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NUR 106 CE2

6-19-2009
Pediatric Clinical Rotation Quiz

1. Describe the physical assessment of the infant, toddler, child, and adolescent.
Include vital signs, height and weight, head and neck, face, pupils, nose, ears, abdomen
(Include each system).
Infant: Infants should be examined in a comfortable environment, especially concerning temperature, and
safety of the infant. Allow the parent's to participate in the exam and allow them to ask questions to let them
feel they have more control and understanding of the examination. Upon assessment of the infant, their skin
should be warm, and with in normal limits of color as related to their race, there should be no pallor, cyanosis,
or other abnormal discolorations, the hair should be strong and fine, some hair loss on the back of the head is
normal for infants, fine hair is seen on the arms, legs, face and back, but there should be no tufts of hair at the
tailbone or other areas of the spine as this may indicate Spina Bifida. The fingernails should be strong, flexible
and have pink nailbeds with a 3 second or less capillary refill time, there should be no cyanosis or clubbing of
the fingernails. The reflexes should be present as expected for the age of the infant. The baby's head should be
symmetrical with the fontanels soft but not sunken as this may indicate dehydration. Features of the face should
be proportionate to the size of the head, ears should align at the auricles on an imaginary line from the outer
canthus of the eyes. Eyes are symmetrical with facial features, corneal light reflex is symmetric, although the
extraocular movements may not be symmetric in the newborn. Sclera of the eyes should be white with no
discoloration, cornea should be clear, no excessive tearing or tear duct blockages should be seen. Conjunctiva is
pink and moist, eyelids cover eyes completely when closed, yet when open reveal most of the iris except the
top of the iris. Upon the internal exam of the eye the red reflex is present. Pupil's should be PEARLAA. Mouth
is pink and moist, hard and soft palates intact with no cleft palate, tongue is pink and symmetric in appearance,
no pointing of the tongue or abnormal size of the tongue should be seen as this can indicate Down Syndrome.
It is normal for infants to have a white film on their tongue, but it is usually easily scraped away, if it is not it
may be thrush. Tonsils are usually not visible. Infant should have a strong and lusty cry. No obstructions of the
nose or mouth should be seen in an infant with no visible defects. Teeth are not usually present in infants until 6
months of age or older unless it is a pernicious tooth, gums should be pink and moist with no lacerations or
lesions. Abdomen of the infant is a more rounded shape than the abdomen of an older child, liver is palpable 1-
2cm below the right sternal border, bowel sounds should be heard in all four quadrants and may be heard in all
areas of the abdomen, heart sounds should be heard with regular rhythm, lung sounds should be clear although
hard to distinguish upper or lower lobes from one another. Normal Vital Signs of the Infant: Temp: 97.7-
99.5F; Pulse: 120 - 160 beats per minute depending on activity level; Resp: 23 - 50 breaths per minute, may be
irregular in rate and even have apnea; Blood Pressure: 110/71 mm Hg.
Toddler: Toddlers should have similar findings to infants when concerning the skin, fingernails, pupils, and
capillary refill time. However toddlers are upright and usually walking by the age of 18 months of age, therefore
creating an upper body with considerable lordosis, bowed legs, pigeon toed and an unsteady gait that increases
their risk of falling and injuring themselves. Safety is the number one priority for children of all ages, but due to
the toddler's increased mobility and desire to get into everything, it is especially important to keep safety in
mind when performing an exam on them. When examining a toddler, try to keep the most invasive and
uncomfortable parts of the exam towards the end of the exam. Using games or activities to help the child
participate in the exam also is helpful, involving the parent's helps to comfort the toddlers fear of the unknown
as well as giving the parents a hands on approach to the medical exam by allowing them to assist you in
positioning the child or calming the child. The normal vital signs are as follows: Blood Pressure: 112/61 (BP is
influenced by a child's age, height, weight and gender; as the child grows the blood pressure should stabilize to a
normal adult pressure) Temp: 96.8 - 100.4F; Pulse: 75 - 100 beats per minute; Respirations: 20 -30 breaths per
minute. Growth can be evaluated by using the child's height, weight, head circumference and BMI. Growth
charts developed by the National Center For Health Statistics include: weight for age percentiles; stature for age
percentiles; weight for stature percentiles; BMI for age percentiles; these charts help in determining the childs
growth patterns to make sure they are growing within the normal ranges of other children. Toddlers are known
mess makers but should be fairly clean in appearance, with no foul odors, and no apparent distress noted. They
may however have bruises, scratches and bumps from their many adventures, and accidents, but any signs of
abuse should be reported. The toddler should have white, clean deciduous teeth, with no signs of nutrition
deficits, or problems such as the common, "baby-bottle mouth". The tonsils if visible should not be swollen, red
or show any signs of infection, they may however catch small food particles in their crevices. The uvula should
be midline, soft and hard palates intact with no defects, tongue should be pink and moist as well as the oral
mucosa. The gingiva should be pink in color and adhere tightly to the teeth, there should be no signs of
bleeding, or swelling in the gums. Speech in the toddler can vary from baby-talk to small fragmented sentences,
the toddler may have some sounds they find hard to pronounce well. Hearing should be equal in both ears,
there should not be any obstructions of the ear canals, the tympanic membrane should be a pearly gray color, no
redness or foreign objects should be seen, although ear wax (cerumen) is not an abnormal finding. The light
reflex is visible, and internal ear is free from any lesions or discharge. Eyes of a toddler should be able to follow
the six cardinal gazes, although it may be difficult to get the child to actually follow directions for any length of
time. Corneal light reflex is symmetric, gaze should also be symmetric with no lag in either eye or eyelids.
Vision can sometimes be tested using a chart made of shapes or familiar pictures that the child can identify. The
pupils, sclera, corneas, conjunctiva, and tear ducts should be similar to the findings of the infant, although tear
production is increased in the toddler or older infant. Muscle tone should be firm, no weakness or flaccidity
should be seen. The child should be able to follow short simple commands, although they may try to show
their want for independence and tell you no. Abdomen should be symmetric with breathing, no retractions.
Breath sounds, heart sounds, and bowel sounds are heard clearly through the chest wall. No abnormal sounds
should be heard, it may be possible to see peristalsis in the abdomen of the toddler. No masses should be felt on
palpation, the liver, spleen, descending colon are palpable. Pulses should be easily felt in all locations, should be
regular in rate and rhythm. Deep tendon reflexes should be present and normal, no primitive reflexes should
exist by this age. Fontanels should be closed, hair should cover the symmetric skull that is larger in proportion
to the body. Toddlers may still wear diapers or may be potty training, genitalia should not be much different
than that of an infant, although they have grown in size and the child may show a fascination with them. If the
parents are concerned about this reassure them that this is normal for children of this age group.
Child: An examination of a child does not differ much from the exam of the toddler. Allow the child to
participate in the exam by making games out of the different assessments techniques. Parents are also
encouraged to participate. Explain everything you need to do, so that the child feels they are important as a
person and will be more willing to participate in the exam if they are comfortable with the environment and
person(s) involved in the examination. Most findings are as seen in the toddler. Eyes are now able to be tested
for vision and color vision using the Snellen chart, if the child is still unable to recognize the alphabet, then
familiar shapes, pictures, and colors may be used. Teeth of a child should be white, and pearly, no signs of decay
or nutritional deficit are also normal findings. Depending on the age of the child their teeth may be loose or
missing due to the growth of their permanent teeth. Children who are starting to get their permanent teeth
should not have any malocclusions or signs of decay, teaching proper oral care is important to help ensure
healthy teeth. Tonsils are visible, but should so no signs of infection or inflammation, the tonsils may catch food
particles in their crevices. Speech should be easily understood, and spoken with no speech impediments. Lymph
nodes are possible palpable at this age but if so they should be non tender, small and mobile. No abnormal
masses should be palpable in a healthy child. The stature of a child is erect with firm muscle tone, no flaccidity
or weakness in any extremeties, Full range of motion in the joints should be noted, with no crepitus, popping,
or pain. Breathing should not produce any retractions of the ribs, should be symmetrical when the abdomen
moves with inspiration and expiration, normal breath sounds should be heard, although it may still be difficult
to distinguish the locations of the sounds. Adventitious sounds are not a normal finding. No signs of
malnutrition should be seen such as under weight, over weight (morbid). Appearance should be clean, well
groomed for a child, no smells, discharge or other abnormalities noted. Bumps, bruises, lacerations, broken
bones, scrapes, and sprains are normal in this age group because of their increasing mobility on bicycles,
skateboards, and increasing activity levels. Any signs of abuse should be reported immediately. The spine of the
child should be erect with no deviations in its curvature, the curvature should be similar to those in the adult,
double 'S' shape. Monitor for any signs of Scoliosis or other spinal deformities. Growth should be on average
according to the growth chart, but may be on the low or high end of the average percentiles.
Adolescents: During adolescence many changes occur, and so must the examination. The adolescent may no
longer want the parent to be present in the exam room. Vital signs are comparable to those in the adult.
Puberty has usually begun in this age group, all though it may occur earlier or later in some individuals. The
adolescent may be withdrawn, and thus hard to engage in the exam, asking questions about friends, school, and
activities may help open up the communication barrier. Head should be proportional to size of the body, facial
features are symmetric, neck is erect and trachea is midline. Lymph nodes may be palpable, and if so should be
non tender and mobile. Tonsils should be comparable to the findings in an adult or child, no signs of infection
or inflammation, some may have had tonsils removed by this age group. Speech should be clear and well
articulated, no speech impediments or tics. Muscles are well defined by this age, and should be equal in tone
and strength bilaterally, it is normal for one arm to be slightly larger than the other due to that being the
dominant arm. Scars may be visible, but look for any signs of self inflicted wounds or scars, as this may indicate
emotional distress. Emotional distress is increased in the adolescent. Eyes should be symmetric in gazes, no lags
in movement of the orbit or eyelids should be seen. Hair on the head should be clean and strong, watch for
signs of malnutrition such as overly shiny hair, weak hair that is easily pulled from the root, limp or dull hair.
Many adolescents are concerned with their appearances, and weight and may starve themselves, become
bulemic, and/ or overly work out just to get to an usually unhealthy weight. Be watchful for any signs of drug
or alcohol use, adolescents are known to experiment at this time. The abdomen should be a 2:1 ratio, similar to
the adult. Males may start to grow secondary hair on the face, underarms, chest, and pubic areas, hair thickens
on the legs and arms. Females start to develop breasts, they should be firm, nipples are still not the same size as
those in an adult, there should be no nipple deviation, or lumps or masses, tenderness is common if the girl is
close to or on her monthly menses. Secondary hair growth has started under the arms and pubic areas, hair on
the legs may start to turn darker and coarser. Menarche may have already occurred depending on the child,
average age of menarche is 12 years although it may occur earlier or later. Hips have also started to widen
signaling that the adolescents body is preparing for any future childbirths or pregnancy. Adolescents may sleep
longer than they did in child hood, they stay up late in the night and want to sleep all day, this is normal, unless
it starts to interfere with everyday activities of living. Boys have increased in height by age of 15, and the
shoulders have begun to get broader. Muscles are more pronounced in the male because of increased
testosterone levels. Sexual maturation is occurring with the increase in the size of the testes and penis. Voice
changes occur in the male adolescent and may sometimes be embarrassing, Acne is common for both sexes at
this age. Friends have more influence on the adolescent, and more importance to the adolescent than the
parents do. Sexual desires and interest is also increasing and experimentation is common for adolescents.
Teaching sex education, and safe sex is important, the kids may also be interested in the changes occurring in
their bodies, they may be embarrassed to openly talk about these issues so approach these topics with caution.
Most physical findings during adolescence are similar to those of the adult, although unfinished in maturation.

2. What age of the infant should the anterior and posterior fontanel close?
The anterior fontanel should close by the age of 18 months if the anterior fontanel closes too early it may cause
growth restrictions for the child's brain which can cause severe neurological damages. The posterior fontanel
should close by the age of 3-4 months. Failure of these fontanel's to close can also lead to increased risks for
brain damages due to the unsteady gait of the toddler which often results in many falls.

3. Describe each: a) Rooting reflex b) Palmar grasp c) Plantar grasp d) Moro reflex
e) Asymmetric tonic neck reflex.
a) Rooting reflex: A reflex normally present from birth to 6 months of age, infant will turn their head to the
side when the cheek of the mouth is touched on the same side. b) Palmar grasp: Reflex present from birth until
4 months of age, infant will grasp an object when palm is stroked or touched; such as putting your finger in the
palm of the infants hand. c) Plantar grasp: A reflex that is present from birth to around 8 months of age.
Touching the sole of the infant's foot will result in the toes curling downward. d) Moro reflex: Also known as
the startle reflex, this is normally present from birth to around 6 months of age. This reflex occurs when the
baby is startled by a loud noise or vibration, the reflex results in the extension of the upper extremities and
flexion of the lower extremities. e) Asymmetric tonic neck reflex: Occurs from birth to 3-4 months of age.
Also called fencer position because of the infant's similarity to a fencer. When the child's head is turned to the
side, the opposite sides extremities will flex and the same sides extremities will extend. Infant's that show these
reflexes past the normal age the reflex has usually subsided may have neurological damage. The same is true for
older children and adults who regain these reflexes, they too usually have severe neurological damages.

4. Erickson's theory focuses on psychosocial development. Apply each type of development


with its appropriate stage, i.e. infancy(birth - 1 year) Type= Psychosocial Stage = Trust vs
Mistrust. Continue this sequence from birth to adolescent (Discuss each stage and
development).
Infancy - Trust vs mistrust - The infant is developing a trust of themselves, others, and of their
world/environment. Infant's trust others that their needs are going to be met, such as being fed. The most
important element that must be achieved during this phase is the quality of the relationship and care between
and given by the parent to the infant. Inability for this element to be achieved results in mistrust. The trust
learned in infancy lays out the foundation for all of the following stages of development. Trust allows the infant
a feeling of security and comfort, which helps them in experiencing unfamiliar and unknown situations with
minimal fear of the situation.
Toddler - Autonomy vs shame - The toddler has begun to realize they have control over others, they have
also begun to realize that they are their own person. The toddler will begin to show that they know this by
saying "no" to almost anything asked, they are trying to make their own decisions, trying to separate somewhat
from the parents. Having their own will has consequences though, parents may not understand what is going
on and become agitated, whereas if the toddler just continued to be dependent on the parent they would be
awarded with affection. The child is trying to find their will and has to go through the consequences of getting
into trouble to find it. The toddler is also gaining control over more than just the environment, they are starting
to gain control over bodily functions and start potty training which again can bring much joy and affection to
the child, as well as shame and scolding. The toddler must achieve this stage of development prior to going on
to the next stage, if they do not they may never gain the ability to trust in their self mastery of skills.
Preschool - Initiative vs guilt - The preschool age child has the will and want to do almost anything, they
are unaware of their inability to be successful at everything the try, due to the physical limitations or abilities
they may not have. Guilt can occur when the child is unable to achieve the task and they believe they have
misbehaved in some way.
School Age Child - Industry vs inferiority - Children are able to have more concrete thoughts. School and
friends have a large influence on how the child sees them selves. The child gets the sense of industry through
the achievements they have made in learning. Ridicule by other students, teachers and other peers due to
school related issues is common in this age group and can make nervous habits start to form such as nail biting.
Children in this stage of development are learning their social status in the world.
Adolescents - Identity vs role confusion - The adolescent is developing a sense of personal identity as well
as their group identity or how they fit into a particular group of friends. Friends have a big influence on their
behaviors at this age. Adolescents are trying to find their purpose, and may seem almost lost at times, confusion
of who they are is common, they are wanting to become adults but still a child and this is very frustrating for
them. Interest in sex increases as does the interest in the opposite sex. Risky behavior is also common for teens
to participate in because they view themselves as invincible or that nothing bad would ever happen to them, the
sense of safety and security from the previous psychosocial stages is probably the cause of this. During this stage
the teen is learning who they are, how they fit into the world, their interests in careers, sexuality, and friends.
This can and usually is a very confusing time in life, and the teen is at an increased risk for suicide, drug abuse,
and sexual promiscuity because of this.

5. There are immunizations that are administered at different stages of development. Please
list each immunization required beginning at birth throughout the adolescent stage.
Immunizations are given to a child from birth to adolescence. The immunizations that are recommended by the
CDC for infants less than 12 months of age are as follows: Hepatitis B - Birth; Hepatitis B, rotavirus vaccine,
diphtheria and tetanus toxoids, pertussis, Haemophilus influenzae type B, pneumococcal vaccine and the
inactivated polio virus, these are given or recommended for infants 2 months old. At 4 months the infant will
receive; rotavirus vaccine, diphthteria and tetanus toxoids and pertussis also called DTap, pneumococcal vaccine
(PCV) and IPV also known as the inactivated poliovirus. 6 months of age the infant should get; Hep B (between
6 & 12 months of age), Rota, DTaP, PCV, IPV (by 6-18 months of age). Infants who are 6 - 12 months of age
should receive a yearly influenza vaccine.
Toddlers again receive another round of vaccinations. 12 - 15 months the child should get the Hib, PCV, IPV.
6 - 18 months the child will get the measles, mumps and rubella or MMR, as well as the varicella vaccination.
At 12 - 23 months Hepatitis A is given in two separate doses at least six months apart. 15 - 18 months the DTaP
is given again. 12 - 36 months of age the toddler should get the yearly trivalent inactivated influenza vaccine
(TIV).
Ages 4 - 6 years the child is again to receive the DTaP, IPV, MMR and varicella vaccines. The TIV should still
be given yearly to all preschool age children.
Children between the ages of 5 - 12 are recommended by the CDC to get: DTaP, IPV, MMR, and the
varicella vaccines if they have not received them by the age of 4 or 5 years then should be given them by the age
of 6. 11 and 12 years of age the CDC recommends Tdap(diphtheria and tetanus toxoids and pertussis vaccine),
MMR, human papillomavirus vaccine or HPV given in 3 doses, as well as the MCV4 (memingococcal
vaccine).
Adolescents that are healthy are recommended by the CDC to get the following vaccines if they did not get
them at the age of 11 or 12 to then get them between the ages of 12 to 20 years: Tdap, HPV, Hep B, IPV,
MMR series, varicella series, and MCV4. Scoliosis screening should also be continued throughout these years.

6. Discuss the nutritional status from infancy to adolescent.


Infants: Breastfeeding is best for an infant, but feeding them iron - fortified formulas are acceptable alternatives.
Solid foods can start to be introduced by the time the infant has doubled his birth weight or about 5 or 6
months of age. Solids should be started with iron fortified cereals, then giving the infant one new pureed food
every 3 - 5 days, the reasoning behind only giving one food at a time is so that the child can be assessed for any
food allergies. Breast milk and/or formula should be decreased as the infant increases their intake of solids.
Giving the infant a sippy cup when they are able to hold a cup with handles, around 6 months or after, is
recommended to aid in weaning the child from breast feeding or bottles. One breast or bottle feeding should be
replaced with the sippy cup until the child has become comfortable with it and then additional feeding may be
replaced, the bedtime feeding should be replaced last.
Toddlers: By the age of 12 months the toddler should be able to consume cow's milk and should be receiving 3
- 4 glasses a day, servings should be kept in small amounts to avoid overwhelming the child. Finger foods are
the easiest to feed a toddler who is always on the run. Cheerios is a great snack for this age group. Choking is
always a hazard especially in the toddler who wants to put everything in their mouths. When feeding keep food
cut small, and not to give hard candies or hard veggies or fruits as these are choking hazards. Keep a cup of juice
or milk available during meal times to help the child rinse down the food. Toddlers are usually very picky eaters
and it may be extremely difficult to get them to eat what they need too. Doctors sometimes may recommend
giving them supplements such as Pedia-Sure to ensure adequate caloric intakes, children of this age group
should be given food in a manner that is appealing to them, such as making smiley faces on their plates, and
giving colorful varieties of different foods.
Children: Ages 3 - 5 their caloric intake is recommended to be 1800 kcal a day, or about half the amount of an
adult. This age group may continue having picky eating habits, and parents may need to keep different varieties
of healthy snacks around to ensure adequate intake of calories. Any parent who has any concerns about their
child's nutritional intake should consult with their pediatrician.
Age 5 - 12 years the child has started to increase their intake of food, by the end of the school age years their
caloric intake is comparable to the adults. Keeping healthy varieties of food for the child to snack on helps in
ensuring that adequate and healthy foods are being given.
Adolescents: Puberty increases the metabolic requirements for the teenager and so increases their want to eat.
Teens seem to eat their parents out of house and home at this age, but it is quite normal. Some nutrients are not
taken in adequate amounts and may need to be given as supplements. These nutrients are, iron, calcium, and
vitamins A and C. Teenagers tend to grab quick foods, such as hamburgers, chips, candies, and sodas. Keeping
the house stocked with healthy foods that are quick such as juice boxes, water bottles and fruits may aid in
keeping the teen away from some of those foods. Parents and care givers need to be watchful for eating
disorders that may develop during this time. Teens tend to be overly consumed by the way they look or think
they should look, and so some take drastic measures to get to their goal weight. Anorexia nervosa, Bulimia
nervosa, and over eating are the most commonly known eating disorders. Obesity can be avoided in most
children by making sure they have plenty of physical activity and consuming only what is needed. The caloric
intake should not exceed a 2500 or 3000 calorie diet a day.

7. Intramuscular medication administration for the infant and child should be administered
with caution. What is the preferable route/muscle used? What are some other sites
commonly used? Discuss age of client.
When giving IM medications the age of the patient should be considered as well as the type, amount and
viscosity of the medication that is going to be given. The condition of the muscles should also be assessed when
selecting the site for the IM injection. Always try to keep pain in the child to a minimum, some suggestions are
to pick the smallest gauge needle that can deliver the medication, and applying anesthetic creams prior to the
injection. For infants and children under 2 years of age the vastus lateralis is the usual site of injection. For
children older than 2 years the ventral gluteal site can be used. In both the vastus lateralis and the ventral gluteal
sites, the muscle can accommodate up to 2ml of fluid. The deltoid muscle is used in older children and this
muscle can only hold 1ml of fluid, so the ventral gluteal and vastus lateralis muscles are alternate sites for
injections. The deltoid muscle should not be used for infants or children with under developed muscles, but
may be used in toddlers with adequate muscle mass.

8. Pain Management is required for all clients, but it should be considered with great caution
for the pediatric population. Describe the most commonly used Pain assessment tools
used; indicate the age of the infant, child and adolescent.
Children experience pain just as anyone else. The child's pain is whatever the child says it is and exists whenever
the child says it does. The child's report of the pain is the most reliable diagnostic measurement of pain. For
children that cannot verbalize their pain different methods or tools are used. The self report pain scale in useful
in children 7 years of age or older. Children that are 2 months up to 7 years of age the FLACC tool can be used.
FLACC stands for: Faces, Legs, Arms, Cry and Consolability, it is a postoperative pain tool. Behaviors are
scored from a 0 - 2, with 0 meaning no pain. The behaviors assessed are, facial expressions, position of the legs,
activity level, crying and the ability to be consoled. Another pain assessment tool is known as FACES, this scale
is used for children 3 years of age and older. FACES uses drawings of faces, from smiling to crying faces, the
child picks out the face that they identify with the most when asked how much it hurts. The sad crying face
indicates the worst pain. The Visual Analog Scale (VAS), is a scale that is numbered from 0 - 10 with 0
indicating no pain and 10 indicating the worst pain. This scale is commonly used on children 7 years or older,
and up to adults. Nurses who are assessing the childs pain level need to be aware of the child's past history with
pain, their cognitive level or impairments that may prevent the pain being reported properly, and how the child
perceives the pain.

9. Discuss the impact of hospitalization upon the infant, toddler, preschooler, school-age
child and the adolescent. What level of understanding does each exhibit?
Infant: Infants are unable to express themselves and do not understand why they are in the hospital or shy
different procedures may need to be done, they are also unable to follow directions at this age. Hospitalization is
a very stressful time for the child and the parents. The infant may experience stranger anxiety, or cry when a
strange person picks them up or even comes into the room. Tantrums and crying are common behaviors
exhibited when the infant is uncomfortable or in pain. The infant may even be unable to sleep due to the
strange surroundings, noises, people, and procedures. Keeping a calm voice when speaking to the infant may
help the child in feeling more safe and secure while in the hospital.
Toddler: The toddler has a limited ability to follow directions, as well as a limited ability to describe their
feelings or symptoms, or their ability to understand what is going on around them. Toddlers have many fears
while in the hospital and may experience separation anxiety from their parents. Tantrums and crying are
common for the toddler to exhibit when anything is being done to them they may not like or are
uncomfortable with.
Pre-school child: The preschool aged child still has a limited ability to describe their symptoms, they know
what illness feels like but do not understand why they have it. Young children have fears related to magical
thinking. During their hospitalization they too may have separation anxiety from their parents, they may
believe they are being punished or in trouble when ill or hospitalized. Many fear the nurses or doctors and
believe they are going to harm them. Nurses can help the child by speaking in soft re-assuring tones, and by
trying to minimize pain and discomfort as much as possible.
School-age: Children of this age group have more of an ability to describe their symptoms and feelings. They
are starting to understand the relationship between cause and effect. Children may fear losing control over
decisions, and may question or seek out information as a way to keep a sense of control. Depression and stress is
common when the child is separated from their friends and family, and even the regular routine of being at
home. Telling the truth to school-age children is important, because they are beginning to sense when they are
being lied to. All age groups besides the infant may exhibit developmental regressions when hospitalized, due
to the stressful situations.
Adolescent: Has a stronger understanding of the relationship between cause and effect, and are able to
understand more of the disease process and procedures being done. Teens may develop body image
disturbances because of the illness, they have many fears of losing control over decisions and being separated
from their friends and activities. Depending on how the teen perceives the illness and treatment they may or
may not be compliant with the treatment, especially if it may make them appear different from their peer
group. Remember that the peers of this age group have the largest influence at this time in their lives
10. What is stranger anxiety?
Stranger anxiety is a form of distress that children experience when exposed to people unfamiliar to them.
Symptoms may vary, but include: getting very quiet and staring at the stranger, verbally protesting by cries or
other vocalizations and/or hiding behind a parent. Stranger anxiety is a typical and therefore normal part of the
developmental sequence that most children experience. It is also known to occur when a baby is coddled and
sheltered by their parents to such a degree that the child is afraid of anything that seems different to what they
have gotten used to. This has been known to occur less in children that have been around many different
people while growing up and not constantly with the mother or father.

11. Nursing Care of Children with System Disorders:


Define each disease process, including treatment, management of care, and signs and
symptoms.
a) Asthma-
Asthma is a chronic inflammatory disorder of the bronchioles and airway. It causes an intermittent yet
reversible obstruction of the bronchioles. The child with asthma may have frequent coughing,
wheezing, shortness of breath, tightness of the chest that may or may not be aggravated by allergens.
Asthma involves the inflammation or hyperresponsiveness of the airways triggered by the release of
mast cells, eosinophils and T lymphocytes. Asthma is categorized into 4 stages with each stage an
increased severity of symptoms. Stage 1 = Mild Intermittent; symptoms occur less than 2 times a week
with no symptoms in between attacks. Stage 2 = Mild Persistent; Symptoms occur more than 2 times
a week, symptoms may affect activities, and nighttime symptoms are greater than 2 times a month.
Stage 3 = Moderate Persistent; Symptoms occur daily, and require daily use of beta2-adrenegic
agonist to help control the symptoms. Activity is affected and symptoms usually persist more than 2
times a week an may even last several days. Nighttime symptoms occur 1 time a week or more. Stage
4 = Severe Persistent; Symptoms are continual, extremely affecting physical activities, symptoms
occur frequently in the day and night.
Management of the asthmatic child starts with controlling the child's environment or by decreasing
the child's exposure to aggravating factors such as: Pollens, dust, animal fur and dander, smoke from
cigarettes or wood, strong smelling chemicals or foods, cold dry air, sudden temperature changes,
perfumes, limiting physical activity, prompt treatment of respiratory infections, and keeping the child
out of emotional distress as this is also known to trigger asthma attacks. Other ways to help in the
treatment of the child is to give prescribed medications as ordered, give oxygen as needed during an
attack, place the child in a tripod or orthopneic position to help the lungs expand with less exertion,
help to decrease fear in the child having an attack by keeping calm, monitor vital signs and oxygen
saturation. Medications that are commonly used to help treat and control asthma symptoms are as
follows: Beta2 - adrenergic agonists such as Albuterol are usually inhaled or given orally, these
medications help inhibit the release of histamines, increase ciliary motility, and relieve the
bronchospasm. They can be used as prophylaxis, long term or short term for symptoms.
Glucocorticoids such as Prednisone help relieve inflammation in the airways, and suppress mucus
production as well as promote the responsiveness of beta2 receptors in the bronchial tree. The use of
steroids help decrease the frequency of the symptoms as well as the severity, these drugs are used as
short term treatments. Anti-Inflammatory drugs and allergy medications are used as prophylactic
treatments for asthma sufferers. These drugs inhibit the release of histamines and other inflammatory
immune cells.
b) Tonsillitis/Tonsillectomy-
Tonsillitis is an acute inflammation of the tonsils. The palatine tonsils which are located on both sides
of the oropharynx are the tonsils removed during a Tonsillectomy. Tonsils are highly vascular masses
of lymphatic tissues, they filter pathogens helping to protect the respiratory and gastrointestinal tracts,
they also serve as contributors to antibody formation. Tonsillitis occurs when the tonsils become
swollen, red, and inflamed, yellow pus may also be seen on the surfaces of the tonsils. In some cases
the tonsils become so swollen that they can block the nose and throat, which can interfere with
normal breathing, swallowing food and drink, sleeping, talking, and drainage of the sinuses.
Tonsillitis can be causes by viral or bacterial pathogens, and is more common in younger children due
to the immature immune system. Treatment of tonsillitis depends on the severity of symptoms and
the type of pathogen (viral or bacterial). Viral tonsillitis is treated with tylenol or ibuprofen for pain
and inflammation, rest, increased fluids and warm salt water gargles. Bacterial tonsillitis should be
treated the same except for the administration of an appropriate antibiotic medication. Throat
lozenges can also be used to help alleviate soreness of the throat. Tonsillectomy is performed on
children who have chronic tonsillitis or a severe case of tonsillitis that is interfering with breathing,
and intake of fluids and food. Treatment of postoperative children after the tonsils have been
removed include: proper positioning of the child to help facilitate drainage, elevation of the head of
the bed when the child is fully awake, assessing the child for bleeding; some signs of bleeding that
may be overlooked are continuous swallowing, clearing the throat, restlessness, bright red emesis,
tachycardia and/or pallor. Assessing the patency of the airway is crucial after any surgery, especially
one that involved the throat. Vital signs should be assessed at regular intervals. Pain management such
as ice packs for the throat, analgesics, and keeping the throat moist. Once the gag reflex has returned
the child should be encouraged to drink plenty of clear fluids as tolerated, advancing the diet slowly
with first adding soft bland foods. Instruct the child and the parents to discourage them from clearing
their throat, blowing the nose, or even coughing to help protect the surgical site. Instruct the parents
to call the pediatrician should any signs of bleeding, infection, or difficulty breathing occurs after
discharge of the patient. Symptoms of tonsillitis to be aware of are as follows: sore throat, difficulty
swallowing, fever, inflammation and redness of the tonsils, halitosis, breathing through the mouth,
snoring, and or a nasal sounding voice. Diagnostic tests the physician may order to help identify
tonsillitis and its pathogen may include: throat cultures for group A β-hemolytic streptococci, and
they may also order a CBC to assess for infection and/or anemia prior to a tonsillectomy.
c) Pharyngitis (strep throat)-
Strep throat is an infection of the respiratory tract caused by the Group A β-hemolytic streptococci
(GABHS). Young children are at an increased risk for respiratory infections due to their immature
immune systems and smaller respiratory tracts. Other factors that can increase the child's risks for
respiratory infections include: compromised immune system, otitis media, malnourishment, allergies,
asthma, chronic medical conditions (cystic fibrosis, congenital heart disease), seasons also seem to play
a factor in respiratory infections, they are more common to become infected during the winter and
spring. Children who are premature, have RSV, or are exposed to second hand smoke are also at
increased risk. The infection itself is not usually a serious problem, but children who are infected may
be at an increased risk for acute rheumatic fever, which is an inflammatory disease of the heart, joints
and central nervous system, and also be at risk of getting acute glomerulonephritis an acute kidney
infection. Both of these secondary diseases can cause severe permanent damage, especially the
rheumatic fever. Symptoms of pharyngitis include: fever, headache, abdominal pain or discomfort,
swollen, tender lymph nodes, inflamed pharynx, with or with out exudate, sore throat, difficulty
swallowing, they may or may not have sinus drainage or inflamed tonsils. Management of care
includes diagnostic tests to identify the infection, so that proper treatment can be started. These
include throat cultures. Medications administered for strep throat may include; tylenol or ibuprofen
for pain and fever, penicillin to eliminate the pathogen, penicillin is usually given for 10 days to
eliminate any organisms that may initiate rheumatic fever. Other drugs that have been used include,
clarithromycin, azithromycin, clindamycin, amoxicillins, and oral cephalosporins. Other treatments
to help alleviate the symptoms can include, bed rest, warm or cold compresses on the neck, saline
rinses, throat lozenges (for older children), cool liquids or ice chips may also help relieve some pain.
Parents should be instructed on the importance of giving the antibiotics as prescribed and to not stop
giving the antibiotics even if the child is feeling better. Explain to the parents that not finishing the
antibiotic may lead to future heart problems (rheumatic fever).
d) Croup
1. Bacterial (epiglottis)-
Also known as acute epiglottitis , this respiratory infection is usually caused by the Haemophilus
influenzae bacteria. This condition requires immediate medical attention, it is a serious obstructive
inflammatory infection of the upper epiglottis. Signs and symptoms of this condition can include: an
abrupt onset of symptoms such as a sore throat, drooling, tripod position, open mouth breathing,
stridor, retractions may be visible when inspiration occurs, reddened throat, mild hypoxia, to severe
cyanosis. If this condition is not treated immediately in severe cases the progressive obstruction can
lead to hypoxia, hypercapnia, acidosis, decreased muscle tone, decreased level of consciousness, and
if the obstruction is complete it can cause sudden death. Treatment requires keeping the airway clear
and patent, intubation or tracheostomy may be needed in severe cases. Repeated examinations of the
throat should not be done to prevent further obstruction. Oxygen that is humidified is given either by
mask, cannula or straight into the intubation or trach. Observation of the child should be done until
the swelling has subsided, usually with in 24 hours after antibiotic therapy has started. Corticosteroids
are also used to help alleviate the swelling, and is usually helpful in the immediate treatment of acute
epiglottitis. Yearly influenza vaccinations may help prevent this condition from occurring and
parent's should be made aware of this as the condition can occur more than once.
2. Acute laryngitis, acute larygotrachebronchitis-
Laryngotracheobronchitis is an inflammation of the trachea, larynx and bronchi, this is the
most common type of croup. This condition is caused by either a viral or bacterial pathogen and
is most common in children 5 years or younger. The gradual onset of symptoms may be preceded by
an upper respiratory infection. Maintenance of treatment includes, keeping a patent airway,
assessment of respiratory status, oxygen saturation, pallor and/or cyanosis, giving humidified oxygen,
elevation of the head of the bed to help facilitate easier breathing, bed rest, encouraging fluids,
medications such as tyenol for fever and pain, bronchodilators to help relieve stridor and relax the
smooth muscles, corticosteroids may also be administered to help reduce inflammation, epinephrine
may be given as a nebulized breathing treatment to help alleviate stridor, retractions and/or difficulty
breathing. Antibiotics should be given as prescribed if the pathogen is bacterial, all of the medication
should be taken as directed and finished. Symptoms of acute laryngitis include: low grade fever,
agitation, restlessness, stridor on inspiration, brassy cough, crackles, wheezing, retractions, anxiety,
pallor, diaphoresis, tachypnea, labored breathing. Severe cases can lead to cyanosis intermittently that
can progress to apneic episodes leading to cessation of breathing.
3. Bronchitis and Pneumonia-
Bronchitis is characterized by a dry, hacking cough, that is nonproductive and worse in the night than
in the day time hours. The cough usually becomes productive by the 2 - 3rd day. Bronchitis is an
inflammation of the trachea and bronchi, usually associated with other upper respiratory infections
and caused by viral pathogens. Treatments include analgesics, antipyretics, humidifiers, and cough
suppressants. Many patients recover with in 5 to 10 days.
Pneumonia can occur as a primary disease or secondary to another illness. Classification of pneumonia
is usually done by the etiologic agent such as; viral, bacterial, mycoplasmal, or foreign substances).
The infectious agent is usually introduced to the lungs through the bloodstream or through
inspiration. The most common cause of pneumonia in children is the M. pneumoniae occurring in
children 5 to 12 years of age. It is most common in the fall and winter and is more prevalent in large
families or in children who live in crowded conditions or go to daycares. General symptoms may
include; fever, chills, headache, general malaise, myalgia, anorexia, rhinitis, sore throat, dry, hacking
cough that is non productive initially. Production of sputum that is seromucoid and later becoming
mucopurulent or blood streaked is also common. Fever may be intermittent or may last days to
weeks, dyspnea also occurs but infrequently. X-ray examination of the lungs show evidence of the
illness usually before the physical manifestations are apparent. The x-ray will show patchy,
infiltration that is diffuse, with a peribronchial distribution. Most children recover in 7 - 10 days, with
symptomatic treatments similar to those used in bronchitis. Resting for the following week usually
helps to improve the persons condition as well.
e) Cystic Fibrosis-
Cystic Fibrosis is a chronic disease produced by a disorder of an autosomal recessive trait. The disease
is characterized by mucus production of the exocrine glands. The mucus is abnormally thick, and in
large amounts which causes obstructions of the small passageways of affected organs. Respiratory tract
is the most commonly affected area, but the gastrointestinal tract and the reproductive systems are also
affected. Respiratory symptoms are caused by the trapped mucus in the airways, which can lead to
bacterial infections of the respiratory tract and tissue destruction of the lungs. CF is a fatal genetic
disease, death is usually the result of respiratory failure. Other symptoms and signs of CF are
emphysema, atelectasis, airway obstruction, wheezing, pulmonary hypertension, chronic hypoxemia,
which leads to a barrel shaped chest, cyanosis, dyspnea, clubbing of the fingernails and toenails, repeat
respiratory infections. Diagnostic testing includes, quantitative sweat chloride testing, which is one of
the most reliable tests when diagnosing CF. The disease causes a dysfunction of the sweat glands also
which then causes the sodium and chloride found in saliva and sweat to increase. Treatment for CF
revolves around keeping the airway clear, so that aeration is improved, as well as reducing the risks
for respiratory infections. Percussion and postural drainage is done at least once in the morning after
awakening and once before bed, this should not be performed immediately following a meal or
immediately prior to a meal. Medications such as bronchodilators, mucinex, as well as antibiotics to
fight any infections that may occur. Cough suppressant should not be given. Teaching the parents
and child to use forced expiratory techniques and development of a physical exercise program with
the aim of establishing an effective habitual breathing pattern is also recommended. Vibration devices
can also be used to help break up the mucus in the air passageways. Oxygen should be given as
needed, as well as any suction that may be needed. When giving oxygen care givers must monitor for
oxygen narcosis, ss include: vomiting, fatigue, numbness and tingling of the extremeties, malaise, and
substernal distress. The last therapeutic resort for a child with end stage CF is lung transplantations.
f) Tetralogy of Fallot-
Tetralogy of Fallot is a congenital heart defect, it is characteristic of 4 defects of the heart; VSD or
ventricular septal defect, pulmonic stenosis, overriding aorta, and right ventricular hypertrophy.
These defects can produce symptoms that are mild to severe depending on the severity of the defects.
Mixing of oxygenated blood and unoxygenated blood fails to provide enough oxygen to the organs
and other tissues and this can lead to hypoxia. Many infants born with this defect show symptoms
with in the first few months of life, they may have cyanotic episodes, faint, tire easily, there is a
characteristic murmur associated with the defect as well. Clients who have this congenital heart defect
are also at higher risks for emboli, seizures, loss of consciousness and sudden death following anoxic
spells. Surgical treatment is recommended early in the child's life, usually the first few months
following birth. There are two options for treatment, the first is a temporary shunt used for patients
who are unable to undergo complete repair at the time. This surgery focuses on increasing pulmonary
blood flow and to increase oxygen saturations, the procedure provides blood flow to the pulmonary
arteries from the right or left subclavian artery through a tube graft. This is not the preferred
procedure though as it is thought to result in pulmonary artery distortion. The second treatment
option is complete repair of the defects. This procedure involves the closure of the ventricular septal
defect, resection of the infundibular stenosis, with placement of a pericardial patch to enlarge the right
ventricular outflow. In some repairs the patch may extend across the pulmonary valve annulus
making the pulmonary valve incompetent. Treatment prior to any surgery should involve family
teaching that includes teaching them to put the child in a knee to chest position if hypoxemia or
cyanosis occurs, they should also be told to attempt to calm the child and call for help. Activity should
be limited to prevent exhaustion in the child, feeding the child small, and frequent meals may help
the child tolerate more calories.

g) Iron Deficiency Anemia, Sickle Cell Anemia (include the 4 stages of SCA)-
Iron Deficiency Anemia is where the iron stores are depleted, this results in decreased amounts of
iron needed for hemoglobin production. This disorder is commonly caused by blood loss, increased
metabolic demands, gastrointestinal malabsorption syndromes, and dietary inadequacies. Upon
assessment of clients with this type of anemia, pallor may be noted as well as fatigue, weakness and
irritability. Treatment includes oral iron supplements, dietary changes to iron rich foods, and teaching
the client and parents. Teaching should include how and when to give the iron supplement, they
should give the supplement between meals for maximal absorption as well as give it with a
multivitamin or fruit juice high in vitamin C because this also increases the absorption of iron into the
body.
Sickle Cell Anemia is caused by the inheritance of a gene for a structurally abnormal portion of the
hemoglobin chain. This disease is prevalent among African-Americans, but is also seen in persons of
Mediterranean, Indian, and/or Middle Eastern descent. Signs and symptoms of sickle cell anemia are
not usually present before 4 - 6 months of age, because the infant still has fetal hgb in the blood. The
disease is characterized by the sickling of the RBC's, this is usually caused by an increased oxygen
demand, such as when a person has an infection, emotional distress or pain, it can also be caused by
decreased levels of oxygen. The sickled RBC's are rigid, and lead to obstructions of capillary blood
flow and tissue hypoxia which causes tissue ischemia. Tissue ischemia is the primary cause of pain in
sickle cell sufferers. Four main stages of sickle cell anemia crisis exist, the first stage being split into
acute and chronic. Vaso-occlusive crisis : Acute- lasts 4-6 days and is extremely painful.
Manifestations include: swollen hands, joints, feet, vomiting, fever, anorexia, hematuria, obstructive
jaundice, and visual disturbances. Chronic- Manifestations include: increased risk of respiratory
infections, and/or osteomyelitis, retinal detachment and blindness, renal failure and enuresis, systolic
murmurs, liver failure, seizures, and skeletal deformities. The 2nd stage is Splenic Sequestration;
manifestations include: pooling and clumping of blood in the spleen also known as hyprsplenism.
Pooling and clumping of the blood can also occur in the liver. Tachycardia, dyspnea, weakness, pallor
and shock are common. The 3rd is called Aplastic Crisis- this involves extreme anemia because of
decreased RBC production. The final stage is called Hyperhemolytic, this involves an increase in the
rate of RBC destruction which leads to severe anemia, jaundice and reticulocytosis. Pallor or cyanosis
is commonly seen. Treatment for sickle cell sufferers include prevention exposure to infectious
agents, maintaining normal hydration; Crisis treatment involves oxygen therapy as needed, pain
management, rest and keeping the child/person adequately hydrated.
h) Hemophilia-
Hemophilia is a group of bleeding disorders that results from a deficit in specific coagulation proteins.
Identifying the specific coagulation deficit is needed for treatment with the specific replacement
agent. Aggressive treatment with replacement therapy is initiated to prevent crippling effects due to
joint bleeding. Hemophilia is an X-linked recessive disorder, but may also occur due to a gene
mutation. Additional treatments may include, pain relief management, and protecting the patient
from any harm or injury. Symptoms of hemophilia include: abnormal bleeding in response to trauma
or surgery, many cases are diagnosed following circumcision in males, frequent nosebleeds, easy
bruising, clotting factor tests may be abnormal, joint bleeding that can result in pain, swelling, and
limited range of motion in the affected joints. Monitor the client for bleeding, be prepared to give
replacement therapy as ordered, monitor urine for blood, assess neurological status to watch for
intracranial hemorrhage. Parent's need to be taught the signs to watch for internal bleeding, and that
the child may need protective devices when walking or playing to protect them from injury that may
cause bleeding.
i) Communicable Diseases
1. Varicella (chickenpox)-
Chickenpox is caused by the Varicella-zoster virus. It is transmitted by direct contact, droplet, and
through contaminated objects. Signs and symptoms of the virus include: slight fever, general malaise,
anorexia, headache, irritability, itching, macular rash that appears on the scalp and trunk and then
migrates to the face and extremities. The lesions become pustules, begin to dry and then develop a
crust, the lesions can also sometimes be found in the mucous membranes of the mouth, genital areas
and rectal areas. Treatment is usually symptomatic, unless the child is immunocompromised. In
children with compromised immunity, administration of the Varicella immune globin is given to
minimize the severity of the outbreak as well as giving Acyclovir IV. Infected children should be
isolated from other children or persons who have not had the virus or the vaccine. It is especially
important to isolate them from anyone who may be pregnant.
2. Rubella (German Measles)-
Rubella is characterized by a low grade fever and mild rash that lasts 2-3 days, the child may also
experience headache and malaise. The rash usually begins on the face and then spreads to the body.
Isolation of the child is important, especially from pregnant women and other children who have not
had the virus. Transmission of the virus can occur by direct contact, airborne, or by indirect contact.
Supportive treatment of symptoms is usually all that is needed.
3. Rubeola (measles)-
Rubeola is caused by the Paramyxovirus and is transmitted by airborne, direct contact, and
transplacental. Symptoms include: fever, malaise, swollen lymph nodes, cough, conjunctivitis, Koplik
spots on buccal mucosa, red, maculopapular rash that begins at the hairline and then extends down
the body and eventually turning brown, runny nose, the symptoms usually worsen and then decrease
about 2 days after the rash has appeared. Treatment includes post exposure prophylaxis by giving the
immunization within 72 hours or the immunoglobulin within 6 days of exposure, other treatments
include supportive symptomatic treatment.
4. Pertussis (whooping cough)-
Whooping cough is caused by the Bordatella pertussis virus, transmission occurs via direct contact,
droplet, or indirect contact. Symptoms usually include cold or respiratory infection symptoms
followed by an increasing severe cough, that has a loud, whooping sound on inspiration. infected
persons may experience respiratory distress, cyanosis, listlessness, irritability and/or anorexia. Isolation
of the child is needed during the communicable period usually 10 days after transmission and
symptoms appear. Droplet precautions should be instituted. Bordatella pertussis vaccine should be
given as ordered, reducing environmental factors that cause coughing, such as smoke, strong odors,
sudden temperature changes, dust, and dry air. Ensure the child is adequately hydrated and receiving
enough calories. Suction of secretions and humidified oxygen should be given as needed. Vital signs
should be monitored regularly along with the pulse oximetry and cardiopulmonary status.
5. Mumps-
Mumps is caused by the same virus as measles, the paramyxovirus. It is transmitted through direct
contact and droplet. Droplet precautions should be taken when a child is suspected of having
mumps. Symptoms include: jaw or ear pain that is aggravated by chewing, parotid gland swelling,
fever, headache, malaise, and anorexia. IV fluids should be given to ensure adequate hydration if the
child is unable to eat or drink or has vomiting. Bed rest is recommended for the patient until parotid
gland swelling has subsided, hot or cold compresses to the neck may help pain and swelling, analgesics
may also be given. In some cases orchitis is present, if this occurs apply warmth and local support and
tight fitting underpants.
6. Epstein Barr-
Also called Infectious Mononucleosis, the incubation period is 4-6 weeks and is transmissible by
direct intimate contact. Sometimes also known as the "Kissing Disease". Symptoms include, fever,
malaise, fatigue, headache, nausea, sore throat, enlarged red tonsils, abdominal pain, puffy eyes, and
anorexia. Diagnostic tests include; mono spot blood smear for heterophile antibodies (specific for the
disease), WBC are elevated with atypical lymphocytes detected, AST and ALT liver enzymes may
also be elevated. Treatment includes supporting symptoms, monitoring for splenic rupture, restriction
of activity level (may need to be restricted for up to 3 months), and ensuring the child receives plenty
of fluids and rest.
7. Skin Conditions
A) Tinea pedis (ringworm)- Athlete's foot (tinea pedis) is a
fungal infection of the skin that causes scaling, flaking, and itching of affected areas. It is
typically transmitted in moist areas where people walk barefoot, such as showers or
bathhouses. Although the condition typically affects the feet, it can spread to other areas of
the body, including the groin. Athlete's foot can be prevented by good hygiene, and is
treated by a number of pharmaceutical and other treatments. Athlete's foot causes scaling,
flaking, and itching of the affected skin. Blisters and cracked skin may also occur, leading to
exposed raw tissue, pain, swelling, and inflammation. Secondary bacterial infection can
accompany the fungal infection, sometimes requiring a course of oral antibiotics.
The infection can be spread to other areas of the body, such as the groin, and usually is
called by a different name once it spreads, such as tinea corporis on the body or limbs and
tinea cruris (jock itch or dhobi itch) for an infection of the groin. Tinea pedis most often
manifests between the toes, with the space between the fourth and fifth digits most
commonly afflicted. Athlete's foot can usually be diagnosed by visual inspection of the skin,
but where the diagnosis is in doubt direct microscopy of a potassium hydroxide preparation
(known as a KOH test) may help rule out other possible causes, such as eczema or psoriasis.
A KOH preparation is performed on skin scrapings from the affected area. The KOH
preparation has an excellent positive predictive value, but occasionally false negative results
may be obtained, especially if treatment with an anti-fungal medication has already begun.
If the above diagnoses are inconclusive or if a treatment regimen has already been started, a
biopsy of the affected skin (i.e. a sample of the living skin tissue) can be taken for
histological examination. A Wood's lamp, although useful in diagnosing fungal infections
of the hair (Tinea capitis), is not usually helpful in diagnosing tinea pedis since the common
dermatophytes that cause this disease do not fluoresce under ultraviolet light. However, it
can be useful for determining if the disease is due to a non-fungal afflictor. Conventional
treatment typically involves daily or twice daily application of a topical medication in
conjunction with hygiene measures outlined in the above section on prevention. Keeping
feet dry and practicing good hygiene is crucial to preventing reinfection. Severe or
prolonged fungal skin infections may require treatment with oral anti-fungal medication.
Zinc oxide based diaper rash ointment may be used; talcum powder can be used to absorb
moisture that kills off the infection.

B) Tinea capitis- Tinea capitis (also known as "scalp ringworm")


is a superficial fungal infection (dermatophytosis) of the scalp. The disease is primarily
caused by dermatophytes in the Trichophyton and Microsporum genera that invade the
hair shaft. The clinical presentation is typically a single or multiple patches of hair loss,
sometimes with a 'black dot' pattern (often with broken-off hairs), that may be
accompanied by inflammation, scaling, pustules, and itching. Uncommon in adults, tinea
capitis is predominantly seen in pre-pubertal children, more often in boys than girls.
Treatment of tinea capitis requires an oral antifungal agent; griseofulvin is the most
commonly used drug, but other newer antimycotic drugs, such as terbinafine, itraconazole,
and fluconazole have started to gain acceptance.

C) Tinea corporis- a superficial fungal infection (dermatophytosis)


of the arms and legs, especially on glabrous skin, however it may occur on any part of the
body.It may have a variety of appearances; most easily identifiable are the enlarging raised
red rings with a central area of healing (ringworm). The same appearances of ringworm
may also occur on the scalp (tinea capitis), beard area (tinea barbae) or the groin (tinea
cruris, known as jock itch or dhobi itch). Most cases are treated by application of topical
antifungal creams to the skin, but in extensive or difficult to treat cases systemic treatment
with oral medication may be required. In general ringworm responds well to topical
treatment. Topical antifungals are applied to the lesion twice a day for at least 3 weeks. The
lesion usually resolves within 2 weeks, but therapy should be continued for another week
to ensure the fungus is completely eradicated. The most commonly used antifungal creams
are Clotrimazole, Ketoconazole, Miconazole, Terbinafine and Tolnaftate. If there are
several ringworm lesions or if the lesions are extensive, oral antifungal medications can be
used. Oral medications are taken once a day for 7 days and result in higher clinical cure
rates. The antifungal medications most commonly used are Itraconazole and Terbinafine.
D) Impetigo contagiosa (bacteria)- Impetigo contagiosa is a
cutaneous condition characterized by a staphylococcal, streptococcal, or combined
infection that presents with discrete, thin-walled vesicles that rapidly become pustular and
then rupture. People who suffer from cold sores have shown higher chances of suffering
from impetigo. Those who normally suffer from cold sores should consult a doctor if
normal treatment has no effect. Impetigo also causes flu-like symptoms which may cause
fatigue, weakness of muscles, headaches and vomiting. Good hygiene practices can help
prevent impetigo from spreading. Those who are infected should use soap and water to
clean their skin and take baths or showers regularly. Non-infected members of the
household should pay special attention to areas of the skin that have been injured, such as
cuts, scrapes, bug bites, areas of eczema, and rashes. These areas should be kept clean and
covered to prevent infection. In addition, anyone with impetigo should cover the impetigo
sores with gauze and tape. All members of the household should wash their hands
thoroughly with soap on a regular basis. It is also a good idea for everyone to keep their
fingernails cut short to make hand washing more effective. Contact with the infected
person and his or her belongings should be avoided, and the infected person should use
separate towels for bathing and hand washing. If necessary, paper towels can be used in
place of cloth towels for hand drying. The infected person's bed linens, towels, and
clothing should be separated from those of other family members, as well. Whilst suffering
from impetigo it is best to stay indoors for a few days to stop any bacteria getting into the
blisters and making the infections worse. When a person has impetigo it is common for
him/her to get it a 2nd time in the space of 6–9 months. This usually occurs in persons aged
12–16.

E) Pediculosis (head lice)- Head-louse infestation is widely


endemic, especially in children. It is a cause of some concern in public health, although,
unlike human body lice, head lice are not carriers of other infectious diseases. Head lice are
spread through direct head-to-head contact with an infested person. The most common
symptom of lice infestation is itching. Excessive scratching of the infested areas can cause
sores, which may become infected. Lice on the hair and body are usually treated with
medicated shampoos or cream rinses. Nit combs can be used to remove lice and nits from
the hair. Laundering clothes using high heat can eliminate body lice. Efforts to treat should
focus on the hair or body (or clothes), and not on the home environment.
Some lice have become resistant to certain (but not all) insecticides used in commercially
available anti-louse products. A physician or pharmacist can prescribe or suggest treatments.
Because empty eggs of head lice may remain glued on the hair long after the lice have been
eliminated, treatment should be considered only when live (crawling) lice are discovered.

F) Candidiasis (thrush)- Most candidial infections are treatable and


result in minimal complications such as redness, itching and discomfort, though
complication may be severe or fatal if left untreated in certain populations. In
immunocompetent persons, candidiasis is usually a very localized infection of the skin or
mucosal membranes, including the oral cavity (thrush), the pharynx or esophagus, the
gastrointestinal tract, the urinary bladder, or the genitalia (vagina, penis). Children, mostly
between the ages of three and nine years of age, can be affected by chronic mouth yeast
infections, normally seen around the mouth as white patches. However, this is not a
common condition. Oral candidiasis can be treated with topical anti-fungal drugs, such as
nystatin, miconazole or amphotericin B. Topical therapy is given as an oral suspension
which is washed around the mouth and then swallowed by the patient.
Patients who are immunocompromised, either with HIV/AIDS or as a result of chemotherapy, may require systemic
treatment with oral or intravenous administered anti-fungals.

G) Herpes Simplex (HSV1)- Herpes simplex is most easily


transmitted by direct contact with a lesion or the body fluid of an infected individual.
Transmission may also occur through skin-to-skin contact during periods of asymptomatic
shedding. Barrier protection methods are the most reliable method of preventing
transmission of herpes, but they merely reduce rather than eliminate risk. Oral herpes is
easily diagnosed if the patient presents with visible sores or ulcers. There is currently no
cure for herpes; no vaccine is currently available to prevent or eliminate herpes, although
vaccines of varying effectiveness are currently in phase III trials. Also, treatments are
available to reduce viral reproduction and shedding, prevent the virus from entering the
skin, and alleviate the severity of symptomatic episodes. Non-prescription analgesics can
reduce pain and fever during initial outbreaks. Topical anesthetic treatments such as
prilocaine, lidocaine or tetracaine can also relieve itching and pain

H) Herpes Simplex (HSV2)- When symptomatic, the typical


manifestation of a primary HSV-1 or HSV-2 genital infection is clusters of genital sores
consisting of inflamed papules and vesicles on the outer surface of the genitals resembling
cold sores. These usually appear 4–7 days after sexual exposure to HSV for the first time. In
males, the lesions occur on the shaft of the penis or other parts of the genital region, on the
inner thigh, buttocks, or anus. In females, lesions appear on or near the pubis, labia, clitoris,
vulva, buttocks or anus. Other common symptoms include pain, itching, and burning. Less
frequent, yet still common, symptoms include discharge from the penis or vagina, fever,
headache, muscle pain (myalgia), swollen and enlarged lymph nodes and malaise.Women
often experience additional symptoms that include painful urination (dysuria) and cervicitis.
Herpetic proctitis (inflammation of the anus and rectum) is common for individuals
participating in anal intercourse. After 2–3 weeks, existing lesions progress into ulcers and
then crust and heal, although lesions on mucosal surfaces may never form crusts. In rare
cases, involvement of the sacral region of the spinal cord can cause acute urinary retention
and one-sided symptoms and signs of myeloradiculitis (a combination of myelitis and
radiculitis): pain, sensory loss, abnormal sensations (paresthesia) and rash. Historically this
has been termed Elsberg syndrome, although this entity is not clearly defined. In pregnancy
it is recommended that the woman deliver via cesarean section if an active lesion is present
to reduce the risk of infecting the infant.

I) Scabies- The characteristic symptoms of scabies infection include


superficial burrows, intense pruritus (itching), a generalized rash and secondary infection.
Acropustulosis, or blisters and pustules on the palms and soles of the feet, are characteristic
symptoms of scabies in infants. S-shaped tracks in the skin, and are often accompanied by
small, insect-type bites called nodules that may look like pimples ]. These burrows and
nodules are often located in the crevasses of the body, such as between fingers, toes,
buttocks, elbows, waist area, genital area, and under the breasts in women. Secondary
infection is often due to impetigo, a type of bacterial skin infection, after scratching.
Cellulitis may also occur, resulting in localized swelling, redness and fever. Scabies is highly
contagious and can be spread by scratching, picking up the mites under the fingernails and
simply touching another person's skin. They can also be spread onto other objects like
keyboards, toilets, clothing, towels, bedding, furniture, and anything else that the mite may
be rubbed off onto, especially if a person is heavily infested. However, the parasite tends to
die if outside a human body for more than 72 hours. A single dose of Ivermectin has been
reported to reduce the load of scabies but another dose is required after 2 weeks for full
eradication. Permethrin used topically is also used, but this tends to take longer than the
Ivermectin.

J) Lyme Disease- Lyme disease is diagnosed clinically based on


symptoms, objective physical findings (such as erythema migrans, facial palsy, or arthritis), a
history of possible exposure to infected ticks, as well as serological tests. When making a
diagnosis of Lyme disease, health care providers should consider other diseases that may
cause similar illness. Most but not all patients with Lyme disease will develop the
characteristic bulls-eye rash, and many may not recall a tick bite. Laboratory testing is not
recommended for persons who do not have symptoms of Lyme disease. Congenital
transmission of Lyme disease can occur from an infected mother to fetus through the
placenta during pregnancy. The risk for fetal harm is much higher in the first three months
of pregnancy than later. Prompt antibiotic treatment almost always prevents fetal harm.
Pregnant Lyme-disease patients cannot be treated with the first-choice antibiotic,
doxycycline (see below), as it is potentially harmful for the fetus. Instead, erythromycin is
usually given; it is less effective against the disease but harmless for the fetus. Antibiotics are
the primary treatment for Lyme disease; the most appropriate antibiotic treatment depends
upon the patient and the stage of the disease. The antibiotics of choice are doxycycline (in
adults), amoxicillin (in children), erythromycin (for pregnant women) and ceftriaxone.
Alternative choices are cefuroxime and cefotaxime. Macrolide antibiotics (such as
erythromycin) have relatively low efficacy when used alone; they are administered to
pregnant women since they are harmless to the fetus, in contrast with most Lyme-disease
antibiotics.