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Head lice (Pediculus humanus capitus) are about the size of a sesame seed and can easily be seen, although they hide quickly in response to light. Their eggs, called nits, are barely visible, whitish ovals cemented to hair shafts. Head lice are extremely contagious, especially among school children. Main symptom: itching Female louse lives about 1 month and lays eggs which hatch in 7-10 days which are found in the hair shafts close to the scalp Child commonly ridiculed/embarrased Lice visible to eye, as are nits (eggs)
They afflict an estimated 6 to 12 million children in the United States. Twice as many girls as boys get head lice, not because of greater hair length, but because girls have more physical contact with one another and share more personal articles (hats, clothing, combs, headphones) that can transmit head lice. Head lice are rare among AfricanAmericans, possibly because the shafts of hair have a shape that lice cannot grasp easily.
BODY LICE (PEDICULUS HUMANUS CORPORIS)
identical in appearance to head lice but are more difficult to find. When not feeding, they tend to hide in the seams of clothing and folds of bedding. Signs of their presence are scratch marks, hives, or small red pimples, usually on the shoulders, torso, or buttocks. If the lice are not treated, the person can develop complications such as bacterial infection of the affected area. Body lice can also spread blood infections
Pediculcide (Nix) a shampoo Applied twice a week apart Daily combing with a metal nit comb for manual removal No need to cut child’s hair because of lice Lice easily spread in school setting—prevention in community setting important
Machine wash all bedding, clothing, etc. and then dry in hot dryer Vacuum rugs, furniture, mattresses Soak combs, brushes, hair accessories for 1 hour in pediculacide In group settings, store each child’s things separately Discourage sharing of clothing items, i.e hats
Avoid physical contact with infested child Inspect group of children regularly for infestation Provide educational programs on transmission, treatment, and prevention of pediculosis
BURNS IN CHILDREN
Deaths and Injuries Deaths and Injuries In 2001, more than 500 children age 14 and under died and 40,000 were injured in residential fires. Of these, 40 children were under 1 year old 226 children were aged 1-4 years 153 children were aged 5-9 years 101 children were aged 10-14 years
In 2001, nearly 4,500 children visited the emergency room due to residential fire injures. Of these, 1,555 children were aged 0-4 years 1,135 children were aged 5-9 years 1,765 children were aged 10- 14 years It is estimated that flames and burns are responsible for one-fourth of all fire-related deaths and injuries.
Approximately 75,000 children ages 14 and under are treated in hospital emergency rooms for thermal burn-related injuries, including flames and contact burns. Children age 14 and under account for nearly half of all emergency room treated thermal burns. An average of 16 children ages 14 and under die and nearly 31,500 children are treated in hospital emergency rooms for scald burnrelated injuries each year. Children ages 4 and under account for nearly all of these deaths and the majority of these injuries. Children ages 4 and under are especially at risk for scald and contact burns and are at the greatest risk for fire related deaths.
Common injury in pediatrics Four types of burns Thermal Chemical Electrical Radioactive
Caused by open flames, steam hot liquid Flush with cool water
Acids Neutralize or dilute the chemical consult poison control
Direct current, alternating current, lightening Disconnect source of current; move to area of safety
Solar, x-rays, radioactive agents shield skin, limit exposure, move person from source
BURN RISK: DEVELOPMENTAL CONSIDERATIONS
Infants: Scalds, house fires Toddlers: Pull hot liquids on themselves Preschool: Scalds, contact with hot appliances School-age: Playing with matches, combustion experiments Adolescents: Accidental or risktaking behaviors
Local response: Edema increased capillary permeability and vasodilation increased hydrostatic pressure within capillaries loss of water, lytes, protein into interstitial spaces—not a big deal with minor injury Young children have larger body surface areas than adults and greater insensible water loss. The relevance?
Minor burns usually heal 3-6 days and leave no scarring More severe burns take longer and have increased risk for infection First aid for minor burns: stop the burning process and put injured area under cool running water Why would you not use ice?
DEPTH OF INJURY
Superficial: first degree burns Partial thickness: second degree burns Full thickness: third degree burns Fourth degree burns: include muscle, fascia and bone Which type might be most painful? Least painful?
Scalds – hot water Severe sun burns
Sunburns Low intensity flash burns Cooking burns
DEEP PARTIAL THICKNESS SECOND DEGREE BURN
Epidermal, upper dermis, portions of deep dermis Pain, hyperesthesia, sensitive to cold air Blistered mottled red, weeping, edema Recover in 2 to 4 weeks, some scars, depigmentation, contractures Infection may convert to full thickness
FULL THICKNESS BURNS RD DEGREE BURN 3
Chemical, flame, prolonged exposure to hot liquids Epidermis, entire dermis and some subcutaneous tissue, may involve connective tissue, muscle, bone Pale, waxy, yellow, brown, mottled, wound is dry and leathery, firm to touch, no pain sensation, possible shock Recuperative; loss of digits or extremities, eschar sloughs, grafting
SYSTEMIC RESPONSE TO SEVERE BURNS
Cardiovascular: Burn shock r/t decreased cardiac output associated with myocardial depressant factor (enzyme) which decreases cardiac contractility Fluid/electrolyte loss compound problem further Adequate fluid replacement = normal CO
INDICATIONS OF ADEQUATE FLUID RESUSCITATION
Urine Output: 2 ml/kg/hr children 30 50 ml/hr adults 30Sensorium Conscious/alert Sensorium: Pulse: Increased BP: Normal/Increased Temperature: Increased N/V: Absent Serum Electrolytes: Normal range
Renal: increased fluid loss in circulationdecreased renal plasma blood flowdecreased glomerular filtration BUN and Creatinine increased d/t tissue breakdown May have hematuria from RBC hemolysis Myoglobinuria can occlude renal tubulesincreased risk of renal failure
GI: perfusion reduced d/t altered blood flowileus of gut Metabolism: accelerated rate with burns. Children have reduced glycogen storesincreased breakdown of fats and proteinsprolonged starvation state Anemia Metabolic acidosis d/t fluid shifts & loss
Burn Damage increases capillary permeability Water, electrolytes, and albumin molecules are smaller and are more easily lost from vascular space This increase permeability and inflammatory process causes leakage into the interstitial space, which causes edema formation IMPORTANT: Must fluid resuscitate at the same rate of fluid leakage • • •
GOAL OF FLUID
Maintain vital organ function while avoiding complications of inadequate or excessive fluids
RULE OF NINE
Large Bore IV Isotonic Solution Ringers Lactated, Normal Saline Begin as soon as possible Burns > 40% TBSA should have 1 amp Bicarbonate is added to each liter of fluid
Airway, breathing, circulation History and type of burn - 10% of burns are due to child abuse Other injuries (example: falls, explosion) Pain assessment Fluid status
PREVENTION OF INSECT BITES AND STINGS Know the insects common in your locale Teach children to avoid dangerous insects Apply a commercial insect repellant - DEET: Precautions
Inspect skin for ticks after playing outside Wear long pants and sleeves to avoid tick bites Stay calm when near stinging insets Avoid eating sweetened foods and beverages when outside Treat pets for fleas and ticks
• Inflammation of the meninges • Newborns and infants at greatest risk • Higher morbidity and mortality than viral meningitis • Common bacterial causes
–Haemophilus influenzae type B –Neisseria meningitides –Streptococcus pneumoniae –Group B Streptococcus
Bacterial Meningitis: Signs and Symptoms (Infants)
• Fever • Changes in feeding pattern • Vomiting, diarrhea • Anterior fontanelle bulging or flat • Alert, restless, lethargic, or irritable • Difficult to console • High-pitched, moaning cry
Bacterial Meningitis: Signs and Symptoms (Children)
• Fever • Confusion, delirium, irritable, lethargic • Vomiting • Muscle or joint pain
Bacterial Meningitis: Signs and Symptoms (Children) (cont’d)
• Hemorrhagic rash (meningococcal meningitis)Hemorrhagic rash The rashes appear in about 75% of the patients and may be quite variable. They can be as small as 1-2 mm and appear as tiny red, purple-black spots or they may be much larger resembling bruises. Their most common location is armpits, groin and ankles, and areas where pressure may be applied (e.g. underwear and socks).
Bacterial Meningitis: Signs and Symptoms (Children) (cont’d)
• Meningeal irritation
–Headache –Photophobia –Nuchal rigidity
The child with bacterial meningitis assumes an opisthotonic position, with the neck and the head hyperextended, to relieve discomfort.
To test for Kernig sign, raise the child’s leg with the knee flexed. Then extend the child’s leg at the knee. If any resistance is noted or pain is felt, the result is a positive Kernig sign. This is a common finding in meningitis.
To test Brudzinski sign, flex the child’s head while in a supine position. If this action makes the knees or hips flex involuntarily, a positive Brudzinski sign is present. This is a common finding in meningitis.
Progression of Symptoms
• • • • • • • • Seizures Apnea Cerebral edema Subdural effusion Hydrocephalus Disseminated intravascular coagulation (DIC) Shock Increased intracranial pressure
Bacterial Meningitis: Treatment
• Labs and cultures (blood, urine, cerebrospinal fluid) • Intravenous antibiotics • Steroids, anticonvulsants, antipyretics • IV fluids, fluid resuscitation • May be left with severe Neurologic deficits
Viral (Aseptic) Meningitis
• Inflammatory response of meninges • Most common cause: Enterovirus • Child not as ill-appearing as child with bacterial meningitis
Viral Meningitis: Signs and Symptoms
• Irritable or lethargic - general malaise • Fever • Headache • Photophobia • Upper respiratory symptoms • Positive Kernig and Brudzinski signs indicate meningeal irritation • Seizures are rare
Viral Meningitis: Treatment
• Labs and cultures (blood, urine, cerebrospinal fluid) • Intravenous antibiotics until cultures are negative - treat as bacterial meningitis until proven otherwise • Treatment of symptoms is supportive • Symptoms usually resolve in 3 to 10 days • Neurologic deficits are uncommon
• Acute encephalopathy • Associated with use of aspirin and a mild viral illness • With decreased aspirin use, condition is now rare • Condition develops over five stages
Reye Syndrome: Treatment
• Diagnosis by history, lab findings • Treatment is supportive • Often require treatment for increased intracranial pressure • Mortality is high
• Reye's syndrome is usually treated in the hospital. Severe cases may be treated in the intensive care unit. The hospital staff will closely monitor your child's blood pressure and other vital signs. Specific treatment may include: • Intravenous fluids. Your child may be fed through an intravenous (IV) line. Glucose and an electrolyte solution containing sodium, potassium and chloride may be given through the IV, too. • Insulin. Small amounts of insulin may be used to increase sugar metabolism. • Corticosteroids. These medications may be used to reduce swelling in the brain. • Diuretics. These medications may be used to increase fluid loss through urination. • If your child has trouble breathing, he or she may need assistance from a breathing machine (ventilator).
• Babies who are born with myelomeningocele also have a sac-like mass that bulges from the back, but a layer of skin may not always cover it. In some cases, the nerves of the spinal cord may be exposed. A baby who also has hydrocephalus will have an enlarged head, the result of excess fluid and pressure inside the skull.
• The treatment largely depends on the type of spina bifida a child has and how severe it is. • meningocele form of the disease usually has an operation during infancy in which doctors push the meninges back and close the hole in the vertebrae. Many children with this type of spina bifida have no other health problems down the road, unless there is nerve tissue involved with the sac.
• Babies born with the myelomeningocele form of the disease need more immediate attention and typically have surgery within the first 1 to 2 days of their lives. During this first surgery, doctors typically push the spine back into the vertebrae and close the hole to prevent infection and protect the spine. • A baby who also has hydrocephalus will need an operation to place a shunt in the brain. The shunt is a thin tube that helps to relieve pressure on the brain by draining and diverting extra fluid. • In addition, some children need subsequent surgeries to manage problems with the feet, hips, or spine.
• The U.S. Public Health Service recommended in September 1992 that all women of childbearing age consume 400 micrograms (ug) of folic acid daily to reduce their risk of having a pregnancy affected with spina bifida or other neural tube defects. Folic acid is a B vitamin. For women, this amount of folic acid on a daily basis spina bifida or anencephaly, both of which are neural tube defects (NTDs) in the baby.
Myelodysplasia: Pre-op Nursing Care
• Cover sac with sterile dressing (warm saline) • Monitor for CSF leakage • Place infant in prone position with knees slightly flexed • Assess bowel, bladder function • Monitor for signs of infection • Feed with head turned to one side
Myelodysplasia: Post-op Nursing Care
• Monitor for wound healing • Monitor for signs of infection • Monitor for signs of hydrocephalus, increased ICP • Place in prone or side-lying position • Measure head circumference daily • Assess intake and output • Avoid latex products
Cerebral Palsy (CP): Background Information
• Cerebral palsy caused by insult to central nervous system
–Congenital –Hypoxic –Ischemic –Infectious
• Very premature infants at high risk • Birth asphyxia accounts for only 9% of cases
• Even though cerebral palsy affects muscle movement, it isn’t caused by problems in the muscles or nerves. It is caused by abnormalities in parts of the brain that control muscle movements. • The majority of children with cerebral palsy are born with it, although it may not be detected until months or years later. • A small number of children have cerebral palsy as the result of brain damage in the first few months or years of life, brain infections such as bacterial meningitis or viral encephalitis, or head injury from a motor vehicle accident, a fall, or child abuse.
Early signs of cerebral palsy
• usually appear before a child reaches 3 years of age. • The most common are a lack of muscle coordination when performing voluntary movements (ataxia);
–stiff or tight muscles and exaggerated reflexes (spasticity); –walking with one foot or leg dragging; –walking on the toes, a crouched gait, or a “scissored” gait; –muscle tone that is either too stiff or too floppy.
• At birth a baby with cerebral palsy is often limp and floppy, or may even seem normal. •
Types of Cerebral Palsy
• Spastic – hypertonia, exag. DTR, contractures, abnorm spinal curve • Dsykinetic – impair vol muscle, tremors, inconsistent muscle tone • Ataxic – abnor vol muscle mov, wide based gait • Mixed – no dominant pattern
Nurses in the Community: Care of the Child with CP
• Continuous support • Coordination of care - referrals • Working with schools to individualize education plan • Adaptive devices • Transition to adult living
Coarctation of the aorta
• a birth defect in which the aorta, the major artery from the heart, is narrowed. • The narrowing results in high blood pressure before the point of coarctation and low blood pressure beyond the point of coarctation. • Most commonly, coarctation is located so that there is high blood pressure in the upper body and arms and low blood pressure in the lower body and legs. Symptoms can include localized hypertension, cold feet or legs, decreased exercise performance, and heart failure.
RHEUMATIC HEART DISEASE
• Rheumatic heart disease is the result of rheumatic fever caused by streptococcal bacteria. Most likely to strike children between 5 and 15 years old, rheumatic fever can scar heart valves to the point where they may not function properly
– Cause: group A streptococcus – Heart damage can occur: carditis or inflammation of the heart muscle – Also can affect any of the valves, giving symptoms of the particular valve dysfunction
• The best defense against rheumatic heart disease is to prevent rheumatic fever from ever occurring. By treating strep throat with penicillin or other antibiotics, doctors can usually stop acute rheumatic fever from developing. • People who've already had rheumatic fever are more susceptible to attacks and heart damage. That's why they're given continuous monthly or daily antibiotic treatment, maybe for life. If their heart has been damaged by rheumatic fever, they're also at increased risk for developing bacterial endocarditis, an infection of the heart's lining or valves.
• In April 2007, the American Heart Association updated its guidelines for prevention of endocarditis and concluded that there is no convincing evidence linking dental, gastrointestinal or genitourinary tract procedures with the development of endocarditis. The prophylactic use of antibiotics prior to a dental procedure is now recommended ONLY for those patients with the highest risk of adverse outcome resulting from endocarditis, such as patients with a prosthetic cardiac valve, previous endocarditis, or those with specific forms of congenital heart disease. The guidelines no longer recommend prophylaxis prior to a dental procedure for patients with rheumatic heart disease unless they also have one of the underlying cardiac conditions listed above.
• Digoxin (Lanoxin) increases contractility • May be given PO in liquid or tablet form, IV • Infant:
– change in behavior – fussiness – Irritability – intolerance to feedings,
Signs of Toxicity
– Lethargy or drowsiness – Confusion – HA – Hallucinations – Visual changes – syncope
• GI system
– N/V – Diarrhea – Anorexia, weight loss, failure to thrive – ABD pain
When to hold Digoxin
• When pulse is
– Infant –less than 90-100 – Children- less than 70
– Always check potassium level before administer digoxin • digoxin normally competes with K+ ions for the same binding site on the Na+/K+ ATPase pump.
• Furosemide (Lasix) diuretic given IV or PO as liquid or tablet • Assessing for effectiveness—UO or number of wet diapers • Spironolactone (aldactone) mild diuretic which spares potassium (why is that desirable?)
• Comes PO only, as tablet or can be made into a liquid suspension • Captopril (Capoten) ACE inhibitor pulmonary and systemic vasodilator which helps reduce the workload of the heart • BP important to determine tolerance to drug • Comes PO in tablet or can be crushed and mixed with liquid
TETRALOGY OF FALLOT
• Tetralogy of Fallot has four key features.
– A ventricular septal defect (a hole between the ventricles) – many levels of obstruction from the right ventricle to the lungs (pulmonary stenosis) are the most important. – Also, the aorta (major artery from the heart to the body) lies directly over the ventricular septal defect, and the right ventricle develops thickened muscle.
• What is it? It is a hypercyanotic spell • It occurs when the infundibulum spasms • Infundibulum is the area below the valve, also called the outflow tract • Blood is shunted L due to spasm • The hypoxia acidosis, which increases pulmonary vascular resistance
• Knee chest position for infants— • Squatting in children • Both reduce venous blood return, increases systemic vascular resistance shunts more blood to the right • O2 100% • Morphine IV or IM
• Call for assistance • Inderal PO q6h or q8h – beta blocker to help prevent the spasms from occurring • If infant is having frequent ‘tet’ spells, it is time for surgical intervention
Most infants with tetralogy of Fallot develop cyanosis in the first year of life. The skin, lips, and mucous membranes inside the mouth and nose take on a noticeably dusky blue color. Only some infants with very severe obstruction of the right ventricle outflow turn blue at birth. A small number of children with tetralogy of Fallot never turn blue at all, especially if the pulmonary stenosis is mild, the ventricular septal defect is small, or both. In some children, the cyanosis is quite subtle and may go undetected for some time.
• Tetralogy of Fallot is treated surgically. A temporary operation may be done at first if the baby is small. Complete repair comes later. Sometimes, the first operation is a complete intracardiac repair.
• Temporary Operation In small and very blue infants, a shunt operation may be done first to provide adequate blood flow to the lungs. This lets the baby grow big enough to have a full repair. The shunt is built between the aorta and the pulmonary artery. The shunt is removed when a complete intracardiac repair is done later.
Complete repair tends to be done early in life. Once it was more common to do a temporary operation first and a complete repair later in childhood. To do a complete repair, the surgeon closes the ventricular septal defect with a patch and opens the right ventricular outflow tract by removing some thickened muscle below the pulmonary valve, repairing or removing the pulmonary valve and enlarging the peripheral pulmonary arteries that go to both lungs. Sometimes a tube is placed between the right ventricle and the pulmonary artery. This is sometimes called a Rastelli repair.
POST OP CARE
• Observe VS –may have arterial and central lines in place • Maintain respiratory status—may be mechanically ventilated at first, then try to get patient to cough • Monitor I & O, meaning all drainage tubes. Also, be aware of all IV fluids patient is getting
• Observe for complications of heart surgery: • CHF, respiratory distress, bleeding, neurologic changes, tamponade, infection • Pain management • Support for family—keeping them informed of child’s progress and allowing them to stay at the bedside as much as possible
• Common in infants and children • Causes: URI, being flat when feeding, flat in crib with bottle propped, smoking &/or odors on clothes from smoking • S & S: crying, fussiness, change in feeding, fever, vomiting, tugging on ear or rubbing affected ear
• Broad term of upper airway illnesses examples • Affect large numbers of children between 3 months and 3-5 years • Inflammation of the larynx, trachea, bronchi • Usually viral • Croup is most likely to occur during the fall, winter, and early spring, and symptoms are most severe in kids younger than 3 years of age
• • • • • Barking cough fast or difficult breathing grunting noise or wheezing while breathing. Occurs most often at night Last 3-5 days
• Humidified oxygen or cool mist
– This treatment helps to moisten secretions and inflamed tissues to open the airway and soothe irritation.
• Children who are not responding to mist will receive nebulizer treatments to breathe • Corticosteriod • Racemic epinephrine aerosols
• Inflammation of the epiglottis • Potentially life-threatening • Usually caused by H. influenzae type B (Hib) - Hib vaccination now required for children • Signs and symptoms: Fever, drooling, difficulty swallowing
• Avoid inspecting mouth or throat • Allow child to maintain position of comfort • CBC, blood cultures,
• Antibiotics IV • You may wear a mask that delivers oxygen to your lungs
– Possible intubation
• RSV accounts for the majority o cases • Pathophysiology • Symptoms: Nasal symptoms, cough, fever, wheezing, tachypnea, retractions, decreased activity level, decreased oral intake, dehydration
Signs and Symptoms
• • • • Tachypnea Significant retractions Poor oral intake Lethargy
• KNOW AND READ THE PATHO
• Occurs most often in infants and toddlers • Treatment
– O2 – IV hydration – Suctioning – Bronchodilator therapy
• Bronchitis is an inflammation of the large breathing tubes (airways) that are called bronchi, which causes increased production of mucus and other changes. Although there are several different types of bronchitis, the two most common are acute and chronic (primarily affects adults).
• runny nose, usually before a cough starts • malaise (an overall body discomfort or not feeling well) • chills • slight fever • back and muscle pain • sore throat
• In the earlier stages of the condition, children may experience a dry, nonproductive cough which progresses later to an abundant mucus-filled cough. Younger children may have some vomiting or gagging with the cough. The symptoms of bronchitis usually last seven to 14 days, but may also persist for three to four weeks.
• Medications to help suppress the cough or loosen and clear secretions may be helpful • Bronchodilator inhalers will help open airways and decrease wheezing • antibiotics play a limited role in treating bronchitis, they become necessary in some situations.
– In particular, if the doctor suspects a bacterial infection, antibiotics will be prescribed. People with chronic lung problems also usually are treated with antibiotics
• Approximately 17.3 million Americans have asthma • The cost of illness related to asthma is around $6.2 billion per year in the United States. • Each year, an estimated 1.81 million people with asthma require treatment in the emergency department with approximately 500,000 hospitalizations. • Children younger than the age of 18 years account for 47.8% of the emergency department visits and 34.6% of the hospitalizations due to
• Asthma is a disorder caused by inflammation in the airways (called bronchi) that lead to the lungs. • This inflammation causes airways to tighten and narrow, which blocks air from flowing freely into the lungs, making it hard to breathe. • The inflammation may be completely or partially reversed with or without medicines.
• Inflammation of the airways is linked to bronchial hyperresponsiveness, which means that the airways leading to the lungs can narrow when they are exposed to anything to which they are sensitive, making it hard to breathe.
• So an asthma flare is caused by 3 important changes in the airways that make breathing more difficult:
– Inflammation of the airways
– Excess mucus that results in congestion and mucus "plugs" that get caught in the narrowed airways
– Bronchoconstriction (bands of muscle lining the airways tighten up)
• Many things can cause asthma, including
– Allergens - mold, pollen, animals – Irritants - cigarette smoke, air pollution – Weather - cold air, changes in weather – Exercise – Infections - flu, common cold
Symptoms include wheezing, breathlessness, chest tightness, cough, particularly at night or after exercise/activity.
• Pulse ox • Chest x-ray-hyperexpansion, atelectasis and flattened diaphragm, hyperinflation • Pulmonary function test • Peak expiratory flow • CBC, CMP, if fever blood cultures
• Short-acting beta-2 agonists. These bronchodilators begin working within minutes and last four to six hours • corticosteroids
– prednisone, methylprednisolone, hydrocortisone and others
• Respiratory treatments
– Inhaled corticosteroids • fluticasone (Flovent), budesonide (Pulmicort), triamcinolone (Azmacort), flunisolide (Aerobid) and beclomethasone (Qvar). Advair Diskus
• Common childhood illness • Affects up to 40% of children • Associated with atopic dermatitis (form of eczema) and asthma • 80% of asthmatic children suffer from allergic rhinitis
Dehydration: Three Types
• Isotonic • Loss of sodium and water is equal • Serum sodium is normal • Hypotonic • More sodium is lost than water • Serum sodium is low • Hypertonic • More water is lost than sodium • Serum sodium is high
Etiology of Dehydration in Children
• Diarrhea (5 million deaths from dehydration worldwide) • Vomiting - nasogastric tubes • Hemorrhage • Burns
Pathophysiology of Dehydration
• Initial dehydration (First 3 days) • Most of fluid loss (80%) is from extracellular fluid compartment • 20% is from intracellular fluid compartment
Symptoms of Severe Dehydration
Severe dehydration is a medical emergency and parents should seek immediate medical attention. These children appear lethargic (meaning they are difficult to keep awake) or may be unconscious. They also may have:
• poor drinking or may be unable to drink • a parched mouth and tongue • minimal or no urine output • greater than 9 percent weight loss • increased heart rate, weak pulses, deep breathing, and cool, mottled extremities • capillary refill that is very prolonged or minimal • recoil on skin turgor test in more than 2 seconds • deeply sunken eyes (and/or fontanel in a baby)
Symptoms of Minimal Dehydration
Most children who are sick, either with a cold or mild stomach bug, will have minimal or no dehydration. These children are alert and appear well and have: normal thirst or may refuse some liquids
• a moist mouth and tongue • normal to slightly decreased urine output • less than 3 percent weight loss • normal heart rate, pulses, breathing, and warm extremities • capillary refill less than 2 seconds • instant recoil on skin turgor test • eyes not sunken (and/or fontanel in a baby)
Symptoms of Mild to Moderate Dehydration
Once dehydration worsens, children may begin to feel tired, restless, and irritable, which makes it difficult to get them to drink more fluids. Other signs and symptoms of mild to moderate dehydration,include: • increased thirst
• • • • a dry mouth and tongue decreased urine output 3 to 9 percent weight loss normal to increased heart rate and pulses, normal to fast breathing, and cool extremities • capillary refill greater than 2 seconds • recoil on skin turgor test in less than 2 seconds • slightly sunken eyes (and/or fontanel in a baby)
Treatment of Dehydration
• Oral rehydration solutions • Intravenous fluid replacement • Choice of fluid • Amount of fluid • Frequent monitoring and reassessment • Weight • Labs
Nursing Interventions: Dehydration
• • • • • Prevent dehydration Provide oral rehydration fluids Monitor intravenous fluid administration Monitor response to therapy Teaching
• Electrolytes in usually equals electrolytes out • Body maintains balance unless disease state occurs • Blood levels measure serum electrolytes only - may vary in other fluid compartments
• Reflect osmolality of body fluids • Sodium balance and water balance are closely tied • Most abundant extracellular ion
• Body fluids are too concentrated - more sodium than water • Causes: Decreased water intake or increased solute intake - diabetes insipidus • Treatment • Fluid replacement • Treat underlying cause
• Body fluids are too dilute - more water than sodium • Causes: Water intoxication, diluted formula, SIADH • Complications: Cerebral edema, seizures • Treatment: Replace sodium
• • • • Most abundant intracellular ion Essential electrolyte Can shift in and out of cells Excreted primarily by urine, but also in sweat, feces
• Excess potassium in the blood • Causes
• Increased potassium intake (oral, IV) • Shift of potassium out of cells into interstitial fluid (massive cell death, old transfused blood, acidosis) • Decreased potassium excretion (renal failure)
• Treat underlying cause • Cation exchange resin (Kayexalate) • Dialysis
• Decreased potassium in the blood • Causes
• Decreased potassium intake (NPO status, IV fluids) • Shift of potassium into cells (alkalosis, insulin therapy) • Increased potassium excretion (diuretics, diarrhea, others)
• Replacement (IV or oral) • Treat underlying cause
• Most abundant mineral in the body • Involved in • Muscle and nerve function • Bone strength • Hormone secretion • Blood clotting
• Excess of calcium in the plasma • Most of calcium is stored in bones • Causes • Increased calcium intake • Shift of calcium from bones to extracellular fluid (hyperparathyroidism, prolonged immobility)
• Treatment: • Furosemide (Lasix) increases calcium excretion • Glucocorticoids decrease absorption • Phosphate (binds with calcium) • Dialysis
• Serum deficit of calcium • Most of calcium stored in bones • Causes
• Decreased intake of vitamin D and/or calcium • Hyperphosphatemia • DiGeorge syndrome
• Treat underlying cause • Replace calcium (oral or IV) • Vitamin D
• Necessary for enzyme function, nerve function • Absorbed in ileum • Present mostly in the cells and bones small amount in extracellular fluid • Excreted in urine, sweat, and feces
• Excess magnesium in blood • Causes • Renal failure • Excess magnesium intake (IV) • Treatment: • Diuresis • Dialysis
• Decreased magnesium in blood • Causes • Malnutrition, decreased intake • Chronic diarrhea • Prolonged suctioning • Treatment • Treat underlying cause • Replacement
• Tightly regulated • Balance of acids (hydrogen) and bases (bicarbonate) • Enzymes and cells operate in a very narrow range of pH
Normal pH Varies by Age
• • • • Slightly basic Infants: 7.36 to 7.42 Children: 7.37 to 7.43 Adolescents: 7.35 to 7.41
Types of Acids in the Body
• Carbonic acid
• Carbon dioxide and water • Lungs excrete carbon dioxide
• Metabolic (noncarbonic) acids
• • • • • Pyruvic acid Sulfuric acid Lactic acid Hydrochloric acid Can be neutralized by buffers in body fluids • Can be excreted by the kidneys
• Binds hydrogen ions when there are too many • Releases hydrogen ions when there are not enough • Types of buffers
• • • • Bicarbonate Protein Hemoglobin Phosphate
• Once buffers are saturated, kidney excretes acids
Nursing Interventions: Hypernatremia
• Monitor sodium level, intake and output, urine specific gravity • Assess level of consciousness • Consider underlying cause • Teaching • Prevention in the hospital setting - free water with tube feedings
Nursing Interventions: Hyponatremia
• • • • • • Monitor sodium level, intake and output ADH levels Formula preparation - dilution? Monitor level of consciousness Seizure precautions Prevention in the hospital setting
• Use normal saline rather than sterile water for irrigations • Avoid tap water enemas
Nursing Interventions: Hyperkalemia
• Stop any potassium-containing fluids from infusing • Administer medications • Glucose and insulin • Bicarbonate • Calcium • Kayexalate
Nursing Interventions: Hyperkalemia (cont’d)
• Monitor cardiopulmonary status • Prevention in the hospital setting • Risk increases with use of old blood for transfusion • IV fluids that contain potassium • Don’t give potassium-containing fluids to a child who has oliguria or anuria
Nursing Interventions: Hypokalemia
• Ensure adequate potassium intake • If child is taking digitalis, hypokalemia potentiates digitalis toxicity - assess for nausea, vomiting, bradycardia • Cardiac monitoring • Potassium replacement (oral or IV)
Nursing Interventions: Hypercalcemia
• Encourage fluid intake • Increase mobility • Avoid calcium-rich foods, calcium supplements • Avoid vitamin D supplements
Nursing Interventions: Hypocalcemia
• Calcium replacement (oral or IV) - never given IM: Causes tissue necrosis • Calcium supplementation • Teaching
Nursing Interventions: Hypermagnesemia
• Monitor serum levels, blood pressure, reflexes • Monitor for cardiac arrhythmias • Avoid magnesium-containing substances
• Dietary sources • Medication (milk of magnesia) • Sea salt
• Diuresis • Dialysis
Nursing Interventions: Hypomagnesemia
• Monitor reflexes, cardiac functioning, muscle cramps • Replace magnesium (oral, IM, or IV) • Increase magnesium in diet - food choices • Teaching
Developmental Dysplasia of the Hip (DDH)
• Femoral head and acetabulum improperly aligned • May include hip instability, dislocation, subluxation, or dysplasia • Occurs in girls more than boys - unilateral in 80% of cases • Cause: Unknown - genetic factors likely
• Hip dysplasias • Acetabular dysplasia: mildest form • Subluxation: largest percent of congenital • hip dysplasias • Dislocation: • (the following slide demonstrates the three types)
The asymmetry of the gluteal and thigh fat folds is easy to see in this child with developmental dysplasia of the hip.
• Diagnosing: • Ortolani’s test: hear the click • Barlow’s test: feel the slipping in and out of the femur head from the acetabulum • Will see uneven gluteal folds in infant • Limping, toe walking in older children • Trendelenberg sign: pelvis tilts downward on normal side instead of upward
• Treatment: • Begun as early as possible to prevent deformity • Pavlik harness: keeps femur centered in acetabulum with flexion, prevents hip extension • Harness can be very effective if there are no other complications • Older infants and toddlers may require traction
• Delay in treatment may end in requiring surgery, which is not always effective due to adaptive changes over time • Care required during treatment?
• “Brittle bone disease” • Genetic condition affecting collagen production • Manifestations
– Frequent fractures – Blue sclerae – Thin, soft skin – Short stature
• Group of inherited diseases - Duchenne most common • Muscle fibers degenerate • Onset varies (birth to late in life) • Progression varies (few years to many years) • All are terminal
• Duchenne muscular dystrophy is the most common childhood form of muscular dystrophy, with symptoms beginning usually between 2 to 6 years of age in boys. Children who are affected start out by falling frequently, having trouble getting up from sitting or lying down, and may waddle when they walk.
• Treatment: • No known cure • Treatment mainly symptomatic to achieve the highest level of function possible • Complications:
•Contracture deformities immobility •Disuse atrophy •Infections •Obesity—why?
• Respiratory problems—infections • Cardiac problems—CHF • Primary cause of death is from respiratory failure—infection or weakness of diaphragm
• • • •
Guillain-Barre Syndrome Infectious polyneuritis Uncommon in children Is a progressive demyelinating polyneuropathyprogressive ascending paralysis • Immune mediated disease associated with viral infection • Most common ages are 4-10 years
• Treatment: primarily supportive • Earlier diagnosis made, better the outcome • Earlier the age, the better outcome • Use of plasmapharesis, no respiratory complications better outcome • Full recovery usually occurs —may take up to 1 year or more • Nurse’s role: preventing complications of immobility
• Multidisciplinary team approach is used, for both the acute phase and the rehab phase • In summary: CP, MD and GuillainBarre all have immobility issues as major components which is the nurse’s role to address. • Think how immobility affects each age group—ability to socialize, grow physically and cognitively
Pauciarticular Juvenile Rheumatoid Arthritis
• Pauciarticular JRA refers to a form of juvenile rheumatoid arthritis which affects four or fewer joints. • Pauciarticular is the most common form of JRA; about half of all children with JRA have this type. • This type of JRA affects mostly girls. Girls under age 8 are most likely to develop this type of JRA. • Girls are more commonly affected 3-5:1 (CDC)
• is a disease of few joints. It most commonly affects the knees, elbows, wrists, and ankles. • The joints are usually affected asymmetrically (one joint on one side). • Children affected by pauciarticular disease usually have a positive antinuclear antibody (ANA) test and are prone to an inflammatory eye condition, iridocyclitis. • Children with pauciarticular JRA generally do well.
Polyarticular Juvenile Rheumatoid Arthritis
• Polyarticular JRA refers to a form of juvenile rheumatoid arthritis which affects five or more joints. • a disease of many joints. • This is the type of juvenile arthritis which doctors consider to be most similar to adult rheumatoid arthritis. • About 30 percent of all children with JRA have polyarticular disease. • Girls are two times more likely to have this disease than boys.
• The joints are usually affected symmetrically (on both sides). • Often the small joints of the hands are affected, as well as other joints. • Low grade fever, weight loss, and anemia may occur, and in severe cases growth problems. • Most children with polyarticular disease test negative for rheumatoid factor and their prognosis is usually good. • A minority of children test positive for rheumatoid factor and seemingly are at more risk for chronic, progressive destruction and joint damage.
• Treatment: • No cure • Goal: manage pain
•preserve joint ROM •minimize effects of inflammation •(joint deformity) •Promote normal growth and •development
• Treatment plan involves multidisciplinary team • NSAIDs are the first drugs used • SAARDs: slower acting antirheumatic drugs such as methotrexate (which is an antineoplastic drug) • Corticosteroids: have many adverse effects one major one is decreased physical growth • Biologic agent: Etanercept is newly approved
• Cytotoxic agents: cyclophosphamide, azathiopine, cyclosporine, chlorambucil • Have risk of toxicity, these drugs are used in transplants and as chemo agents • Physical management: PT to preserve joint function • Synovectomy not recommended in children • Cortisone shot into affected joint can be tried first
• Joint replacement may be seen in older child • This is a life long chronic condition and families should be informed about community support available; I.e. the Arthritis Foundation and the American Juvenile Arthritis Foundation
• Infection of the bone, usually a long bone in lower extremity • Acute or chronic • Occurs at any age - boys more than girls (due to trauma) • Cause: Microorganism, usually bacterial • Symptoms: Pain, swelling, decreased mobility, fever • Treatment: Antimicrobials (oral or IV) for 3 to 6 weeks
Osteomyelitis: Nursing Care
• • • • • • Immunization status (tetanus) Obtain cultures and blood work Administer fluids and medications Protect from spread of infection Encourage well-balanced diet Home care teaching - considerations for home IV therapy
• Case History: This 13 y.o. healthy teenager sustained a both bones (radius and ulna) forearm fracture, grade I open, playing football at summer camp. It was washed out and plated 3 days later. • Clinical Course: He developed fever, chills, and drainage of the wound several weeks after treatment. He was referred shortly after given oral antibiotics, 6 weeks after injury, with the following presentation.
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