Peds Exam 2

Eyes

• binocular vision by 3 to 7 months

• visual acuity development by 5 years of age

Ears

• hearing intact at birth

• short, wide and horizontally placed eustachian tubes in young children increase risk of middle ear infections

HEENT Common Meds

• antibiotics

• antihistamines

• analgesics

Antibiotics (oral, otic, opthalmic)

actions: treatment of bacterial infections of the eyes and ears
indications: acute otitis media, otitis externa, conjunctivitis
nursing implications: teach families to complete the entire course as prescribed, check for drug allergies prior to administer

Antihistamines

actions: block histamine reaction
indications: allergic conjunctivitis
nursing implications: topical drops used, oral agents usually precribed if allergic rhinitis accompanies the conjunctivitis

Analgesics

actions: pain relief
indications: otitis media, otitis externa, after eye or ear surgery
nursing implications: narcotic analgesics may be necessary in some instances

Any Age - HEENT Signs and Symptoms of Visual Impairment

dull, vacant stare

Infant - HEENT Signs and Symptoms of Visual Impairment

• does not fix and follow

• does not make eye contact

• is unaffected by bright light

• does not imitate facial expression

Toddler & Older Child - HEENT Signs and Symptoms of Visual Impairment

• rubs, shuts and covers eyes

• squints and blinks frequently

• holds objects close or sits close to television

• bumps into objects

• displays head tilt or forward thrust

Otitis Media

etiology: bacterial or viral

pathophysiology: dysfunction of eustachian tubes

diagnostic evaluation: assessing the tympanic membrane

therapeutic management:

• pharmacologic: antibiotics

• surgical: myringotomy

Hearing Acuity

• maybe transient or permanent

• unilateral or bilateral

• language development is dependent on the ability to hear

• types: conductive, sensorineural, mixed

Conductive Hearing Loss

transmission of sound through the ear is disrupted

Sensorineural Hearing Loss

damage to the hair cells in the cochlea or along the auditory pathway

Mixed Hearing Loss

attributed to both conductive or sensorineural problem

Sleep Apnea

upper airway obstruction (partial or complete) that disrupts respirations during sleep
symptoms: snoring, breathing pauses, gasping on arousal, disturbed sleep, secondary enuresis, day time sleepiness, day time behavioral problems
diagnosis: sleep study
treatment: adentonsilectomy or CPAP/BIPAP
nursing care: early detection/observation, education, counseling

Respiratory Disease in Children

accounts of 50% of childhood illness:

• upper respiratory tract infections

• croup

• lower respiratory tract infections

• asthma

• bronchopulmonary dysplasia

• cystic fibrosis

• ciliary dyskinesia

General Aspects of Respiratory Infections

etiology and characteristics:

• infectious agents

• age

• size

• resistance

• seasonal variations

Upper Respiratory Tract

• oranasopharynx

• pharynx

• larynx

• upper trachea

Lower Respiratory Tract

• lower trachea

• bronchi

• bronchioles

• alveoli

Clinical Manifestations of Respiratory Infections

• vary with age

• generalized signs and symptoms and local manifestations differ in young children

  • anorexia, vomiting, diarrhea and abdominal pain

  • cough, sore throat, nasal blockage or discharge

  • respiratory sounds

Upper Respiratory Tract Infections

acute viral nasopharyngitis “common cold”

therapeutic management: often managed at home
prevention: widespread in the general population, hand washing, no eye and nose touching
care management: hydration, nasal suctioning
family support: education on respiratory complications and prevention

Influenza

• commonly known as the flu

• caused by orthomyxoviruses (A, B, C)

• clinical manifestations: dry cough, hoarseness, fever, chills

• therapeutic management: hydration, antipyretics

• prevention: vaccine recommendations

Tonsillitis

frequent co-occurence with pharyngitis

etiology: frequent URIs

clinical manifestations: inflammation

therapeutic management: tonsillectomy and adenoidectomy

• frequent swallowing

Infectious Mononucleosis

etiology and pathophysiology: herpes-like epstein-barr virus
diagnostic tests: spot test (mono)

Acute Epiglottitis

medical emergency

clinical manifestations:

• sore throat

• pain

• tripod positioning

• agitation

• drooling

• difficulty swallowing

• inspiratory stridor

• mild hypoxia

• distress

• no cough

therapeutic management:

• prevention of progressive respiratory obstruction

• intubation

• tracheostomy

DO NOT VISUALIZE EPIGLOTTIS

Croup Syndromes

• characterized by hoarseness, barking cough, inspiratory stridor, and varying degrees of respiratory distress

• affects larynx, trachea and bronchi

• types: epiglottis, laryngitis, laryngotracheobronchitis, tracheitis

• most often caused by H. influenzae type B

Acute Laryngotracheobronchitis (LTB)

• most common of the croup syndromes

• generally affects children <5 years of age

• organisms responsible: RSV, parainfluenza virus, M. pneumoniae, influenza A and B, pneumococci, staphylococci

Manifestations of LTB

• usually preceded by an upper respiratory tract infection

• inspiratory stridor

• suprasternal retractions

• barking or seal like cough

• increasing respiratory distress and hypoxia

• can progress to respiratory acidosis and respiratory failure

Therapeutic Management of LTB

• maintaining the airway

• maintain hydration (orally or IV)

• nebulized mist with supplemental O2

• nebulizer treatments: epinephrine or steroids

Acute Spasmodic Laryngitis

• aka spasmodic croup

• paroxysmal attacks of laryngeal obstruction

• occurs chiefly at night

• mild or absent inflammation

• most commonly affects children 1-3

Therapeutic Management of Acute Spasmodic Laryngitis

• humidified oxygen

• antipyretics

• antibiotics

• potential for intubation or mechanical ventilation

Infections of the Lower Airways

• lower airways: considered the reactive portion of the lower respiratory tract

• include bronchi and bronchioles

• cartilaginous support not fully developed until adolescence

• constriction of airways

Bronchiolitis

description: most common infectious disease of lower airways, maximum obstructive impact at bronchiolar level
age group: usually children 2-12 months old, rare after 2 years
etiologic agents: viruses (RSV primarily, adenoviruses, para-influenza viruses, human metapneumovirus, and mycoplasma pneumoniae)
predominant characteristics: labored respirations, poor feeding, cough, tachypnea, retractions and flaring nares, increased nasal mucus, wheezing, may have fever
treatment: supplemental oxygen if <90%, bronchodilators, suction nasopharynx, adequate fluid intake, adequate oxygenation

Pneumonias

• primary disease or complication

• causative agents: bloodstream infection or inhaled organisms

• treatments oriented towards support and symptoms

Pertusis (Whooping Cough)

• caused by bordetella pertussis

• in the US, occurs most in unimmunized children

• highest incidence in spring and summer

• highly contagious

• risk to young infants

Aspiration Pneumonia

• risk for child with feeding difficulties

• interprofessional care management

  • prevention of aspiration

  • feeding techniques, positioning

  • avoidance of aspiration risks

    • hydrocarbons, lipids

    • solvents

    • talcum powder

Asthma

• chronic inflammatory disorder of the airways characterized by recurring symptoms, airway obstruction and bronchial hyper responsiveness

• genetic susceptibility plus environmental triggers

• inflammation causes an increase in bronchial hyper responsiveness to a variety of stimuli

• most common chronic disease of childhood

• third leading cause of hospitalization in children under 15y

• may occur at any age, but over 80% will be diagnosed by 4y

• reactive airway disease: 50% of children <1y will wheeze, only 20% will go on wheeze again in early childhood

Cystic Fibrosis

• multisystem involvement

• autosomal recessive trait

  • increased viscosity of mucous gland secretions

  • elevation of sweat electrolytes

  • increase in enzymatic constituents of saliva

  • autonomic nervous system abnormalities

• defective gene inherited from both parents with an overall incidence of 1:4

Prognosis of Cystic Fibrosis

• medial survival is 40 years

• progressive and incurable disease

• transplantation: increases life expectancy, availability of organs, surgical complications

CF Pathophysiology

increased viscosity of mucus gland secretion
secretion results in mechanical obstruction
thick inspissated mucoprotein accumulates, dilates, precipitates, and coagulated to form concretions in glands and ducts

CF Diagnostic Evaluations

• sweat chloride test

• universal newborn screening

• DNA identification of mutant genes

CF Presentation

• wheezing respiration

• dry nonproductive cough

• patchy atelectasis

• cyanosis

• clubbing of fingers and toes

• repeated bronchitis and pneumonia

• meconium ileus

• distal intestinal obstruction syndrome

• excretion of undigested food in stool; increased bulk, frothiness and foul odor

• wasting of tissues

• prolapse of the rectum

• delayed puberty in girls

• sterility in boys

• salty tasting skin

• dehydration

• hyponatremic

• hypochloremic alkalosis

• hypoalbuminemia

CF complications

• complications are present in almost all patients with CF, but onset/extent is variable

• stagnation of mucus and bacterial colonization result in destruction of lung tissue

• tenacious secretions are difficult to expectorate: they obstruct bronchi and bronchioles

CF Respiratory Progression

1. gradual progression follows chronic infection

2. bronchial epithelium is destroyed

3. infection spreads to peribronchial tissue weakening bronchial

4. peribronchial fibrosis ensues

5. O2/CO2 exchange decreases

6. chronic hypoxemia: causes contraction/hypertrophy of muscle fibers in pulmonary arteries/arterioles

7. pulmonary hypertension

8. cor pulmonale

9. pneumothorax

10. hemoptysis

CF Management of Respiratory Complications

• airway clearance therapies

• bronchodilator medication

• physical exercise

• aggressive treatment of pulmonary infections

• aerosolized antibiotics

• home IV antibiotic therapy

CF Management of Gastrointestinal Problems

• replacement of pancreatic enzymes

• high protein, high calorie diet

• relief of intestinal obstruction (ileus)

• reduction of rectal prolapse

• treatment of chronic gastroinestinal reflux

CF Management of Endocrine Problems

• eventually pancreatic fibrosis occurs; diabetes mellitus may result

• pancreatic enzyme deficiency

• sweat gland dysfunction

• failure to thrive

• increased weight loss despite increased appetite

Accident

an event independent of human will caused by outside forces acting rapidly & resulting in physical or mental injury

Common Injury Locations

• homes

• yards

• schools

• childcare settings

• playgrounds

• sports fields

Risk of Injury & Developmental Stages

• injury rates are low for infants and increase with age

  • most common in kids 2-5 due to curiosity, walking, climbing and running

• attempting activities before developmental readiness

• line of sight and speed perception

• self assertion

• challenges rules

• desire for peer approval

Common Childhood Injuries

• SIDS

• brain injury

• concussion

• burns

• fire

• choking

• strangulation

• suffocation

• falls

• poisoning

• drowning

• child passenger safety

• suicidality

• gun violence

SIDS

• death of an infant younger than 1 year that is unexplained after thorough investigation, autopsy and review

• 90% deaths occur before 6 months, peak between months 1-4

• suffocation, asphyxia, entrapment and strangulation also common

Back to Sleep

• always sleep on back until 1 year

• firm mattress

• fitted sheet

• CPSC standards

• no toys, soft objects, bumper pads, etc.

Anaphylaxis

acute response to an allergen that involves may organ systems and may be life threatening

• usually happens 5-10 mins after exposure/ingestion

• management: assessment and support of ABC

• O2, epinephrine, bronchodilators, fluids, antihistamins, maybe corticosteroids

• 4-6 hr observation

• d/c planning: identify allergens, teach to use epi-pen, epipen prescription, allergy action, plan for school, avoid allergens, recognize signs and symptoms

Signs of Anaphylaxis

• airway: SOB, breathing difficulties, can’t swallow

• skin: hives, redness, itchy rash, swelling

• stomach: cramps, diarrhea, nausea and vomiting

• heart: drop in BP, increase HR, faintness, weak pulse

TBI & Concussion

• type of brain injury that changes he way the brain usually works

• 830,000 pediatric patients present with it a year in US

• mild is about 75% of reported cases in US

• recovery: days to months

• concussion is most common type

Head Injury

• falls, MVA, child abuse, bike + pedestrian accidents

• ABCs, neuro function: LOC, pupil response, seizure activity, gait, speech

• history: LOC, prior heath status, nature of injury

• diagnostics: Xray of head and neck, CT, MRI

Minor Head Injury

• no LOC or penetration changes

• pt acting normal

• healthy status prior

• monitor at home

Severe Head Injury

• maintain airway

• monitor breathing, circulation and neuro status

• prevent/cease seizures

• assess LOC

• signs of ICP?

• administer mannitol as ordered

• manage pain and sedation

• monitor for the development of complications

  • hemorrhage

  • infection

  • cerebral edema

  • herniation

S/Sx that Require Follow Up

• constant headache

• slurred speech

• dizziness

• extreme irritability

• vomiting 2+ times

• clumsiness or difficulty walking

• oozing blood or watery fluid from nose or ears

• difficulty waking up

• uneven pupils

• unusual paleness

• seizures

• any s/x of increased ICP

Brain Injury Prevention

• proper seatbelts/car seating

• helmet use

• safety gates

• safety guards on windows

Burns

• scald/thermal (hot objects)

• electrical

• chemical

• friction

• cold/frostbite

Burn Prevenion

• hot water heater below 120, check bath water temp

• install smoke detectors

• barriers around fireplaces/hot pipes/radiators

• cover electrical outlets

• no kids in cooking areas

• no bottles in microwave

Choking

• greater risk in young kids

  • explore via mouth

  • still learning chewing/eating

• s/sx:

  • difficulty speaking/breathing

  • inability to cough

  • wheezing sounds

  • clutching throat/gesturing

  • cyanosis

  • confusion and LOC

Choking/Strangulation Prevention

• keep away small objects

• be aware of older kids toys

• cut foods

• caution with specific foods

• supervised mealtime

• choking and cpr education

• review toy age requirements

Poisoning

• meds

• cosmetics

• cleaning products

• arts/crafts

• batteries

• lead containing

• automotive products

• gardening products

• pesticides

• certain plants/mushrooms

Poisoning Physical Exam

• hyper or hypotension and thermia

• respiratory distress or hyperventilation

• pupilary dilation or constriction

Poisoning Labs/Diagnostics

• chem panel

• ECG

• LFT

• urine/blood toxicology

• specific drug levels

Poisoning Nursing Management

• ABCs

• monitor Vs

• STAT labs

• activated charcol

• polyethylene glycol for bowel irrigation

• dialysis for blood removal of toxin

• naloxone if opiate or narcotic

Drowning

• greatest risk for ages 1-4

• even a bucket of water with a few inches is a risk

Submersion Injury

• aspiration leads to poor oxygenation with retention of carbon dioxide

• alveolar surfactant is depleted leading to pulmonary edema

• hypoexemia results

• risk of renal complications

Submersion History Work-Up

• detailed history of the event

  • where: pool or ocean

  • length of submersion

  • witnessed?

  • cold or warm water?

  • extenuating circumstances?

  • LOC when found?

  • CPR?

  • AED?

  • cervical spine injury?

  • last meal?

• ABG, ECG, CXR, serum electrolytes

• ABCs":

  • scene CPR

  • cervical stabilization

  • suction airway

  • 100% O2

  • intubation?

  • NG or OG

  • compressions?

  • hypothermia?

Abuse Assessment

Ten-4-Faces

• trunk

• ears

• neck

• 4 years and yoinger

• frenulum

• auricular area

• cheek

• eyes

• sclera

• patterned bruising

Adolescent Safety Tips

• quest for independence

• peer relationships are important

• risk taking

• body image

• experimentation

• mental health

Acquired Heart Disease

• disease, condition or characteristic that is not congenital but develops after birth

• resulting from exposure to something, such as an antigen or antibiotic, virus, bacteria, post surgical, side effect of med, etc

Infective Endocarditis (IE)

• rare but lifethreatening inflammation of the inner lining of the heart chambers and valves

• commonly caused by microorganisms, usually bacteria or fungi, entering the bloodstream and settling on heart valves

Risk Factors of Infective Endocarditis

• CHD (septum or valve defects)

• prosthetic valves

• central venous catheters

History and Exam of Infective Endocarditis

• prolonged, unexplained fever

• lethargy

• weight loss

• flu-like symptoms

• petechiae - conjunctiva, oral mucosa, extremities

Diagnostic and Treatment of Infective Endocarditis

• blood culture - bacteria, fungi

• CBC - anemia, leucocytosis

• urinalysis - microscopic hematuria

• echocardiogram - cardiomegaly, abnormal valve function, vegetation

• ECG - prolonged P-R

• 4 to 6 weeks of antibiotic or antifungal treatment

Nursing Management of Infective Endocarditis

• good oral hygiene

• ID card

• notify PCP or cardiologist of fever or flu like symptoms

• dental prophylaxis for high-risk patients

Acute Rheumatic Fever

• a systemic inflammatory disease that acts as a delayed autoimmune reaction (2-4 weeks) after untreated GAS (strep throat) or skin infections

• primarily affects 5-15yo

  • more common in disadvantaged areas

Clinical Manifestations of Acute Rheumatic Fever

• carditis (50-80%) - often most serious

• polyarthiritis (60-80%)

• sydenham chorea (10-30%)

• subcutaneous nodules (<10% of patients)

• erythema marginatum (<6% of patients)

Diagnosis of Rheumatic Fever

Jones Criteria + previous group A strep

• 2 major +

Jones Criteria

• major:

  • joint involvement

  • o looks like a heart = myocaritis

  • nodules, subcutaneous

  • erythema marginatum

  • sydenham chorea

• minor:

  • c - crp increased

  • a - arthralgia

  • f - fever

  • e - elevated ESR

  • p - prolonged PR interval

  • a - anamnesis of rheumatism

  • l - leukocytes

Rheumatic Fever Treatment

• antibiotics

• steroids

• aspirin

Kawasaki Disease

• acute vasculitis - 6 months to 5 years

• thought to be post-viral

• appears to be autoimmune

• attacks the coronary arteries - causes thrombosis

• requires chronic management

Symptoms

• High fever - for > 5 days (39.9C or 103.8F)

• Desquamation (peeling) hands or feet, perineal region

• Strawberry tongue

• Diffuse, erythematous, polymorphous rash

• Bilateral conjunctivitis

Kawasaki Disease

• Tx - high dose IVIG, aspirin

• Nursing Management:

  • monitor cardiac

  • promote comfort

    • chapped lips

    • achy joints

    • irritability

    • fevers

• Child and Family Education:

  • continue to monitor temp

  • cardiology f/u

  • report toxic effects of aspirin therapy

  • no nsaids while on aspirin

  • ROM exercises for joint pain

Cardiomyopathy

• increasing incidence among children

• risk factors include genetic or congenital heart defects

• also occurs as a result of inflammatory or infectious process

• result of chronic hypertension

• no cure

  • management is directed at improving heart function and blood pressure

  • ace inhibitors

  • beta blockers ca channel blockers

  • pacemakers

  • heart transplantation

Hypertension

• increasing prevalence among children and adolescents

• important to screen and treat

• can lead to cardiomyopathy

• weight reduction, appropriate diet, increased physical activity

• some children require medications such as antihypertensives & diuretics

• managed by nephrologists

Dyslipidemia

• high lipid levels are a risk factor for cardiovascular disease

• increasing prevalence in kids and teens

• asymptomatic (screening and early intervention, 9-11, 18-21)

• high LDL, low HDL, high triglycerides

• 60 mins physical activity

• low fat dairy, whole grains, lean protein

Fetal Circulation (Before Birth)

• placenta (oxygenated blood enters via umbilical vein)

• ductus venosus (shunts some oxygenated blood from umbilical vein directly to the inferior vena cava, bypassing the liver)

• foramen ovale - opening between RA and LA, bypasses the non-functioning fetal lungs

• ductus arteriosus - connects pulmonary artery to aorta, shunts most blood away from lungs

• umbillical arteries - returns deoxygenated blood from fetus to placenta

• high pulmonary vascular resistance - keeps most blood out of lungs

Summary: oxygenated blood from the placenta to preferentially goes to brain and heart, bypassing lungs and liver via shunts

Placenta Purpose

• the fetus doesn’t breathe air, so the placenta provides oxygen and nutrients

• blood flow bypasses the lungs

Summary Transition at Birth

first breath —> lungs expand —> pulmonary resistance drops —> systemic vascular resistance rises after umbilical cord clamping

Key Changes at Birth

• lungs inflate —> pulmonary vessels dilate —> increased blood flow

• umbillical cord clamp —> higher systemic resistance

• foramen ovale closes functionally

• ductus arteriosus constricts, closes within hrs to days, becomes ligamentum arteriosum

• ductus venosus closes, becomes ligamentum venosum

• umbilical vessels obliterate, become ligaments

Neonatal Circulation

Lungs now oxygenate blood, all fetal shunts close

• blood flows through pulmonary cirulation for oxygenation

• all shunts closed

Congenital

born with it

• defects occur before birth that change the flow of blood through the heart

• risk factors:

  • genetic - family history, Down’s syndrome

  • maternal - infection, diabetes, drug and alcohol use

Hypoxia - Low O2

• commonly seen with R-L shunting

• tetralogy of fallot, transposition of the great vessels, truncus arteriosus, tricuspid atresia

• S/S:

  • blue babies - cyanosis

  • poor feeding

  • poor weight gain

  • clubbing fingers

  • dyspnea

  • tachypnea

  • polycythemia (hydrate!)

Congestive Heart Failure

• commonly seen with L-R shunting:

  • ASD

  • VSD

  • PSA

  • AVSD

• s/s:

  • weight gain

  • pale with cool extremities

  • periorbital edema

  • reduction in # of wet diapers

  • grunting during feeding

  • diaphoresis

  • dyspnea

Defects

holes in heart septum

• push blood from L to R of heart

• overloads lungs with too much fluid