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Providing Care to Children (and their families)

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Bonnie Cooley

on 3 June 2016

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Transcript of Providing Care to Children (and their families)

Providing Care to Children (and their families) part 1
HEENT
Otitis media (ear infection)
Caused by blocked eustachian tube
common complication of acute respiratory infection
eustachian tubes in children are shorter, wider and straighter, which makes them more prone to otitis media
Avoid by breastfeeding at least first 6 months of age, avoid exposure to allergens, feed in upright position to encourage drainage
Symptoms: fever, ear pain, crying, irritability, lethargy, pulling or rubbing ear
Medical interventions: Antibiotics (if symptomatic or young)
Nursing interventions: encourage fluid intake, avoid chewing
reinforce to parents to use analgesics such as tylenol or ibuprofen as recommended or antibiotics

tonsillitis/tonsillectomy
tonsillitis=inflammation and infection of tonsils (lymphoid tissue in the pharynx)
adenoiditis=inflammation of the adenoids (pharyngeal tonsils) located on the posterior wall of the nasopharynx
Persistent/recurrent sore throat may need tonsillectomy
S/S: difficulty swallowing, mouth breathing, fever, enlarged tonsils, enlarged adenoids may cause a nasal quality of speech, snoring, mouth breathing, OSA
Post op: monitor for bleeding and clotting studies. Patient should be prepared for sore throat. have suction available (but do not use unless obstructed), position side lying, discourage coughing, clearing of the throat or nose blowing. Provide ice collar or analgesics (rectally or IV), Avoid red/purple or brown liquids. Avoid milk products such as milk, ice cream and pudding initially. Try soft foods 1-2 days postop. Do not give straws, forks or sharp objects that may be put in mouth. Keep away from crowds until healing occurs. May expect mouth odor, slight ear pain and low grade fever for a few days. Child may return to normal activities 1 to 2 weeks postop

Metabolic/GI
Fever: Children may run fevers more often than adults
Cause for concern:
if < 3 months and temp > 100.5
if 3-6 months and temp with excessive irritability, lethargy
or
temp > 102
if >6 months and a temp >102 lasting longer than a day and no other symptoms
newborn and temp < 97
Measures to decrease temp:
DO NOT use alcohol or cool baths (promotes chilling, which drives temp up)
Cool the room temperature, remove blankets/heavy clothing
Reinforce difference in antipyretic dosing (infant drops vs childrens)
Renal:
Glomerular nephritis

Injury to the glomerulus--destruction, inflammation, and sclerosis of kidneys occur
antigen-antibody reaction produced by an infection elsewhere in the body
loss of kidney function
Signs/symptoms: periorbital and facial edema (more prominent in the morning)
anorexia
decreased urinary output
cloudy or brown urine (hematuria)
pallor, irritability, lethargy
headaches, flank pain or abdominal pain
dysuria
hypertension
Increased BUN and creatinine
Pediatric Nursing
The miracle is not that we do this work, but that we are happy to do it.

Mother Teresa
Why vaccinate?
Over 35,000 cases of polio reported in the 40's and 50's in the US
Salk invented IPV (inactivated poliovirus vaccine) in 1955
The last case of polio in the US was in 1979.
Polio still affects children (and adults) in Afghanistan and some parts of Africa
http://www.cdc.gov/vaccines
http://www.aapredbook.org
Grant, a 6 month old infant is brought in to the clinic. He has not been seen since his 2 month check up. His parents want to know if he has to start all his immunizations all over again. What do you tell her?
a. Yes
b. No
The nurse teaches parents that absolute contraindications for pediatric immunizations would include which of the following:
a. Anaphylactic reaction to previous immunization
b. Soreness, redness and swelling at the previous injection site
c. Respiratory illness with low-grade fever
d. Febrile seizure 1 month after the previous injection of vaccine
A 6 year old child is to receive regularly scheduled immunizations. The parent states the child is not feeling well and asks the nurse to defer the immunizations until next week. The nurse's best response is which of the following:
a. Give the parent an immunization appointment for next week
b. Ask if the child has missed school
c. Ask if the child has ever had a reaction to immunizations
d. Check the child's temperature
A 10 year old child has just received his first immunization of influenza vaccine. His lips begin to swell, and he states, "It feels like my throat is closing shut and my chest is tight when I breathe." The nurse recognizes these as signs of which of the following:
a. An anxiety reaction due to receiving an injection
b. A local allergic reaction to the influenza vaccine injection
c. A common systemic allergic reaction to immunization
d. A life-threatening reaction to the influenza vaccine
What would you do if.....
A parent brings his 13 month old son in with fever of 101, flushed cheeks, irritability, and anorexia. He is diagnosed with otitis media. The parent says "We missed our 12 month appointment, I'd like to go ahead and get my son's 12 month shots now"
What would you do if........
You are preparing to give immunizations to a 5 year old and the mother tells the child, "These don't hurt at all--be a big boy."
2 weeks--1 month:
Alerts to sound
Fixes on caretakers' face
Moves all extremities well
Lifts chin up when lying prone
2 months:
Alerts to sound, has social smile
Follows 180 degrees horizontally, lifts chin and chest off table in prone position, head is steady with supported sitting, unfisted 50% of the time
4 months:
Turns to voice, coos and is beginning to laugh
up on wrist in prone position, rolls prone to supine
Good head control
Brings hand to midline
Bats at objects
Excited upon seeing food
6 months:
Turns well to voice and sounds
Babbles
Rolls supine to prone and sits with support
unilateral reach, grab and transfer
Prefers mother or primary caregiver
12 months:
Follows one step commands with gesture and plays gesture games (waves bye-bye)
Uses mama, dada and 1-2 other words specifically
crawls, pulls to stand and cruises on furniture
Mature pincher, directed pointer, throws and releases
Uses cup, finger foods, helps with dressing, shy with strangers
18 months
Points to body parts, follows comands with gesture, uses 7-10 words or jargon
Walks well, stoops and recovers and runs
Turns pages without ripping, scribbles spontaneously
Uses spoon and fork
Takes off shoes and socks
24 months:
Uses 2-3 sentences. Has 50 word vocabulary (50% intelligible to strangers)
Runs well, walks up and down stairs
Turns pages, interested in crayons and markers
Parallel play
Removes shoes and pants
36 months:
Uses pronouns, prepositions and plurals
Has a 250 word vocabulary (50% intelligible to strangers)
Alternates feet going up stairs, stands on one foot and pedals tricycle
Tripod pencil grasp, copies a circle and draws a person
Shares toys some, Symbolic play
4 years:
Alternates feet on stairs
Hops, jumps forward
Can cut, paste
Dresses with help
Knows name, sex and gender
5 years:
Walks on tiptoe
Knows five colors
Copies triangle
Dresses and undresses alone
Displays sexual curiosity
Separates from mother easily
6 years:
Ties shoelaces
Knows left from right
Does well in school
Prints first name
Draws 6-part man
Imitates
Defines words
7-11 years:
Has friends
Does well in school
Sense of achievement
Sexual development starts
Tells time
Reads for fun
Sense of humor
12-17 years:
Sexual development
Self care
Decisions for future
18-21 year olds:
Sexual maturity
Parental independence
college or occupation
intimacy vs isolation
What would you do.....
A 12 month old child presents with his parents and is diagnosed with a strep throat. The child has not been to this clinic before. The child is unable to sit without assistance.
Safety:
Car seat/booster until age 8
rear facing until 2 years of age or until they reach the height/age requirement on the safety seat
Back seat or if no back seat, then front seat without airbag
Booster acceptable if 4--8 years as long as weight/height limits are not exceeded
How is caring for a child different than caring for an adult?
What techniques will you use?
What would you do if..........
You receive orders for your 4 year old patient who was admitted after having an emergency appendectomy. You receive the following post op orders:
VS: per post op routine
Diet: Clear liquids, advance as tolerated
IV: NS @ 150 ml/hr
Call for Temp > 100.5, BP < 80/50, P < 90
Dr. McStuffins



Scale: Daily maintenance fluid needs
Weight Fluid needs per 24 hours
Newborn (0-72 hours) 60-100 ml/kg
0-10 kg (0-22 lbs) 100 ml/kg
11-20 kg (24-44 lbs) 1000 ml plus 50 ml/kg>10 kg
>20 kg (>44 lbs) 1500 ml plus 20 ml/kg >20 kg

Pain in Children
Children may not be able to tell you
Look for other behaviors:
change in expression
change in play (or not playing)
irritability
lethargic
not interested in eating
Sometimes location of pain isn't
clear
What would you do if........

You note small round well-healed scars on the back and abdomen of a six year old being seen for the first time in the clinic. There is little interaction between the child and parent. The child does not flinch or cry when immunizations are given.
Possible indications of physical abuse:
Unexplained bruises, burns or fractures
Bald spots on the scalp
Apprehensive child
Extreme aggression or withdrawal
Fear of parents
Lack of crying (older infant, toddler, or young preschool child) when approached by stranger
Spinal fractures without history of trauma from a sports injury
Possible indications of Neglect:
Inadequate weight gain
Poor hygiene
Consistent hunger
Inconsistent school attendance
Constant fatigue
Reports lack of child supervision
Delinquency
Possible indications of emotional abuse:
Speech disorders
Habit disorders such as sucking, biting and rocking
psychoneurotic reactions (hysteria, phobias, anxiety)
learning disorders
suicide attempts

Possible indications of sexual abuse:
Difficulty walking or sitting
Torn, stained or bloody underclothing
Pain, swelling or itching of genitals
Bruises, bleeding or lacerations in genital or anal area
Unwillingness to change clothes or unwillingness to participate in gym activities
Poor peer relations
What would you do if...........
A 3 month old is brought in to the clinic because of irritability, high-pitched cry, tremors of his left hand, and lethargy. He has no interest in eating. He is afebrile. Mother reports he was fine yesterday when she left for work. This morning when she woke up, she noted these changes.
What questions do you ask?
Eczema/Contact Dermatitis
Itchy, scaling, papules/vesicles
commonly found in antecub and popliteal areas
Goals: relieve itching, hydrate, and prevent infection

Impetigo:
Caused by staph/strep
VERY CONTAGIOUS
May start with another lesion which gets infected
Treatment: topical and/or oral antibiotic
separate bed linens/towels/dishes
Scabies:
Female burrows into the epidermis, lays eggs the eggs hatch in 3-4 days
Infectious the entire time
Treatment includes topical application of a scabicide (elimite) kills the mites
All clothing, bedding and pillowcases must be changed daily (washed in HOT water or sealed in plastic bag for 4 days
LICE (pediculosis capitis)
transmitted by direct/indirect contact including sharing of brushes, hats/towels/linens
louse lays eggs close to scalp (nits)
Inspect all contacts of infected child
Pediculicide--follow directions on box
Use fine tooth comb for treatment daily, wear gloves
discard hairbrushes or soak in boiling water for 10 minutes
For 1 week after treatment, change linen daily and wash in hot water, dry in HOT dryer for 20 minutes
Vacuum furniture and carpets frequently throwing out the vacuum bag

The school nurse prepares a list of home care instructions for the parents of school children who have been diagnosed with pediculosis capitis (head lice). Which should be included in the list:
a. Use anti-lice sprays on all bedding and furniture
b. Use a pediculicide shampoo and repeat treatment in 14 days
c. Launder all the bedding and clothing in cold water and dry on low heat
d. Vacuum floors, play areas, and furniture to remove any hairs that may carry live nits
A mother of a 3 year old child tells the nurse that the child has been continuously scratching the skin and has developed a rash. On data collection, which finding indicates that the child may have scabies:
a. Fine, grayish-red lines
b. Purple colored lesions
c. Thick, honey colored crusts
d. Clusters of fluid filled sacks
Tinea (capitis, corporis, pedis, cruris)[ringworm]
Fungal infections, usually treated topically
Red, may be itchy
Spread by touching infected person, damp showers, pets, etc.

Imagine......
You are 6 years old. You've been admitted to the hospital after a tonsillectomy. You're having significant pain from the surgical site. Your mother is staying with you in the hospital. Your roommate is a 1 year old with a "bad cold."
You don't want to express your pain because the nurse will make you swallow yucky medicine. The nurse tells your mom, with you listening that you can't go home until you drink and pee. You don't like strange potties. It hurts to drink.
Now it's getting dark and you're afraid. Your mom has gone to the bathroom. The IV pump at your bedside starts to beep. People are talking in the hall but you're lonely. You want to go home. You feel a tear fall down your cheek. You wipe it away and the IV band on your hand scratches you.
The nurse comes in and says hi, smiles and turns on the bright lights. He's holding a drink, a thermometer, and a computer. You can tell he means business. Your mom isn't back yet and you're really scared.
Myringotomy:
Surgical incision into the TM to provide drainage usually with insertion of tympanoplasty tubes to equalize pressure and allow continued drainage
Make sure parents and child know ears must be kept dry (earplugs while bathing, shampooing and swimming--no diving or submerging underwater)
No nose blowing for 7-10 days after surgery
Tubes will fall out on their own (or may need to be removed after 2-3 years)
Epistaxis
Highly vascular
bleeding usually results from direct trauma, foreign bodies, nose picking and inflammation
Recurrent epistaxis may indicate underlying disease
Remain calm, keep the child calm and quiet
Have child sit up and lean forward
Apply continuous pressure to the nose with the thumb and forefinger for at least 10 minutes
Insert cotton or wadded tissue into each nostril and apply or a cold cloth to the bridge of the nose if bleeding persists

Vomiting
Risk of dehydration, metabolic alkalosis
Causes: infectious diseases, increased intracranial pressure, toxic ingestion, food intolerance, mechanical obstruction, metabolic disorders and psychogenic disorders
Diarrhea:
Cause of dehydration
Causes: infectious disorders, antibiotic therapy, parasitic infections
Chronic diarrhea causes: rotavirus, malabsorption, inflammatory bowel disease, immune deficiencies, food intolerances
Croup:
May be viral or bacterial (
parainfluenza viruses, RSV, Mycoplasma pneumoniae, and influenza
)
Most commonly occurs in children < 5
May be preceeded by URI

Bronchitis
Inflammation of the trachea and bronchi
Usually preceeded by URI
Usually viral (rhinivirus, parainfluenza, adenovirus and RSV) May also be caused by mycoplasma pneumoniae
Usually occurs in winter
Signs/symptoms: dry, hacking cough worse at night becomes productivein 2-3 days

RSV
Inflammation of bronchioles causing a thick production of mucus and occludes bronchioles and small bronchi
Highly communicable and transferred by direct contact with respiratory secretions
Occurs primarily in winter and spring, usually in children under 2 years (peaks at 6 months)
Diagnostic: Nasal swab-
Asthma
episodes of wheezing, dyspnea, chest tightness, cough (esp morning or night), mucus plugging
May start as irritability, restlessness, headache, feeling tired, chest tightness
Hacking, nonproductive cough
The cough may become rattling when secretions accumulate
Breath sounds may be coarse with crackles, coarse rhonchi and inspiratory and expiratory wheezing with prolonged expiration
Children may sit in upright hunched over position to facilitate the use of accessory muscles (child won't lie down)
Cystic Fibrosis
Autosomal recessive trait affects multiple systems--affects exocrine glands
Respiratory/GI/Reproductive systems blocked by abnormally thick/copious secretions causing obstruction of small passageways

SIDS
Cardiac Defects:
Rheumatic Fever
Enuresis:
Cryptochordism
Duchenne's Muscular Dystrophyn
Neural Tube Defects
Hydrocephalus
Reye's Syndrome
Hemophilia
von Willibrand's Disease
ADHD
Autism
Intellectual Disability
Eating Disorders
Communicable Diseases:
Chicken Pox (varicella)
Pertussis
Rocky Mountain Spotted Fever
Fifths Disease
Influenza
unexpected death of an apparently healthy child < 1 year of age
> in winter months
> during sleep periods, not nec at night
most frequently in 2-3 month old infants
> in male infants
> in Native Americans, African Americans, Hispanics, lower socioeconomic infants
< in breast fed infants and infants who use pacifiers
at risk: infants with soft bedding or sleep in non-infant bedding, overheating, co-sleeping, mother who smoked cigarettes or used drugs during pregnancy, and infants exposed to cigarette smoke after birth
inflammatory autoimmune disease affecting connective tissue of heart, joints, skin, blood vessels and central nervous system
Most serious complication is rheumatic heart disease which affects heart valves
occurs 2-6 weeks after an untreated or partially treated streptococal infection of the URI

Unable to control urination/bladder function, even after reaching an age the child should have function (by 5)
primary/secondary
assess for UTI
limit fluid intake in evening hours
void just before bed
involve child in changing bed sheets
provide rewards when dry
meds: tricyclic antidepressants, antidiuretics, antispasmodics
1 or both testes don't descend through the inguinal canal into the scrotom (may descend by 3 months of life)
Early referral (before 6 months of age)
Should be corrected by 1 year (sperm making ability begins as early as 12 months of age
fertility affected
risk of testicular cancer affected

Onset between 2-4 years of age
Child starts getting "clumsy"
life expectancy around 20 years
No cure, supportive care

Spina bifida (cystica)
meningocele (protrusion of meninges and saclike cyst containing CSF) No spinal cord involvement. Neurologic deficits not usually present
myelomeningocele (protrusion of meninges, CSF, nerve roots and portion of the spinal cord) The sac is prone to rupture. Neurologic deficits present
An imbalance between CSF absorption and production caused by tumors, hemorrhage, infections, trauma
Results in head enlargement (if prior to suture closing) and increased ICP

an acute encephalopathy that follows a viral illness (influenza/varicella) usually 4-7 days prior
Cerebral edema and fatty liver
Signs/Symptoms: malaise, nausea, vomiting, altered liver functioning (progressive lethargy), progressive neurologic deterioration.
Provide rest, decrease stimulation. Monitor for altered mental status, increased ICP, altered hepatic function, impaired coagulation/prolonged bleeding time
Bleeding disorder from a deficiency of specific coagulation proteins
Hemophilia A (classic hemophilia)=deficiency of factor VIII
Hemophilia B (Christmas disease)=deficiency of factor IX
Treatment is replacement of the missing clotting factor
Transmitted ban X-linked recessive disorder (may also occur as a gene mutation)
Carrier females pass on defect to affected males, female offspring rarely born with the disorder
Bruise easily, joint bleeding that causes pain/tenderness. Immobilize joint if pain occurs
Monitor neurologic status
May be treated with DDAVP (vasopressin) increases plasma factor VIII
Avoid contact sports
Use protective devices when participating in sports such as bicycling, etc.
Bleeding disorder, deficiency of a protein called von Willebrand's factor (vWF)
Causes platelets to adhere to damaged endothelium--increased tendency to bleed from mucous membranes
Signs/symptoms: epistaxis, gum bleeding, easy bruising, excessive menstrual bleeding
von Willebrand's factor also carries factor VIII, so may have deficiency of it as well
Treatment includes administration of clotting factors
Inappropriate degrees of inattention, overactivity, impulsivity
Signs/symptoms: fidgets with hands/feet or squirms in seat, easily distracted by external stimuli, poor attention span, difficulty following directions, talks excessively, shifts from one uncompleted activity to another, interrupts others
Treatment: behavioral therapy, medication, maintaining a consistent environment, appropriate classroom placement
Behavioral therapy focuses on preventing undesirable behaviors
Promote self esteem
Stimulant medications may be prescribed with effects including weight loss, nervousness, insomnia, tics, increased blood pressure
Autism
Complex neurodevelopmental disorders of unknown etiology composed of qualitative alterations in social interaction and verbal impairment with repetitive, restricted and stereotype behavioral patterns
Subaverage intellectual functioning along with deficits in adaptive skills
(Down's syndrome)
Signs/symptoms: delays in fine and gross motor skills, speech delays, decreased spontaneous activity, nonresponsiveness, irritabililty, poor eye contact during feeding
Interventions: promote functioning, refer to community and educational services, safety precautions
anorexia nervosa: fear of gaining weight, distorted body image. Obessive behaviors regarding food to maintain control. May over-exercise, starve, purge after eating
bulimia nervosa: binge eating, maybe followed by purging. Feel guilt after binging. Usually normal weight individual.
Binge-eating: compulsive overeating without purging or compensating
*purging may be induced vomiting, laxatives, diuretics, enemas
Increased pulmonary flow
Decreased pulmonary flow
Obstruction to systemic flow
Mixed

Heart failure:
Left sided:
crackles/wheezes
cough/dyspnea
grunting (infants)
nasal flaring
orthopnea
periods of cyanosis
retractions
tachypnea
Right sided:
ascites
hepatosplenomegaly
oliguria
peripheral edema, especially dependent edema and periorbital edema
weight gain
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