NURS 366 EXAM 3

Child abuse

Child abuse

Has a huge effect on brain development and can lead to cognitive impairment. Head trauma can cause a subdural hematoma - brain bleeding. Adult violence against children leads to childhood terror, leading to teenage violence and anger leading to adult rage - destructive toward others and self.

Adverse child experiences

ACEs include abuse (emotional, physical, sexual), neglect, and household dysfunction (mother treated violently, mental illness, substance abuse, parental separation or divorce, prison)
As the number of ACE increases, the risk for the following health outcomes increases: alcoholism, COPD, depression, fetal death, illicit drug use, ischemic heart disease, liver disease, risk for intimate partner violence, multiple sex partners, suicide attempts, unintended pregnancies

Healthcare and child abuse

Pediatrics/family practice: prevention, recognition, treatment
Gynecology: sexual assault or abuse
Radiology/orthopedics: accidental v non-accidental fractures
Pathology: SIDS vs infanticide
Emergency: recognition/treatment of acute abuse

Mandated reporting

Must have reasonable grounds to believe
Nurse will be immune from civil or criminal liability
Must report immediately - call CPS or police
You do not have to prove that the child has been abused/neglected

Child risk factors

Emotional/behavioral difficulties
Chronic illness
Physical disabilities
Developmental disabilities
Preterm birth
Unwanted/unplanned

Children who are difficult to raise are more at risk for abuse - more parents stress

Parents risk factors

Low self-esteem
Poor impulse control
Substance abuse/alcohol abuse
Young maternal or paternal age
Abused as a child
Depression or other mental illness
Poor knowledge of child development or unrealistic expectations for child
Negative perception of normal child behavior

Environment risk factors

Social isolation
Poverty
Unemployment
Low educations achievement
Single-parent home
Non-bio related male living in the home
Family or intimate partner violence

Child protective factors

Above average cognitive ability
High ego control (high degree of impulse control and modulation)
External attribution of blame (attribute cause to something outside oneself)
Presence of spirituality
Ego control and ego resilience (able to insulate themselves from environmental distracters)
High self-esteem or sense of self-worth

Family protective factors

Presence of a caring and supportive adult
Positive family changes (interventions)
Structures school environment
Involvement with religious community
Involvement in extracurricular activities or hobbies
Access to good health, education, and social welfare services

Cultural factors

Transcultural human problem
Many cultures will misunderstand other cultures' behaviors as child abuse/neglect when it is really normal for them
Need to be educated on other cultures to recognize normal behavior

Interviews

Parent: note legal obligation - be open, use a private setting. Do not be angry or place blame. Do not give your own feedback

Child: use language they can understand. Be calm, sympathetic, and do not suggest answers/criticize. Do not let the family know your own personal opinions

Types of neglect

Medical care neglect: parents are not giving the child needed medical care (diabetes)
Safety neglect: lack of supervision - small child left alone at home with a pool or parents are drunk when they drown
Emotional neglect: failure to provide adequate love and support
Educational neglect: child is not sent to school
Physical neglect: the home is nasty

Growth chart

Very important to pay attention to child's growth. Abuse/neglect can lead to lack of weight gain and growth in that period of their life

Neglect history

Lack of well child care
Chronic illness not treated
Eye glasses, hearing aids, dental care not provided
Multiple unintentional injuries
Excessive school absences impair education
Domestic violence
Consider societal component
International adoptees - was orphanage care bad?

Neglect physical findings

Undernutrition (growth chart)
Poor hygiene
Developmental delay
Untreated medical conditions/rampant cavities
Apathy, poor interpersonal reactions

Neglect behavioral findings

Depression, anxiety, sleep disturbances
Enuresis, excessive masturbation
Impaired interpersonal relations
Discipline problems, aggressive behavior
Poor school performance
Role reversal
Excessive household responsibilities

Neglect treatment

Stop deprivation
Educate caretaker
Complete exam, screening lab - consider physical and sexual abuse
Acute and long term follow-up care

Neglect over-reporting

These observations can often be mistaken as neglect, but do not necessarily mean the child is being neglected:

Minor injuries with lax supervision
Minor acute illnesses not seen by doctor
Mild nutritional or environmental lapses
Hygiene/clothing not to middle class standards
Cultural differences

Signs of physical abuse

Parents delay in taking their child in to the emergency room
Injuries that do not align with the story
Intracranial bleeding
Intra-retinal hemorrhages
Bruises, fractures, or burns at different healing stages
Bruises on face instead of normal bruises on shins
Patterned bruises or burns - look like an object (belt buckle)
Bone that is not yet ossified is prone to twisting injury

Physical abuse - diagnosis

Relies on nature and extent of injuries and the caretaker explanation and response
Biomechanical plausibility - are there multiple injuries obtained at different times? Does the story make sense biomechanically?
Immediate medical needs
Past medical and social history - lots of visits
Level of risk if the child goes home

Developmental stages at risk for abuse

Colic
Not sleeping at night
Separation anxiety
Normal exploratory behavior
Normal negativism
Feeding problems - injuries may be around mouth and face
Toilet training - injuries may be in buttocks area

Important to educate parents about normal behavior to diffuse the anger at home

Brain trauma

Death
Severe neurologic disabilities
Visual impairment
Behavior, learning disabilities may be recognized years later
Total morbidity 68%

Fractures

Red flags for abuse:

Metaphyseal-epiphyseal
Multiple/different stages of healing
Non-ambulatory infants
Skull, long bones, ribs
Bucket handle fractures

Abdomen injuries

Ruptured liver/spleen
Intestinal perforation
Intramural hematoma duodenum
Pancreas/kidney/bladder injury
Ruptured blood vessel/chylous ascites
Foreign bodies

Sexual abuse

Child is too young to understand sexual activity, is unable to give informed consent, or violates the social taboos of family roles

Sexual abuse presenting complaints

Specific history or suspicions
Anogential injury - unexplained, inconsistent
Sexually transmitted diseases, vaginitis, pregnancy
Acute traumatic response/regression
Eroticization - inappropriately interested in sex/sexual behaviors
Nonspecific behavioral changes

Signs of sexual abuse

Abrasions/bruising genitalia
Tear posterior hymen
Decreased posterior hymenal tissue
Injury/scars posterior fourchette, hymen
Bruising/lacerations anus

Sexual abuse physical exam

Use knowledge gained from routine exams
Do a complete exam
Acute assault (within 72 hours) or acute symptoms require URGENT examination - sperm sample
Uncooperative child - can use relaxation techniques, postpone the exam, or use anesthesia if urgent
Speculum exam rarely needed for prepubescent girls unless there is a foreign body or tear
Document exam position
Surgical consult - deep injury, bleeding
Colposcope for documentation
Rape kit for acute assault

Sexual abuse treatment

Care of physical injury and STDs
Pregnancy prevention
Safe environment
Acute and long-term follow up
Counseling

Child abuse prevention

Primary - healthy, better educated parents with strong support systems and communities
Secondary - nurse home visitation, developmental interventions in high risk families
Tertiary - foster care, counseling, parents psychotherapy

Sexual abuse vs sexual play

Frequency
Coercion
Development asymmetry - one is 13 the other is 3
Beyond normative behaviors for age - excessive

Liver anatomy

Largest internal organ - 3 lbs. Dual blood supply - hepatic artery brings oxygen rich blood and portal vein carries incompletely saturated blood with oxygen and supplies 60-70% of the liver. Portal vein carries blood from the stomach, intestines, pancreas, and spleen. Venous outflow from the liver is carried by the hepatic veins into the inferior vena cava. During CHF, blood can back up into the liver causing nausea, abdominal pain, and decreased appetite

Liver cells

Hepatocytes: produce bile
Kupffer's: remove old and defective blood cells, bacteria, and other foreign material from portal blood.

Liver functions

Produce bile
Metabolize hormones and drugs
Synthesize proteins, glucose, and clotting factors
Store vitamins and minerals
Changes ammonia produced by deamination of amino acids to urea
Converts fatty acids to ketones

Liver assessment

History, physical, diagnostic tests
Diagnostic: ultrasound, CT, MRI, liver biopsy
Labs: confirm the diagnosis of liver disease. Serum levels of liver enzymes assess cell injury, liver's ability to produce proteins, and excretory functions of the liver

Lab tests

Elevated serum enzyme tests usually indicate liver injury earlier than other indicators of liver function
ALT: liver specific. Elevated ALT can mean lowered liver function
AST: derived from organs other than the liver, but can still assess injury to liver
Both enzymes are present in liver cells

Synthetic capacity can be reflected in measures of serum protein levels and prothrombin time
Hypoalbuminemia may indicate severe liver disease
Deficiencies in clotting factors can occur - will measure PT, PTT, and INR

Excretory function:
GGT: function in the transport of amino acids and peptides into cells. Sensitive indicator of hepatobiliary disease
ALP: present in membranes between liver cells and bile ducts. Released by disorders affecting the bile duct
Serum bilirubin - explained further in next card

Bilirubin

Substance that gives bile its color. Formed from old red blood cells. Hemoglobin is broken down to free bilirubin, which is insoluble in plasma and transported in plasma attached to albumin. As it passes the liver, free bilirubin moves into hepatocytes where it becomes conjugated bilirubin and soluble in bile. It can then be secreted in bile and passes into the small intestine to help with digestion. If we do not have healthy albumin and a healthy liver, unconjugated bilirubin will hang out in the plasma and cause jaundice

Jaundice

Results from abnormally high concentrations of bilirubin in the blood. Bilirubin has a high affinity for elastic tissue, such as the sclera.
Causes of jaundice include excessive destruction of RBCs (hemolytic blood transfusion reaction), impaired uptake of bilirubin by the hepatocytes, decreased conjugation of bilirubin (liver disease), and obstruction of bile flow from the liver or bile ducts to the intestines (gallstones, tumors)

Cirrhosis

Characterized by diffuse fibrosis and conversion of normal liver architecture into structurally abnormal nodules. Fibrous tissue forms constrictive bands that disrupt flow in the vascular channels and biliary duct systems of the liver, causing decreased liver function and portal hypertension - can't get blood out

Post necrotic cirrhosis

Accounts for 10 to 30% of cases - not alcohol related.
Small to large nodules
Follows viral hepatitis (B or C) or an autoimmune disease.
May be a toxic response to drugs and other chemicals
Predisposing factor in hepatic cancer when it caused by hep B

Biliary cirrhosis

Involves inflammation and scarring of small intrahepatic bile ducts, portal inflammation, and progressive scarring of liver tissue.
Seen mostly in women 30 to 65 years
Accounts for 2 to 5% of cases
Familial occurrences are found between parents and children
Antimitochondrial antibodies are found in 98% of patients with the disease - autoimmune mechanism

Body attacks own mitochondria and causes scarring in the bile ducts and liver tissue

Alcohol

Supplies calories but cannot be broken down or stored as proteins, fat, or carbohydrate.
Takes two hours to metabolize one drink
Metabolism of alcohol leads to chemical attack on certain membranes of the liver
Even after alcohol intake has stopped and all alcohol has been metabolized, the processes that damage liver cells continue for many weeks and months.
Changes are divided into three stages:
Fatty changes - ethanol's direct effect on normal hepatocyte lipid metabolism
Alcoholic hepatitis - liver is angry and there will be chronic inflammation
Cirrhosis - patient who has been told year after year to stop drinking - ALT and ALP through the roof

Alcoholic liver disease and cirrhosis

Causes 200,000 deaths annually. 5th leading cause of death in the US. Most deaths attributable to liver failure, bleeding esophageal varices, and kidney failure

Cirrhosis manifestations

Vary from asymptomatic hepatomegaly to hepatic failure. Often there are no symptoms until the disease is far advanced. Most common signs: weight loss, edema, weakness, anorexia
Diarrhea, jaundice, abdominal pain (epigastric area, dull, aching, sensation of fullness)

Late manifestations of cirrhosis

Related to portal hypertension and liver cell failure
Splenomegaly, ascites (secondary to portal vein obstruction and decreased levels of serum albumin), esophageal varices (secondary to portal hypertension), bleeding (secondary to decreased clotting factors), thrombocytopenia (secondary to splenomegaly), encephalopathy (secondary to livers inability to metabolize ammonia, which is a CNS depressant)
When the liver cannot convert ammonia, we can give them lactulose to help - has high concentrations of sugar and it will make the patient poop a lot - will get rid of ammonia through the feces

Ascites

Occurs when the amount of fluid in the peritoneal cavity is increased. Related to livers inability to maintain osmotic pressure and fluid balance in the vasculature
Spider angiomas - body is creating new vessels to feed the big belly. Late clinical manifestation and are a bad sign
Late-stage manifestation of cirrhosis and portal hypertension. Not uncommon to see 15 liters or more. Can manifest in the scrotum as well
Abdominal pain, dyspnea, insomnia, difficulty walking, difficulty with ADLs
Treatment: dietary restriction of sodium, diuretics (oral potassium), fluid restriction, paracentesis - drains the belly (temporary), pertoneovenous shunt (fluid shifted into superior vena cava - risk for CHF)

Portal hypertension

Increases resistance to flow in the portal venous system.
Secondary to prehepatic obstructions - portal vein thrombosis, external compression due to cancer or enlarged lymph nodes
Intrahepatic obstructions: increased resistance secondary to fibrous tissue
Posthepatic obstructions: thrombosis of hepatic veins, severe right sided failure that impedes outflow of venous blood from the liver

Esophageal varices

Pressure in portal vein increases collateral channels (thin-walled varicosities) develop in the submucosa of the gastric fundus and esophagus - subject to rupture and hemorrhage
Created by the pressure created when fluid is not able to leave a sick liver.

Varices treatment

Prevent hemorrhage
Treat portal hypertension and esophageal varices with beta blockers, vasopressin (reduces blood flow and pressure) and endoscopic band ligation

Transjugular intrahepatic portosystemic shunt

Catheter introduced into the internal jugular vein and then advances through the inferior vena cava into the right hepatic vein. Liver tissue is punctured to encounter a main branch of the portal vein and an expandable shunt is placed between the hepatic vein and the branch of the portal vein, creating an opening to reduce pressure, not improve liver function

Maximizing liver function

Nutritious diet - limit protein and eat potassium (diuretic)
B vitamins and fat-soluble vitamins
Adequate rest
Treat underlying cause - avoid alcohol, remove biliary obstruction, avoid drugs that further liver stress - Tylenol, phenobarbital, thorazine

Ethical issue

Do nurses have the obligation to care for a client with lifestyle issues?
Difficult, self-induced, easy to judge, demanding. Responsibility to assist in the care of those who are in need. Refer client to substance abuse center. Health care workers must look beyond abusive personalities and treat the person holistically

Gallbladder

Distensible, pear-shaped muscular sac
Located on ventral surface of liver
Function is to store and concentrate bile - can hold 20 to 50 ml of bile
Entrance of food into the intestine causes contraction of the gallbladder and relaxation of the sphincter of Oddi. Stimulation for gallbladder contraction is hormonal
Common bile duct connect with hepatic duct and pancreatic duct

Cholelithiasis

Gallstones
Caused by precipitation of substances contained in bile - cholesterol and bilirubin
Factors contributing to formation: abnormalities in the composition of bile, stasis of bile, inflammation of gallbladder, obesity (more cholesterol), women (multiple pregnancies)

Many do not have symptoms, but symptoms start when the stones obstruct bile flow. Small stones can pass into the common duct and produce indigestion and biliary colic - pain is generally abrupt and increases steadily. Will reach climax at 30 to 60 minutes. Large stones are more likely to cause obstruction and jaundice
Additional manifestations: flatulence, bloating, belching, intolerance of fatty foods

Diagnostics: ultrasound, CT, monitor fluid and electrolyte balance
Treatments: ERCP to remove stones from the common bile duct, monitor for complications such as pancreatitis, and diet modifications - low fat

Cholecystitis

Acute or chronic inflammation of the gallbladder associated with cholelithiasis.
Associated with complete or partial obstruction of bile flow. Inflammation is caused by chemical irritation from the concentrated bile, along with mucosal swelling and ischemia resulting from venous congestion and lymphatic stasis
Bacterial infection may arise secondary to ischemia and chemical irritation.
Manifestations: pain, precipitated by fatty meal, vomiting, jaundice, fever, elevated WBC, total serum bilirubin and ALP elevated

Diagnosis: ultrasound, MRI, CT
Treatment: laparoscopic cholecystectomy - removing the gallbladder. Treatment of choice. Easy surgery - can return to work in one week. Removal does not usually interfere with digestion. Can also get an open cholecystectomy. Need antibiotics and pain management

Pancreas

Lies beneath the stomach. Symptoms of disease do not usually appear until the disorder is far advanced.
Exocrine pancreas secretes digestive enzymes
Breaks down dietary proteins
Secretes amylase which breaks down starch and lipase
Pancreatic enzymes are secreted in the inactive form and become activated in the intestines - enzymes would digest pancreatic tissue

Acute hemorrhagic pancreatitis

Life-threatening. Escape of activated pancreatic enzymes into the pancreas and surrounding tissue causing autodigestion and hemorrhage
Associated factors: biliary tract obstruction (gallstones), alcohol abuse (potent stimulator of pancreatic secretions - known to cause partial obstruction of the sphincter or Oddi), hyperlipidemia, hyperparathyroidism, viral infections, abdominal and surgical trauma, steroids and diuretics

Diagnosis: CT, MRI, total serum amylase levels (rise within first 24 and stay elevated for 48 to 72), serum lipase (rise within first 24 and stays elevated for 5 to 14 days), elevated WBC, hyperglycemia (islet cell damage), elevated serum bilirubin

Treatment: pain relief - Demerol causes fewer spasms of sphinter of Oddi than morphine, putting the pancreas to rest - NPO until bowel sounds present, gastric suctioning, TPN, restoration of lost plasma volume - IV fluids and electrolytes. Need to check if there has been damage to islet cells causing diabetes

Chronic pancreatitis

Chronic irreversible inflammation (monocyte and lymphocyte) that leads to fibrosis with calcification.
Progressive destruction of pancreas
Types: chronic calcifying - chronic protein plus form in pancreatic ducts. Seen most in alcoholics. Chronic obstructive - stenosis of the sphincter of Oddi caused by cholelithiasis that has been left untreated for a long time

Caused by genetics, trauma, or cystic fibrosis

Symptoms: similar but less severe than acute pancreatitis. Recurring episodes of epigastric and ULQ pain. Attacks are often precipitated by alcohol use or overeating. Anorexia, nausea, vomiting, constipation, flatulence, eventually pancreatic functions become deficient - diabetes and malabsorption syndrome. Primary manifestation of malabsorption is steatorrhea

Treatment: treat coexisting biliary tract disease, low-fat diet, signs of malabsorption can be treated with pancreatic enzymes (enteric coated capsule), treat diabetes, quit drinking, pain relief, advanced cases - subtotal or total pancreatectomy. ERCP may provide some pain relief by performing sphincterotomy, dilation of strictures, removal of stones, or stenting of pancreatic ducts

Skin anatomy

Skin
Hair
Nails
Various glands
Most visible organ of body
Devote a lot of time to improving its appearance - when something goes wrong, effects are immediately apparent

Epidermis, dermis, subcutaneous layer, connective tissue.
Dermis: hair follicle, sebaceous glands, nerves, sweat glands, arteries, veins

Skin functions

Protection - covers and protects tissues and organs from impacts, chemicals, infections, and loss of body fluids.
Temperature maintenance: regulates heat exchange with the environment. Burn patients have difficult time regulating temp
Synthesis and storage of nutrients - epidermis synthesizes vitamin D with exposure to UV light. It is absorbed by the liver and converted into calcitriol by the kidneys - essential for absorption of calcium and phosphorous by the small intestine
Dermis stores fat
Sensory reception - touch, pressure, pain, temp. Relay info to nervous system
Excretion and secretion: glands excrete salt, water, organic waste. Specialized glands secrete breast milk

Transdermal drug administration

Sticky, drug-containing patch
Contains extremely high concentrations of the drug - lipid soluble, carried across epidermis, slow moving, absorbed into circulation
Placed over skin
Make work for several days, making pills unnecessary

Scopolamine - used for motion sickness
Estrogens
Nicotine - used most often in hospital

Aging changes

Skin injuries and infection become more common - epidermis thins as stem cell activity declines
The sensitivity of the immune system is reduced - amount of macrophages residing in skin decreases
Muscles become weaker, and bone strength decreases. Secondary to reduced calcium and phosphate absorption due to decline in vitamin D production
Sensitivity to sun exposure increases - produce less melanin because melanocyte activity declines (pale skin)
The skin becomes dry and often scaly - glandular activity declines, reducing oil and sweat
Hair thins and changes color - follicles stop functioning or produce thinner, finer hairs. Decreased melanocyte activity creates gray hair
Sagging and wrinkling of the skin - dermis becomes thinner, and the elastic fiber network decreases in size. The skin becomes weaker and less resilient
Decrease ability to lose heat - blood supply to dermis is reduced, sweat glands become less active, combination makes older clients less able to lose heat, overexertion and overexposure to high temps can be dangerous
Skin repairs proceed relatively slowly - skin repair 3-4 weeks in young adults, but 6-8 weeks in older adults

Skin assessment

Objective data:
Past health history: jaundice (liver), delayed wound healing (diabetes), cyanosis (respiratory issues), pallor (anemia)
Medications: acne or hair loss as side effects
Surgery or other treatments
Health perception and health management pattern: sunscreen

Physical assessment:
Skin: evenly pigmented, warm, good turgor, no petechiae (small broken blood vessels), purpura (vasculitis), lesions, or excoriations
Nails: pink, oval, adhere to nail
Hair: shiny and full, amount and distribution appropriate for age, clubbing, no flaking of scalp, forehead, or pinna

Pruritis

Itching
Can be caused by almost any physical or chemical stimulus - drugs, insects, dry skin
Treatment: itch/scratch cycle must be broken to prevent excoriation, lichenfication (from scratching an area too long - skin becomes thick, leathery, dark), and infection. Avoid heat or rubbing (vasodilation) - promote a cool environment
Keep skin moist, dryness increases itch sensation - wet dressings, hydrating creams and lotions

Eczema

Chronic condition of itchy skin linked to hay fever and asthma. May affect any area, but appears on arms and behind knees. Tends to flair periodically and then subside. Link to allergens and genetics
Manifestations: red, brownish gray patches. Itching, which may be severe at night. Small, raised bumps which may leak fluid and crust over when scratches. Thickened, cracked, or scaly skin. Raw, sensitive skin from scratching
Treatment: eliminate allergens, reduce inflammation, relieve itching, cool, wet compresses, prevent future flare-ups, mild non-irritating soaps, moisturize skin, cotton clothes. Apply creams and ointments to relieve itching. Need to try to identify what causes flare ups and avoid.

Dermatitis

General term for inflammation of the skin
-Contact: direct contact to irritant
-Seborrheic: scalp and facial - oily skin, hereditary. Dandruff
-Atopic (eczema): itchy rash - allergies, genetic tendency
-Perioral: dental products, makeup
-Neuro: localized - chronic irritation. Usually linked to eczema
-Stasis: buildup of fluid under the skin of the legs - varicose veins, circulation issues
Many causes, not contagious, not life-threatening
Clinical manifestations: red, swollen, itchy lesions. Can lead to cellulitis.
Treatment: corticosteroid creams, wet compresses, avoiding irritants

Psoriasis

Autoimmune disease that appears on any site of the body. Skin is regenerating too fast. Associated with other serious health conditions such as diabetes, heart disease, and depression. Not contagious
Clinical manifestations: bright red areas of raised patches on the skin, often covered with loose silvery scales. Can be localized or general - itchy
Treatment: no cure. Treatment is focused on controlling symptoms. Reduce inflammation, suppress rapid turnover of epidermal cells, topical steroids. Artificial UVB light slows the growth of skin cells

Acne

Inflammatory disorder of sebaceous glands. More common in teens but seen in adults. Flare can occur before menses, with use of corticosteroids, or birth control pills.
Clinical manifestations: blackheads, whiteheads, pustules, nodular acne. On face, neck, back, chest
Treatment: extractions, topical creams, systemic antibiotics, Accutane (form of vitamin A) - long lasting remission. Not always has to do with hygiene and diet

Skin tears

Acute traumatic wounds
These are not pressure ulcers
Result from separation of the epidermis and the dermis - mostly seen in older adults (steroids). Difficult to prevent and treat
Most commonly seen in upper extremities due to wheelchair, bumping into objects, transfer and falls, tape removal, positioning
Treatment: appropriate wound care and dressings - minimize tape use. Prevention is key - use of long sleeves and pants, padded garments, gloves, gentle adhesives, frequent moisturizing, good nutrition, use pillows, appropriate use of equipment, educate staff

Pressure ulcers

Area of skin that breaks down when you stay in one position too long
Constant pressure against skin reduces blood supply to area and tissue dies.
Seen in bony areas
Factors: bedridden, fragile skin, chronic conditions (diabetes, vascular), immobility secondary to spinal or brain injury, malnourishment, mental disability, older age, urinary incontinence or bowel incontinence
Stage I: reddened area, nonblanchable
Stage II: skin blisters, forms open sore, may be red or irritated
Stage III: breakdown looks like a crater, damage to tissue below skin
Stage IV: deep damage to muscle and bone, and sometimes tendons and joints
Treatment: wound care and dressings, reduce pressure on bony areas, improve nutrition and underlying conditions, keep skin clean and dry, good hygiene, educate patient, family, and healthcare providers. Turn q 2 hours

Sunburn

Melanocytes produce melanin to protect skin from UV rays. If UV rays exceed what can be blocked, we burn
Drugs that cause photosensitivity: anticancer drugs, antidepressants, antidysrhythmics, antihistamines, diuretics (Lasix, HCTZ), hypoglycemic, NSAIDs
Health promotion: advocate for safe sun practices - strongest between 10 and 4. Can still sunburn with overcast. Can be more sunburnt in snow and water. Protect with clothing and sunscreen. Recommended SPF of 15 daily - 30 min before goin outdoors and q 2 hours and immediately after swimming

Cellulitis

Inflammation of subq tissues from enzymes produced by bacteria - break in skin. S aureus and strep usually causative agent
Clinical manifestations: hot, tender, red, swollen, chills, fever, malaise
Treatment: moist heat, immobilization and elevation, systemic antibiotic therapy, hospitalization if severe, progression to gangrene, amputation if severe

Herpes zoster

Shingles. Nerve fiber contains dormant varicella virus. Weakening of immune system reawakens virus and travels to end of nerves. Will have painful blisters filled with pus. These blisters pop and then crust over and heal. We can then end up transferring the virus to someone who has not had chicken pox.
Occurs frequently in autoimmune patients
Manifestations: grouped vesicles, unilateral on trunk, face, and lumbrosacral areas. Will not cross the midline. Burning, mild to severe outbreak, and neuralgia preceding outbreak
Treatment: antiviral agents, analgesic, wet compresses, white petroleum on lesions, scarring, vaccine to prevent shingles in adults who have had chicken pox

CDC

Provides information on vaccines. Does not regulate schools or child care centers.
Advisory committee on immunization practices provides schedule recommendations, policies, and procedures
Provides education for parents and providers, common questions about vaccines an preventable diseases, vaccine information sheets, and more.

Contraindications for vaccines

Anaphylactic reaction to a vaccine contraindicates further doses of that vaccine. Anaphylactic reaction to a vaccine constituent contraindicates the use of vaccines containing that substance. Moderate or severe illness with or without fever. Live virus in immunocompromised patient and patients with acquired passive immunity
Vaccines are NOT contraindicated with mild illnesses and fever

Side effects of vaccines

NOT CONTRAINDICATIONS
Soreness, redness, or swelling at injection site, low grade fever, fussiness, drowsiness, decreased appetite.
Symptoms often start within hours to 1-2 days after. Acetaminophen and ibuprofen can be used. Continued use of the sore extremity will help with the pain.

VIS and documentation

Provider is responsible for reviewing risks/benefits of vaccine. VIS provides updated info about vaccine risk/benefits for specific vaccines. Publication date of VIS is part of vaccine documentation - IMPORTANT
Documentation: complete date of administration, name of vaccine, manufacturer and lot number, site and route of administration, name and title of person administering, informed consent, adverse reactions reported to vaccine adverse event reporting system

Vaccine barriers

Too many shots at once (comfort and overwhelming immune system), not natural, concern about ingredients, vaccine will cause another disease or condition, these diseases do not exist, it won't happen to me attitude, religious, herd immunity (think since everyone is immune, they do not need to get the vaccine), but actually some vaccines require 95% vaccination to reach herd immunity

Hepatitis B

Contagious liver disease spread through contact with blood or bodily fluids, people who are chronically ill can pass the virus even when asymptomatic. Contact with contaminated objects - virus can live up to 7 days
Infections can lead to fatal liver problems
Three series vaccine over a 6 month period
1st dose generally at hospital before discharge
2nd dose at least 4 weeks after first
3rd dose at least 8 weeks after 2nd but no earlier than 24 weeks
Contraindications: life-threatening allergy to yeast or any other vaccine component, previous life-threatening allergic reaction to previous dose

Rotavirus

Virus that causes diarrhea
Two or three series vaccine
1st: 2 months
2nd: 4 months
3rd: 6 months
PO liquid vaccine
Contraindications: severe combined immunodeficiency, history of intussusception, severe anaphylaxis after previous dose
This vaccine can only be given during the indicated ages. Would not give this to a 1 year old because they are beyond the risk.

DTaP

Diphtheria: spread person to person - respiratory complications
Tetanus: enters body through cuts or wounds - painful muscle tightening
Pertussis: spread person to person - coughing spells, difficult to eat, drink, breathe
Five series vaccine: 2 months, 4 months, 6 months, 15-18 months, 4-6 years
Contraindications: brain or nervous system disease within 7 days of previous dose, fever over 105 after previous dose.
TDaP: given as booster starting at 11-12 years and approximately every 10 years thereafter. Important for pregnant women

Haemophilus influenza type B

Bacterial infection spread person to person. Decreased incidence of bacterial meningitis in children <5 years old. Bacteremia, meningitis, epiglottitis, cellulitis, infectious arthritis
1st: 2 months
2nd: 4 months
3rd: 6 months
Final: 12-15 months
No specific contraindications - should not be given to anyone less than 6 weeks

Pneumococcal vaccine

Pneumococcal disease is caused by strep pneumoniae bacteria. Spreads person to person. Can cause pneumonia, blood infections, and meningitis. Difficult to treat due to resistant strains.
1st: 2 months
2nd: 4 months
3rd: 6 months
4th: 12-15 months
No specific contraindications

Polio

Virus that can cause paralysis and meningitis. Used to be common in the US
OPV: risk of vaccine associated polio paralysis. Has not been used in the US since 2000
IVP: more injections, increased cost, no new VAPP since use.
1st: 2 months
2nd: 4 months
3rd: 6-18 months
4th: 4-6 years
Contraindications: allergy to neomycin, streptomycin, polymyxin B

MMR

Measles: rash, cough, runny nose, fever, pneumonia, seizures, brain damage. Spread person to person through air
Mumps: fever, headache, swollen glands, deafness, meningitis
Rubella: rash, mild fever, prenatal complications (miscarriage, birth defects)
1st: 12-15 months
2nd: 4-6 years
Contraindications: anaphylaxis to gelatin or neomycin, has HIV or other immune problem, high dose oral steroid treatment, cancer and cancer treatment, pregnancy

Varicella

Common childhood disease. Spread person to person through air or contact with vesicle fluid
1st: 12-15 months
2nd: 4-6 years
Often given as combo with MMR.
Contraindications: anaphylaxis to gelatin or neomycin. Immunocompromised, pregnancy

Hepatitis A

Virus spread by person to person contact via fecal-oral route and sexual contact or contaminated food/water
Minimum age is 12 months
1st: 12-23 months
2nd: 6-18 months after first
No specific contraindications

HPV

Most common sexually transmitted virus in US. Prevent HPV related cervical cancer. Recommended to boys and girls 11-12 years of age so they are vaccinated before they come in contact
Cervarix: bivalent vaccine for females only
Gardasil: quadrivalent vaccine for males and females
Gardasil 9: protects against 9 of the types of HPV. Females and males. Newest HPV vaccine
1st: now
2nd: 1-2 months after 1st
3rd: 6 months after 1st dose and 12 weeks after 2nd
Contraindication: pregnancy

Meningococcal

Serious bacterial illness that can cause meningitis - death, loss of limbs, nervous system problems, deafness, seizures, stroke. Particular risk for college students living in dorms and military recruits
1st: 11-12 years
2nd: 16 years
No specific contraindications
Five different strands of the bacteria - different brands cover different strains. Menactra is most common and covers 4 of them

Influenza

Virus most active between October and May. Recommended yearly for children 6 months and older.
1st dose for children 6 months to 8 years is given as two separate doses 4 weeks apart.
6-35 months: 0.25 mL
3 years and older: 0.5 mL

Live attenuated vs inactivated - nasal spray vs injection
Contraindications: anaphylaxis to eggs, gelatin, history of Guillan-Barre syndrome

Vaccines at birth

Hepatitis B 1

Vaccines at 2 months

Hep B 2
Rotavirus
DTaP
Hib
Pneumococcal
Polio

Vaccines at 4 months

Rotavirus 2
DTaP 2
Hib 2
Pneumococcal 2
Polio 2

Vaccines at 6 months

Hep B 3 (up to 18 mo)
Rotavirus 3
DTaP 3
Hib 3
Pneumococcal 3
Polio 3 (up to 18 mo)
Start Flu shot

Vaccines at 12 months

Hib 4 (up to 15 mo)
Pneumococcal 4 (up to 15 mo)
MMR 1 (up to 15 mo)
Varicella 1 (up to 15 mo)
Hep A 1 and 2 (up to 15 mo)

Vaccines at 15 months

DTaP 4

Vaccines at 4-6 years

DTaP 5
Polio 4
MMR 2
Hep A 2

Vaccines at 11-12 years

Meningococcal 1
TDaP booster 1
HPV (3 dose series)

Vaccines at 16-18 years

Meningococcal 2

Administering vaccines

All IM except MMR is subq and flu is ID. Polio can be IM or subq. Rotavirus is oral. Varicella and zoster are subq. MMRV is subq

Subq:
Infants: 5/8" vastus lateralis
12 months or older: 5/8" vastus lateralis or back of arm

IM:
Newborn: 5/8" vastus lateralis
Infants: 1" vastus lateralis
Toddlers: 5/8-1 3/4" deltoid or vastus lateralis
Children 3-18: 5/8-1 3/4" deltoid or vastus lateralis
Adults: 1 - 1 1/2" deltoid