SABIO REVIEWER LP 1 TO LP 4

UNIT 1: ALTERATIONS WITH INFECTIOUS, INFLAMMATORY RESPONSES

Pathogens
 any organism that causes disease
 classified into five types of microorganisms: viruses, bacteria, rickettsia, helminthes, and
fungi
STAGES
 incubation period
o time between the invasion of an organism and the onset of symptoms of infection
o EX: tetanus: 2 to 21 days
 prodromal period
o time between the beginning of nonspecific symptoms (low-grade fever) to the
onset of disease (diarrhea and vomiting)
o short: hours to a few days
 Illness
o Stage during which specific symptoms occur
 convalescent period
o interval between when symptoms first begin to fade and when the child returns to
a healthy baseline.
 Chain of infection
o method by which organisms are spread and enter a new individual to cause
disease
o Reservoir o Portal of entry
o Portal of exit o Susceptible host
o Means of transmission
 nosocomial infections- infections transmitted in healthcare facilities
o children <2 years old w/ nutritional deficit, immunocompromised, catheters,
antibiotic therapy

SCARLET FEVER-or scarlatina

o bacterial illness
o strep throat.
o Features: bright red rash that covers most of the body; almost always
accompanied: sore throat and a high fever
o most common in children 5 to 15 years of age
o antibiotic treatments have made it less threatening
o left untreated: affect the heart, kidneys and other parts of the body
o Symptoms:
  Red Rash  Difficulty swallowing
 Red lines- fold of skin  Enlarged glands in the
 Flushed face neck (lymph nodes)
 Strawberry tongue that are tender to the
 Fever w/chills touch
 Very sore and red  Nausea or vomiting
throat, sometimes  Headache
with white or
yellowish patches
>Causative agent: beta-hemolytic streptococci, group A
>Incubation period: 2 to 5 days for streptococcal pharyngitis
>Period of communicability: greatest during acute phase of respiratory illness; 1 to 7 days
>Mode of transmission: direct contact from a person with the disease and large droplets, not
fomites or household pets
>Immunity: One episode of disease gives lasting immunity to scarlet fever toxin. No vaccination
is available
>Prevention: Wash hands, don’t share utensils or food, cover mouth/nose when sneezing or
coughing
Therapeutic Management
 Soft/Liquid diet  Penicillin
 Analgesic  Give full course of medication

IMPETIGO
 common and highly contagious skin infection that mainly affects infants and children:
children ages 2 to 5.
 red sores on the face, especially around a child's nose and mouth, and on hands and feet
 sores burst and develop honey-colored crusts
 Treatment with antibiotics: keep your child home from school or day care until he or she
is no longer contagious- 24 hr after antibiotic treatment
 SYMPTOMS: mild itching, soreness
 bullous impetigo- larger blisters that occur on the trunk of infants and young children
 ecthyma- penetrates deeper into the skin-causing painful fluid- or pus-filled sores that
turn into deep ulcers
>Causative agent: beta-hemolytic streptococcus, group A or S. aureus including MRSA
>Incubation period: 7 to 10 days for impetigo (AAP, 2015).
>Period of communicability: from outbreak of lesions until lesions are healed.
>Mode of transmission: direct contact with lesions
>Immunity: none
>Prevention:
  Gently wash the affected areas with mild soap and running water and then cover lightly
with gauze.
 Wash an infected person's clothes, linens and towels every day and don't share them with
anyone else in your family.
 Wear gloves when applying antibiotic ointment and wash your hands thoroughly
afterward.
 Cut an infected child's nails short to prevent damage from scratching.
 Wash hands frequently.
 Keep your child home until your doctor says he or she isn't contagious
>Treatment
 Penicillin/ erythromycin:7-10 days
 Wash with water and soap
 Antibiotic/ cream applied in sores

DIPHTHERIA
o rare illness
o Signs
 Purulent nasal  Hoarseness of voice
discharge  Sore throat
 Brassy cough  Swelling of lymph
 Fever nodes
Causative agent: Corynebacterium diphtheriae (Klebs-Loffler bacillus)
Incubation period: 2 to 5 days with a range of 1 to 10 days (AAP, 2015)
Period of communicability: In untreated persons, the organism is contagious from nares, throat,
skin, and eyes for 2 to 6 weeks following infection; 48 hours after initiation of antibiotics in
treated children and adults.
Mode of transmission: direct contact or indirect contact droplets
Immunity: contracting the disease gives lasting natural immunity.
Prevention:
Active artificial immunity: diphtheria toxin given as part of diphtheria, tetanus and
pertussis (DTaP) vaccine
Passive artificial immunity: diphtheria antitoxin
Isolate sick person
Antibiotic-7 days
Clinical Forms
 Faucial. Pharyngeal spreads---tonsils across the soft palate to the uvula and over the
pharyngeal wall into the nasopharynx.
 Laryngeal –cause suffocation.
 Tonsillar–confined to the tonsils, where absorption of the toxin is moderate.
 Nasal –toxin is poorly absorbed by the lining of the nose
Management
 Penicillin/ erythromycin
 Bed rest
 Maintenance of open airway in patients with respiratory diphtheria

PERTUSSIS – whooping cough

 Vaccine preventable under 5 yrs. Old
 violent, uncontrollable coughing which makes it difficult to breathe, eat, or drink.
 first identified in the 16th century
 1906- Bordetella pertussis- Bordet isolated this org.
 Spreads: direct face-to-face contact, through sharing of a confined space, or through
contact with oral, nasal, or respiratory secretions from an infected source
STAGES
 incubation period of pertussis ranges from 3-12 days
 a 6-week disease each lasting 1-2 weeks
1- Catarrhal phase- initial phase; infectious during this period- communicable for 3 or more
weeks after the onset of cough
a. nasal congestion, rhinorrhea, and sneezing
b. accompanied by low-grade fever, tearing, and conjunctival suffusion
2- Paroxysmal phase.
a. intense coughing = several minutes; in older infants and toddlers- paroxysms of
coughing occasionally are followed by a loud whoop; posttussive vomiting and
turning red with coughing are common in affected children
3- Convalescent phase
a. chronic cough=last for weeks
MANAGEMENT
Supportive therapy
 Hospitalize: with severe disease and complication
 Diet: clinically age appropriate
 Activity: as tolerated
 Monitoring: > 1 yrs. Old treated on an outpatient basis if they do not fulfill the criteria for
hospital admission
PHARMACO
 Antimicrobial agents given during the catarrhal phase may ameliorate the disease.
 Antibiotics: treat all household members and close contact
 Vaccines: DTaP
ASSESSMENT: Continuous
 Airway patency. Maintaining patent airway is always the first priority.
 Auscultation. Auscultate lungs for presence of normal or adventitious breath sounds.
  Respirations. Assess respirations, note quality, rate, pattern, depth, flaring of nostrils,
dyspnea on exertion, evidence of splinting, use of accessory muscles, and position for
breathing
Nursing Diagnosis
Based on the assessment data, the major nursing diagnosis are:
• Ineffective airway clearance related to copious and tenacious bronchial secretions.
• Impaired breathing pattern related to decreased airway patency (
Intervention:
 Educate
o take a deep breath, hold for 2 seconds, and cough two or three times in succession
o Sitting position, use of pillow or hand splints when coughing, use of abdominal
muscles for more forceful cough, use of quad and huff techniques, use of incentive
o spirometry, and the importance of ambulation and frequent position changes
 Upright position as tolerated
 3 liters of water per day
 Administer meds: antibiotic, mucolytic, bronchodilators: effectiveness and side effects
 Provide postural drainage, percussion, and vibration as ordered

TETANUS- Lockjaw
 acute, spastic paralytic illness
 onset: gradually occur 1-7 days: severe muscle spasm stimulated by external stimuli and
autonomic dysfunction causing arrhythmias, tachycardia and diaphoresis
Causative agent: Clostridium tetani- found in soil and the excretions of animals.
It enters the body through an open wound. If the wound is shut off from an oxygen source,
tetanus bacilli begin to reproduce.
Incubation period: 3 days to 3 weeks: length nadepende ha distance han infection ngadto CNS.
Period of communicability: none
Mode of transmission: direct or indirect contamination of a closed wound
Immunity: development of the disease gives lasting natural immunity
Active artificial immunity: tetanus toxoid contained in DTaP vaccine
Passive artificial immunity: tetanus antitoxin
CAUSES:
 Dead or necrotic tissue
 Calcium salts
 Pyogenic infection from other organisms
 Dirt
 Other objects like pieces of glass, splintered wood, etc.
CLINICAL FORMS
Generalized tetanus:
 common form involves masseter muscles
  Sardonic smile
 drooling, sweating, irritability and persistent back spasms (opistothonus)
 severe cases: involve the autonomic nervous system, with cardiac arrhythmias,
fluctuations in blood pressure, profound sweating, and dehydration
Localized tetanus
 Confined to musculature at the site of primary infection: good prognosis
Cephalic tetanus
 Head: poor prognosis
MANAGEMENT
 Surgical removal of necrotic tissues.
 Administration of muscle relaxants, sedatives and proper ventilation.
 Administration of barbiturates or diazepam for mild tetanospasms.
 Paralyze patient’s muscles by use of curare-like agent so that respiratory function may be
maintained by positive-pressure breathing apparatus in case of sever tetanospams.
 Tracheostomy should be performed after onset of the first tetanospasm in order to
minimize respiratory complications.
 Good supportive care should include control of the environment to reduce auditory and
visual stimuli if tetanospasms are frequent and severe

ANTHRAX
 Bacillus anthracis- forms spores
 not known to spread from one person to another.
Incubation period: 1 to 7 days (inhalational), 1 to 12 days (cutaneous), 1 to 7 days
(gastrointestinal)
Mode of transmission: originally contracted from contact with the feces of infected cows or
sheep; not transmittable from person to person
active artificial immunity: At present, the anthrax vaccine is not used in children but is
available for adults 18 to 65 years of age who work with anthrax in the lab, certain vets who
handle animals or animal products contaminated with anthrax, and only some members of the
military
passive artificial immunity: not available
There are three types of anthrax:
 skin (cutaneous) -sore to blister to skin ulcer w/ black area in center; do not hurt: 60
days treatment using antibiotics,
 lungs (inhalation) - cold or flu symptoms and can include a sore throat, mild fever and
muscle aches. Later symptoms include cough, chest discomfort, shortness of breath,
tiredness and muscle aches. (Caution: Do not assume that just because a person has cold
or flu symptoms that they have inhalation anthrax.) ; require I.V. treatment with multiple
drugs
 digestive (gastrointestinal) - nausea, loss of appetite, bloody diarrhea, and fever,
followed by bad stomach pain.
Diagnose:
 Nasal swab: several people to detect contamination by anthrax in the environment, but
this does not confirm infection by anthrax in an individual.
  blood, tissue, and spinal fluid cultures (before antibiotics); x-ray to identify mediastinal
widening in inhalation anthrax
TREATMENT:
 I.V. corticosteroids may be given to adjunct therapy in severe cases.
 Symptomatic treatment includes analgesics, antiemetics, and emergency drugs for
circulatory collapse.
 An anthrax vaccine has been available for veterinarians
Complications
1. Anthraxrax meningitis – is the intense inflammation of the meninges of the brain and
spinal cord.
2. Anthrax sepsis – develops after the lymphohematogenous spread of B. anthracis from
primary lesion
Nursing Interventions
1. Monitor vital signs and hemodynamic parameters closely for circulatory collapse.
2. Monitor temperature for response to antibiotic therapy.
3. Auscultate chest for crackles, indicating need for better secretion mobilization.
4. Monitor oxygen saturation and arterial blood gases periodically to determine oxygenation
status and acid-base balance.
5. Monitor level of consciousness and for meningeal signs such as nuchial rigidity.
6. Provide supplemental oxygen or mechanical ventilation, as needed.
7. Position for maximum chest expansion and reposition frequently to mobilize secretions.
8. Suction frequently and provide chest physiotherapy to clear airways, prevent atelectasis, and
maximize oxygen therapy.
9. Administer I.V. fluids to encourage oral fluid intake to replace the fluid lost through
hyperthermia and tachypnea.
10. For G.I. anthrax, maintain G.I decompression, monitor emesis and liquid stool output, and
medicate for abdominal pain, as needed.
11. Advice the patient and family that anthrax is not transmitted person to person; one must
come in contact with the spores to contact infection

ROUNDWORMS (ASCARIASIS)

Parasitic infection- the condition when worms lives inside the human body

ROUNDWORMS
- Parasites that use human body to stay alive, feed and reproduce

ASCARIASIS
- the name of the infection
- causative agent is roundworm Ascaris lumbricoides - predominates in areas of:
• poor sanitation; associated with
• malnutrition;
• iron-deficiency anemia; and
• impairments of growth and cognition.
- may present with pulmonary or potentially severe gastrointestinal complaints
Ascaris lumbricoides
- largest of the intestinal nematodes
- measuring 15-35 cm in length in adulthood

Pathophysiology
✓ Infection begins with consumption of embryonated (infectious) eggs found in
fecescontaminated soil or foodstuffs.
✓ They hatch in the small intestine, releasing small larvae that breach the intestinal wall.
✓ Usually 1-2 weeks after infection, larvae move to the pulmonary vascular beds and then to the
alveoli through the portal veins, causing pulmonary symptoms such as cough and wheezing.
✓ They develop, copulate, and deposit eggs in the intestines after moving up the respiratory tract
and being swallowed.
✓ Adult worms can dwell in the gut for 6-24 months, causing partial or total bowel blockage, or
they can move into the appendix, hepatobiliary system, or pancreatic ducts, and infrequently
other organs such as the kidneys or brain.
✓ It takes 9 weeks from egg intake to new egg passage, with an additional 3 weeks required for
egg molting before they are capable of infecting a new host.

Statistics and Incidences

✓ Affects ¼ to 1/3 of the world’s population and around 4 million in the US.
✓ High-risk groups include international travelers, recent immigrants, refugees, and international
adoptees.
✓ Indigenous to rural southeast, with children aged 2-10 years to be more heavily infected in this
and all other regions.
✓ 1.4 billion people are infected worldwide
✓ The rate of complications ranges from 11-67%, with intestinal and biliary tract obstruction as
most common serious sequelae.
✓ Responsible for an estimated 730,000 cases of bowel obstruction annually, 11,000 of which are
fatal.
✓ Responsible for a plurality (28%) of nonobstetric etiologies of acute abdomen in one series of
pregnant patients in Bangladesh
✓ No racial predilection is known
✓ Male children are thought to be infected more frequently
Clinical Manifestations
Most patients are asymptomatic. But when symptoms occur, they are divided into two
categories:
1. early (larval migration); and
2. late (mechanical effects)

✓ Respiratory symptoms: Occurs in the early phase (4-16 d after egg ingestion), result from
the migration of larvae through the lungs; classically, these symptoms occur in the setting of
eosinophilic pneumonia (Löffler syndrome):
 • Fever;
• nonproductive cough;
• dyspnea;
• wheezing

✓ Gastrointestinal symptoms: Occurs the late phase (6-8 wk after egg ingestion), symptoms
are more typically related to the mechanical effects of high parasite loads such as:
• passage of worms (from mouth, nares, anus);
• diffuse or epigastric abdominal pain;
• nausea;
• vomiting;
• pharyngeal globus;
• “Tingling throat”;
• frequent throat clearing; and
• dry cough

Assessment and
Diagnostic Findings
✓ CBC count
✓ Sputum analysis
✓ Stool exam
✓ Chest radiography
✓ Abdominal radiography
✓ CT scan
✓ Ultrasonography

Medical Management
Treatment is divided according to the phases
of infection: 1. early infection (larval
migration); and
2. established infection (adult phase).

✓ Benzimidazoles: mainstay of treatment of symptomatic and asymptomatic infections that

have low human toxicity and exert their action directly on worms. Most common are
albendazole and mebendazole.
✓ Bowel obstruction: treatment includes:
• intravenous hydration;
• nasogastric suctioning;
• electrolyte monitoring; and
• laparotomy if conservative measures fail;
• colonoscopy and esophagogastroduodenoscopy (EGD) may be useful in removing
obstructing masses of worms
Pharmacologic
Management
✓ Albendazole: Decreases ATP production in worm, causing energy depletion, immobilization,
and finally death.
✓ Mebendazole: Causes worm death by selectively and irreversibly blocking uptake of glucose
and other nutrients in the susceptible adult intestine where helminths dwell.
✓ Piperazine citrate: Recommend for GI or biliary obstruction secondary to ascariasis; causes
flaccid paralysis of the helminth by blocking the response to worm muscle to acetylcholine.
✓ Pyrantel pamoate: Depolarizing neuromuscular blocking agent; inhibits cholinesterases,
resulting in spastic paralysis of the worm.
✓ Ivermectin: Binds selectively with glutamate-gated chloride ion channels in invertebrate nerve
and muscle cells, causing cell death.
✓ Levamisole: May inhibit worm copulation via agonism of L-subtype nicotinic acetylcholine
receptors in male nematode muscles

Nursing Management:
Nursing Assessment
✓ History: Soil-transmitted worm infections, including infections that affect poor and deprived
communities, where there is overcrowding and poor sanitation.
✓ Physical exam: General symptoms include:
• Fever;
• Jaundice;
• Cachexia;
• pallor; and
• urticaria; pulmonary symptoms include:
• wheezing, rales; and
• diminished breath sounds GI symptoms include:
• abdominal tenderness;
• distention;
• nausea; and
• vomiting

Nursing Diagnosis
✓ Fluid volume deficit: related to fluid loss secondary to diarrhea.
✓ Impaired sense of comfort: pain related to smooth muscle spasm secondary to migration of
parasites in the stomach.
✓ Imbalanced Nutrition: less than body requirements: related to anorexia and vomiting.
✓ Hyperthermia: related to decrease in circulation secondary to dehydration

Nursing Care Planning and Goals

✓ Maintain fluid and electrolyte balance
✓ Lost or diminished pain
 ✓ Improve nutritional requirements
✓ Maintain normothermia indicated by the absence of signs and symptoms of hyperthermia,
such as tachycardia, skin redness, temperature and blood pressurenormal

Nursing Interventions
✓ Improve fluid and electrolyte balance:
-
Monitor intake and output of fluids;
-
observe signs of dehydration;
-
give oral rehydration solution to assist in adequate hydration; - observe
accurate intravenous fluid administration.
✓ Reduce pain and discomfort:
- Assess the extent and characteristics of pain;
- give a warm compress on the abdomen; - teach a method of distraction to reduce
pain; - set a comfortable position that can reduce pain.
✓ Improve nutrition:
- Give adequate and nutritious food;
- measure body weight every day;
- explain the importance of adequate nutrition; and - maintain good oral hygiene.
✓ Maintain normothermia:
- Teach the client and family the importance of adequate feedback;
- monitor fluid intake and output;
- monitor the temperature and vital signs;
- provide tepid sponge baths; and
- administer analgesics as indicated

ENTEROBIASIS (PINWORMS)

ENTEROBIASIS

- a benign intestinal disease

- also called pinworm, seatworm, or threadworm infection
• pinworm, a white threadlike worm that invades the cecum and may enter the appendix
- causative agent is nematode Enterobius vermicularis
- most prevalent helminthic infection in the US

Enterobius
vermicula
ris -
a small
nematode
- helminthic infestation has an estimated prevalence of 40 million infected individuals in the US
 - female nematode averages 10 mm X 0.7 mm, whereas males are smaller
- pinworm eggs spread pinworms from person to person
- infestation often occurs in family clusters
- Infestation does not equate with poor home sanitary measures

Pathophysiology
✓ Its life cycle 6 to 8 weeks, after which reinfestation commonly occurs without treatment.
✓ E. vermicularis is an obligate parasite; humans are the only natural host. ✓ Fecal-oral
contamination via hand-mouth contact or via fomites
✓ After ingestion, eggs usually hatch in the duodenum within 6 hours.
✓ Worms mature in as little as 2 weeks and have a lifespan of approximately 2 months.
✓ Adult worms inhabit the terminal ileum, cecum, vermiform appendix, and proximal ascending
colon; the worms live free in the intestinal lumen.
✓ The female worm migrates to the rectum after copulation and, if not expelled during defecation,
migrates to the perineum (often at night) where an average of 11,000 eggs are released.
✓ Eggs become infectious within 6-8 hours and, under optimum conditions, remain infectious in
the environment for as long as 3 weeks
Statistics and Incidences
✓ Highest in school-age children and next highest in preschoolers.
✓ Prevalence is approximately 5-15% in the general population; humans are the only known host.
✓ A study reported that Enterobius vermicularis infections were found in 4.2% of infants, 16.7%, of
preschool-aged children, and 26.3% of school-aged children.
✓ Secondary bacterial skin infection may develop from vigorous scratching to relieve pruritus.
✓ Most infected are children younger than 18 years, people who take care of infected children,
and people who are institutionalized at which prevalence can reach 50%

Clinical Manifestations
Symptoms of enterobiasis in children include:

✓ Perianal itching: primary symptom mostly at night when female worm leaves anus to
deposit ova.
✓ Erythema: infestation can occur without these signs.
✓ Abdominal pain: may sometimes be severe and can mimic acute appendicitis.
✓ Visual worm sighting: usually accepted as evidence of infestation and for treatment

Assessment and
Diagnostic Findings
• Cellophane tape test:
- captures the eggs from around the anus
- performed in the early morning, just before or as soon as the child wakens
- the tape is then examined microscopically for eggs in the laboratory
Medical Management
✓ Handwashing: prevents disease transmission.
✓ Personal hygiene: reduces re-infection

Pharmacologic
Management
✓ Anthelmintics: Mebendazole is not currently available in the US while Pyrantel pamoate
or albendazole (not currently approved for this use by the US Food and Drug Administration)
are recommended alternatives. A second dose given 2 weeks after the initial dose. ✓ Anal
albendazole: may help with symptoms of pruritus ani

Nursing Management
Nursing Assessment
✓ History: if patients are symptomatic, pruritus ani and pruritus vulvae are common presenting
symptoms while worms may be incidentally discovered in the perineal region
✓ Physical exam: worms found in stools or on the patient’s perineum before bathing in the
morning

Nursing Diagnosis
✓ Risk for impaired skin integrity related to intense perianal scratching.
✓ Acute pain related to smooth muscle spasm secondary to migration of parasites in the
stomach.
✓ Imbalanced Nutrition: less than body requirements related to anorexia and vomiting.
✓ Hyperthermia related to decrease in circulation secondary to dehydration

Nursing Care Planning and Goals

✓ Reduce discomfort from perianal itching.
✓ Diminish pain to a tolerable level
✓ Regain adequate nutrition
✓ Reduce or eliminate increase in temperature

Nursing Interventions
✓ Administer medications as ordered: pyrantel, mebendazole, or albendazole may destroy the
causative parasites, while effective eradication involves patient’s family treatment.
✓ Inform patient of the side effects of pyrantel: Stool may be bright red and may cause
vomiting and the tablet form of this drug is coated with aspirin and shouldn’t be given to
aspirin-sensitive patients.
✓ Improve skin integrity: Apply antipruritic ointment or albendazole to control scratching and
prevent excoriations.
✓ Diminish pain: An antihelminthic medication is prescribed.
✓ Improve hygienic status: Avoid scratching the area and nail-biting, do thorough handwashing
before and after meals, and do not shake bed linens to avoid aerosolization of eggs.
✓ Diminish increase in temperature: Administer antipyretics as prescribed; tepid sponge baths
may also be given.
✓ Inform patient
 HOOKWORMS

HOOKWORM infection

- a common helminth infection

- causative agent are nematode parasites Necator americanus and Ancylostoma duodenale
- affected the poorest among the least-developed nations
- a consequence of inadequate access to clean water, sanitation, and health education
- acquired through skin exposure to larvae in soil contaminated by human feces
• Soil becomes infectious about 9 days after contamination and remains so for weeks,
depending on conditions
- may persist for many years in the host and impair the physical and intellectual development of
children and the economic development of communities

Pathophysiology
• A mature female A duodenale worm produces 10,000-30,000 eggs per day in the intestine,
while a mature female N americanus worm produces 5000-10,000 eggs per day.
• Each egg grows into an infective larva after deposition upon soil
• These larvae are developmental halted and nonfeeding; if they are unable to infect a new
host, they die when their metabolic reserves are depleted, which normally occurs after about
6 weeks.
• Larval development is most prolific in sandy, wet soil with an ideal temperature of 20-30°C;
under these conditions, the larvae hatch in 1 or 2 days to become rhabditiform larvae,
commonly known as L1.
• Rhabditiform larvae feed on excrement and molt twice before becoming infective filariform
larvae or L3 after 5-10 days.
• The L3 go into developmental arrest and can live in wet soil for up to 2 years; but, if exposed to
direct sunshine, dryness, or salt water, they become dehydrated. L3 are found in the top 2.5
cm of soil and travel upwards in search of moisture and oxygen.
• Within 10 days, he larvae move through the dermis, entering the circulation and traveling to
the lungs; once in the lungs, they break into alveoli, creating a moderate and typically
asymptomatic alveolitis with eosinophilia.
• The adults reach sexual maturity in 3-5 weeks, and the female worms begin to produce eggs
that appear in the feces.

Statistics and Incidences

✓ Worldwide, hookworms infect an estimated 472 million people.
✓ Hookworm infection and disease are most likely to be found in immigrants, refugees, and
adoptees from tropical countries.
✓ Cutaneous larva migrans is endemic in the southeastern states and Puerto Rico
 ✓ Human infection with A duodenale or N americanus affects approximately 472 million people
worldwide.
✓ Most prevalent in tropical and subtropical zones
✓ Highest prevalence reported among school-aged children and adolescents in endemic areas
✓ Increasing prevalence, from 15% at age 10 years to 60% at age 70 years and older; egg counts in
stool also increase in a similar pattern.
✓ Males and females are equally susceptible to hookworm infection

Causes
✓ Necator americanus
✓ Poor sanitation
✓ Limited access to clean water

Clinical Manifestations
✓ Ground or dew itch: rash appears on the palms or soles and may last for 1-2 weeks
✓ Pulmonary symptoms: Cough, fever, and reactive bronchoconstriction may be noticed, with
wheezing audible on auscultation.
✓ GI symptoms
✓ Symptoms of anemia: often insensitive.; patients may exhibit pallor, chlorosis (greenish-
yellow skin discoloration), hypothermia, spooning nails, tachycardia, or signs of high-output
cardiac failure.
✓ Cutaneous larva migrans: manifests as pathognomonic, raised serpiginous tracts (creeping
eruptions) with erythema that may last as long as 1 month if untreated; lesions seen on lower
extremities but may be limited to the trunk or upper extremities, depending on the site at which
the infective larvae entered the body

Assessment and Diagnostic

Findings ✓ Blood
studies:
- CBC and peripheral blood smear findings shows symptoms of iron-deficiency anemia;
- microscopy indicates hypochromic,
- microcytic red blood cells (RBCs);
-may be attributable to adult worm adhesion to the intestinal mucosa
✓ Stool examination: Direct microscopic inspection of fecal samples where eggs are visible and
the material is preserved in formalin and produced as a wet mount.

Medical Management
✓ Iron therapy: for patients with anemia and malnutrition may require
✓ Antihelmintics: for patients with cutaneous larva migrans who have minimal symptoms
✓ Blood transfusions: indicated in rare cases of acute severe gastrointestinal (GI) hemorrhage;
in patients with chronic anemia, blood should be administered slowly and are usually followed
by a diuretic to prevent rapid fluid overload
Pharmacologic
Management
✓ Antihelmintics: includes benzimidazoles and pyrantel pamoate; 400-mg single dose of
albendazole is recommended, but notes that albendazole is still not FDA approved for the
treatment of hookworm infection

Nursing Management
Nursing Assessment
✓ History: majority of infected people are from endemic areas who have a history of wearing
open footwear or walking barefoot
✓ Physical exam: minimal skin and pulmonary findings; physical findings in the early stage of
the disease differ from those in the late stage

Nursing Diagnosis
✓ Acute pain related to mucosal irritation.
✓ Ineffective tissue perfusion related to blood loss.
✓ Impaired skin integrity related to persistent scratching of the affected area.
✓ Deficient knowledge related to the disease process and treatment

Nursing Care Planning and Goals

✓ Diminished pain
✓ Perfusion will return to normal
✓ Reduced itching and scratching
✓ Acquired knowledge about diseases and treatments

Nursing
Interventions ✓
Reduce or
diminish pain:
- Provide rest periods to promote relief, sleep, and relaxation;
- Acknowledge reports of pain;
- Avoid sources of discomfort; and
- Determine the appropriate pain relief method.
✓ Improve tissue perfusion:
- Submit patient to diagnostic tests as indicated; - Administer blood transfusion as
indicated.
✓ Protect skin integrity:
- Monitor site of impaired tissue integrity for signs of infection;
- Provide skin care as needed;
- Keep a sterile dressing technique during wound care;
- Clip the patient’s nails as necessary;
 -Teach about proper handwashing, wound cleansing, dressing changes, and application
of topical medications.
✓ Enforce knowledge about the disease and its treatment:
- Determine priority of learning needs;
- Render physical comfort for the patient;
- Include the patient in creating the teaching plan;
- Help the patient in integrating information into daily life; and
- Provide clear, thorough, and understandable explanations and demonstrations

GIARDIASIS

GIARDIASIS
- a major diarrheal disease found throughout the world
- causative agent is flagellate protozoan Giardia intestinalis (previously known as G.
lamblia or G. duodenalis)
- represents a zoonosis with cross-infectivity between animals and humans
Giardia intestinalis
- most commonly identified intestinal parasite in the US
- most common protozoal intestinal parasite isolated worldwide
- can cause asymptomatic colonization or acute or chronic diarrheal illness
- has been found in as many as 80% of raw water supplies from lakes, streams, and ponds
and in as many as 15% of filtered water samples

Pathophysiology
✓ Most often results from fecal-oral transmission or ingestion of contaminated water.
✓ Person-to-person spread, with 25% of family members with infected children themselves
becoming infected.
✓ Giardia has one of the simplest life cycles of all human parasites with 2 stages: 1. the
trophozoite, which exists freely in the human small intestine; and
2. the cyst, which is passed into the environment.

✓ Upon ingestion of contaminated water or food, excystation occurs in stomach and the
duodenum in the presence of acid and pancreatic enzymes.
✓ The trophozoites pass into the small bowel where they multiply rapidly, with a doubling time of
9-12 hours; as trophozoites pass into the large bowel, encystation occurs in the presence of
neutral pH and secondary bile salts.
✓ Cysts are passed into the environment, and the cycle is repeated

Statistics and Incidences

✓ Identified in stool specimens, causing about 1.2 million annual episodes of illness.
 ✓ From 1964-1984, G lamblia caused at least 90 water-borne outbreaks of diarrhea, affecting
23,000 people; it involved small water systems using untreated or inadequately treated surface
water.
✓ High among individuals who camp and backpack in mountainous Western states.
✓ Incidence is greatest in northern states.
✓ Endemic infection occurs most commonly from July through October among children younger
than 5 years and adults aged 25-39 years.
✓ The asymptomatic carriage rate in children may be as high as 20% in southern regions and in
children younger than 36 months who attend daycare centers.
✓ Has a worldwide distribution, occurring in both temperate and tropical regions.
✓ Prevalence rates vary from 4-42%; in industrialized world, overall prevalence rates are 2-5%.
✓ In the developing world, G. intestinalis infects infants early in life and is a major cause of
epidemic childhood diarrhea; prevalence rates of 15-20% in children younger than 10 years.
✓ Giardiasis does not have race predilection
✓ Giardiasis is slightly more common in males than in females
✓ According to 2003–2005 data, the greatest number of reported cases occurred among children
aged 1-4 and 5-9 years and adults aged 35-44 years

Causes
✓ Person to person transmission
✓ Water-borne transmission
✓ Venereal transmission through fecal-oral contamination and food-borne epidemics

Clinical Manifestations
✓ Diarrhea
✓ Malaise, weakness due to loss of electrolytes with diarrhea
✓ Abdominal distention
✓ Malodorous, greasy stools
✓ Anorexia and weight loss

Assessment and
Diagnostic Findings
✓ Stool examination
✓ Stool antigen detection
✓ String test

Medical Management
✓ Fluid therapy
✓ Diet, maintenance on a lactose-free diet for several months may be helpful.
✓ Activity, activity restrictions are not indicated but isolation may be required to prevent
spreading of infection
Pharmacologic
Management
✓ Antibiotics: nitroimidazole derivatives and acridine dyes; most experts recommend
metronidazole and tinidazole but treatment has failure occurrence

Nursing Management
Nursing Assessment
✓ History: history or occurrence of parasite load, virulence of the isolate, and the host immune
response.
✓ Physical exam: no known unique physical findings are attributable to giardiasis

Nursing Diagnosis
✓ Diarrhea related to enteric infections.
✓ Fluid volume deficit related to GI losses.
✓ Impaired sense of comfort: pain related to smooth muscle spasm.
✓ Hyperthermia related to decrease in circulation secondary to dehydration

Nursing Care Planning and Goals

✓ Maintained fluid and electrolyte balance
✓ Lost or diminished pain
✓ Increased appetite and weight according to age
✓ Maintained normothermia indicated by the absence of signs and symptoms of hyperthermia

Nursing Interventions
✓ Restore Fluid & Electrolyte balance:
- Weigh patient daily and note decreased weight;
- Record number and consistency of stools per day;
- If desired, use a fecal incontinence collector for accurate measurement of output;
- Monitor and record intake and output;
- Note oliguria and dark, concentrated urine;
- Discuss the importance of fluid replacement during diarrheal episodes.
✓ Reduce pain or discomfort:
- Assess the extent and characteristics of pain;
- Give a warm compress on the abdomen;
- Teach the client and caregivers about methods to distract from the pain, and set a
position that can reduce the pain.
✓ Improve hyperthermia:
- Provide tepid sponge baths; administer antipyretics as prescribed
 SUPERFICIAL FUNGAL INFECTIONS
Four most frequent Definition Risk Factors Assessment/Clinical Medical
superficial fungal Manifestations/Signs and Management
infections Symptoms

1. Tinea Pedis fungal infection of feet those who use -May appear as an acute (i.e., - Soak feet in
known as athlete’s communal showers or inflamed vesicles) or chronic (i.e., vinegar
foot swimming pools scaly, dusky, or red rash) and water solution
infection on the soles of the feet
or between the toes with client - Resistant
complaints of pruritus infections: griseofulvin
or
tervinafine

- Terbinafine
(Lamisil) daily for 3
months
2. Tinea Capitis ringworm of the scalp poor hair hygiene -Characteristically results in red, - Griseofulvin for 6
and a contagious scaling patches in the scalp; small weeks
fungal infection of the pustules or papules may be seen
at the edges of the patches. - Shampoo hair 2 or 3
hair shafts and a
common cause of hair times with Nizoral or
-Hair becomes brittle and breaks selenium sulfide
loss
easily at the scalp. shampoo

3. Tinea Corporis fungal infection that nonhuman varieties -Begins with erythematous - Mild
affects the face, neck, cause an intense macules advancing to rings of conditions: topical
trunk, and extremities inflammatory reaction vesicles with central clearing antifungal
and highrisk for those creams
-the lesions are found in clusters
who have contact with
on the scalp, hair or nails. - Severe
pets or pet objects
conditions;
griseofulvin or
terbinafine
4. Tinea Cruris fungal infection of the most frequenly occurs -Manifests with small, red, scaly - Mild
groin, which may in young joggers, obese patches extending to circular conditions: topical
extend to the inner people, and those who plaques with elevated antifungal
scaly or vesicular borders creams
thighs and buttocks wear tight
area, also known as underclothing
“jock itch” -Clients complain of itching - Severe
conditions;
griseofulvin or
terbinafine
Pathophysiology
• The fungal infections are caused by fungi, tiny representatives of the plant kingdom that feed
on organic matter. They affect only the skin and its appendages to these Skin disorders

Nursing Management
Laboratory and diagnostic study findings
✓ Skin culture and sensitivity testing identify the causative organism
✓ Under Wood’s light, the infected hair appears fluorescent: aids in diagnosing tinea capitis

Nursing Diagnosis
✓ Impaired skin integrity
✓ Deficient knowledge
✓ Disturbed body image
✓ Acute pain
✓ Imbalanced nutrition: less than body requirements
✓ Risk for infection

Nursing Interventions
✓ Providing general nursing care for fungal skin diseases, which focuses on
- enhancing skin integrity,
- providing pain relief,
- preventing infection, and
- providing client and family teaching.

✓ Provide nursing care for the client with tinea pedis

- Administer fungal foot sprays
- Teach the client to keep his feet as dry as possible, including the area between the
toes.
• Place small pieces of cotton between the toes at night to absorb moisture.
• Socks must be made of absorbent white cotton since synthetic material don’t absorb
perspiration.
• Apply talcum powder or antifungal powder twice daily.
• Alternate shoes to dry completely before being worn again.

✓ Provide nursing care for the client with tinea corporis.

- Administer prescribed medications, which may include topical antifungal medication.
- Use a clean towel and washcloth daily.
- Thoroughly dry all skin areas and skin folds that retain moisture.
- Encourage the client to wear clean cotton clothing next to the skin.
- Be careful around pets and pet objects.

✓ Provide nursing care for the client with tinea capitis.

- Administer prescribed medications, including griseofulvin, an antifungal agent.
- Use separate combs and brushes and to avoid exchanging hats and other headgear.
- Household pets must be examined, because familial infections are relatively common.
 ✓ Provide nursing care for the client with tinea cruris.
- Administer prescribed medications, which may include topical antifungal medication.
- Avoid excessive heat and humidity as much as possible, including avoiding wearing
nylon underwear, tight-fitting clothes, and wet bathing suits.
- Clean, dry and dust the groin area with a topical antifungal agent.

CANDIDIASIS

Oral thrush
- also called oral candidiasis (kan-dih-DIE-uh-sis)
- when fungus Candida albicans accumulates on the lining of the mouth
- causes creamy white lesions, usually on your tongue or inner cheeks, your gums or tonsils, or
the back of your throat.
- may spread to the roof of your mouth
- more likely to occur in babies and older adults because of reduced immunity, people who
have suppressed immune systems or health conditions and those who have certain
medication.
Candida
- a normal organism in the mouth
- can overgrow sometimes and cause symptoms

Symptoms (Children and

adults)
✓ Creamy white lesions on your tongue, inner cheeks, and sometimes on the roof of your mouth,
gums and tonsils
✓ Slightly raised lesions with a cottage cheese-like appearance
✓ Redness, burning or soreness that may be severe enough to cause difficulty eating or swallowing
✓ Slight bleeding if the lesions are rubbed or scraped
✓ Cracking and redness at the corners of your mouth
✓ A cottony feeling in your mouth
✓ Loss of taste
✓ Redness, irritation and pain under dentures (denture stomatitis)

In severe cases:
✓ lesions may spread downward into the esophagus — the long, muscular tube stretching from
the back of your mouth to your stomach (Candida esophagitis)
• If this occurs, you may experience difficulty swallowing and pain or feel as if food
is getting stuck in your throat
Infants and breast-
feeding mothers -
Infected infants may
experience:
• Distinctive white mouth lesions
• Trouble feeding
• Fussy and Irritable feeding
- Infection can be passed by infant to mother, when breast-feeding, and may then passed back
and forth between the mother's breasts and the baby's mouth.

- Mothers whose breasts are infected may experience:

• Unusually red, sensitive, cracked or itchy nipples
• Shiny or flaky skin on the darker, circular area around the nipple (areola)
• Unusual pain during nursing or painful nipples between feedings
• Stabbing pains deep within the breast

Causes
✓ Failure of protective mechanisms to prevent invasion of harmful organisms: increasing the
number of candida fungus and allowing an oral thrush infection to take hold.

Risk factors

✓ Weakened immunity: Some medical conditions and treatments can suppress your immune
system
✓ Diabetes: saliva may contain large amounts of sugar, which encourages the growth of candida
✓ Vaginal yeast infections: Vaginal yeast infections are caused by the same fungus that causes
oral thrush, and infection can be passed to baby
✓ Medications: Drugs such as prednisone, inhaled corticosteroids, or antibiotics disturb the
natural balance of microorganisms in the body
✓ Other oral conditions: Wearing dentures, especially upper dentures, or having conditions
that cause dry mouth

Complications
- Oral thrush is seldom a problem for healthy children and adults.
- For people with lowered immunity, such as from cancer treatment or HIV/AIDS, thrush can be
more serious.
- Untreated oral thrush can lead to more-serious systemic candida infections.

Prevention
✓ Rinse your mouth: If involve to corticosteroid inhaler usage, be careful to rinse your mouth
with water or brush your teeth after using it.
 ✓ Brush your teeth at least twice a day and floss daily or as often as your dentist
recommends.
✓ Check your dentures: Remove your dentures at night and properly clean and properly
handle dentures.
✓ See your dentist regularly: especially if you have diabetes or wear dentures.
✓ Watch what you eat: limit the amount of sugar-containing foods you eat
✓ Maintain good blood sugar control if you have diabetes: reduce the amount of sugar in
your saliva, discouraging growth of candida.
✓ Treat a vaginal yeast infection
✓ Treat dry mouth

Diagnosis
If thrush is limited to your mouth, the doctor may:
✓ Examine mouth to look at the lesions
✓ Take a small scraping of the lesions to examine under a microscope
✓ If needed, do a physical exam and certain blood tests to identify possible underlying medical
condition that may be the cause of oral thrush

If thrush is in your esophagus, the doctor may recommend:

✓ Biopsy: tissue sample is cultured to determine which bacteria or fungi, if any, are causing the
symptoms.
✓ Endoscopic exam: doctor examines the esophagus, stomach and upper part of the small
intestine (duodenum) using a lighted, flexible tube with a camera on the tip (endoscope)
✓ Physical exam: If needed, a physical exam and certain blood tests may be done to try to
identify any possible underlying medical condition that could cause thrush in the
esophagus

Treatment
Treatment may depend on your age, your overall health and the cause of the infection.

✓ Healthy adults and children: doctor may recommend antifungal medication. If medications
are not effective, medication may be given that works throughout your body.
✓ Infants and nursing mothers: If infection is present, doctor may prescribe a mild antifungal
medication for your baby and an antifungal cream for your breasts.
✓ Adults with weakened immune systems: Most often your doctor will recommend
antifungal medication.
✓ Thrush may return after treatment if causes are not addressed properly

OSTEOMYELITIS

Osteomyelitis is an infection of the bone.

• Acute Osteomyelitis is often the result of a hematogenous spread of bacteria.

• Staphylococcus aureus (trauma or secondary infection) in older children
 • Streptococcus pyogenes in younger children
• Occur directly by outside invasion from a penetrating wound, open fracture or contamination
during surgery
• The age of the child often determines where the infection will take place:
a) Below 1-year-old – the capillaries near the epiphysis are often the transport for bacteria.
b) Older children – the rich sluggish blood flow makes the metaphysic the most common
site based on the location of the vascular sinusoids

Pathophysiology

 Circulation of infectious microbes through the bloodstream to susceptible bone leads to

inflammation, increased vascularity and edema.
 The organisms grow, pus forms within the bone, and abscess may form. This deprives the bone
of its blood supply, eventually leading to necrosis

Causes

• The Bloodstream – some germs in the body, such as from pneumonia or UTI  Injuries -
severe puncture wounds can carry germs deep inside your body.
• Surgery – during replacing of joints or repair of fractures.
Risk factors

• Recent injury or orthopedic surgery - severe bone fracture or a deep puncture wound gives
bacteria a route to enter your bone or nearby tissue (animal bite or nail piercing). Surgery can
open a path for germs to enter a bone.
• Circulation disorders
Diseases that impair blood circulation include:

a. Poorly controlled diabetes

b. Peripheral artery disease (smoking)
c. Sickle cell disease
• Problems requiring intravenous lines or catheters - the use of medical tubing to connect the
outside world with your internal organs can serve as a way for germs to get into your body.
When this type of tubing might be used include:

a. Dialysis machine tubing

b. Urinary catheters
c. Long-term intravenous tubing (central lines)
• Conditions that impair the immune system
Factors that may suppress your immune system include:

a. Cancer treatment
b. Poorly controlled diabetes
c. Needing to take corticosteroids or drugs called tumor necrosis factor inhibitors
 • Illicit drugs – illegal drug injection using nonsterile needles and less likely to sterilize their skin
before injections.

Assessment/Clinical Manifestations/Signs And Symptoms

 Localized bone pain
 Tenderness, heat, and edema in the affected area
 Guarding the affected area
 Restricted movement in the affected area
 Purulent drainage from a skin abscess

Systemic symptoms
 High fever and chills in acute osteomyelitis
 Low-grade fever and generalized weakness in chronic osteomyelitis

Laboratory and diagnostic study findings

 White blood cell count reveals leukocytosis  Erythrocyte sedimentation rate is elevated 
Blood culture identifies the causative organisms.
 Radiographs and bone scan demonstrate bone involvement in advanced disease Medical
Management
 Initial goal is to control and arrest the infective process.
 Affected area is immobilized; warm saline soaks are provided for 20 minutes several times a day
 Blood and wound cultures are performed to identify organisms and select the antibiotic
 Intravenous antibiotic therapy is given around the clock.
 Antibiotic medication is administered orally (on empty stomach); continued for up to 3 months
 Surgical debridement of bone is performed with irrigation; adjunctive antibiotic therapy is
maintained
Nursing Diagnosis
 Pain related to inflammation and swelling
 Impaired physical mobility associated with pain, immobilization devices, and weight-bearing
limitations
 Risk for extension of infection: bone abscess formation
 Deficient knowledge about treatment regimen

Nursing Management
 Protect the affected extremity from further injury and pain by supporting the limb above and
below the affected area.
 Prepare the client for surgical treatment, such as debridement, bone grafting or amputation, as
appropriate.
 Administer prescribed medications, which may include opioid and non-opioid analgesics and
antibiotics.
 Promote healing and tissue growth.
a. Prescribed local treatments (warm saline soaks, wet to dry dressings)
b. Provide a diet high in protein and vitamins C and D

Nonsurgical Management
 Drug Therapy
 Infection Control
 Hyperbaric Oxygen Therapy (HBO)

Surgical management
• Sequestrectomy – removal of the infected bone and allowing for restoration of tissue
• Bone Graft – (also known as Papineau Procedure or Open Cancellous Bone Graft) is one of the
most popular surgical techniques. The surgeon excises necrotic bone, grafts the bone, and
covers the skin, if necessary.
• Bone Segment Transfers – iliac crest and the fibula are the most common sites for bone-graft
harvesting.
• Muscle flaps - uses only muscle for defect coverage.

Postoperative Care
Assess the client’s neurovascular status:

 Pain
 Movement
 Sensation
 Warmth
 Temperature
 Distal pulses
 Capillary refill
Complications
 Bone death
 Sepric arthritis
 Impaired growth
 Skin cancer

Prevention
 Talk to your physician
 Take precautions to avoid cuts, scrapes, and animal scratches
 For a minor injury, clean the area immediately and apply a clean bandage.
 Check wounds frequently for signs of infection

SCOLIOSIS
 A lateral curvature of the spine found in thoracic, lumbar, or thoracolumbar spinal segment.
 The curve may be convex to the right (more common in lumbar curves) or to the left (more
common in lumbar curves).
 Rotation of the vertebral column around its axis occurs and may cause rib cage deformity.
 It is often associated with kyphosis (humpback) and lordosis (swayback)

Etiology and pathophysiology

1. Idiopathic Scoliosis
 65% of cases
 Possible causes include genetic factors, vertebral growth abnormality
 Classified into 3 groups; infantile (birth – 3 yo) and juvenile (bet. 11 and 17 yo)
2. Congenital Scoliosis - malformation of one or more vertebral bodies that results in asymmetric
growth.
 Type I – failure of vertebral body formation e.g. isolated hemivertebra, wedged
vertebra, multiple wedged vertebrae, and multiple hemivertebrae.
 Type II – failure of segmentation e.g. unilateral unsegmented bar, bilateral block
vertebra.
 Commonly associated with other congenital anomalies.
3. Paralytic or Musculoskeletal Scoliosis – develops several months after symmetrical paralysis of
the trunk muscles
4. Neuromuscular Scoliosis - children with medical conditions that impair the ability to control the
muscles that support the spine.
5. Osteopathic Conditions – fractures, bone disease, arthritic conditions, infection
6. Miscellaneous Factors - spinal irradiation, endocrine disorders, postthoracotomy, and nerve
root irritation.

Assessment
 Poor posture, uneven shoulder height.
 One hip is more prominent than the other.
  Scapular prominence.
 Uneven waistline or hemline
 Spinal curve observable or palpable on both upright and bent forward.
 Back pain may be present but is not a routine finding in idiopathic scoliosis.
 Leg length discrepancy

Nursing Diagnosis
 Disturbed body image related to negative feelings about spinal deformity and appearance in
brace.
 Risk for impaired skin integrity related to mechanical irritation to brace.
 Risk for injury related to postoperative complications

Diagnostic Evaluation
 X-ray of the spine in the upright position, 36-inch cassette, shows characteristic curvature.
 MRI, myelograms, or CT scan
 Pulmonary function tests for compromised respiratory status.
 Evaluate for renal abnormalities in children with congenital scoliosis

Therapeutic management
 Less than 20 degrees – close observation and x-ray every 6 months
 Greater than 20 degrees – conservative, body brace, it could include surgery or a combination
of both surgical and nonsurgical measures
 Greater than 40 degrees – surgery with spinal fusion to maintain spinal stability and to prevent
further progression of the deformity until bone growth is complete.

Bracing
 One of the oldest forms of correction
 Miwaukee brace was the first type used for this purpose
 Child wears the prescribed brace for 23 hours per day
 At night, a child may be prescribed a Charleston bending brace that confines the spine to an
overcorrected position.
 Assess children and parents on how to safely apply these braces.
 Frequent follow-up healthcare visits are necessary to check
 Caution children and parents not to loosen straps if rubbing to exert adequate compression and
traction on areas that are curved.
 Alert parents and children to notify their healthcare provider instead

Halo traction
 A ring metal (a halo) is held in place with about four stainless steel pins inserted into the skull
bones
 Counter-traction is applied by pins inserted into the distal femurs or the iliac crests.
  Used for those children who have severe scoliosis, experience respiratory involvement or
cervical instability or have a high thoracic deformity or decreased vital capacity from severe
spinal curvature and rotation.
 For the first 24 hours, children experience a nagging level of pain at the pin insertion sites
 The pin sites in the skull heal within 1 week without obvious scarring

Surgical intervention: Spinal instrumentation

 It is necessary if the spinal curvature is greater than 40 degrees.
 Rods and screws are placed next to the spinal column to provide a firm reduction of the
curvature
 Disadvantage; prevent spinal growth and limit motion of the lumbar section.

Nursing Interventions
 Prepare the child for casting or immobilization procedure by showing materials to be used and
describing procedure in age-appropriate terms.
 Promote comfort with proper fit of brace or cast.
 Allow the child to express fears and ask questions about deformity and brace wear.
 Assess skin integrity under and around the brace or cast frequently.
 Good skincare to prevent breakdown around any pressure areas.
 Instruct the patient to examine the brace daily for signs of loosening or breakage.
 Instruct patient to wear cotton shirt under brace to avoid rubbing.
 Instruct about which previous activities can be continued in the brace.
 Provide a peer support person when possible so the child can associate positive outcomes and
experiences from others

JUVENILE IDIOPATHIC ARTHRITIS (JIA)

 also called juvenile arthritis/ juvenile rheumatoid arthritis

 involves joints of body, blood vessels, and other connective tissue
 shares clinical manifestation of chronic joint inflammation
 etiology of JRA is unknown, genetic component is complex, making clear
distinctions in subtypes difficult
Pathophysiology

 systemic onset JRA as an autoinflammatory disorder like cryopin-associated

periodic fever
 multiple genes are important for disease onset and manifestations
 humoral and cell-medicated are involved in pathogenesis
 T lymphocytes release proinflammatory cytokines & favoring type-1 T-
lymphocyte response
  Studies of T-cell receptor expression confirm recruitment of T-lymphocytes
specific for synovial noncell antigens
 Abnormalities in humoral immune system: increased presence of
autoantibodies, increased serum immunoglobulins, presence of circulating
immune complex, complement activation
 B-lymphocyte infiltration and expansion cause chronic inflammation of
synovium
 Synoviocyte proliferation due to macrophages and t-cells invasion
Statistics and Incidences

 Peak at 1-3 y/o and 8-12 y/o

 Approx. 300,000 children in US have some type of arthritis
 prevalence ranged from 1.6 to 86.1 per 100,000
 occurs more in disparate areas such as British Columbia and Norway
 Mortality rate in Europe is less than 1%, and less than 0.5% in America
 Most deaths associated with JRA in Europe are r/t amyloidosis, in US are
infections
Clinical Manifestations

 Arthritis – either intra-articular swelling or pain, warmth, erythema of joint

 Loss of motion – hips, temporomandibular and small joints demonstrate loss
of motion and pain
 Synovitis – fingers are swollen, range of motion is painful
 Swelling – soft, boggy feeling in popliteal fossa
 Joint inflammation – occurs first and if untreated, leads to irreversible chances
in cartilage, ligaments and menisci
Assessment and Diagnostic Findings

 Inflammatory markers – elevated erythrocyte sedimentation rate (ESR) or C-

reactive protein (CRP) level, thrombocytosis, leukocytosis, complement, and
in a reverse fashion, albumin and hemoglobin
 Complete blood count and metabolic panel – complete blood count, liver
function tests, assessment of renal function with serum creatinine levels
before treatment of NSAIDS, methotrexate (MTX) or tumor necrosis factor-
alpha inhibitors
 Antinuclear antibody test – positive ANA means increased risk of anterior
uveitis
 Radiography – used when only single joint is affected to exclude other
diseases
  Computed tomography and magnetic resonance imaging – CT scan to
analyze bony abnormalities, MRI for most sensitive radiologic indicator of
disease activity
 Ultrasonography – to detect subclinical synovitis, asymptomatic
inflammation and bone erosions
Medical Management

 Exercise – preserve range of motion and muscular strength

 Synovectomy – rarely needed, used for single or jut a few joints involved
with very active synovitis
 Osteotomy and arthrodesis – for severe joint destruction or deformity
 Total hip and knee replacements – provide excellent relief of pain and restore
function
Pharmacologic Management

 Nonsteroidal anti-inflammatory drugs (NSAIDs) – interferes with

prostaglandin synthesis with inhibition of enzyme to relieve pain and
swelling
 Disease-modifying antirheumatic drugs (DMARDs) – prevent disease
progression and loss of function
 Corticosteroids – potent anti-inflammatory drugs used to bridge time until
DMARDs are effective
 Immunomodulators – develops agents that block cytokines and its effects

Nursing Management

 To maintain mobility and preserve joint function

Nursing Assessment

 Medical history – asses duration of symptoms, affected joints, pain

description, changes in physical activity, general health, history of arthritis,
previous illness, other symptoms
 Physical exam – Assess vital signs, auscultate heart and lungs, palpate
abdomen, examine the skin
Nursing Diagnosis

 Acute pain r/t tissue distension by inflammation, joint destruction

 Impaired physical mobility r/t skeletal deformities, pain, discomfort, activity
intolerance, decreased muscle strength
  Disturbed body image r/t changes in ability to perform usual tasks
 Self-care deficit r/t musculoskeletal impairment
 Deficient knowledge r/t lack of exposure/recall
Nursing Care Planning and Goals

 Report pain is relieved/controlled.

 Appear relaxed, able to sleep/rest and participate in activities appropriately.
 Follow prescribed pharmacological regimen.
 Incorporate relaxation skills and diversional activities into pain control program.
 Maintain position of function with absence/limitation of contractures.
 Maintain or increase strength and function of affected and/or compensatory
body part.
 Demonstrate techniques/behaviors that enable resumption/continuation of
activities.
 Verbalize increased confidence in ability to deal with illness, changes in lifestyle,
and possible limitations.
 Verbalize understanding of condition/prognosis, and potential complications.
Formulate realistic goals/plans for future
Nursing Interventions

 Physical therapy – Exercise, application of splints, and heat.

 Activity - Encourage the child to perform activities of daily living to maintain
function and independence.
 Pain relief – Provide firm mattress or bed board, small pillow; elevate linens with
bed cradle as needed; and suggest patient assume position of comfort while in
bed or sitting in chair.
 ROM exercises – Assist with active and passive ROM and resistive exercises and
isometrics when able.
 Emotional support – Encourage verbalization about concerns of disease process,
future expectations; give positive reinforcement for accomplishments; and
acknowledge and accept feelings of grief, hostility, dependency.
 Health education - Review disease process, prognosis, and future expectations;
discuss patient’s role in management of disease process through nutrition,
medication, and balanced program of exercise and rest; and assist in planning a
realistic and integrated schedule of activity, rest, personal care, drug
administration, physical therapy, and stress management
Evaluation
Goals are met as evidenced by
 Reported pain is relieved/controlled.
 Appeared relaxed, able to sleep/rest and participate in activities appropriately.
 Followed prescribed pharmacological regimen.
 Incorporated relaxation skills and diversional activities into pain control
program.
 Maintained position of function with absence/limitation of contractures.
 Maintained strength and function of affected and/or compensatory body part.
 Demonstrated techniques/behaviors that enable resumption/continuation of
activities.
 Verbalized increased confidence in ability to deal with illness, changes in
lifestyle, and possible limitations.
 Verbalized understanding of condition/prognosis, and potential complications.
Formulate realistic goals/plans for future.
MYASTHENIS GRAVIS

 In myasthenia gravis, there is interference in ACh processing which leads to

symptoms of progressive muscle weakness or inability to contract.
 May be impaired synthesis or storage of Ach, insufficient ACh release,
inadequate ACh receptors present at motor end plates, opposition of ACh by an
anti-ACh factor or excessive cholinesterase.
 In adults, defect is most often a motor end plate insufficiency; In children, mostly
from autoimmune process
 Occurs in three forms in childhood: neonatal transient myasthenia, congenital
myasthenia, and juvenile myasthenia
 80% of patients have elevated titers for ACh receptos antibodies which prevent
ACh molecule from binding to receptor sites or cause damage to it.
 Often associated with thymic tumors
 A neuromuscular disease characterized by considerable weakness and abnormal
fatigue of the voluntary muscles
Assessment

 Weakness and fatigue

 Difficulty chewing
 Dysphagia
 Ptosis
 Diplopia
 Weak, hoarse voice
 Difficulty breathing
 Diminished breath sounds
 Respiratory paralysis and failure
Complications

 Myasthenic Crisis - a complication of myasthenia gravis characterized by

worsening of muscle weakness, resulting in respiratory failure that requires
intubation and mechanical ventilation
 Cholinergic Crisis - an over-stimulation at a neuromuscular junction due to an
excess of acetylcholine (ACh), as a result of the inactivity of the AChE enzyme,
which normally breaks down acetylcholine
Primary Nursing Diagnosis

 Ineffective airway clearance r/t difficulty in swallowing and aspirations

Diagnostic Evaluation

 Injection of edrophonium (Tensilon) is used to confirm the diagnosis (have

atropine available for side effects). Improvement in muscle strength represents a
positive test and usually confirms the diagnosis.
 MRI may demonstrate an enlarged thymus gland.
 Test includes serum analysis for acetylcholine receptor and electromyography
(EMG) to measure electrical potential of muscle cells
Arms raised above shoulders to fatigue is an exercise that is performed during Tensilon
test. Drug Tensilon is administered and response in muscles is evaluated to help
diagnose or differentiate between other conditions.
Medical Management

 Directed at improving function through administration of anticholinesterase

medications by reducing and removing circulating antibodies.
 Usually managed on outpatient basis unless required
Pharmacologic Highlights

 Anticholinesterase drugs such as Pyridostigmine bromide (Mestinon),

neostigmine bromide (Prostigmine); neostigmine methylsulfate can be given as a
continuous infusion if the patient cannot take oral medication. Anticholinesterase
drugs blocks the action of the enzyme anticholinesterase, producing
symptomatic improvement; atropine used to treat cholinergic side effects;
medications must be administered on time or patient may be too weak or unable
to swallow the drug.
 Prednisone is used to suppresses the autoimmune activity of MG
 Nonsteroidal immunosuppressants such as Azathioprine (Imuran),
cyclophosphamide (Cytoxin) is used to suppress autoimmune activity when
patients do not respond to prednisone; can produce extreme
immunosuppression and toxic side effects
Nursing Interventions
1. Monitor respiratory status and ability to cough and deep breathe adequately.
2. Monitor for respiratory failure.
3. Maintain suctioning and emergency equipment at the bedside.
4. Monitor vital signs.
5. Monitor speech and swallowing abilities to prevent aspiration.
6. Encourage the client to sit up when eating.
7. Assess muscle status.
8. Instruct the client to conserve strength.
9. Plan short activities that coincide with times of maximal muscle strength.
 10. Monitor for myasthenic and cholinergic crises.
11. Administer anticholinesterase medications as prescribed.
12. Instruct the client to avoid stress, infection, fatigue, and over-the counter
medications.
13. Instruct the client to wear a Medic-Alert bracelet.
14. Inform the client about services from the Myasthenia Gravis Foundation

UNIT 3: A CHILD WITH VISION DISORDER

Vision occurs because light rays reflect from an object through the corneas, aqueous,
humors, lenses and vitreous humors to the retinas.

 Light rays may not be able to reach the retinas or focus correctly there, resulting
in a vision disorder.
Retinas are studded with rods, which are instrumental for night vision and for
detecting movement in the visual field.
Fovea Centralis (the center of the macula) is an area of closely packed cones on the
retinas where color is best perceived.
Single Binocular Vision is learning to work the other eye to interpret a dual image as
one.
Stereopsis is depth perception, or the ability to see objects as three-dimensional.

 Children with one vision is unable to view three dimensional figures and tend to
reach farther or closer than the actual distance of an object.
Stereo Fly Dot Test is a test where the image of a fly is constructed from a series of
colored dots.
Accommodation is the adjustment the eye makes to focus on a close image.

 Children who cannot accommodate are unable to fuse their vision to follow a
penlight toward their nose this way; instead, they demonstrate double vision or
diplopia.
Disorders that Interfere with Vision
REFRACTIVE ERRORS
Refractive Errors is the shape of the eye does not bend the light correctly, resulting to
blurry vision.

 Normally, this bending causes a ray of light to fall directly on the retina.
With Refractive Errors, the light rays do not hit the retina accurately as the child grows
older but at a point behind the retina.
MYOPIA
Myopia is being near sighted. The lens of the eye tends to shorten which makes it
difficult for them to see things from afar.

 Normally, the lens of the eye bends to absorb the light and process at the retina
to view image.
 In myopia, the tendency is that the lens of the eye could not capture the light
which makes the image blurry.
 This occurs when your cornea is curved too much or your eye is longer than
normal.
Signs and symptoms:
1. Eyestrain
2. Episodes of Headaches
Diagnostic Examination:
1. Ophthalmologists use Snellen Chart or preferably, Jaeger Chart to test patients
who may have myopia.
2. Tonometry can be used to monitor eye pressure as it can not only detect myopia
but also glaucoma.
3. Using refraction tests, ophthalmologists can prescribe glasses or lenses that could
correct their perception to improve vision.
4. Slit-lamp is used to assess parts of the eye such as the cornea, lens, iris and retina.
5. Color vision test can be used to assess if the patient also has color blindness.
Medical Management:
1. Using prescription glasses and lenses could correct the refraction errors.
2. Avoid eye strains by putting rest periods in between reading or using
cellphones.
3. LASIK Surgery permanently corrects the vision without any use of glasses or
lenses as it reshapes the cornea and flattens the corneal tissue to reduce
nearsightedness.
4. Ophthalmic eye drops are given as a pain reliever after surgery to moisten the
eye.
HYPEROPIA
Hyperopia is being far-sighted. It is the opposite of being near-sighted as a patient can
see distant object clearly but views the nearby object blurry.
  Instead of image being reflected through the retina, it is reflected at the back of it.
 This occurs when your cornea is curved too little or your eye is shorter than
normal.
Signs and Symptoms:
1. Eye pain
2. Complaints of blurred vision on near objects
3. Eye strain
4. Crossed eyes apparent in children
5. Frontal headache while reading at arm’s length
6. Fatigue
7. Difficulty on focusing on things that near
Medical Management
1. Prescription glasses are given to patients with hyperopia prescribed by licensed
optometrist and ophthalmologist.
2. Eye surgery through assessment from eye surgeon.
3. Eye examination with the consultation of an ophthalmologist.
4. Seek medical consultation to detect glaucoma.
5. Refractive Surgery such as Photorefractive Keratectomy flattens the cornea for
the lens to focus properly and LASIK Surgery to scrape a part of the cornea and
gets flapped in order to change the focus of the lens.
ASTIGMATISM
Astigmatism is the imperfection in the curvature of the eye which tends to blur distant
and near vision.

 It can occur when the surface of the cornea or the lens has mismatched curves,
causing blurry vision.
 Instead of one having a round-ball like shape, having astigmatism is related to
having the surface shaped like an egg.
Signs and Symptoms
1. Blurred or distorted vision
2. Eyestrain or discomfort
3. Headaches
4. Difficulty with night vision
5. Squinting
See an eye doctor if your eye symptoms detract from your enjoyment of activities or
interfere with your ability to perform everyday tasks.
Children and Adolescents
Children do not usually realize that their vision is blurry, which makes eye testing
recommended with the consultation of their pediatrician, ophthalmologist and
optometrist.
Causes
The cornea, the clear front surface of your eye along with the tear film.
The lens, a clear structure inside your eye that changes shape to help focus on near
objects.
Each of these elements have a round surface, which incoming light can be refracted
equally to create sharply focused image directly on the retina.
There is a refractive error if there is a mismatch of curves between the cornea and the
lens, thus, possibly creating two different image instead of one and being blurry in
vision.
Astigmatism is a refractive error as it occurs when either the cornea or lens have steeply
mismatched curves.

 Corneal Astigmatism is when the surface of the cornea have mismatched curves.
 Lenticular Astigmatism is when the surface of the lens have mismatched curves.
Diagnosis
An eye examination is tested to detect Astigmatism.
It involves directly aiming a bright light at the eyes and will be tested by the patient
looking at different lenses.
These tests are done to examine the vision and determine the prescription needed to
provide clear vision with eyeglasses or lenses.
Treatment
Treatments such as corrective lenses and refractive surgery are done to improve vision
clarity and eye comfort.
Corrective Lenses include eyeglasses and contact lenses to counteract uneven
curvatures of the cornea and lens.

 Orthokeratology uses lens to correct and temporarily reshape the cornea for
vision improvement.
Refractive Surgery is a surgical procedure to fix vision problems as the laser reshapes
the curves of the cornea.
  Laser-Assisted In-Situ Keratomileusis (LASIK) is a procedure where the
surgeon makes a thin, hinged flap in the cornea to reshape it.
 Laser-Assisted Sub-Epithelial Keratectomy (LASEK) is a procedure that loosens
the cornea’s thin protective cover known as the epithelium, instead of creating a
flap.
 An Excrimer Laser is used to change the curvature of the cornea to
reposition the loose epithelium.
 Photo-Refractive Keratectomy (PRK) is a procedure where it is similar to
LASEK but instead of making the epithelium loose, it removes it as it can
naturally grow and conform to the new shape of the cornea.
 Epi-LASIK uses a special mechanized blunt blade to loosen the epithelium
instead of LASEK’s special alcohol.
 Small-Incision Lenticule Extraction (SMILE) is a procedure that reshapes the
cornea using a laser to create lens-shape tissue called lenticule below the cornea.
Other types of refractive surgeries include:

 Clear Lens Extraction

 Implantable Contact Lenses
Some of the possible complications that can occur after refractive surgery include:

 Under-correction or overcorrection of your initial problem

 Visual side effects, such as a halo or starburst appearing around lights
 Dry eye
 Infection
 Corneal scarring
 Vision Loss
STRABISMUS
Strabismus is the inward deviation of the eyes which makes the eyes crossing.

 It is noted before the patient reaches the age of 6 months.

 It is associated with maldevelopment of stereopsis and motion movements in
which the eyes are not aligned properly.
Pathophysiology
The exact cause of the disease is unknown but it is strongly believed that it is an inborn
and irreversible defect of fusion
Types of Strabismus are:

 Esotropia – inward turning of the eye

  Exotopia – outward turning of the eye
 Hypertopia – upward turning of the eye
 Hypotopia – downward turning of the eye
Statistics and Incidences
Occurs in 12 million people in a population of 245 million (5 out of 100 people)
Causes
The exact cause is still yet to be identified;
Genetics can be considered since it can be inherited as a complex genetic trait; which
makes it likely that both genes and environment are considerable factors.
Loci Susceptibility is considered too since identifiable regions of a chromosome can be
inherited with the illness, thus explaining the risk of the illness.
Clinical Manifestation
Esotropia is turning of both eyes and may occur with near and far fixation or even both.
Pursuit Asymmetry is when the movement of the eye is impaired; thus the ability to
track objects using the eye is abnormal.
Latent Fixation Nystagmus is defined clinically as nystagmus or repetitive and
uncontrolled movement of the eye, which appears on covering one eye and beats
towards the uncovered eye.
Amblyopia or Lazy Eye is reduced vision in one eye caused by abnormal visual
development early in life; thus, eyes often wanders inward or outward.
Pharmacological Management
Combination of anti-biotic steroid ointments are used to control inflammation and
prevent infection.
Neurotoxins such as BOTOX inhibits transmission of nerve impulses in neuromuscular
tissue.
Nursing Management
Assessment

 History of the patient to assess potential risk such as family history and potential
secondary ocular history.
 Physical Exams can be used to associate in detecting a spectrum presentations
such as amblyopia, impaired binocularity, etc.
Diagnosis
  Risk for injury related to impaired sensory function.
 Disturbed sensory perception related to structural damage.
 Knowledge deficit related to impaired vision.
 Social isolation related to the limited ability to participate in diversion activities
and social activities secondary to impaired vision
Care Planning and Goals

 Patient will be free from risk of injury

 Patient will have restored and functioning sensory perception
 Patient will understand the condition, treatment and intervention.
 Patient will be able to interact with the others.
Interventions

 Prevent Injury
 Patch Therapy and Vision Therapy
 Enforce caregiver’s knowledge
Evaluation

 Patient will be free from risk of injury

 Patient will have restored and functioning sensory perception
 Patient will understand the condition, treatment and intervention.
 Patient will be able to interact with the others.
CATARACT
A Cataract is the clouding of the lens of the eye which tends to make the vision blurry.
The lens of the eye loses water and increase in size and density as age progresses,
resulting in compression of lens fibers.
It forms when:

 Oxygen uptake is reduced

 Water content decreases
 Calcium content increases
 Soluble proteins turn insoluble
Compression of lens fibers causes a painless, progressive loss of transparency that is
often bilateral.
Causes
It can be related to age-related deterioration or Senile Cataracts.
Traumatic Cataracts develop when a foreign object damages the lens.
Complicated Cataracts are developed from secondary effects of:

 Metabolic Disorders
 Radiation Damage
 Eye Inflammation
Toxic Cataracts results from chemical toxicity.
Congenital Cataracts are developed from maternal infection during the first trimester.
Complications

 Retinal Disorders
 Pupillary Block
 Adhesions
 Acute Glaucoma
 Macular Edema
 Retinal Detachment
After-cataract or Posterior Capsular Opacity is when lens epithelial cells regenerate lens
fibers which obstructs vision.

 Can be treated with Yttrium-Aluminum-Garnet (YAG) laser to the affected tissue

 Without surgery, it could potentially lead to vision loss.
Assessment

 Opaque or cloudy white pupil

 Gradual loss of vision
 Blurred vision
 Decreased color perception
 Vision that is better in dim light with pupil dilation
 Photophobia
 Absence of the red reflex
Primary Nursing Diagnosis
Sensory and Perceptual Alterations (visual) related to decreased Visual Acuity

 Anxiety
 Deficient Knowledge (diagnosis and treatment)
 Risk for Infection and Injury
Diagnostic Evaluation
No specific laboratory tests can identify cataracts immediately.
Diagnosis are based from:

 History
 Visual Acuity Tests
 Direct Ophthalmoscopic Test
Ophthalmoscopy or Slit-Lamp Examination examines the back of the eye or the fundus
to identify lens opacity and eye abnormalities.
Medical Management
There are no medical treatments for Cataracts.
Although the use of Vitamin C, E and beta-carotene are being investigated for potential
treatment.
Use of glasses may help improve vision temporarily.
Mydriatics can be used but can increase the glare in vision.
Surgical Management
The only cure for cataracts are surgical removal of the opaque lens

 It can be removed when the visual deficit is as low as 20/40

In bilateral cataracts, the more advanced cataract is removed.
Extra-capsular Cataract Extraction removes the anterior lens capsule and cortex; only
the posterior capsule is left intact.

 An intraocular lens is implanted to where the lens was placed, at the posterior
chamber.
Intra-capsular Cataract Extraction removes the entire lens within the intact capsule.

 An intraocular lens is placed in either posterior or anterior chamber.

Pharmacologic Highlights
An inhibitor called Acetazolamide is used to reduce intraocular pressure with the
formation of hydrogen and bicarbonate ions.
Phenylephrine causes abnormal dilation of the pupil constriction.
Post-operative Medication are prescribed to:

 Reduce Infection - Gentamicin or Neomycin

 Reduce Inflammation – Dexamethasone
Acetaminophen is prescribed for mild discomfort.
Tropicamide is prescribed to induce ciliary paralysis.
Nursing Intervention
1. Structure home environment with conductive lighting and reduce fall hazards.
2. Magnifying Glasses and Large-Print Books is recommended.
3. Assist the patient with daily living to remedy self-care deficits.
4. Encourage the patient to verbalize anxiety or fear of visual loss or surgery.
5. Help plan events to solve the problems with social isolation.
Documentation Guidelines

 Presence of Complications
 Response to Eye Medication
 Reaction to Supine Position
Home Health Teaching

 Avoid movements that requires forward flexion and rapid movement like
Vacuuming.
 If permitted by the doctor, driving, sports and machine operation can be
resumed.
 Clients fitted with cataract eyeglasses need information about altered spatial
perception.
 Instruct the client to look through the center of the corrective lenses and to turn
the head, rather than only the eyes, when looking to the side.

UNIT 4: A CHILD WITH HEARING DISORDER

Hearing loss is when there is an interruption or interference of sound reaching the
inner ear or with the external ear.
The term sensorineural loss is when the inner ear cannot receive sound due to
interference as the eight cranial nerves are affected.
It results from a disease that affects sound transmitted to the cerebral cortex and
condition of the cochlea.
Hearing or Conduction loss obstructs the external ear with:
 Cerumen or Wax
 Foreign object.
 Immobile or Damaged Tympanic Membrane
Otitis Media is an inflammation of the middle ear which obstruct sound to be
transmitted to the ear drum.
Serous Otitis Media occurs when the middle ear is filled with fluid.
Nerve damages may disrupt hearing abilities and is usually:
 Congenital or Inherited
 Occur after drug therapy
 Infection such as meningitis or rubella
 Exposure to loud sound
Slight hearing impairment can be caused by:
 Inflating automobile airbags during accident
 Acute Otitis Media
 Ruptured Tympanic Membrane
Slight Hearing Impairment (<30 dB)

 Unable to hear whispered words or faint speech.

Mild Hearing Impairment (30-50 dB)

 Beginning speech impairment may be present

Moderate Hearing Impairment (55-70 dB)

 Speech impairment is present and may require therapy.

Severe Hearing Impairment (70-90 dB)

 Difficulty with any sounds but nearby loud voices

Profound Hearing Impairment (>90dB)

 Hears almost no sound.

OTITIS MEDIA

It is an infection of the middle ear caused by a bacteria or virus.

It is most common in infants and toddlers during winter months.

Eustachian Tube is a small passageway that connects the throat and middle ear.
An inflammation of the tube accumulates secretion in the middle ear and negative air
pressure due to lack of ventilation.
The inflammation results to otitis media with effusion or an abnormal collection of fluid
in cavities of the tissue.
The illness is followed by:
 Upper Respiratory Infection or Cold
 Purulent discharge from the affected ear
In older childre006E
 Fever
 Irritable
 Severe earache
In neonates
 Afebrile or having no fever
 Appear lethargic
Myringotomy is a surgical procedure which inserts tubes through the tympanic
membrane to equalize the pressure inside the ear.
The tubes remain in place until they fall out spontaneously.
There is a high risk for children exposed to passive tobacco smoke and decreased
incidence in breast-fed infants.
Symptoms in Children
 Ear pain when lying down
 Trouble sleeping
 Crying more than usual
 Trouble responding to sound
 Loss of balance
 Fever
 Headache
 Loss of appetite
Symptoms in Adults
 Ear pain
 Fluid from ear
 Trouble hearing
Risk Factors
 Age: children between the ages 6 months to 2 years are more susceptible to ear
infections because their ears are still developing.
  Group Child Care: they are more likely to get colds and ear infection than
children at home because they are exposed to more infections such as cold.
 Infant Feeding: babies who are bottle-fed, especially while lying down are
susceptible to ear infection than babies who are breast-fed.
 Seasonal Feeding: During season of fall and winter increases risk of having ear
infection, especially with seasonal allergies.
 Poor Air Quality: Exposure to tobacco smoke and high levels of pollution
increases risk of ear infections.
 Alaska Native Heritage: Ear infection are common among the people because of
the weather.
 Cleft Palate: Bone and Muscle Abnormalities make it difficult for the Eustachian
tube to drain.
Complications
 Impaired Hearing
 Speech or Developmental Delays
 Spread of Infection
 Tearing of the Eardrum
Prevention
 Prevent common colds and other illnesses
 Avoid second-hand smoking
 Breast-feed the baby
 If bottle feeding, hold the baby in a upright position
 Vaccination
Diagnosis
Diagnosis are based on the symptoms described and results after the exam.
An otoscope is used to look at the ears, throat and nasal passage.
A stethoscope is used to detect obstruction in breathing.
Pneumatic Otoscope
It is used for ear infection diagnosis.
The instrument enables determination of the mobility of a patient's tympanic membrane
(TM) in response to pressure.
Using the instrument, the doctor gently puffs air against the ear drum.
If the middle ear is filled with fluid, the doctor will observe little to no movement of the
eardrum.
 Additional test may be considered such as:
 Tympanometry is a test that measures the movement of the eardrum as it seals
off the ear canal and adjusts the air pressure to make it move.
 Acoustic Reflectometry is a test to measure how much sound is reflected back
from the eardrum or Tympanic Membrane.
o The more pressure there is from fluid in the middle ear, the more sound
the eardrum will reflect.
 Tympanocentesis pierces the eardrum to drain fluid from the middle ear for
bacteria and virus detection.
Nursing Care Plan
The goal for otitis media is to:
 Relieve Pain,
 Improve hearing and communication,
 Avoidance of re-infection
 Increased knowledge about condition and management
Nursing Diagnosis

 Acute Pain related to inflammation and increased pressure in the middle ear
Possibly evidenced by

 Child verbalizes “my ear hurts”

 Crying episodes
 Infant is pulling at ear
 Rate pain on an appropriate pain scale for age and development
Desired Outcomes

 Child will experience relief from pain as evidenced by sleeping through the
night, not pulling the ear and decrease crying episodes.

Nursing Interventions Rationale

Pain scale measures the changes in the

Assess client’s description and frequency of level of pain by different providers. 
pain; Use a pain rating scale. Observe if the Preverbal infants vigorously pull or rub the
infant is tugging or rubbing an ear. affected ear, roll the head and appear
irritable.

Monitor and record vital signs closely. A normal response to pain is an increase in
 respiratory rate, heart rate,
and blood pressure; fever may cause
discomfort.

Encourage and assist the parent to hold and Promotes physical comfort and distraction
comfort the client. for a child experiencing illness.

Movement of the eustachian tube, such as

Encourage the mother to provide and offer
with chewing, may further aggravate the
liquid to soft foods.
pain.

Administer pain medication such as Analgesic such as acetaminophen and

acetaminophen or ibuprofen as prescribed. ibuprofen alter response to pain.

Provides information about the effectiveness

Monitor child for relief of pain and any side
of the medication and prevents untoward
effects of medication.
effects.

Have the child sit up, put pillows behind Elevation promotes drainage and reduces
the head, or lie on the unaffected ear. pressure from fluid.

Reassure parents that the discomfort

Parents may be concerned about their child’s
usually subsides within a day
pain but may not know to continue the
on antibiotics but reinstruct the importance of
antibiotic after symptoms subside.
compliance with the whole prescription.

Instruct the use of a warm heating pad or

Heat promotes vasodilation thus reduces
an ice pack application. Advise parents to
discomfort; Cold compress may decrease
turn the heating pad on low and cover it
edema and pain.
with a towel to ensure safety.

Otitis Media with Effusion (OME)

It is the collection non-infected fluid in the middle ear.
It can be referred to as Serous Otitis Media
The fluid accumulates in the middle ear as a result of common colds and sore throat.
The fluid in the ear resolves itself within 4-6 weeks.
In some cases, the fluid may be present longer than expected which causes a temporary
decrease in hearing.
Also in some cases, the longer presence of fluid may cause infection as it is referred to
as Acute Otitis Media.
Children within 6 months and 3 years old have higher risk of developing OME and it is
more common in boys.
OME is a result of poor function of the Eustachian Tube, the canal between the middle
ear and throat.
The tube ventilates the middle ear and maintains equalized pressure on both sides of
the eardrums.
Some reasons the Eustachian tube may not work properly include:

 An immature Eustachian tube, which is common in young children

 An inflammation of the adenoids
 A cold or allergy, which can lead to swelling and congestion of the lining of the
nose, throat and Eustachian tube as the swelling prevents the normal flow of air
and fluids)
 A malformation of the Eustachian tube
Risk of developing OME
 Having a cold
 Spending time in a day care setting
 Being bottle-fed while lying on the back
 Being around someone who smokes
 Absence of breastfeeding
 History of ear infections
 Craniofacial abnormalities such as cleft palate
Signs and Symptoms
 Hearing Difficulties
 Tugging at one or both ears
 Loss of balance
 Delayed Speech Development
Testing and Diagnosis
The physician will inspect the patient’s medical history and conduct a physical
examination which includes inspection of the outer ear and eardrums.
Same with the Otitis Media
Treatment
Treatment for OME depends on many factors and is tailored for each child.
Myringotomy or Ear Tubes involves making a small opening in the eardrum to drain
the fluid and relieve the pressure from the middle ear.
The removal of adenoids is also recommended if infected.
Adenoids are part of the immune system and help protect the body from viruses and
bacteria.
Outcome
Most will recover and have no long-term effects of the disorder.
If the patient underwent adenoid surgery, ongoing monitoring is needed to ensure
proper recovery.
In some cases, it can lead to long-term issues such as:
 Recurrent acute otitis media (AOM)
 Problems with speech and language development
 Structural changes to tympanic membrane
 Permanent hearing loss.
Impacted Cerumen
Earwax builds up in the ear and blocks the ear canal; it can cause temporary hearing
loss and ear pain.
Earwax cleanses the external ear as it gradually moves outward.
Wax accumulation rarely is extensive enough in children that it interferes with hearing
and removing it can diminish its protective function, so it should not be removed
routinely.
Cotton swabbing may scratch the ear that could cause secondary infection and push
accumulated cerumen farther into the ear canal, resulting in plugging of wax.
Commercial softeners are available if cerumen accumulates to such an extent that
hearing is affected.
A dilute solution of hydrogen peroxide may be necessary to dissolve cerumen.
Aforementioned should not be done regularly as it keep the ear canal constantly moist
and result to external otitis.