peds exam 2

live vaccines must be given

1 month apart

live vaccine examples

rota, MMR, varicella

the catchup schedule provides schedule for children

who do not get first doses at recommended times

are more than 1 month behind in any given vaccine or series

the catchup schedule advises on

minimum age and intervals between doses

vaccine footnotes

give additional info

helps clarify questions

vaccines should not be given before

the minmum age listed on the vaccine schedule bc child is unable to develop immunity before that age

do not give vaccines after

maximum age

maximum age for vaccines indicate that

risk of exposure to disease is minimum after that age or child had probably been exposed and does not need

HIB, PNEUMOCOCCAL, ROTA

minimum dose intervals are approved by

the advisory committee on immunization practices, AAP, AAFP

a decreased interval between doses of any vaccine may interfere with

final level of protection

ACIP allows for up to ___ days prior to minimum interval

4 days

any and all vaccines can be

administered together on the same visit

can you restart vaccine series?

NEVER DO THIS NO MATTER HOW LONG SINCE THE PREVIOUS DOSE

increased interval between doses

does not decrease final level of protection

if live vaccines are not given on the same day

space them more than 28 days apart

if two live vaccines are given closer than 28 days apart

the vaccine given second should be repeated

live vaccines should never

be given to pregnant women

HPV SHOULD NOT EITHER

live virus vaccines are given ____ a TST to ___

BEFORE

reduce the reaction to TB testing

best practice is to administer PPD or draw blood on ____ as live vaccine given

same day

if live vaccine and TST/IGRA not done on same day

wait 4+ weeks after live vaccine to give the PPD or draw blood

simultaneous admin of antibodies and inactivated vaccines is recommended for

post-exposure prophylaxis of some infections such as hep b, rabies, tetanus

inactivated vaccines can be given ________ as an antibody product

any time before, after, or at the same time

for live vaccines separate antibody administration from

vaccine administration

wait _____ after vaccination before giving immune globulin

2 weeks

wait _____ after giving antibody before giving vaccine

exceptions include

3 months or more

yellow fever, zoster, lost dose of anti-Rho D, oral typhoid, LAIV, rota

contraindications for vaccine admin

severe febrile illness

immunocompromised child or household member

recently acquired passive immunity (blood transfusion, immunoglobulin, or maternal)

known allergic response

parental fears, misinfo, and questions

religious beliefs

common vaccine components that may cause serve allergic reaction in sensitized persons

egg

neomycin, streptomycin, polymyxin B

latex

eggs are a part of

yellow fever and influenza

neomycin, etc are part of

any vaccine containing IPV

not contraindications to vaccination

mild illness

antimicrobial therapy

disease exposure or convalescence

pregnant or immunocompromised person in the house

breastfeeding

preterm birth

allergy to products not present in the vaccine or allergy that is not anaphylactic

family history of adverse events

TST

multiple vaccines

immunization screening questionnaire for children

• Is the child sick today?

• Does the child have allergies to medications, food, a vaccine component or latex?

• Has the child had a serious reaction to a vaccine in the past?

• Has the child had a health problem with lung, heart, kidney, or metabolic disease (e.g. diabetes), asthma, or a blood disorder? Is he on long-term aspirin therapy?

• If the child is between ages 2-4, has a healthcare provider told you that the child had wheezing or asthma in the past 12 months?

• Has the child, sibling, or a parent had a seizure: has the child had brain or other nervous system problems?

• Does the child have cancer, leukemia, AIDS, or any other immune system problem?

• In the past 3 months, has the child taken cortisone, prednisone or other steroids, or anticancer drugs, or had radiation treatments?

• In the past year, has the child received a transfusion of blood or blood products or been given immune (gamma) globulin or an antiviral drug?

• Is the child/teen pregnant or is there a chance she could become pregnant during the next month?

• Has the child received vaccinations in the past 4 weeks?

vaccine adverse reactions

minor reactions are most common

can be local or systemic

local reactions to vaccines

injection site reactions (pain, swelling, redness)

more likely with inactivated

usually mild, self-limiting

systemic reactions to vaccines

fever, malaise, headache

nonspecific

severe vaccine reactions

anaphylaxis

encephalitis (pertussis antigen)

chronic arthritis (rubella vaccine)

thrombocytopenia purpura (measles vaccine)

death

allergic rxns to vaccines are

due to vaccine or component

risks minimized by screening

live attentuated vaccines are more likely to cause severe or fatal reactions in _____ individuals than inactivated

immunocompromised

vaccine adverse event reporting system (VAERS)

• Created in 1990 as a means to collect and unify all the adverse events reports

• National reporting system administered by CDC and FDA

• Depends on healthcare providers to report adverse events (Passive Reporting system) 

• Reporting can be done via:

  • Online form

  • Fax

  • Mail

• Receives 28,000 reports/day; More than 371,000 reports received as of 12/31/10

national childhood vaccine injury act of 1986

• Requires vaccine information be provided by all public and private vaccination providers before each dose of vaccine

  • Called Vaccine Information Statements (VIS)

national childhood vaccine injury act of 1986 required the following documentation for each dose

• Date of administration

• Manufacturer and lot number

• Name, title and work address of person administering the vaccine

• Vaccine Information Statement (VIS):

  • Date given

  • Publication date of VIS (found of bottom of VIS)

herd immunity

a form of indirect protection from infectious disease that can occur with some diseases when a sufficient percentage of a population has become immune to an infection, whether through previous infections or vaccination, thereby reducing the likelihood of infection for individuals who lack immunity. Immune individuals are unlikely to contribute to disease transmission

generalized rash

• entire body 

  • viral, allergic, chicken pox 

localized rash

• specific area 

  • limited to a defined area 

  • athletes feet, poison ivy 

  • can be linear or localized 

viral rash

• may be benign and self limiting 

• may be due to contagious childhood illness 

• Warts

  • verruca 

  • HPV

  • elevated, rough papules-alone or grouped 

  • Direct contact

  • increased risk in eczema, public showers 

  • TX: cryotherapy, salicylic acid, electrocautery, may resolve spontaneously 

measles

• highly contagious virus: droplet/contact 

• incubation: 10-20 days 

• contagious: 4 days before until 5 days after birth 

• high fever, conjunctivitis, cough, rhinorrhea, red eyes, sore throat THEN red, flat rash starts on face, spreads down 

• Management: supportive-acetaminophen, hydration

  • antibiotics for secondary infections: OM, pneumonia 

  • vitamin A 

    • reduce pneumonia in complications 

• Koplik's spots-inside mouth, 2-3 days after Sx

mumps

• men can become sterile due to orchitis 

  • parotitis 

  • most contagious before swelling begins 

  • incubation: 14-21 days 

  • Transmitted: droplet/direct 

  • fever, muscle aches, headache, earache worse with chewing then parotid gland enlarges by day 3 

  • management: acetaminophen, analgesics, hot/cold packs 

  • complications: sensorineural deafness, orchitis, encephalitis  

bacterial rashes

• antibiotic treatment 

• return to school 24 hours after TX begins 

fungal rashes

• commonly seen in school age children 

• spread by direct contact 

• incubation period uncertain 

• contact can be with infected person, surface or sharing combs/brushes 

• Pruritic, annular lesions with raised outer border and central clearing

• Tinea cruris

• Candidiasis 

tinea corporis

• (body) erythematous rings, topical antifungal e.g. 

•            Miconazole 2%, Ketoconazole 2%

tinea capitis

• (scalp)- may be asymptomatic, Selenium 2.5% shampoo twice weekly

tinea pedis

• (athlete’s foot)- severe itching with and dryness and scaling, aluminum subacetate solution soaks 20 min bid, topical antifungal

allergic rashes

• Often hive like

• Result of histamine release of an allergen due to medication, food or pollen. 

• Itchy round or oval lesions

• Prevention: Future avoidance with the allergen if identified

eczema

• Atopic Tendency:  inherited

• The Allergic Triad

•   Asthma 

  • Allergic rhinitis     

•   Atopic dermatitis

• Food allergy, asthma, sensitive/ reactive skin

• Infants:  can present as milk allergy, food allergy.  

• Infants:  generalized distribution

• Children:  antecubital, popliteal fossae, ankles, wrists, feet.  Symmetric.

• TREATMENT:  

• Antihistamines

• Moisturizers:  cream/ointment, frequent application

• Topical corticosteroids for flare ups

• Topical immunomodulators- to decrease inflammation during flares

• Antibiotics for secondary bacterial infections

• Phototherapy in severe cases  

bites and stings

• variety of causes 

• bees are most common 

• Lyme Disease

• Rocky Mountain Spotted Fever

pediculosis capitis

• HEAD LICE

• Scalp itching, red bumps, nits

• Treatment:  1% permethrin shampoo

• Remove all nits 

• Launder clothing, bedding, or bag for 14 days

• Resistant:  malathion 0.5%

• Avoid sharing combs, hats, hair accessories, headphones, pillows, towels

• Itching is due to reaction to louse saliva.  Nits are very small, and stick to hair shaft-es

• especially around the ears and at the base of the neck.

• Flea bites 

lyme disease tx

•  less than 8 yrs  Amoxicillin 14-21 days, older than 8 doxy 

RMSF tx

• Doxy for 7-10 days 

scabies tx

•  5% Permethrin to entire body for 8-14 hours

At least ___ of students today are diagnosed with a chronic condition making them vulnerable to infections.

25%

backbone to preventing the spread of infectious rashes

Hand washing, skin hygiene and immunization

• 6 year old female with a fever of 100.4 (38.0 c).  

• Complained to her mom that she had a sore throat earlier in the week.

• Macular erythematous rash on cheeks

• Maculo-papular rash on trunk and upper extremities 

fifth disease

• 5 Year old boy with a history of strep throat 2 weeks ago

• Peeling skin on hands, feet, elbows and knees

• Several days after beginning treatment for strep he had a sandpaper like rash on his trunk.

scarlet fever

• 12 year old girl. Rash started 4 days ago on the corner of her right lip

• Rash has become fluid filled pustules extending down the chin

• Red lesions with honey-colored crusts

impetigo

• 15 year old boy. With rash spreading from neck up to face.

• Began with itchy patches and pustules

• Spread now annular, scaly lesions with central clearing

ringworm

• 6 year old boy with a history of asthma

• Food allergies

• Itchy, dry erythematous on arms, abdomen, behind knees and elbows

eczema

• 11 year old girl with annular enlarging rash

• Rash is not itchy

• Low grade fever

lyme disease

• 8 Year old Female with small red itchy welts in a row.

• Rash started two days ago.

• Rash is on the face, neck and extremities.

bed bugs

• 7year old male with a painful cluster like rash.

• Started three days ago.

• Rash is only on the left buttock and flank.

shingles

• 3 month old male with temp of 100.2 & itchy generalized rash.

• Started 3 days ago.

• Macules, Papules and Vesicles.

varicella

• 6 Year old male with a temperature of 103 for 4 days.

• On day 5 a rash started on his face and upper neck

• rash spread to extremities

measles

• 5 Year old female with small blisters and red spots on palms of hands soles feet and in her mouth.

• She complains of a sore throat.

• She has a fever of 100.5.

coxsackie

• 16 year old female with an itchy, red raised generalized rash.

• No fever or other complaints.

• Denies exposure to sick friends.

hives

macule

• flat, pigmented, well-defined, less than 1 cm

• skin irritations like sun burns

• viral rash like the illness leaving their body 

• drug rxn (photosensitivity) 

• measles, freckle

papule

• elevated, well-defined, less than 1 cm 

• eczema maybe scaly or papular 

• hives

• molluscum contagiosum 

• scabies, insect bites, acne, mono

vesicle

• elevated lesions, up to 1 cm, contains fluid, blister like 

• chicken-pox, cold sores, allergic reactions, shingles, poison ivy  

bulla

• elevated lesion, larger than 1 cm, containing fluid, blister, friction like latex reaction, burns 

pustule

• pus-filled, elevated, well-defined 

• acne, scabies, chicken pox, staph infection 

wheal

• raised, itchy, reddish hue, may come and go, smooth and elevated 

• hive/allergic reaction, food stings, medications, acute r chronic, hard to determine the cause, physical due to cold, heat, sun, exercise

GI assessment for children

• Hx: pattern of elimination 

• clinical examination and observation 

  •  activity, is skin moist/dry, lips, mucous membranes, do eyes appear sunken, sunken fontanel?

• I and O

• Weight and Height 

• Abd assessment 

• Lab tests

  • Stool exam- appearance- color, consistency, amount, frequency

  • O&P- lab test to identify presence of infection

  • Stool culture:  same for bacterial infection

  • Occult blood guaiac- identifies presence of blood in stool, ie heme 

GI dx procedures

• upper/lower GI

  • barium or air swallowed or enema, assesses structure, function, ID’s masses.  May be given via NGT. 

• US

• MRI/CT

• Endoscopy 

• Colonoscopy 

consequences of GI dysfunction

malabsorption

fluid and electrolyte disturbances

malnutrition

poor growth 

fluid balance replacement

• insensible water loss

  • through skin and resp tract, evap, urine/stool 

  • fever: 12% increase per degree C

• urine and stool 

increased fluid reqs

• fever, tachypnea

• radiant warmer, phototherapy (preterm infants)

• vomiting and diarrhea, DI, acidosis 

• shock, burn, postoperative bowel surgery 

decreased fluid reqs

• heart failure 

• increased ICP 

• renal failure 

• postop 

distribution of fluid

• total body water (TBW) 

• involves ICF and ECF 

  • intravascular, interstitial, transcellular 

water balance

• under normal conditions the amount of water ingested closely approximates the amount of urine excreted in a 24-hr period

• Water in food and from oxidation closely approximates the amount lost in feces and through evaporation

factors affecting water balance in infants

• greater fluid intake and output relative to size 

• disturbances occur more frequently and rapidly 

• body surface area (BSA) 

  • larger quantities of fluid lost through the skin 

• metabolic rate 

  • greater production of metabolic wastes 

• kidney function 

  • immature and inefficient in excreting waste 

umbilical hernia

• common in the NB period 

• typically resolves in the first years of life 

• nursing care management 

  • assessment, anticipatory guidance and education to family 

inguinal hernia

• pathophysiology 

• clinical manifestations

  • hernia versus incarcerated or strangulated hernia 

• nursing care management 

  • assessment, pre and post op care, support to child and family 

congenital diaphragmatic hernia

• opening between abdominal/thoracic cavities 

• causes compression/incomplete lung development (hypoplastic) 

• SRDS at birth 

• life threatening 

• NIU, intubation, ECMO then surgery once stable 

• long hospitalization, prone to respiratory complications 

esophageal atresia and TEF

• congenital defect where the esophagus fails to connect to the stomach 

• abnormal connection between trachea and esophagus 

• pathophysiology

  • occurs week 4/5 embryonic dev 

  • vacterl 

  • often have cardiac/vertebral anomalies 

• clinical manifestation 

  • bubbling/frothing at mouth, drooling 

  • cyanosis, coughing, choking 

  • aspiration, not able to pass NG tube 

• diagnostic eval 

• ng tube to suction, npo until repaired 

• maternal risk factors: increased maternal age, smoking, low SES, european ethnicity

• vertebral, anorectal, tracheal, esophageal, renal, radial 

omphalocele

• bowel covered with peritoneal sac, seen at birth or on ultrasound 

  • associated with other anomalies-cardiac, pulmonary 

  • surgical repair

  • keep sac sterile/moist 

  • prolonged hospitalization

  • maternal risk: alcohol, smoking, obesity, SSRIs  

  • Nursing care management: 

    • assessment and monitoring 

    • cover gastroschisis with sterile, moist dressing 

    • thermal regulation

    • fluid management 

    • care of high-risk infant 

    • prevention of infection and complications

    • long-term support to family 

gastroschisis

• bowel herniates through a defect in the abdominal wall to the right of umbilical cord 

• may need staged repair to replace intestines  

biliary atresia

• progressive inflammatory process-bile duct obstruction

• pathophysiology-immune/infection 

• clinical manifestations: prolonged jaundice beyond 2 weeks, dark urine, light stools, hepatomegaly

• dx evaluation: CBC bili, LEFTS, US abdomen, liver biopsy, exploratory laparotomy 

• therapeutic management: supportive care, then kasai, may need liver transplant in future 

biliary atresia nursing care management

• assessment and prioritization of care 

• education of tx and support for long-term care to patient and family 

• nutrition 

• pharmacologic therapies, phenobarb, ursodeoxycholic acid 

• Especially DIRECT bilirubin elevation

• Nutrition- fat soluble vitamin supplements, MV, minerals(iron, zinc, selenium)

• G tube/TPN feeding for growth failure with low sodium solution

• Phenobarbital stimulates bile flow, U –acid decreased cholestasis and pruritus from jaundice

cleft lip and cleft palate

• facial malformations that occur during embryonic development-lip may be uni or bilateral 

• may appear separately or together 

• family HX

• etiology and pathophysiology

  • maternal/environmental factors/genetic 

  • exposure to etoh, smoking, anticonvulsants, retinoids, steroids

  • folic acid deficiency during pregnancy 

  • therapeutic management 

    • surgical repair 

    • multiple surgeries 

• Cleft lip – most common birth defect in US!

• CL alone more common males, CP alone more common females

• Folic acid supplementation protective

• EXAM- gloved hand, palpate hard and soft palate

• Multidisciplinary team: craniofacial- plastics, ENT, orthodontics, speech, peds, nursing, audiology, SW, psychology

surgical correction of cleft lip and palate

• closure of the lip defect 2-3 mo, revisions later 

• palate repair at 6-12 mo age, revisions needed 

• speech often hypernasal-may need further repair surgically

• nursing considerations

  • support family and encourage parent-infant bonding 

  • promote healthy self-esteem 

  • pain management 

  • feeding 

  • preoperative and postoperative care 

  • long term 

    • AOM 

    • dental problems 

• Revisions to improve scar appearance, symmetry

• BMT’s at same time as repair- prone to ear infections

• Orthodontics- prone to dental anomalies

• Speech challenges- especially with cleft palate

• Feeding: wide nipple for bottle feeding if only cleft lip

• Special cut nipple for lip and palate

• POSTOP- no sucking on nipple or pacifier, no straws, spoons, forks- can damage incision

cleft lip/palate feeding

• CL Infant feeding:  NUK nipple or Playtex nurser, check support. 

• CL- breastfeeding usu ok, CP- need special feeding system, bottles- pump, non-nutritive sucking encouraged

• Cleft palate nurser- squeeze bottle in coordination with baby’s suck

• Noisy feeding, swallow lots of air, need extra burping

postop CP

 cup feeding/syringe feeding,

avoid prone position. 

Clear liquids x 24 hours, then liquids x 2 weeks.

Soft diet x 6 weeks.

No utensils in mouth to avoid injuring repair.

“No-No’s”.  

post op CL

•  May be able to breast/bottle feed, others syringe feed- provider decides