Chp 23/24 Physical Assessment

How do you assess the tympanic membrane of a child OLDER THAN 3?

UP and BACK

What are the early s/s of cystic fibrosis?

Wheezing and dry cough, bronchiolitis, pneumonia, purulent and copious sputum

Bacterial pharyngitis has an abrupt onset. The child will have experience similar symptoms as a viral infection. They may also have:

abdominal pain, headache, vomiting and usually lasts 3-5 days

Those with allergic rhinitis can also have allergic salute or allergic shiners which are:

allergic salute= crease in nose allergic shiners= dark circle eyes

Pulses can rise significantly in infants and children that have:

anxiety, fever, exercise, inflammatory illness, shock, or heart disease

Temperature can be done axillary, rectal, temporal, and oral. For an infant < 3 months __________ is preferred. For an infant older than 3 months temporal. Oral is used for children 5-6 years of age.

axillary

In order to be treated, a provider must observe the tympanic membrane. ____________ treatment is mainstay. As an alternative, watch and wait x 48-72 hours prior to antiniotics.

Antibiotic

_________ pulses are measured in children younger than 2 years

Apical

Which action would the nurse include in the plan for care for a 6-month-old infant with respiratory syncytial virus (RSV) who is in respiratory distress? A. Begin a clear fluid diet. B. Maintain droplet and contact precautions. C. Administer prescribed antibiotic immediately. D. Allow parents and siblings to room in with the infant.

B. Maintain droplet and contact precautions. DO NOT PUT ANYTHING IN MOUTH BC CAN ASPIRATE RSV is highly contagious therefore precautions; also why we DO NOT let parents sit in the room No antibiotics because it is a virus

A client is experiencing an acute episode of bronchial asthma. The nurse would focus on which goal when creating the client's plan of care?

B. Removing mucous secretions from the chest.

What will the tympanic membrane look like with otitis media?

Bulging, opaque tympanic membrane that usually looks red, with decreased mobility; diffuse light reflex; and obscured landmarks

What are the precautions for RSV?

Contact isolation and scrupulous hand hygiene (can live on non-porous surfaces for up to 6 hours)

For a child with epiglottis: DO NOT:

DO NOT leave child unattended DO NOT examine or attempt to obtain culture; any stimulation by tongue depressor or culture swab could trigger complete airway obstruction

How do you assess the tympanic membrane of a child YOUNGER THAN 3?

DOWN and BACK

What will the drainage be like with acute otitis media?

Drainage, usually yellowish green, purulent, and foul smelling (indicates perforation of the tympanic membrane)

What is viral pharyngitis?

Erythema, inflammation of pharynx and tonsils

Epiglottis is life threatening and rapidly progressive. It is almost always caused by:

H. Influenzae

What is the home treatment for croup?

Humidity- cool or warm air

RSV Prevention is crucial. How is it prevented?

Intramuscular palivizumab (Synagis) administered monthly IM (virus fighting antibodies)

What is cystic fibrosis?

It is a genetic disorder of the cell membranes. Causes thick, sticky mucus to build up in air passages, lungs, salivary glands, sweat glands, pancreas, and reproductive organs

Who is at higher risk for ear infections or issues?

Kids who go to daycare and kids that are bottle fed

What is status asthmaticus?

Life-threatening episode of airway obstruction that is unresponsive to common treatment

__________ pulses are measured in children older than 2 years

Radial

What is the causative agent for 50% cases of bronchiolitis?

Respiratory syncytial virus (RSV)

What is SIDS?

Sudden infant death of an infant younger than 1 year old. The exact cause is unknown. Usually occurs during sleep. More common in boys. Most common in winter months.

T/F Respiratory failure can be unrecognized or untreated respiratory distress. It is the most common cause of cardiopulmonary arrest in children.

TRUE

T/F: PANCREATIC ENZYMES HAVE TO BE TAKEN WITH EVERY MEAL OR SNACK

TRUE

What is Croup?

*BARKING COUGH sudden onset of harsh, metallic, barky cough, sore throat, inspiratory stridor and hoarseness

What are the GI manifestations of CF?

-Meconium ileus in newborn (super sticky and thick meconium that can cause a bowel obstruction) -Steatorrhea, bulky, frothy stools -Voracious appetite with no weight gain -Loss of appetite -weight loss -failure to grow -distended abdomen -anemia

Nursing Care for Resp Alterations: Maintain Fluid balance:

-Orally (clear liquids) or IV prn -saline nose drops

History taking from parents

-Prenatal & birth history -Family composition, health and lifestyle -Growth & development (achieved and when) -Family genetic diseases -Congenital defects

What are the differences in a childs respiratory system?

-Smaller airways and undeveloped cartilage -Less well developed intercostal muscles -Eustachian tubes relatively horizontal -Tonsillar tissue normally enlarged -More flexinle larynx, susceptible to spasm

How does viral pharyngitis present?

-Vesicles or ulcers on tonsils -Fever (usually low grade, may be high) -Hoarseness, cough, rhinitis, conjunctivitis, malaise, anorexia (early) -Cervical lymph nodes may be enlarged, tender -usually lasts 3-4 days

Other cystic fibrosis manifestations:

-abdominal distention -vomitting -failure to pass stools -rapid development of dehydration

What is the treatment for Croup?

-allow chid to remain in comfort position -pulse oximetry -blow by humidifed oxygen -racemic epinephrine -dexamethaosne -neck films -KEEP CHILD QUIET- LESS AIR USED

Basic Principles of the physical exam:

-apply knowledge of growth and development -establish trusting relationship -respect cultural needs and differences -systematic approach (head to toe; painful at end) -involve parents

Caring for a child with Tonsillectomy:

-assess the child for post operative bleeding -excessive swallowing -elevated pulse, decreasing blood pressure -signs of fresh bleeding in the back of the throat -vomiting bright red blood -restlessness not associated with pain

Increase in work of breathing & respiratory effort is demonstrated by:

-body position -mental status -vital signs -breath sounds -work of breathing -skin color

How do you gain a child's cooperation and trust?

-dont go too fast, -give choices but not control -talk with the child, not at the child -keep a security object near or with the child

Manifestations of Asthma

-dry cough -wheezing -SOB, dyspnea on exertion -retractions, nasal flaring -tachypnea, orthopnea -restlessness, apprehension, diaphoresis

Long term management of Asthma includes:

-environmental control (irritants and allergens) -exercise (warm the air, breath through nose covering mouth) -infection -emotions -monitor symptoms (early treatment is better, peak flow meter)

When assessing respiratory, compare one side to the other. Look for:

-equal breath sounds -diminished breath sounds -poor exchange -abnormal breath sounds -cough

What are some therapeutic management of CF?

-exercise and physical fitness -chest physical therapy -flutter mucus clearance device- hand-help pipe that facilitates removal of mucus -antibiotic therapy intermittent or continuous -immunzations -treatment of complications -lung transplant

Asthma is a reversible obstructive airway disease that is characterized by:

-increased airway resposiveness to a variety of stimuli -bronchospasm resulting from constriction of bronchial smooth muscle -inflammation and edema of the mucous membranes that line the small airways and the subsequent accumulation of thick secretions in the airways

Therapeutic Management for an Acute Asthma Episode:

-physicians office or ER -bronchodilator, usually short-acting beta adrenergic agonist (SABA) such as Albuterol administered via powder nebulizer -If improved= return home with SABA prescription and other routine medications -> antihistamines and corticosteroids

Nursing Care for Resp Alterations: Other

-reduce patient and family anxiety -promote rest, reduce fever, decrease anxiety

Pharyngitis is usually self-limiting and relatively minor however, streptococcal infections can have SERIOUS complications such as:

-rheumatic fever -acute glomerulonephritis *educate the IMPORtANCE TO FINISH ANTIBIOTICS

During an episode of apnea, it is important to note the following:

-time and duration of the episode -color change -bradycardia -O2 saturation -action that stimulated breathing

The child with croup will experience:

-use of accessory muscles to breath -frightened appearance -agitation -cyanosis

RSV is a significant cause of hospitalization in children under ______ years old. It is HIGHLY COMMUNICABLE

1

What are some interventions to help protect against SIDS?

1. Back sleeping at all times 2. Use firm flat services 3. Keep baby sleep area in the same room until 6 months old 4. Keep soft bedding such as pillows/blankets out of crib 5. Do not cover babys head or allow baby to get too hot 6. Do not smoke or use nicotine during pregnancy 7. Breastfeeding!! (helps) 8. Visit HCP regularly 9. Offer baby pacifier at nap time and bedtime (if breastfeeding then wait to use pacifier until breastfeeding is well established)

What are the 4 cardinal signs of Epiglottis? (4 D's)

1. drooling 2. dysphagia (diff swallowing) 3. dysphonia (diff talking) 4. distressed respiratory efforts

Blood pressure routine screening starts at 3 years. Any reading ABOVE ____/__ is considered prehypertensive

120/80

For CF: assess newborn for feeding and stooling patterns. Administer medications to treat infections aggressively (increase lung damage). Offer nutritional support. How often is chest physiotherapy done?

2-4 times a day -assist with mechanical vest -oxygen administration -physical activity alternating with rest

What is epiglottis?

Acute inflammation and swelling of the epiglottis

What is acute otitis media (AOM)?

Acute inflammation of the middle ear caused by bacteria (mostly) or viruses. (often associated with other signs of illness)

What is BRUE?

brief resolved unexplained event

What is apnea?

cessation of breathing 20 seconds or longer

Asthma is the leading cause of acute and chronic illness in children. It is increased with poverty and urban settings. Infection between genetic and environmental factors. What can be triggers for asthma?

cold air, smoke, allergens, infections, stress, exercise, odors, and pollutants

Worsening s/s of cystic fibrosis include:

crackles, wheezes, decreased breath sounds, retractions, hypoxia nasal polyps, sinusitis, digital clubbing, barrel chest

Nurse will observe the rate, depth, and ease of respirations. Resp can be influenced by:

emotion and exercise

General approaches: school age children

establish trust through communication, talk to the child; respect modesty, use drapes, teach about body and personal care

Diagnosis of CF is done through:

genetic testing, sweat test

What is adenoiditis?

infection and infection of the pharyngeal tonsils or adenoids (above the palatine tonsils)

What is otitis media?

infection of the middle ear

What is bronchiolitis?

inflammation of the bronchioles

What is allergic rhinitis?

inflammation of the nasal mucosa -seasonal, recurrent and triggered by specific allergies -usually there is a family history

What is tonsillitis?

inflammation of the tonsils (especially the palatine tonsils)

With cystic fibrosis, a meconium ileus can form due to:

lack of pancreatic enzymes

Nursing Care for Resp Alterations: Facilitate gas exchange:

maintain O2 stats >95% on room air humidified oxygen (35-45%) via hood, mask, nasal respiratory therapy positioning - head at 30-40 degrees suction prn

One of the most important teaching points for parents of a child with RSV is:

meticulous handwashing!!!`

The incidence of these two things peak during _________ ________________.

middle childhood

General approaches: Preschoolers

more cooperative, save invasive procedures until the end; praise the child for cooperation

General approaches: Toddlers

most challenging, least cooperative; establish trust and allow them to handle equipment, toys, books

Croup often beings at ___________ and may be preceded by several days of symptoms of upper respiratory tract infection

night

Like the pulse, assess respirations for:

one full minute

Acute otitis media can manifest as an earache. Infants may:

pull their ears or roll their heads. assess for recent uri and runny nose

General approaches: 0-6 months

relatively easy to examine; do not mind being undressed

Nursing Care for Resp Alterations: Prevent transmission

respiratory and contact precautions prn

Some children can have symptoms year-round. These can include:

rhinorrhea (nasal discharge), itching, sneezing

General approaches: adolescents

straightforward, non condescending approach; can decide who is present for exam; head to toe with genital exam in the middle of exam (allows time for discussion)

General approaches: 6-12 months

stranger anxiety and more difficult to examine; use distraction

What are signs and symptoms of respiratory distress?

tachypnea, hypoxemia accessory muscle use retractions nasal flaring hypoventilation apnea head bobbing respiratory failure

What is otitis media with effusion (OME)?

the presence of fluid behind the tympanic membrane without signs of infection; often follows an episode of AOM and usually resolves in 1-3 months *assess for hearing loss!!

What is the only reliable means of determining if the pharyngitis is bacterial or viral?

throat culture (rapid strep test)

If there is otitis media with effusion for more than 3 months, it can impact the childs hearing and they can need:

tubes surgically implanted to equalize pressure and improve air flow. Tubes usually fall out in 6-12 months.

What is tonsillectomy used for?

used in cases of upper airway obstruction, peritonsillar abscess, obstructive sleep apnea, or other serious problems

An emergency asthma attack can present as:

worsening wheeze, cough, SOB, no improvement with bronchodilator, difficulty breathing, trouble walking or talking, listlessness, weak cry, gray or blue lips or fingernails