NUR 218 PEDS EXAM 1 STUDY GUIDE Role of the pediatric nurse Caregiver Educator Advocate Growth &

development Developmental concepts

Specific alterations in function (care of the child with) Hypersensitivity response Otitis media Otitis media is an inflammation of the middle ear and is sometimes accompanied by infection. Its one of the most common childhood illnesses. About 70% of infants have at least one case of acute otitis media during the first year of life, and 93% have been diagnosed with the problem by age 7. Peak incidence is in the 1st 2 years, esp from 6-20 mos. It occurs more freq among boys and in children who attend daycare centers, in those with allergies, in children exposed to tobacco smoke, and in those who use pacifiers several hours daily. Its most common during the winter months. Children with conditions such as cleft ip and palate or Down syndrome more often experience otitis media. Breast-feeding appears to be protective against otitis media. In the past decade, an incr number of cases have been observed, and recent changes have been made in recommendations for treatment. Etiology and pathophysiology The specific cause is unknown, but appears to be R/T Eustachian tube dysfunction. Often an upper resp infection precedes the devt of otitis media. Pacifier use raises the soft palate and alters dynamics in the Eustachian tube, providing for entry of microorgs from the last nasopharynx. Ethnicity appears to play a role in its incidence (more freq in Amer Indian and Alaska Native). Recurrent otitis media has an incr freq in children of parents who smoke. Children with multiple sublings and those who attend childcare centers have incr incidence. Clinical manifestations Otitis media is the general term for inflammation of the middle ear. Acute otitis media (AOM) is when the child has acute onset of ear pain, marked redniess of the tympanic membrane upon otoscopy, and middle ear effusion. Recurrent AOM indicates repeated bouts of AOM, such as 3 in 6 months, or 4 in 12 mos. Otitis media with effusion (OME) is evidence of fluid in the middle ear w/out inflammation. OME sometimes becomes chronic in nature (more than 3 months) and is more commonly assoc with hearing loss. Infants & young children have characteristic behaviors that can indicate otitis media: pulling at the ear, diarrhea, vomiting, fever, as well as night awakenings with crying (due to incr pressure when prone or supine). Irritability and acting out may be signs of a related hearing impairment. Clinical care Dx with otoscope. AOM is diagnosed with certainty when theres Hx of acute onset, presence of middle ear effusion (bulging or decr mobility of the tympanic membrane, air fluid behind the membrane, or otorrhea/discharge), and S/S of inflammation (erythema of tympanic membrane or discomfort that makes sleep and other activities difficult). Otoscopy includes visual and pneumatic techniques. Occasionally, the middle ear fluid is cultured so that the causative organism can be identified. If the tympanic membrane isnt intact, the culture is easy to obtain; in cases with repeated antibiotic treatment failures, a tympanocentesis may be done.

Treatment Antibiotics for 10 days in children under 6, and 5-7 days for children 6 and over AOM Tx is delayed for 48-72 hrs after Dx in children 6 mos-2 yrs with nonsevere illness at presentation AND uncertain Dx, or in children 2 yrs and older w/out severe symptoms OR uncertain Dx. When prescribed, choice of antibiotic depends on the probable organism, ease of administration, cost, previous effectiveness, and Hx of allergies. First line therapy is amoxicillin 80-90 mg/kg/day. Amoxicillin with clavulanate or cefuroxime are second-line drugs if IM is preferred o Cefdinir 14 mg/kg/day, Cefpodoxime 10 mg/kg/day, cefuroxime 30 mg/kg/day Acetaminophen or ibuprofen for pain relief and return for Tx if S/S continue If tympanic membrane is intact, topical anesthetic eardrops for several days for pain relief

NOT effective: antihistamines, decongestants, steroids Otitis externa Otitis externa is an inflammation of the skin and surrounding soft tissue of the ear canal. Its sometimes called swimmers ear because its common in children who swim frequently, esp during hot and muggy weather. The ear canal can also be injured by q-tips, foreign objects, or sprays used near the face. If the tympanic membrane isnt intact because of tympanostomy tubes or breakage of the membrane, there may be drainage visible in the canal; this drainage may irritate the canal and lead to otitis externa. Any irritation of the canal can become infected with bacteria. Virus, or fungi; sometimes it represents an allergic reaction. The child usually complains of pain and itching, and may have intense pain when the examiner presses on the tragus, or skin tab in front of the ear. Sometimes the ear appears swollen and redness or drainage of the canal may be seen upon otoscopic examination. Treatment remove the dried and flaking epithelium and cerumen Burows solutions or normal saline to irrigate and clean the canal Steroid eardrops are used to decrease inflammation antibiotic drops if a bacterial infection is suspected non-ototoxic ear antibiotic eardrops (eg quinolone) o if the tympanostomy tubes or perforated tympanic membrane acetaminophen or ibuprofen for pain control see a provider if no improvement in 48-72 hrs dont return to swimming for 5 days keep the ear canal dry w/ earplugs or a swim cap & gentle blowdrying [the canal] after bathing dont put Q-tips or other objects in the ear canal (so that the skin can heal) o also, avoid irritants (hair sprays, etc) Signs of otitis media painful ear drainage irritated canal Nursing care Verify that the tympanic membrane is intact with an otoscope Teach families to avoid irritants

o Eg Q-tips, sprays, freq swimming Demonstrate proper instillation of drops & give instructions for use of acetaminophen for pain in the acute period

<<paste in pp652-3>> Conjunctivitis Conjunctivitis is an inflammation of the conjunctiva, the clear membrane that lines the inside of the lid & sclera. There are several types of conjunctivitis, depending on the cause of inflammation. Bacteria, viruses, allergies, trauma, or irritants cause the conjunctiva to become edematous and reddened with a yellow or white discharge. The main difference between bacterial and viral conjunctivitis is that bacterial conjunctivitis has a purulent discharge that may result in crusting whereas the discharge from viral conjunctivitis is serous (watery). Allergic conjunctivitis produces watery to thick drainage and is characterized by itching. Care Bacterial o Antibiotic eye meds (droplet or ointment) o Fluoroquinolones (drops or ointment) Ex ciprofloxacin & other -floxacins o Ceftriaxone for gonococcal in newborns Gonococcal conj is resistant to penicillin o Erythromycin or tetracycline PO for chlamydial conj Adenoviral o Comfort measures Cleaning drainiage with warm cloth, avoiding bright light, avoiding reading Ophthalmic antibiotics as prophylaxis (potential bacterial invasion due to eye rubbing) o For HSV: topical drugs + acyclovir Allergic o Systemic or local antihistamines o Topical steroids & vasoconstrictors o Decongestants with systemic antihistamines for short-term therapy o Mast cell stabilizers for 3 yo and older Ex cromolyn, nedocromil, olopatadine Inhibit histamine release from mast cells, decreasing allergic response Used for itching Nursing mgmt o Prophylactic antibiotics after birth o Eye assessments & referrals, if appropriate o Teach hand hygiene & eye meds instillation to parents o Teach relief of allergic pruritus Clean washcloths with very cold water

Tonsillitis

Tonsillitis is an infection or inflammation (hypertrophy) of the palatine tonsils. Although most children with pharyngitis have infected tonsils, they dont necessarily have tonsillitis. It can be bacterial or viral. Diagnosis requires enlarged tonsils accompanied by pain and inflammation. Symptoms include frequent throat infections with breathing and swallowing difficulties, persistent redness of the anterior pillars, and enlargement of the cervical lymph nodes. If children breathe through their mouths continuously, the mucous membranes may become dry and irritated. Symptomatic treatment is the same as for pharyngitis. Tonsillectomy is recommended for recurrent throat infections (3 per year for 3 years), chronic tonsillitis, or malformation causing nasal speech or a facial growth abnormality. Surgery is postponed or children under 3yo because it can stimulate growth of other lymphoid tissue in the nasopharynx.

Epistaxis Common in school-age children, esp boys The usual source of bleeding is Kiesselbachs veins (in anterior nares) o Due to irritation from nosepicking, foreign bodies, low humidity o Also, forceful coughing, allergies, infections resulting in congestion of nasal mucosa Bleeding from posterior septum is more serious!!! o Can be life-threatening; may need hospitalization Streptococcal pharyngitis (668) Major complaint is sore throat Children who have minimal throat redness and pain, exudate, mild lymphadenopathy, and a low-grade fever, and who have been exposed to someone who has pharyngitis, should have a throat culture o The classic signs of purulent drainage and white patches are not present in all cases of strep throat NOTE: a child who finds swallowing difficult or extremely painful, who drools, or who exhibits signs of dehydration or resp distress should be seen by a physician immediately o These could be signs of epiglottitis or diphtheria Mgmt o Early signs should be treated with oral penicillin or erythromycin (if allergic to penicillin) o Acetaminophen for pain & fever o Cool, nonacidic fluids & soft foods, ice chips, or frozen juice pops to facilitate swallowing & prevent dehydration o Humidification, chewing gum, gargling with warm salt water to soothe irritated throat o Rest o Replace toothbrush after 2 days of meds o Teach to treat immediately since untreated infections can led to rheumatic fever, cervical adenitis, sinusitis, glomerulonephritis, meningitis Iron deficiency anemia (802) Most common type of anemia & most common nutritional deficiency in children

Pathophys: Body needs iron to make hemoglobin. Low iron limits hemoglobin production. Low HgB affects RBC production. Need RBCs to carry oxygen throughout body, so anemia results in less oxygen to cells & tissues Can occur 2 to blood loss, malabsorption, poor nutritional intake o Also 2 to increased internal demands (eg rapid growth periods) Rapidly growing teens with high-fat, low vitamin diets Infants who dont take in adequate solids after 6 mos 7 are fed only breast milk & formula (neonatal iron stores are depleted by now) o Chronic blood loss (ie hemophilia, neonatal blood loss, parasitic GI illness, menorrhagia Clinical manif: pallor, fatigue, irritability o w/prolonged: nailbed deformities, growth retardation, devt delay, tachycardia, systolic heart murmur o Pica and Plumbism are assoc with Fe-def anemia Lead absorption increases in the anemic state Clinical therapy: correct the iron deficiency with oral elemental Fe & high-Fe diet; also, ferrous sulfate for 4wks Care o Screen at 9-12 mos, 15-18 mos, & at adolescence (preemies at 4 mos) o Dietary mgmt Need protein for blood cell production; folic acid to convert iron to Hgb Foods high in iron & vitamin C o Ferrous sulfate (oral) Stains teeth, so drink through a straw Can cause black, green, or tarry stools; constipation; foul aftertaste Minimize these S/E by incr fluid & fiber intake o Be alert for iron overdose! ABD pain, vomiting, bloody diarrhea, SOB, shock

Sickle cell anemia (806) A hereditary hemoglobinopathy (partial or total replacement of normal Hgb with abnormal Hgb) in RBCs o This causes occlusion of small blood vessels, ischemia, & damage to affected organs Most common in Blacks and sometimes in Mediterraneans Pathophys: Hgb in RBCs acquires a crescent shape due to a genetic mutation. These cells are rigid & obstruct capillary flow. These obstructions lead to engorgement & tissue ischemia (shortage of blood supply), which leads to local tissue hypoxia (which causes more sickling and large infarctions) o Damaged tissues become scarred, resulting in impaired function Ex many children suffer from splenic sequestration (blood trapped in the spleen) & need a splenectomy o Infection rate is high due to impaired immunity & bacterial infections are the leading cause of death in young children o Stroke is a risk, as well as gallstone formation, priaprism (sustained erection), acute chest syndrome w/pulmo HTN o Triggers: fever, emo or phys stress o Precipitating factors: high altitudes, poorly pressurized airplanes, hypoventilation, vasoconstriction when cold, emo stress, pregnancy, acidosis, ETOH consumption

basically, ANY condition that increases the bodys need for oxygen or alters the transport of oxygen (ie infection, trauma, dehydration) can result in sickle cell crisis o Sickled cells can resume their normal shape when rehydrated & reoxygenated BUT, their membranes are more fragile & they only live 10-20 days (instead of 120) Here, bone marrow spaces enlarge to make more RBCs Clinical manif: range over all body organs o Children are asymptomatic until 4-6 mos since fetal Hgb is high and inhibits it o Illness from vaso-occlusive events o Infections, impaired resps, neuro symptoms, pain, skin changes are common o Most common reason for hospitalization: acute painful episodes Sickled RBCs cause vaso-occlusion, microinfarction, ischemia Pain from avascular necrosis of bone marrow In back, ABD< chest, joints Chest tightness & SOB o Most common S/S: splenic infarction and hematuria MGMT o Pain control, hydration, oxygenation Parenteral analgesics (eg morphine) via PCA (NOT prn) Oral & IV fluids Reduce blood viscosity Oxygen to provide comfort and decrease incidence of pulmo complications o infection prevention esp if a splenectomy: decr immune function daily prophylactic penicillin from 2 mos -5 yrs o double dose from 3-5 yrs for suspected infection: cultures (blood, urine, throat) to iD source & organism then, aggressive antibiotic therapy o prevention/Tx of assoc complications Tx for crises: hydration, oxygen, pain mgmt, bed rest o Transfusion of RBCs For improved blood & tissue oxygenation, reduction in sickling, temp suppression of production of RBCs with HbS BEWARE! Freq transfusions can cause iron overload o Iron is stored in tissues & organs cuz body cant excrete it Alloimmunization (body makes antibodies to transfusions) Never infuse cold bloodcan incr sickling Take VS before and q15 min throughout transfusion If case of transfusion reaction DC the transfusion Change the IV to normal saline Notify the primary healthcare provider o Emo support

Thalessemias A group of inherited blood disorders of hemoglobin synthesis

Defective hemoglobin is synthesized and leads to hemolysis, which leads to hermosiderin (ironcontaining pigment) deposits in the skin (leads to bronze appearance) Chronic anemia can lead to hyperplasia of bone marrow cavity & thinning of bone marrow cortex o Can lead to skeletal deformities & pathologic fractures Incl enlarged head & thickened cranial bones o Splenomegaly due to hyperactive spleen & from pooling of cells o Long-term hemochromatosis (excessive absorption & accumulation of iron in the body) dramas include Gallbladder disease Liver enlargement & cirrhosis Growth retardation Endocrine complications Jaundice Cardiac complications (incl heart failure) o Death due to liver disease & infection, heart failure from severe anemia or iron overload CARE Largely supportive o Goal: maintain normal hemoglobin levels Blood transfusion q2-4wk May need iron-chelating drug for the iron overload (to excrete Fe via kidneys) o Ex deferoxamine subQ or IV Hematopoietic stem cell transplant from a sibling Normal diet for age: include folic acid & Vit C Avoid iron-rich foods and dont give iron Assess: pallor, FTT, severe anemia, skin discoloration, hepatosplenomegaly Look for Fe overload: ABD pain, vomiting, bloody diarrhea, leading to SOB and shock

Hemophilia (824-8) Hereditary bleeding disorders resulting from deficiency in clotting factors Mostly in boys Potential complications: internal hemorrhaging, transfusion reactions, shock, death Usually, S/S start at 6 mos with mobility and tooth eruption Hemarthrosis & ecchymoses are common Goal of Tx: control bleeding by replacing the missing clotting factor o Transfusion therapy Care o prevention & control of symptoms, limiting joint involvement & managing pain, & providing emo support o control superficial bleeding by applying pressure for 15 min or more o immobilize & elevate affected area, apply ice packs to promote vasoconstriction o avoid rectal temps & suppositories; check BP by cuff as infrequently as possible; avoid IM or subQ injections; use only paper or silk tape for dressings; avoid venipuncture (except for factor replacement); NO heparin flush or aspirin Plumbism (258) o the avg serum lead level is 0.6 g/dL the recommended upper level is 10 g/dL

o many children with it are poor and live in older houses in inner cities o can experience cognitive defects due to exposure no know safe level o lead in paint is the most common source for preschool children also, contaminated food, water, and soil; inhaled dust with lead o why are children at greater risk? They absorb & retain more lead in proportion to their weight than adults do Lead is esp harmful to children under 7 yo o Lead interferes with normal cell function 2+ Esp nervous system, blood cells, kidneys, metabolism of vitamin D & Ca Neuro effects: decr IQ, cognitive defects, impaired hearing, growth delays Ingestion during pregnancy can result in fetal malformations, reduced birth weight, premature birth Severe lead poisoning: encephalopathy, coma, death Lead gets in the body and accumulates in the blood, soft tissues (kidney, bone marrow, liver, brain), bones, and teeth Lead in bones and teeth is released esp slowly, so it can build up o Chelation therapy: administration of an agent that binds with lead, increasing its rate of excretion from the body For > 70 g/dL o Care: screening, education, follow-up Housekeeping interventions Damp mopping of hard surfaces, floors, window sills, baseboards; washing childs hands & face before meals; freq washing of toys and pacifiers Nutrition Increase iron and Ca2+ to counteract their losses Eat at regular intervals since lead is absorbed more readily on an empty stomach Meninginoccemia (832) the most severe disease process that follows infection with Neisseria meningitidis or sometimes H. influenzae or Strep pneumoniae o its thought to be an immune response to the endotoxins of the organism SUDDEN ONSET o Resp infection high fever, petechial rash, massive skin & mucosal hemorrhage, hypotension, disseminated intravascular coagulation, & shock Child is usually under 2 yo and is critically ill & demonstrates multisystem disease o Can progress to critical level w/in 12-49 hrs of onset o S/S: skin turns pink then black (due to tissue damage from reduced oxygen delivery)may need to amputate limbs due to impaired circulation Treatment o Antibiotics o Removal from sources of infection o Multisystem shock mgmt o Might also need TPN, sedation & pain relief, dialysis, or amputation o Prophylactic antibiotics to close contacts of the child MGMT o Begin Tx quickly! Probably need to go to PICU

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Thorough assessments of all body systems IV infusions to ensure timely & correct admin of antibiotics & other therapies Measure urinary output Meticulous skin care (to preserve integrity of tissues) HSCT (hematopoietic stem cell transplant) Autologous (own marrow), isogeneic (from an identical twin), allogeneic (usually a sibling) o Assess skin, mucous membranes, GI/resp/cardiac function, hydration status o Prevent infection, control bleeding, maintain nutrition & hydration, monitor for rejection, provide psychosocial support HIV/AIDS Communicable diseases Dental emergencies (673) Due to trauma during falls, sports, motor vehicle crashes Predominance during toddlerhood (more mobility) Encourage protective gear Mouth has a profuse blood supply, so bleeding may be extensive for even minor injuries o Use clean cloths to absorb blood & prevent choking on it o Get child to ED Dental injuries o Usually due to fracture of a tooth, luxation (partial extrusion), avulsion (complete removal) In avulsion, periodontal ligament holds the tooth in the socket but its attachment is torn Take child to ED immediately Fast care is critical (good chances of tooth survival if reimplanted in 30 min) o Handle the tooth only by the crown (top) rather than the root to avoid further damage o Gently rinse the tooth with a stream of sterile saline o Insert the tooth into the socket o Have the child provide gentle pressure by biting a piece of gauze or a moistened tea bag o Transport liquids: Viaspan, Hanks Balanced Salt Solution Otherwise, cold milk, saliva, saline, water