Pediatrics Unit 3

Immunizations teaching

May cause mild fever or soreness and redness at the injection site

Teach parents to calculate appropriate doses of acetaminophen to relieve pain or fever after immunization (only given for pain/fever; don’t give prophylactically bc of potential to decrease immune response)

Haemophilus influenzae Type B

Bacterium that causes infection in various parts of the body

At one time a leading cause of meningitis in young children, and is a significant cause of conjuctivitis, otitis media, and pneumonia

Rotavirus (live attenuated vaccine)

Rota causes severe diarrhea and dehydration

The series is not started if the infant is more than 14 weeks and 6 days

Avoid immunization if a hx of instussusception or severe combined immunodeficiency

Pneumococcal (PCV13 and PPSV23)

Recommended for children younger than 5 to protect against Streptoccus pneumoniae

Vaccine protects children from meningitis, otitis media, pericarditis and other infections

Inactivated poliovirus (IPV)

Replaced the oral poliovirus vaccine in the US-IPV safer because no live virus

Influenza

Children 8 years of age receiving their first immunization need 2 doses at least 4 weeks apart

Caution in those allergic to eggs or egg products

Tetanus, diphetheria, and acellular pertussis (Tdap) - bacteria

All pregnancy adolescents/women should receive a dose during each pregnancy (ideally 27-36 weeks’ gestation)

Human papillomavirus (HPV-Gardasil)

Prevents the most common causes of genital warts and helps prevent cervical, oral, anal, and penile cancers due to HPV

Most common side effect is syncope

Assessment of general history immunizations

Consider the incubation period of disease and the length of time it takes for symptoms to appear from the child was exposed

What immunizations has the child had? Are they up to date?

Coronavirus (COVID-19) disease process

May have severe symptoms resulting in SARS, multiorgan failure, blood clotting, disseminated intravascular coagulation (DIC) and even death, whereas other pts have a very mild form of the disease reulting in a cold or mild flu-like symptoms

Coronavirus (COVID-19) MIS-C diagnostic criteria: multi-system inflammatory syndrome

Less than 21 years of age presenting with fever, laboratory evidence of inflammation, and evidence of severe illness requiring hospitalization with multisystem organ involvement

Erythema infectiosum (Fifth disease) disease process

Agent: human parvovirus B19

Communicablility: Contagious until the rash appears

Precautions: Droplet

Erythema infectiosum (Fifth disease) clinical presentation

Rash distribution: Erythema of the cheeks, giving “slapped cheek” appearance; the rash appears after red cheeks; characterized by a lacy pattern on the trunk and extremeties

Erythema infectiosum (Fifth disease) Nursing interventions

Emergency care: Sickle cell crisis may occur with human parvovirus B19

Place on droplet precautions

Hand, foot, and mouth disease (HFMD) disease process

Incubation period: 3-6 days

Communicability: Virus may be shed for several weeks

Hand, foot, and mouth disease (HFMD) caregiver education

Clean surfaces and toys with soap and water; disinfect with a solution of 1 tbs of bleach to 4 cups of water

Hepatitis A (HAV) disease process

Transmission: fecal-oral route, contaminated food

Hepatitis A (HAV) clinical presentation

Fever, malaise, poor appetite, nausea, jaundice, abdominal pain, dark urine

Hepatitis A (HAV) caregiver education

Strict hand hygiene and sanitize surfaces, appropriate rest and activity, nutritious, well-balanced diet

Hepatitis B (HBV) disease process

Transmission: Blood or blood products, sexual contact

Hepatitis B (HBV) clinical presentation

Children with chronic hepatitis B may be asymptomatic; risk development of hepatocellular carcinoma later in life

Hepatitis B (HBV) nursing interventions

Blood-borne precautions (universal precautions)

Hepatitis B (HBV) caregiver education

Do not share razors or toothbrushes; lifestyle counseling, important to treat and follow-up

Influenza nursing interventions

Acute hospital care: pneumonia is a complication of the flu and may require hospitalization; ear infections, sinus infections, dehydration, myocarditis, pericarditis are other complications; droplet precautions necessary

Influenza caregiver education

Acetaminophen or IBU for fever (no aspirin)

Mononucleosis clinical presentation

Fever, sore throat, malaise, pharyngitis, enlarged posterioir cervical lymph nodes, with symptoms lasting 1-4 weeks; may develop splenomegaly or hepatomegaly

Mononucleosis diagnostic testing

Positive mono spot test, positive Paul-Bunnell heterophile antibody test, increased lymphocytes, greater than 10% atypical lymphocytes

Mononucleosis caregiver education

To prevent injury to spleen, no contact sports for 6-8 weeks, rest, fever management, hydration, nutrition, counseling and emotional support for teens who must be on bedrest

Mumps (parotitis) disease process

Agent: paramyxovirus

Transmission: Contact with oral and nasal secretions (droplet spread)

Mumps (parotitis) clinical presentation

Swelling of the parotid salvary glands in front of the ear, below the ear, and under the jaw; Boys may have painful swelling of testicles; girls may have ovarian involvement with abdominal pain and breast inflammation

Mumps (parotitis) nursing interventions

Emergency care: Complications include meningitis, encephalitis, glomerulonephrititis, permanent deafness, sterility, myocarditis, joint inflammation

Acute care: droplet spread isolation is required

Mumps (parotitis) caregiver education

Acetaminophen or ibuprofen for fever and pain, bland, soft foods, bland liquids; avoid citrus juices; keep well-hydrated, ice packs or warm compresses to the neck, snug underwear and warmth (orchitis)

Respiratory syncytial virus (RSV) bronchiolitis clinical presentation

As disease progresses in infants and young children, there may be respiratory distress with tachypnea, wheezing, retractions, severe coughing, and poor gas exchange

Respiratory syncytial virus (RSV) bronchiolitis nursing interventions

Acute care: hospitalization may be needed for infants with bronchiiolitis and pneumonia, contact isolation with gowns and gloves; mask if close to the face; frequent assessments of respiratory status; cool humidified air at bedside; administer O2 prn, hydration with IVF prn

Respiratory syncytial virus (RSV) bronchiolitis caregiver education

Careful hand hygiene, cool mist humidier, hydration, do not administer OTC cold/cough products to children younger than 4; teach parents signs of respiratory distresss

Roseola clinical presentation

Rash distribution: popular pink or red rash that appears on the day the fever returns to normal

Roseola nursing interventions

Emergency care may be needed for febrile seizures

Rubella (German measles) vaccine

Specifically covered by the R in the MMR

Rubella (German measles) clinical presentation

Rash distribution: Fine red or pink rash that appears on the face first and spreads downward. The rash lasts approximately 3 days and disappears in the same order that it appeared

Rubeola (measles)

Specifically covered by the M in the MMR

Rubeola (measles) disease process

Transmission: Airborne through respiratory droplets or direct contact with respiratory secretions

Rubeola (measles) Nursing interventions

Emergency care: Complications include ear infections, diarrhea, encephalitis, pneumonia, seizures, deafness, mental retardination, and death; airborne isolation required

Rubeola (measles) caregiver education

Manage fever with acetaminophen and IBU, isolation for 5 days after rash appears, encourage hydration, cool mist humidifier, soft, bland foods

Varicella-zoster (chickenpox) caregiver education

Use acetaminophen for fever, isolation

Pertussis (whooping cough) disease process

The disease is most dangerous to young infants

Pertussis (whooping cough) clinical presentation

Catarrhal phase that lasts 1-2 weeks: cold symptoms, including runny nose, mild cough, fever

Paroxysmal phase that lasts 1-6 weeks or longer: Cough ends with crowing or whoop > vomiting and cyanosis

Recovery phase: Cough gradually becomes less severe

Pertussis (whooping cough) caregiver education

Give small amounts of fluid frequently to keep hydrated, teach signs of respiratory distress and dehydration, rest, use cool mist humidifier

Strep throat/scarlet fever disease process

Agent: Group A beta-hemolytic streptococcus; causes Group A Streptococcus (GAS) pharyngitis and may also cause impetigo

Complications of Group A beta-hemolytic strep include rheumatic fever and poststreptococcal glomerulonephritis

Strep throat/scarlet fever clinical presentation

Scarlet fever is strep throat with a fine, red rash that has the texture of sandpaper. Rash is more pronounced in the armpits and gorin, in the creases of the elbows, and behind the knees. After the rash fades, the skin of the fingers and toes may peel. There may be pallow around the mouth and a white tongue with swollen, red papillae (strawberry tongue)

Strep throat/scarlet fever nursing interventions

Complications of untreated strep throat include glomerulonephritis and rheumatoid fever

Strep throat/scarlet fever cargegiver education

Administer PCN or amoxicillin as ordered, hydration, acetaminophen or IBU for fever, replace toothbrush, throat lozenges

Respiratory disorders physical assessment

Chest diameter, anterior-to-posterior diameter

Work of breathing, respiratory effort

Flaring tachypnea, retractions, paradoxical breathing

Optimal chest expansion when positioned supine with head of bed at 45 D

Respiratory disorders position of comfort

Tripod, jaw thrust, or insistence on sitting upright are signs of air deficiency

Respiratory disorders symmetrical chest rise

Asymmetrical may indicate tension pneumothorax

Respiratory disorders nasal flaring-wideing of nares with inspiration

Signs of air hunger

Respiratory Disorders clubbing of fingertips: loss of 160-degree angle of nail bed

May be a sign of chronic hypoxia such as seen in cystic fibrosis and similar chronic respiratory disorders

Respiratory disorders auscultation: crackles (rales)

Fine cracking noises heard on inspiration

Respiratory disorders auscultation: snoring (rhonchi)

Low-pitched sounds heard throughout respiration

Respiratory disorders auscultation: Stridor

High-pitched sound heard on inspiration in the upper airway in conditions such as croup

Respiratory disorders auscultation: Wheezes

High-pitched musical sounds heard throughout respiration

• Air passing through constricted bronchioles or narrowed smaller airways as in asthma

Respiratory distress can progress to what?

Respiratory failure

Bronchoscopy

Allows the direct visualization of trachea, upper parts of bronchi

Pulmonary function tests

Measures lung volumes, flow rates, and compliance by measuring expirations

Sweat tests

Pilocarpine is used to stimulate sweat glands to measure the amount of sodium and chloride produced to identify cystic fibrosis (CF)

Otitis media

Bottle feeding infant supine can cause reflux of formula from nasopharynx into eustachian tube

Assessment: Pulling at ears; bulging, red, or opaque eardrum; crying; sleep disturbances

Otitis media with effusion (OME)

Collection of fluid in the middle ear with or without symptoms of acute infection; decreased mobility of the eardrum; eardrum appears retracted, either yellow or gray; tinnitus; feeling of fullness; hearing loss; mild inability to maintain balance

Otitis externa (OE)

Swimmers ear

Assessment: Tenderness is the hallmark sign, tragus and/or pinna; purulent drainage; almost exclusively bacterial infection; rapid onset of symptoms

Otitis media, otitis media effusion, otitis externa diagnosis test

Otoscopy (visualization) or pneumatic otoscopy

Tympanometry (measured movement of the eardrum)

Otitis media, otitis media effusion, otitis external caregiver education

Feed infant in upright position, avoid exposure to tobacco smoke, avoid propping the bottle in infants mouth, discontinue use of pacifier after 6 months, stress importance of immunizations, only bacterial infections require antibiotics, myringotomy (incision in eardrum to relieve pressure), tympanovstomy (a tube placed through eardrum to relieve pressure)

Nasopharyngitis

Occurs in the cold months and lasts 4-10 days

Nasal congestion is most prominent symptom

Pharyngitis

Inflammation of throat mucosa and underlying structures

Triad of sore throat, fever, and pharyngeal inflammation

Multitude of causes: Virus, bacteria, fungi, noninfectious agents

Influenza

Viral infection spread through contact or inhalation of droplets

Contagious 1-2 days before onset of symptoms and usually affects upper respiratory

Multiple strains of flu; December to February is peak time in US

Influenza assessment

Abrupt onset, fever, chills, headache, flushed cheeks, cough, malaise, cold symptoms, wheezing may occur if bronchitis present

Influenza diagnosis

Viral culture of nasopharyngeal or throat samples, rapid flu test

Influenza nursing interventions

Supportive care measures, antipyretics, cough suppressants, Tamiflu, annual vaccine

Strep throat

Group A streptococcal organisms are found in the back of the throat

Strep throat symptoms

Painful swallowing, fever, white spots visualized in the back of throat, swollen lymph nodes

Strep throat diagnosis test

Throat swab should be done to determine whether bacterial or viral a recent or ongoing infection with Group A Streptococcus bacteria (strep)

ASO titer indicates recent or ongoing infection with Group A streptococcus bacteria

Tracheitis

Rare, but life-threatening bacterial inflammation

Laryngotracheobronchitis (Croup)

Viral inflammation of larynx, trachea, and bronchioles

RSV and influenza are most common

Laryngotracheobronchitis (Croup) nursing interventions

Allow the child to maintain a position of comfort; cool mist

Asthma assessment

Cough, nonproductive, progressing to frothy, worse at night; SOB; chest pain with tightness; wheezing, prolonged expiration; care of history of exposure to possible food allergies and triggers

Asthma diagnosis

Detailed history and physical exam on 2 occasions; focus on excluding other causes of symptoms, considerable breathlessness and either coughing, wheezing or both; detailed focused questions on presenting symptoms and precipitation of symptoms; family history; dermatological signs (atopic dermatitis); tachypnea with prolonged expiratory phase; CXR reveals hyperinflation; ABGs; pulmonary function tests, spirometry (can confirm or eliminate); peak flow meter; allergy testing to identify triggers

Asthma nursing interventions

Detailed respiratory assessment; assess severity and control of symptoms; elimination or management of triggers; balance between good control with medications; 

Asthma

Asthma is a chronic, obstructive inflammatory disorder caused by hyper-responsiveness  of airways, airway edema, narrowing, and mucous production

Sudden infant death syndrome (SIDS)

Also known as Sudden unexplained death of an infant (SUID)

Peak incidence is 2-4 months of age

Autopsy reveals pulmonary edema, but no other identifiable cause of death

PDA, atrial septal defects (ASDs), ventricular septal defects (VSDs)

Increased pulmonary blood flow-abnormal connection through the septa or the great vessels; increased blood volume on right side of the heart with increased pulmonary blood flow and decreased systemic blood flow

Tetralogy of Fallot (TOF), Tricuspid atresia, Eisenmenger syndrome

Decreased pulmonary blood flow-pulmonary blood flow is obstructed within the right ventricular outflow; destaturated blood shunts from right to the left across an ASD or VSD into systemic circulation, and the neonate is likely desaturated and cyanotic

Coarctation of the aorta (COA), Aortic stenosis, Pulmonary stenosis, Pulmonary atresia, TOF with PA

Obstructive disorders

Transposition of the great vesels, Truncus arteriosus, Total anomalous pulmonary venous return (TAPVR), Hypoplastic left heart, Ebstein’s anomaly

Mixed disorders-blood from systemic and pulmonary circulations is mixed in the heart chambers, desaturation of blood occurs and cardiac output decreases because of increased volume load on ventricles

Cardiac Catheterization

Nurses must provide caregiver education: Small catheters or small, flexible tubes are inserted through small incisions in the neck or groin and threaded to the heart

An invasive procedure where a catheter is inserted through a vein in the groin or neck and guided to the heart using fluoroscopy to measure pressures, evaluate circulation and electrical pathways, perform biopsies, or treat heart defects.

Cardiac caregiver education

Limit physical activity as needed, provide emotional support, and monitor for behavioral issues.

Lifelong cardiology follow-up is required.

Some children need endocarditis prevention before dental/medical procedures.

Adolescents need reproductive counseling, as congenital heart defects can increase pregnancy risks and may be genetically passed to children.

Preparation and post-operative care depend on developmental age and parent involvement

Pre-procedure: Sedative given; local anesthetic used at femoral insertion site.

Post-procedure: Monitor I&O, pulses, heart rhythm, bleeding, perfusion, and infection.

Positioning: Child lies flat with affected limb straight for 4–6 hrs; pressure dressing applied.

Care at home: No tub baths, avoid strenuous activity, but school in ~3 days; give acetaminophen for pain.

Report: fever >24 hrs, chest pain, drainage, or signs of infection.

Follow-up appointments are essential.

Patent ductus arteriousus (increased) nursing interventions

Do NOT cluster care- can result in an increased oxygen demand during clustering

Strict intake and output fluid restrictions and diuretics as ordered

Monitor PO intake, diapers for output, keep cardiology appt, diuretics

Atrial septal defect (ASD) (increased) assessment

Atrial dysrhythmiias

Recurrent respiratory infections, shortness of breath

Tires easily while playing

Poor feeding; poor growth if CHF develops due to left-to-right shunting

Atrial septal defect (ASD) (increased) medical management

Administer meds, such as digoxin and diuretics, to decrease the load on R side of heart

Surgical closure may increase the incidence of pulmonary HTN, resulting in dysrhythmias

Atrial septal defect (ASD) (increased) caregiver education

Surgical closure with a patch may result in arrhythmia

May be on blood thinners for several months after procedure

Make need to take antibiotics for dental work after treatment

Ventricular septal defect (VSD) (increased) assessment

Often asymptomatic or with a heart murmur

Shortness of breath - tachypnea

Feeding difficulties (fatigue eating); failure to thrive

Recurrent respiratory infections

Ventricular septal defect (VSD) (increased) surgical repair

Complications include dysrhythmia

Tetralogy of Fallot (decreased)

Group of 4 heart defects

• pulmonary stenosis, VSD, right ventricular hypertrophy and overriding aorta