NURSING CARE OF HIGH RISK

INFANT
NURSING CARE OF HIGH RISK
INFANT
ACUTE OTITIS MEDIA
MENINGITIS
FEBRILE SEIZURES
ACUTE OTITIS MEDIA
 ACUTE OTITIS MEDIA
• is a painful type of ear infection. It occurs when the area behind
the eardrum called the middle ear becomes inflamed and infected
Symptoms:
• Crying and irritability
• sleeplessness
• pulling on the ears and ear pain
• Headache and neck pain
• a feeling of fullness in the ear
• fluid drainage from the ear
• fever
• Vomiting and diarrhea
• lack of balance
• hearing loss
 ACUTE OTITIS MEDIA
What causes acute otitis media?
• -The eustachian tube is the tube that runs from the middle of the ear
to the back of the throat. An AOM occurs when the child’s eustachian
tube becomes swollen or blocked and traps fluid in the middle ear. The
trapped fluid can become infected. In young children, the eustachian
tube is shorter and more horizontal than it is in older children and
adults. This makes it more likely to become infected.
The eustachian tube can become swollen or blocked for several reasons:
• Allergies and a colds, flu
• sinus infection
• infected or enlarged adenoids
• cigarette smoke
• drinking while laying down (in infants)
 ACUTE OTITIS MEDIA
Risk factors for AOM include:
• being between 6 and 36 months old
• using a pacifier and being bottle fed instead of breastfed
(in infants)
• drinking while laying down (in infants)
• being exposed to cigarette smoke and being exposed to
high levels of air pollution
• experiencing changes in altitude and changes in climate,
being in a cold climate
• having had a recent cold, flu, sinus, or ear infection
 ACUTE OTITIS MEDIA
How is acute otitis media diagnosed?
1. Otoscope-the child’s doctor uses an instrument called an otoscope to look
into the child’s ear and detect:
• Redness, swelling, blood or pus
• air bubbles, fluid in the middle ear
• perforation of the eardrum
2. Tympanometry-During a tympanometry test, doctor uses a small
instrument to measure the air pressure in the child’s ear and determine if the
eardrum is ruptured.
3. Reflectometry-During a reflectometry test, the doctor uses a small
instrument that makes a sound near the child’s ear. The doctor can determine
if there’s fluid in the ear by listening to the sound reflected back from the ear.
4. Hearing test- doctor may perform a hearing test to determine if the child is
experiencing hearing loss.
 ACUTE OTITIS MEDIA
Treatments for AOM:
1. Home care- the doctor may suggest the following home care treatments to relieve the
child’s pain while waiting for the AOM infection to go away:
• applying a warm, moist washcloth over the infected ear
• using over-the-counter (OTC) ear drops for pain relief
• taking OTC pain relievers such as ibuprofen (Advil, Motrin) and acetaminophen
(Tylenol)
2. Medication- the doctor may also prescribe eardrops for pain relief and other pain
relievers. the doctor may prescribe antibiotics if the symptoms don’t go away after a few
days of home treatment.
3. Surgery- the doctor may recommend surgery if the child’s infection doesn’t respond to
treatment or if your child has recurrent ear infections. Surgery options for AOM include:
Adenoid removal- the doctor may recommend that the child’s adenoids be surgically
removed if they’re enlarged or infected and the child has
recurrent ear infections.
Ear tubes- the doctor may suggest a surgical procedure to insert tiny tubes in the child’s
ear. The tubes allow air and fluid to drain from the middle ear.
 MENINGITIS
• Meningitis is an infection
and inflammation of the
fluid and three membranes
(meninges) protecting the
brain and spinal cord. The
tough outer membrane is
called the dura mater, and
the delicate inner layer is
the pia mater.
 TYPES
1. Viral meningitis – cause by virus , most
common type
2. Bacterial meningitis- serious type
3. Fungal meningitis- can develop after fungal
infection spreads from the body to the brain
of spinal cord
4. Parasitic meningitis-
 MENINGITIS
• Bacterial meningitis is serious and can cause
death within days without prompt antibiotic
treatment. Delayed treatment also increases
the risk of permanent brain damage.
• Viral infections are the most common cause of
meningitis. That's followed by bacterial
infections and, rarely, fungal and parasitic
infections. Because bacterial infections can
lead to death, learning the cause is essential.
 MENINGITIS
Bacterial meningitis
• Bacteria that enter the bloodstream and travel
to the brain and spinal cord cause bacterial
meningitis. But bacterial meningitis also can
occur when bacteria directly invade the
meninges. This may be caused by an ear or
sinus infection, and skull fracture
 Meningitis
Signs in newborns
Newborns and infants may show these
signs:
• High fever.
• Constant crying.
• Being very sleepy or irritable.
• Trouble waking from sleep.
• Being inactive or sluggish.
• Not waking to eat.
• Poor feeding.
• Vomiting.
• A bulge in the soft spot on top of the
baby's head.
• Stiffness in the body and neck.
 PATHOPHYSIOLOGY
Invasion of microorganisms- usually upper respiratory tract infection
↓
Bacterial invasion leads to a rapidly increased blood supply to the
meninges with massive neutrophil migration.
↓
The neutrophils then engulf the bacteria and disintegrate. Exudate
from tissue destruction contributes to purulent material.
↓
The purulent material causes the meninges to become inflamed and
increases ICP.
↓
Excessive release of Anti Diuretic Hormone. ADH acts by inhibiting
urination. This in turn leads to water retention, oliguria ,
hypervolemia ,hyponatremia and further increase in ICP.
 MENINGITIS
CLINICAL MANIFESTATION
 Fever
 Neck stiffness- Nuchal rigidity
 Thigh flexion upon flexion of the neck (Brudzinski’s sign)
 Resistance to the passive extension of the knee with the hip
flexed (Kernig’s sign)
 Vomiting, photophobia may be seen
 Petechial rashes
 Acute confusion
 Seizures and cranial nerve palsy
 Coma in severe cases
 MENINGITIS
DIAGNOSTIC EVALUATION
• History Collection
• Physical Examination
• Blood culture
• Analysis of CSF
• CBC, electrolyte levels, RBS
• CT scan, MRI, PET scan
• Skull x-ray
• X- rays of the skull may demonstrate infected sinuses.
 MENINGITIS
COMPLICATIONS
• Hearing loss
• Memory difficulty
• Learning disabilities
• Brain damage
• Gait problems
• Seizures
• Kidney failure
• Shock
• Death
 MENINGITIS
MANAGEMENT
I. MEDICAL MANAGEMENT
A. PHARMACOLOGICAL MANAGEMENT
• Antibiotics- ampicillin, penicillin, amoxycillin
• Antiviral- tenofovir
• Antifungal- fluconazole
• Corticosteroid- dexamethasone
• IV mannitol for diuresis
• IV phenytoin
• Antipyretics- Acetaminophen
 MENINGITIS
B. NON PHARMACOLOGICAL MANAGEMENT
 Maintenance of fluid-electrolyte balance by IV fluid therapy
 Nasogastric tube feeding
 Vitamin supplementation
 Head end elevation 30- 45 degree
 Emotional support and necessary information for
continuation of care at home, follow-up and rehabilitation.
SURGICAL MANAGEMENT
• Cochlear implantation rehabilitation due to deafness
 MENINGITIS
NURSING MANAGEMENT
ASSESSMENT
 Obtain a history of recent infections such as upper
respiratory infection, and exposure to causative agents.
 Assess neurologic status and vital signs.
 Evaluate for signs of meningeal irritation.
 Assess sensorineural hearing loss (vision and hearing),
cranial nerve damage (eg, facial nerve palsy), and
diminished cognitive function.
 MENINGITIS
NURSING DIAGNOSIS
• Ineffective Tissue Perfusion (cerebral) related to
infectious process and cerebral edema
• Hyperthermia related to the infectious process and
cerebral edema
• Risk for Imbalanced Fluid Volume related to fever and
decreased intake
• Acute Pain related to meningeal irritation
• Impaired Physical Mobility related to prolonged bed
rest
 MENINGITIS
GOAL
• To Enhanced Cerebral Tissue Perfusion
• To Reduce Fever
• To Maintain Fluid Balance
• To Reduce Pain
• To Return to Optimal Level of Functioning/
mobility
 MENINGITIS
NURSING INTERVENTIONS
 Enhancing Cerebral Perfusion
 Assess LOC, vital signs, and neurologic parameters frequently.
Observe for signs and symptoms of ICP (e.g. decreased LOC, dilated
pupils, widening pulse pressure).
 Maintain a quiet, calm environment to prevent agitation, which may
cause an increased ICP.
 Prepare patient for a lumbar puncture for CSF evaluation, and repeat
spinal tap, if indicated. Lumbar puncture typically precedes
neuroimaging
 Notify the health care provider of signs of deterioration: increasing
temperature, decreasing LOC, seizure activity, or altered respirations.
 I/V mannitol is administered.
 MENINGITIS
 Reducing Fever
 Administer antimicrobial agents on time to maintain optimal
blood levels.
 Monitor temperature frequently or continuously.
 Institute other cooling measures, such as a hypothermia blanket,
as indicated.
 Administer antipyretics as ordered like paracetamol.
 Maintaining Fluid Balance
 Prevent I.V. fluid overload, which may worsen cerebral edema.
 Monitor intake and output closely.
 Monitor Central Venous Pressure frequently.
 Administration of osmotic diuretic- mannitol
 MENINGITIS
 Reducing Pain
 Assess level, intensity, duration & location of pain.
 Darken the room if photophobia is present.
 Assist with position of comfort for neck stiffness, and turn patient slowly
and carefully with head and neck in alignment.
 Elevate the head of the bed to decrease ICP and reduce pain.
 Administer analgesics as ordered; monitor for response and adverse
reactions. Avoid opioids, which may mask a decreasing LOC.
 Promoting Return to Optimal Level of Functioning
 Implement rehabilitation interventions after admission (eg, turning,
positioning).
 Progress from passive to active exercises based on the patient's
neurologic status.
 MENINGITIS
EXPECTED OUTCOMES
• Enhanced Cerebral Tissue Perfusion
• Fluid Balance Maintained
• Reduced Fever
• Reduced Pain
• Return to Optimal Level of Functioning
 MENINGITIS
HEALTH EDUCATION
• Advise close contacts of the patient with meningitis
that prophylactic treatment may be indicated; they
should check with their health care providers or the
local public health department.
• Encourage the patient to follow medication regimen
as directed to fully eradicate the infectious agent.
• Encourage follow-up and prompt attention to
infections in future.
Febrile seizures
 Febrile seizures
• Febrile seizures are common cause of
convulsions in young children.
• They occur in 2 to 4% of children younger
than five years of age ( between 6 months
and 6 years).
• The majority occur between 12 and 18
months of age.
Epilepsy is defined as a brain disorder
characterized by an enduring predisposition
to generate epileptic seizures and by the
neurobiological, cognitive, psychological,
and social consequences of this condition.
 Febrile seizures
Accepted Criteria
• A convulsion associated with an elevated
temperature more than 38 ⁰ C.
• A child younger than 6 years of age.
• No central nervous system infection or
inflammation.
• No acute systemic metabolic abnormality that may
produce convulsions.
• No history of previous afebrile seizure.
 Febrile seizures
Classification
• Generalized seizures.  the aberrant electrical discharge
diffusely involves the entire cortex of both hemispheres
from the onset, and consciousness is usually lost;
generalized seizures result most often from metabolic
disorders and sometimes from genetic disorders.
• Partial seizures. the excess neuronal discharge occurs in
one cerebral cortex, and most often results from structural
abnormalities; revised terminology for partial seizures has
been proposed; in this system, partial seizures are called
focal seizures.
 Febrile seizures
Causes
• Genetic syndromes. A number of genetic syndromes
are known to causes seizures; however, a number of
more common syndromes should be considered in the
patient who presents with seizures and other findings.
• Metabolic disorders. Many different metabolic
disorders can cause seizures, some as a result of a
metabolic disturbance such as hypoglycemia or
acidosis and some as a primary manifestation of the
seizure disorder.
 Febrile seizures
Phases
1.  prodromal phase involves mood or behavior
changes that may precede a seizure by hours or days.
2. aura is a premonition of impending seizure activity
and may be visual, auditory, or gustatory.
3.  ictal stage is characterized by seizure activity,
usually musculoskeletal.
4.  postictal stage is a period of confusion
/somnolence/irritability that occurs after the seizure.
 Febrile seizures
Clinical Manifestations
• Aura. An aura (unusual sensations) precedes seizures
in about 20% of people who have a seizure disorder.
• Short duration. Almost all seizures are relatively brief,
lasting from a few seconds to a few minutes; most
seizures last 1 to 2 minutes.
• Postictal state. When a seizure stops, people may have
a headache, sore muscles, unusual sensations,
confusion, and profound fatigue; these after-effects are
called the postictal state.
 Febrile seizures
• Todd paralysis. In some people, one side of the
body is weak, and the weakness lasts longer than
the seizure (a disorder called Todd paralysis).
• Visual hallucinations. Visual hallucinations
(seeing unformed images) occur if the occipital
lobe is affected.
• Convulsions. A convulsion (jerking and spasms of
muscles throughout the body) occur if large
areas on both sides of the brain are affected.
 Febrile seizures
Medical Management
• Anticonvulsant therapy. The mainstay of
seizure treatment is anticonvulsant
medication; the drug of choice depends on an
accurate diagnosis of the epileptic syndrome,
as a response to specific anticonvulsants
varies among different syndromes.
 Febrile seizures
• Ketogenic diet. The ketogenic diet, which
relies heavily on the use of fat, such as
hydrogenated vegetable oil shortening (e.g.,
Crisco), has a role in the treatment of children
with severe epilepsy; although this diet is
unquestionably effective in some refractory
cases of seizure, a ketogenic diet is difficult to
maintain; less than 10% of patients continue
the diet after a year.
 Febrile seizures
• Activity modification and restrictions. The major
problem for patients with seizures is the
unpredictability of the next seizure; clinicians
should discuss the following types of seizure
precautions with patients who have epileptic
seizures or other spells of sudden-onset seizures:
driving, ascending heights, working with fire or
cooking, using power tools and other dangerous
equipment, taking unsupervised baths, and
swimming.
 Febrile seizures
Assessment and Diagnostic Findings
• Neuroimaging studies. A neuroimaging
study, such as brain magnetic
resonance imaging (MRI) or head
computed tomography (CT) scanning,
may show structural abnormalities that
could be the cause of a seizure.
• Electroencephalography. Interictal
epileptiform discharges or focal
abnormalities on
electroencephalography (EEG)
strengthen the diagnosis of epileptic
seizures and provide some help in
determining the prognosis.
• Video- EEG. Video-EEG monitoring is the criterion
standard for classifying the type of seizure or
syndrome or for diagnosing pseudo seizures; that is,
for establishing a definitive diagnosis of spells with
impairment of consciousness.
• Lumbar puncture. Detects abnormal 
cerebrospinal fluid (CSF) pressure, signs of infections
or bleeding (i.e., subarachnoid, subdural 
hemorrhage) as a cause of seizure activity (rarely
done).
 Febrile seizures
Nursing Assessment
• History. The diagnosis of epileptic seizures is made
by analyzing the patient’s detailed clinical history
and by performing ancillary tests for confirmation;
someone who has observed the patient’s repeated
events is usually the best person to provide an
accurate history; however, the patient also
provides invaluable details about auras,
preservation of consciousness, and postictal states.
 Febrile seizures
• Physical exam. A physical examination helps in
the diagnosis of specific epileptic syndromes
that cause abnormal findings, such as
dermatologic abnormalities (e.g.,
neurocutaneous syndromes such as Sturge-
Weber, tuberous sclerosis, and others); also,
patients who for years have had intractable
generalized tonic-clonic seizures are likely to
have suffered injuries requiring stitches.
 Febrile seizures
Nursing Diagnosis
• Risk for trauma or suffocation related to loss of large or
small muscle coordination.
• Risk for ineffective airway clearance related to
neuromuscular impairment.
• Situational low self-esteem related to stigma associated with
the condition.
• Deficient knowledge related to information
misinterpretation.
• Risk for injury related to weakness, balancing difficulties,
cognitive limitations or altered consciousness.
 Febrile seizures
Nursing Interventions
Prevent trauma/injury. Teach SO to determine and
familiarize warning signs and how to care for patient during
and after seizure attack; avoid using thermometers that can
cause breakage; use tympanic thermometer when necessary
to take temperature; uphold strict bedrest if prodromal signs
or aura experienced; turn head to side and suction airway as
indicated; support head, place on soft area, or assist to floor
if out of bed; do not attempt to restrain; monitor and
document AED drug levels, corresponding side effects, and
frequency of seizure activity.
 Febrile seizures
• Promote airway clearance. Maintain in lying
position, flat surface; turn head to side during
seizure activity; loosen clothing from neck or
chest and abdominal areas; suction as
needed; supervise supplemental oxygen or
bag ventilation as needed postictally.
 Febrile seizures
• Improve self-esteem. Determine individual
situation related to low self-esteem in the
present circumstances; refrain from over
protecting the patient; encourage activities,
providing supervision and monitoring when
indicated; know the attitudes or capabilities of
SO; help an individual realize that his or her
feelings are normal; however, guilt and blame
are not helpful.
 Febrile seizures
• Enforce education about the disease. Review
pathology and prognosis of condition and lifelong
need for treatments as indicated; discuss patient’s
particular trigger factors (flashing lights,
hyperventilation, loud noises,video games, TV
viewing); know and instill the importance of good oral
hygiene and regular dental care; review medication
regimen, necessity of taking drugs as ordered, and not
discontinuing therapy without physician supervision;
include directions for missed dose.