EENT & Fluids (W9)

how does eye color change in childhood

changes during first 6 mos

how does vision work

light is reflected off object and into eye through cornea, passes through the pupil and lens, refracts light onto the retina

what eye testing chart is best for children

shapes or tumbling E

when may the Snellen chart be used in children?

when you are SURE they know their alphabet

what are types of visual impairment

hyperopia (farsighted, can't see near), myopia (nearsighted, can't see far), astigmatism (abnormal refraction), strabismus (crossed/misaligned eyes), cataracts (cloudy lens), glaucoma (increase IOP), amblyopia (lazy eye)

how is strabismus tx

eye patch stronger/dominant to force increased use of weaker eye

describe retinopathy of prematurity (ROP) and causes

- immature blood vessel in retina constrict and becomes abnormal

- caused by prolonged O2 therapy, respiratory distress, apnea, hypoxia, cerebral palsy

ROP is more common in...

male infants <28wks & weigh <1600g

what are manifestations of ROP

poor tracking (following with eyes), unable to reach developmental milestones

describe conjunctivitus and manifestations

- inflammation of conjunctivae from bacteria, virus, allergy, trauma, or irritants

- itching, burning, mucopurulent dc, watery, crusty eyelids, inflamed, NO LOSS OF VISION

difference in tx w/ bacterial, viral, and allergic conjunctivitus

- bacterial: ABX

- viral: supportive, warm compress

- allergic: antihistamines, mast-cell stabilizer

describe periorbital cellulitis and manifestations

- infection of eyelid and surrounding tissues

- swollen, red eyelid, painful movement, restricted eye movement, fever

tx for periorbital cellulitis

- IV ABX, hot packs

- (may lead to orbital cellulitis or meningitis if not tx promptly!)

how is a foreign body evaluated for in the ER

woods lamp

what is a subconjunctival hemorrhage, how does it heal

bleeding over sclera, heals spontaneously

what is periorbital ecchymosis

black eye, bruising around eye

how is a corneal abrasion dx

sterile fluorescine strip, dye will remain where cells are disrupted

how are the ears different in children

shorter and more horizontal eustachian tubes, small tympanic membrane close to surface

describe conductive hearing loss & causes

- interference of sound transmission

- causes: otitis media, foreign bodies, excessive wax

describe sensorineural hearing loss & causes

- interference of transmission alone nerve pathways

- causes: congenital defects, acquired conditions, infection, ototoxic meds (ex, gentamycin)

describe mixed hearing loss

has both a conductive and sensorineural component

infants vs children sx in hearing loss assessment

- infants: lack of startle reflex, failure to respond to noice, absence of vocalization, delayed verbal component

- older children: speaking in monotone, need for repeated conversation, speaking too loudly for situation

otaoccoustive emission (OAE) hearing test

in newborns, detects inner ear hearing loss and evaluates cochlear & hair cell function

auditory brainstem response (ABR) hearing test

in newborn, electrical response to auditory stimuli

what does tympanometry assess

middle ear ability to transmit sound

at what age is audiometry used

>4y/o

what are risk factors for acute otitis media (AOM)

eustachian tubes, winter months, exposure to large amounts of children, secondhand smoke

there is a lower incidence of AOM in children who...

are breastfed

acute otitis media (AOM) vs otitis media with effusion (OME)

- AOM: infection of structure of the middle ear

- OME: collection of fluid in the middle ear but no infection

what are manifestations of AOM

rubbing, crying, lethargy, purulent dc in middle ear, bulging TM, lymphadenopathy, temp, hearing difficulties & speech delays

cardial sign of AOM

ear pulling

what are manifestations of OME

feeling of fullness in ear, orange discoloration of TM, decreased TM movement, rhinitis, cough, diarrhea, transient hearing loss, balance issues

describe otitis externa (OE, swimmers ear), causes, and manifestations

- inflammation of ear canal from qtips, foreign object, drainage, or wet ear canal

- pain and itching to ear canal, pain to tragus, crusts on outer ear

pt edu w/ AOM, OME, and OE

comfort measures, finish meds, upright position during feeding (keeps milk from filling tubes), clean w/ swab, avoid risk factors, post ABX follow up, immunizations

how are the noses of children different, why is this a concern

obligatory nose breathers until 6mos, edema and nasal dc may interfere w/ intake and breathing

describe nasopharyngitis, s/s, tx

- common cold lasting from 4-10 days

- s/s are red mucosa, nasal congestion, clear nasal drainage

- tx w/ saline drops, nasal sprays, suctioning

nasal spray should NOT be used for more than ___ days bc...

4; risk of dependence and rebound congestion

describe sinusitis and s/s

- inflammation of paranasal sinuses (basically a cold w/ increase nasal drainage)

- s/s are facial pain, HA, fever

describe epistaxis and causes

- nose bleed

- causes by picking, foreign body, low humidity, forceful coughing, allergies

management of epistaxis

- sit upright, head tilted forward to prevent blood form going down throat, squeeze nares for 10-15mins

- cotton ball or tampon to pack if posterior bleed & bleeding wont stop

edu for epistaxis

humidifier, avoid picking, avoid vigorous activities, avoid hot drinks/showers

how are throats different in peds

tonsils usually large, decreases by 10yrs

describe pharyngitis and manifestations

- inflammation of pharynx most commonly in 4-7y/os (80% viral, 20% bacterial: strep)

- sore throat, exudate, low grade fever

what med is used most commonly for pharyngitis

amoxicillin

describe the centor score for strep and what levels warrant strep testing

- 5 categories (age, exudate or swelling, tender swollen throat or lymph nodes, fever >100.4, cough)

- score of 4-5 needs test, scores of 2-3 considers strep

red flags that could indicate strep

fine red sandpaper rash on trunk, halitosis, abd pain

complications of strep

rheumatic fever and glomerulonephritis

describe tonsilitis and manifestations

- inflammation/infection of palatine tonsil (viral or bacterial)

- frequent throat infections, enlargement of cervical nodes

when is tonsillectomy recommended

>3 episodes per year for 3yrs

considerations of tonsillectomy

no red liquids (mimic blood), watch for frequent swallowing = signals increased bleeding, pain relief 24/7 to encourage fluid intake, no sucking, no hard foods, no dairy (increases mucus), hemorrhage common after 7 days (child should remain out of school for 2wks)

describe teh fluid compartments

- intracellular: fluid inside cells

- extracellular: outside of cells (intravascular & interstitial)

why do kids get dehydrated?

increased RR during illness, fever, d/v, hemorrhage, burns, drainage tubes, excessive phlebotomy, phototherapy, high metabolic & respiratory rates, high fluid requirement daily, decreased ability of kidneys to conserve water, little fluid volume reserve, greater amount of skin surface

isotonic (isonatremic) dehydration

H2O = Na+ loss, osmolality and Na+ is normal, mild poor skin turgor and thirst, irritable lethargic, ECV decrease, ICV maintained, shock common in severe cases

hypertonic (hypernatremic) dehydration

H2O > Na+ loss, increase osmolality and Na+, decrease ECV & ICV, increased thrist, skin turgor not lost, very irritable, shock not common

hypotonic (hyponatremic) dehydration

H2O < Na+ loss, decrease osmolality & Na+, decreased ECV & increased ICV, mild thirst, poor skin turgor, lethargic/coma, shock common

1 kg of weight gain/loss is = ____ fluid?

1L

s/s of dehydration

weight loss, decrease Uop, dry lips/membranes, poor skin turgor, lethargic, sunken fontanel, rapid/thready pulse, hypotension, lack of tears, delay cap refill, decrease LOC

tx for dehydration

oral rehydration solutions (pedialyte of WHO ORS)

IV fluid replacement calculation for children

- first 10 kg = 100mL/kg/day

- second 10 kg = 50mL/kg/day

- >20kg = 20mL/kg/day

how do isotonic fluids work; examples

- same concentration as plasma, no net fluid movement, increase intravascular volume

- NS (0.9%), LR, D5W, D5 1/4NS

what are isotonic fluids used for

blood loss, trauma, dehydration r/t n/v/d

how do hypertonic fluids work; examples

- high concentration than plasma, causes fluid to shift from intracellular space (ICF) to interstitial and intravascular space (ECF)

- D10W, 3% NS, D5 1/2NS, D5NS, 5% NS, D5LR

what are hypertonic fluids used for

hyponatremia, hypotonic dehydration, certain types of shock

how do hypotonic fluids work; examples

- lower concentration than plasma, causes fluid to shift from intravascular space (ECF) to interstitial and intracellular space (ICF)

- 1/2 NS (0.45%), 1/4 NS (0.225%), 1/3 NS (0.33%)

what are hypotonic fluids used for

hypernatremia, DKA, cellular dehydration

what causes edema

- excess fluid in the intravascular and interstitial spaces

- excessive IV fluid admin, increased aldosterone, CHF, liver failure, nephrotic syndrome, burns, renal failure

how does excess aldosterone cause edema

retains Na+ and therefore H2O, causing less to be excreted in urine

how is ECF excess tx

furosemie, monitor I/O, daily weight, pump for rate flow, skin care for edematous areas

what causes hypernatremia and what is its tx

- decreased water intake or increased sodium intake, bodily fluids are too concentrated (more Na+ than water)

- tx w fluid replacement and tx underlying cause

normal pH and what does abnormal ranges mean

- normal is 7.35-7.45

- <7.35 = acidic

- >7.45 = basic

causes and manifestations of metabolic acidosis

- DKA, severe diarrhea (excretion of bicarb), renal failure, shock

- kussmaul respirations, hypotension, cardiac arrhythmias, pulmonary edema, hypoxia, confusion, drowsiness, warm flushed skin, n/v/d, muscle twitching, hyperkalemia

causes and manifestations of metabolic alkalosis

- severe vomiting (excretion of acid), excessive GI suctioning, diuretics, excessive HCO3

- restlessness followed by lethargy, decreased RR, hypokalemia, irritability, cramping, paresthesia, tetany, seizures, tingling, tachycardia, dizzy

sensible vs insensible water loss

- sensible: can be measured or visualized

- insensible: can't be measured/visualized but you know its occurring