both child and parents; Emotional consequences; Rule out physical causes; medications, bladder stretching, getting the child up at night; Can reoccur in stressful situations like hospitalization
Hydrocele – excess fluid in the scrotal sac making the scrotum in the newborn appear enlarged. Often reabsorbs without intervention.
Varicocele – Increased dilation of the veins of the spermatic cord. If not identified before adolescence, can lead to infertility.
Dysmenorrhea – painful menses. Due to release of prostaglandin causing smooth muscle contraction of the uterus
Menorrhagia – abnormally heavy menstrual flow
Metrorrhagia – bleeding between menses
Amenorrhea – absence of menstrual cycle. Strongly suggests pregnancy but can be the result of stress, illness, strenuous exercise, extreme dieting
Precocious Puberty… Development of breasts or pubic hair before the age of 8 years; Menses before the age of 9 years; Occurs more often in girls than boys; Early production of gonadotropins in the pituitary; Treatment consists of positive diagnosis and administration of analogue to gonadotrophin-releasing hormone (GnRH) given subq daily until age 12 or 13
Delayed Puberty….Failure of pubertal changes to occur by the age of 14 or 15 years; Family history may show a familial tendency to late maturation Failure to start menstruation by age 17 needs to have physical workup; Can administer estrogen (f) or testosterone (m).
Metabolic System Because this system produces hormones that regulate and coordinate all body systems, dysfunction causes widespread and long-term problems.
Pituitary Disorders… Deficiency of Growth Hormone causes small stature. If untreated may not grow taller than 3 or 4 feet. Excess of Growth Hormone causes excess growth. If GH production is interrupted as a treatment for this, other hormones may be affected –thyroid, cortisol, gonadotropin.
Adrenal Disorders Adrenogenital hyperplasia – excess androgen, causes masculinization and precocious puberty..Cushing’s syndrome – overproduction of cortisol. Moon face, truncal obesity, hirsuitism, susceptible to infection, hypertension.
Thyroid Disorders Congenital hypothyroidism – lethargic, enlarged tongue, retardation; Graves’ disease – usually occurs in adolescence. Symptoms same as for adults
Diabetes Type I Usual onset 5 to 7 years of age or at puberty; Abrupt onset of weight loss, polydipsia, polyuria, fatigue, polyphagia; May begin having problems in school with behavior, fatigue, blurred vision; Must be treated with insulin
Family Education for Endocrine Disorders What causes the problem, How to check blood sugars; Diet; How to administer insulin; Sick day rules; Symptoms that require medical attention
neurologic System Affect cognitive, motor and sensory function; Assessment must include all these areas; Prevention of neurologic problems should be the goal; Long-term effects
Cerebral Palsy…Non-progressive disorders that cause motor dysfunction; Associated with low birth weight, premature birth or birth injury; Probably due to brain anoxia that leads to cell destruction of the motor neurons; Head injury after birth can also cause these symptoms – Shaken Baby syndrome, severe dehydration in the newborn; Life-long effects
Spastic type Cerebral Palsy – excessive tone in the voluntary muscle groups. May affect one side, both sides, upper extremities or all extremities. Drooling.
Dyskinetic Cerebral Palsy – limp, flaccid. In place of voluntary movement, the child makes slow, writhing motions. May have ataxic gait.
Recurrent seizures that can be partial or generalized in nature. May have pre-seizure visual disturbance “aura”. Can be caused by illness, trauma, poisoning. Sometimes the cause is not determined; Recurrent infantile seizures leaves the child with cognitive & developmental impairment; In older children, medication can help control the seizures
Fetal Alcohol Syndrome Epicanthal folds; Short nose, flat mid-nose and low nasal bridge; Thin upper lip; Small ears, low
Musculoskeletal System Problems with the musculoskeletal system usually have specific, localized symptoms; In a child who is walking, a limp needs to be investigated; Assessment includes history, evaluation of gait, pain and range of motion
Legg-Calve’-Perthes disease – avascular necrosis of the femoral epiphysis. Pain in the hip joint. Can cause dislocation when the femur head becomes smaller.
Slipped Capital Femoral Epiphysis – slipping of the femur head in relation to the epiphysis. Gradual onset, change in gait and limping. Need surgical hip reconstruction.
Scoliosis Lateral curvature of the spine; More common in girls than boys, onset age 8 to 15 years; May have hereditary component; Screening is done at schools; Early intervention, brace or surgical placement of rods to support and straighten
Juvenile Rheumatoid Arthritis Sx begin before age 16 yrs ^persist for > 3 months. Joint pain, fever, rash; Peak incidence in 1 to 3 yrs & 8 to 12 yrs, slightly more common in girls; Probably an autoimmune disorder that causes inflammation of joints & connective tissue.
Stages of grief: denial, anger, bargaining, depression, acceptance..May spend a great amount of time at the hospital, sleep deprived, not eating. family and nurses sometimes form bonds during frequent or extended hospitalizations
Very young children under the age of 2 have little understanding of death and may view it as separation or abandonment
Children 2 to 6 years of age are likely to think of death as temporary or reversible; view it as a punishment and think they can wish the person back to life
Between ages 6 and 11 years, children become aware of the finality of death but have difficulty understanding that everyone dies, including themselves.
After age 11 years, most children understand that death is irreversible, universal and inevitable but view their own death as far off.
Children tend to grieve differently than adults although the same stages of grief are seen. Their grief may be delayed. Although cancer is not always a terminal illness, it is often viewed that way
Nurses can educate on the disease, treatments and resources. Treatments are often painful or uncomfortable for the child. Child can have body image disturbance with hair loss, surgical scars or amputations.
Palliative Care The focus is comfort not cure; Pain relief is the main component but not the only one; Emotional support for the family and child
Emotional Support of the Child and Family Resources and support groups; Allowing the child to live one of their dreams; Taking advantage of times when the child is feeling well to do family activities. Making memories. Accepting that each person grieves in a different way
Primary Intervention - Preventative interventions, such as immunizations, healthy lifestyle choices
Secondary Intervention - Screening, early diagnosis and treatment
Tertiary Intervention - Treating disease already established, acute or chronic illness
Recommended immunizations: Hepatitis B; Diptheria, Tetanus, Pertussis (DPT); Polio; Measles, Mumps, Rubella (MMR); Varicella Zoster (Chickenpox); Heptavalene pneumococcal conjugate; Hepatitis A
Active immunity- Immune response (antibodies) to an invading organism or from inoculation with a vaccine containing a foreign antigen
Passive immunity -Immunity acquired by the introduction of preformed antibodies. Antibodies that pass through the placenta or mother’s milk.
Barriers to Immunization Compliance…Complicated schedule with many injections; Parents forget to schedule; Child is sick and misses time for injection; Parents are concerned about possible bad side effects from immunization Parents are reluctant to inflict pain of injection; Parents believe their child is not at risk because other children have been immunized; Parents have never seen the diseases and do not view them as life-threatening
Chain of Infection Reservoir; Pathogens; Susceptible host; Portal of entry; Mode of transmission; Portal of exit
Illnesses of Childhood Infections; Infestations; Injuries; Surgery; Chronic disease
Infections of Childhood Respiratory- RSV, URI, Tonsillitis, croup and epiglottitis; Otitis Media; Gastrointestinal- N&V&D; Skin- impetigo, diaper rash, fungal; Meningitis; Hepatitis; Virus
Viruses – not true cells. Viruses replicate in number inside other cells using the biochemical products of those cells to function; Viral infections include: measles, chickenpox, mumps, shingles, Coxsackievirus, parvovirus (Fifth disease), polio, warts, rabies
Enteroviruses Echoviruses – common organism in aseptic meningitis, diarrhea, acute URI and maculopapular rashes
Coxsackieviruses – Most common in herpangina illness
Polioviruses – Rarely seen since immunizations. Causes paralysis, difficulty breathing. Can leave permanent disability
Bacteria – single cell organisms that duplicate by division. Occur in 3 main shapes: spheres (cocci), rods (bacilli) and spirals (spirochetes).
Bacterial infections include: Strep throat, scarlet fever, whooping cough, diptheria, boils (staph), tetanus, Lyme disease
Pediatric Respiratory System…Barrel shaped chest, ribs & sternum are cartilaginous in the infant, becomes more adult like by age 8; Accessory muscles are poorly developed in the infant, they use the diaphragm for respiratory effort. Infant is an obligate nose breather until 1 to 2 months of age; Small diameter airway, increases potential for obstruction by edema or mucous; Infants have an immature immune system
Children have less pulmonary reserve making them more at risk for respiratory complications
Breathing is quiet and nonlabored in the healthy child. Inspiratory phase is slightly longer or equal to the expiratory phase. Prolonged expiratory phase seen in asthma. Prolonged inspiratory phase seen in croup
Respiratory Illness Immune system immature during infant and toddler stage ; Respiratory illness common due to airborne nature and inconsistent hand washing; Children will compensate for respiratory difficulties, then crash
Common Respiratory Illness Upper respiratory nasopharyngitis, pharyngitis, tonsillitis, influenza, otitis media; Croup Syndromes– acute epiglotitis, laryngitis, laryngotracheobronchitis… TX: fever control, fluids, pain control; Only treat with antibiotics if bacterial in origin.
Common Infections of the lower airways – bronchitis, RSV, bronchiolitis, pneumonia…Main treatment is supportive, fever control, fluids, pain control; Only treat with antibiotics if bacterial in origin.
Treat fevers over 101’F
Acute Nasopharyngitis AKA (Common cold) Most frequent infectious disease in children ; Most commonly occur in fall and winter; Caused by a virus; sx include: nasal congestion, watery rhinitis, low-grade fever, cough, swollen cervical lymph nodes..TX: symptomatic: Rest, fluids, acetaminophen (fever > 101)
Pharyngitis Sore throat; Viral sore throat symptoms are generally mild, sore throat, fever, malaise (Symptomatic treatment).. bacterial cause: Marked inflammation & swelling of tonsils, high fever, very sore throat, lethargy, HA, swollen lymph nodes. Antibiotics
Laryngotracheobronchitis (Croup) (6 months to 3yrs most often caused by virus). (3yrs-6yrs most often caused by H. Influenzae)… Normal or low-grade fever, night time barking cough, inspiratory stridor, retractions, respiratory distress; Warm, moistened air, racemic epinephrine, corticosteroids.
Epiglottitis (Potentially Life-threatening) – Epiglottis swells, obstructing the airway; SX: drooling, change in voice, stridor
Respiratory Syncytial Virus (RSV)- most common cause of lower airway infections in children; Leading cause of pneumonia and bronchiolitis in infants SX: copious clear secreations & can live on hard surfaces for 7 hrs.
Assessment of Child with Respiratory Illness General appearance of the child; Rate & depth of respirations; Cough; Rhinitis, nasal flaring, retractions, accessory muscle use; Fever; Auscultation w/ stethoscope & w/out
Most respiratory collapse is due in part to not being able to recognize respiratory distress.
Respiratory Red Flags (Respiratory distress progressing to respiratory failure) Increased or increasing work of breathing; Decreased or absent breath sounds; Apnea; Gasping respirations, head bobbing; V LOC; Tachycardia; Bradycardia – (late sign, child is about to arrest); Delayed capillary refill
ATA about to arrest
Otitis Media (May follow an URI)…. Ear pain, fever, tugging at the ears, fussy; Treatment depends on severity and frequency; Differences in Eustachian Tube:(kids are more susceptible to middle ear infections than adults); The eustachian tube of a child is shorter and straighter than an adult & Allows infected secretions from sinus or nose to enter middle ear
Foreign Body in Ear Something that does not belong; Often children will intentionally place objects in ear; Unintentional objects such as bugs, sand, or other materials
Meningitis (Viral meningitis is the most common type & bacterial the child goes into isolation for 1st 24 hrs with antibiotics given) Inflammation of the tissues that cover the brain; 90% caused by viruses known as enteroviruses, such as coxsackievirus. Common during the summer and fall. Can also be a sequalae of herpes or mumps.
Etiology & Patho: meningitis… occurs in 1:2000 children peaks in 2 months to 5 yrs of age; Organisms enter the bloodstream through wounds, skull fractures or other focal infections Infection spreads through the arachnoid space, causing swelling and pain Increased intracranial pressure causes pressure on the brain, CSF outflow obstruction; Prompt recognition and treatment are essential to prevent death or residual damage
Viral Meningitis (Aseptic) Often the sequelae of other viral illnesses; Usually self-limiting; Organisms enter the CNS via the bloodstream across the blood-brain barrier (BBB)
Bacterial Meningitis Most frequently involved organisms are: Neisseria Meningitides (meningococcal) and Streptococcus pneumoniae (pneumococcal); Meningococcal occurs in outbreaks in areas of high population density; Bacterial meningitis is a medical emergency
Symptoms of Meningitis (general) Fever; Headache; Nuchal Rigidity; Altered LOC; Photophobia; Nausea and vomiting
Meningitis Signs and Symptoms in Children Fever, infants may have a normal temperature; Nuchal rigidity- classic sign; Irritability, restlessness; Seizures; Respiratory distress, cyanosis; Petechial rash; Bulging fontanelles – late sign
Nuchal rigidity - stiff neck is an early sign, resistance is caused by spasms of the extensor muscles (Meningitis Sign)
Kernig’s sign - Flexing the upper leg to the hip at 90 degrees, then extending the knee causes pain and spasm (Meningitis Sign)
Brudzinski’s sign - Flex the neck toward the sternum, the upper leg at the hip and lower leg at the knee flex (Meningitis Sign)
Red, macular rash (meningococcal) associated with meningitis is a late sign…septic shock may be imminent
Bacterial meningitis CSF Findings: Appearance turbid, cloudy; Increased WBCs; Increased Protein; Decreased glucose; Increased pressure >180mm; C&S grows bacteria
Viral meningitis CSF Findings: Appears clear, sometimes turbid; Increased WBCs, less than bacterial; Protein normal; Glucose normal; Pressure variable; No organism growth
Treatment for meningitis Viral Meningitis is usually self-limiting and requires supportive care..Bacterial meningitis needs antibiotics specific to the organism, support respiratory, treat septic shock (Prevention of bacterial meningitis through immunization)
HIB meningitis vacine
GI System…Plays a major role in maintaining fluid, electrolyte & acid-base balance; Fluid accounts for a larger percentage of infant weight (75%-80%) and children’s total body weight (65%-70%). Adults about 60% of TBW Children tend to have nausea, vomiting and/or diarrhea in response to illnesses in other body systems
Infections of Gastrointestinal Tract Pathogens enter the body by ingestion; Foodborne disease include food poisoning, typhoid, Hepatitis A; Symptoms are fever, nausea, vomiting, diarrhea and abdominal distention, pain
Viral Gastroenteritis Usually rotavirus or adenovirus, (most common cause of severe diarrhea in kids); SX: V&D (watery) for 3-8 days, accompanied by fever & ab. Pain..TX: fluid replacement, supportive. Prevention is immunization w/ live virus vaccine
Mild Dehydration Symptoms Alert, restless, thirsty; Normal BP, pulse, respiration & skin turgor; Mucous membranes moist; Urine output OK, may look normal; Extremities warm, normal capillary fill; Occurs with fluid loss of < 5%
Moderate Dehydration Symptoms…Infants or young children become irritable or lethargic. Older children may feel restless, thirsty; BP may be lower, older children may have postural changes; Tachypnea, tachycardia Mucous membranes dry, increased thirst; Urine output is decreased (<1 ml/kg/hr), dark and increased specific gravity; Fontanels on infants are sunken; Delayed capillary refill (>2 seconds), poor skin turgor
Severe Dehydration Symptoms…Infants and young children are extremely lethargic or comatose. Older children may be lethargic or apprehensive; BP may be undetectable; pulse is rapid, thready to nonpalpable; Very decreased or absent urine output; Extremities are cool, mottled; delayed capillary refill > 3-4 seconds; Happens in fluid loss of >10% of TBW
Fluid Replacement Calculate the maintenance fluid needs of the child; Calculate the replacement for that fluid loss; Calculate continued losses & add to the local maintenance & replacement needs or 20-30 ml/kg re-assess & repeat PRN
Genitourinary Tract (Pathogens enter the GU tract) UTI and STDs…Symptoms include dysuria, frequency, urgency, hematuria, fever, purulent discharge, itching, pelvic or flank pain
Infections of Skin Symptoms include redness, warmth, swelling, drainage, pain, itching
Blood Microorganisms gain direct access to bloodstream; >40% of nosocomial bloodstream infections are from normal skin bacteria; Biting insects introduce organisms into the blood stream; IV drug use with shared needles
Symptoms of blood infection in children are those of systemic infection- fever, malaise, fatigue, muscle aches, joint pain
Tetracycline is not used in children b/c staining of the teeth
Antimicrobial Therapy (Antibiotic, antivirals and antifungals) Four requirements for effective drug treatment: correct drug, sufficient dosage, correct route of administration, sufficient duration of administration
Actions of Antimicrobials: Penicillin, Cephalosporins- inhibit cell wall sythesis
Actions of Antimicrobials: Antifungals- injure the cytoplasmic membrane
Actions of Antimicrobials:Erythromycin, Tetracycline and Gentamycin- inhibit biosynthesis and reproduction
Actions of Antimicrobials: Actinomycin- Inhibits nucleic acid synthesis
Antibiotic Allergy Most antibiotics have some side effects, mainly GI; Symptoms of allergy include: Flushing, wheezing, sneezing, pruritis, urticaria, rashes…Anaphylaxis can cause death
Infestations Head Lice; Fleas; Ticks; Pinworms (hand to mouth transmission); Scabies
Fleas and Ticks Prevent biting; Cover and use insect repellant; Keep domestic animals free of ticks and fleas; Check for ticks after being in the woods or outdoors
Lyme Disease (Disease caused by a spirochete Borrelia Burgdorfori) Transmitted by ticks; Incubation period 3-30 days; Not communicable; Systemic involvement: stiff neck, headache, cranial nerve palsy, painful joints, AV conduction abnormalities…TX: Amoxicillin, Penicillin V or Doxycycline.
Rocky Mountain Spotted Fever (Caused by Rickettsial pathogen called Rickettsia Rickettsii) (Carried by ticks. Most prevalent in western U.S. Not communicable between people) Reddened area at bite site. 2-8 days develop a rash, HA, high fever & V LOC. Rash is often seen on soles of feet & palms of hands. If left untreated, can progress to central nervous system involvement. TX: Tetracycline for 7-10 days Vaccine is available
Quick Assessment Looks Good/ Looks Bad; ABCs : Normal or Abnormal; AVPU scale: Alert, verbal, pain or unresponsive; CUPS scale: Critical, Unstable, Potentially unstable, Stable; Glasgow Coma Scale; Initiation of Resuscitation; reassessments; Broselow Measurements
Pediatric Trauma Trauma is the leading cause of death in children of every age group; Important to do quick evaluation of the severity of injury and do appropriate intervention
Evaluation Parameters in Pediatric trauma Weight – the smaller the child, the greater the risk for severe injury; Airway- Is it patent or maintainable. All pediatric trauma patients should receive supplemental O2; Circulation – BP, Pulses; CNS; Fractures; Wounds
Airway in pediatric trauma…Airway management is the first priority; Anatomic differences in children can make managing the airway challenging; Respiratory failure is the primary cause of death in most pediatric patients Aggressive management to control the airway should be done without delay..All pediatric trauma patients should be on supplemental oxygen
Circulation in pediatric trauma… Circulating volumes are significantly less than adults; Children often do not show classic signs of shock until late due to their healthy cardiovascular system; Important to have baseline pulse and BP and monitor for changes
Central Nervous System in pediatric trauma… Level of consciousness is one of the most important evaluations to determine CNS injury; Changes in the LOC for any period of time, no matter how brief, are a reason for concern
Musculoskeletal Injuries in pediatric trauma… Children’s bones are more cartilaginous & tend to flex allowing energy or force of injury to be transmitted throughout the body; The skeletal framework or ribs do not cover the same areas as the adult (liver &spleen)
Wounds or Soft Tissue Injury in pediatric trauma…Forces applied to the outer body surface are more readily transmitted to the core of the body Children have less muscle mass and body fat than adults so there is less to cushion the vital organs; Any type of penetrating wound is more serious and has the potential for greater damage than in the adult
Pediatric Trauma Score reflects the vulnerability of children to traumatic injury. The minimal score is -6 and the maximum score is +12. There is a linear relationship between the decrease in PTS and the mortality risk (i.e. the lower the PTS, the higher the mortality risk)
Poisonings…Poison exposure is the ingestion of or contact with a substance that can produce toxic effects; Poisoning is an exposure that results in bodily harm; Although responsible for 52% of poison exposure calls, kids < 6 years only account for 3.1% of poisoning fatalities; Mortality from poisoning rises in the adolescent years when teens deliberately expose themselves to potentially lethal substances
Unintentional Poisoning…Unintentional or accidental poisonings outnumber intentional in ALL age groups; Can be caused by misuse or overuse of drugs, environmental exposures, occupational or industrial exposures, bites and stings or therapeutic errors; Accidental poisonings have overall mortality rate of 7:100,000
Intentional Poisoning…In the young child, usually result of play activities
In adolescents, recreational use of substances or suicide; Although suicidal poisonings account for only 8% of exposures, it is responsible for 53% of deaths Mortality from intentional poisoning is 3:1000; Can also be a homicide attempt
Route of Poisoning Ingestion; IV, IM, SQ; Inhalation; Topical; Transplacental
Acute vs. Chronic Exposures to poisonings 92% of exposures are acute; Biggest chronic exposure is lead; Can also be chronic exposure to pharmaceuticals, homeopathic medicines, carbon monoxide and heavy metals
10 Leading Poison Exposures in Kids Less than 6 years old 1. Cosmetics & personal care products; 2. Cleaning substances; 3. Analgesics; 4. Foreign bodies; 5. Topicals; 6. Cold, cough & allergy preparations; 7. Plants; 8. Pesticides; 9. Vitamins; 10. Antimicrobials
Pharmaceuticals (49% of exposures, 85% of deaths) 10 Most Lethal: Analgesics; Antipsychotics, sedatives & hypnotics; Antidepressants; Stimulants & street drugs; Cardiovascular drugs; Alcohols; Chemicals; Anticonvulsants; Gases & fumes; Antihistamines
“One Pill Can Kill” Beta blockers; Benzocaine; Calcium Channel Blockers; Camphor; Clonidine; Atropine; Lindane; Methyl salicylate; Quinidine; Quinine; Sulfonylureas
Red Flag Poisoned Patients The older the child, the more likely to die; Pharmaceutical agents; Intentional poisonings; Polypharmacy; “One pill can kill” substances; Altered LOC/ severe presenting symptoms
Interventions for poisoned patients Good history; Prevent accidental exposures; Educate parents; Know your Poison Control Center number: 1-800-222-1222
Pathophysiology of burns…Functions of the intact skin - thermoregulation, protection, secretion & sensory reception; Burn injury is caused by heat the body cannot dissipate. This causes injury to the skin and underlying tissues; In the presence of severe burns > 30% BSA, systemic pathophysiologic changes will take place.
Depth of Burn Injury Magnitude of burn injury is based on the depth and the extent of body surface area involved; The degree of tissue damage is determined by what agent caused the burn, how hot and how long
Rule of Nines in children Head and neck equal ..18 %; Anterior trunk equals..18 %; Posterior trunk equals ..18 %; Upper extremities (each 9%) ..18 %; Lower extremities (each side 6.75%) ...27 %; Perineum ... 1
Sunburn Superficial burn caused by UV exposure; Dilation of capillaries, erythema, tenderness, edema, occasional blister formation; Prevention; Symptomatic relief
Near Drowning…Hypoxic-Ischemic Brain Injury; Near Drowning is survival for at least 24 hrs after submersion; 50% are under the age of 4 yrs Majority of infant drownings are from the bathtub; Majority of drownings between 1 and 4 yrs are from artificial pools; 90% are in fresh water; Boys are 5 times more likely to drown than girls
Drowning is defined as death within 24 hrs of submersion incident;
Drowning Falls into H2O & is unable to escape; Panics & swallows H2O; Laryngospasm causes coughing, vomiting & increased panic from hypoxia; Dry drowning is aspiration of vomitus, wet drowning is loss of consciousness & inhalation of H2O.
Nursing Care of Child with Near Drowning Maintain ABCs; Monitor Neurologic status; Support VS; Monitor CV status; Early CPR is the child’s best chance for survival; Provide emotional support for the family; prevention Education
Life-threatening Illness: a family in crisis The uncertainty of a child’s life-threatening illness challenges the family’s coping and stability; Each family reacts differently; Unfamiliar environment; Interruption of the parent-child relationship.
Created by: wvc 2