PEDS EXAM 1

Infections of the Lower Airways

*Infections of the Lower Airways:* - Considered the "reactive" portion of the lower respiratory tract - *Includes bronchi and bronchioles* - Cartilaginous support not fully developed until adolescence - Constriction of airways

Influenza

*Influenza "the flu":* caused by the orthomyxoviruses and classified into three distinct groups: - *types A and B, which cause epidemic disease (and are included in the vaccine)*, and - *type C, which causes milder illness and is not included in the vaccine.* - Major changes that occur at intervals of usually 5 to 10 years are called *antigenic shift*; - minor variations within the same subtypes, *antigenic drift*, occur almost annually. - Consequently, antigenic drift can alter the virus sufficiently to result in susceptibility of individuals to a type for which they were previously immunized or infected - *droplet* - more common in winter - The disease has a 1- to 4-day incubation period (average of 2 days), and affected persons are most infectious for 24 hours before and 5 to 7 days after the onset of symptoms - H1N1 (swine flu) is a subtype of influenza type A CLINICAL MANIFESTATIONS: - dry cough and a tendency toward hoaresness - *fever* - *chills* - flushed face - photophobia - myalgia - *sore throat* - *headache* - hyperesthesia - prostration - *vomitting* - diarrhea - sub glottal croup - *symptoms last 4-5 days* - *Complications include severe viral pneumonia* (often hemorrhagic), febrile seizures, encephalitis, encephalopathy, dehydration, and secondary bacterial infections, such as myocarditis, OM, sinusitis, or pneumonia DIAGNOSTIC: - *confirmed by analyzing nasopharyngeal secretions for viral culture or rapid detection testing.* - Influenza A and B can be rapidly detected by direct fluorescent antibody and indirect immunofluorescent antibody staining MANAGEMENT: - acetaminophen, ibuprofen, fluids - *Oseltamivir (Tamiflu), zanamivir (Relenza), and peramivir* are recommended to treat influenza for patients at high risk of complications from the flu - Zanamivir can be used to treat patients ages 7 years and older or as prophylaxis for patients ages 5 years and older. Inhaled; (Diskhaler) twice daily for 5 days - start within 2 days of the onset of symptoms - *Avoid aspirin due to Reye Syndrome* PREVENTION: - *Flu vaccine ANNUALLY for children 6 months-18 years old.* An intradermal preparation of influenza vaccination is available for people 18 to 64 years old. - *Two doses are needed at least 28 days apart to all children 6 months to 9 years in their first or second vaccination seasons to adequately protect them against influenza.* - A topical analgesic cream such as LMX4 or EMLA should be applied to the site beforehand to reduce pain. - During the 2016-2017 influenza season, the live attenuated influenza vaccine, administered intranasally, was discontinued due to concerns about its effectiveness - *NO EGG ALLERGIES* - administered yearly because different strains of influenza are used each year in the manufacture of the vaccine. It is safe and effective provided the antigens in the vaccine correlate with the circulating influenza viruses - *may be given with other vaccines; but at diff sites*

ANS: C

4. A 5-year-old is seen in the urgent care clinic with the following history and symptoms: sudden onset of severe sore throat after going to bed, drooling and difficulty swallowing, axillary temperature of 102.2°F (39.0°C), clear breath sounds, and absence of cough. The child appears anxious and is flushed. Based on these symptoms and history, the nurse anticipates a diagnosis of: A. Group A β-hemolytic streptococcus (GABHS) pharyngitis B. Acute tracheitis C. Acute epiglottitis D. Acute laryngotracheobronchitis

ANS: A

4.After locomotion begins or after age 1, which reflex has typically disappeared? A.Babinski B.Blinking C.Palmer D.Planter

General Aspects of Respiratory Tract Infections

> Respiratory infections are cause of majority of acute illnesses in children > *Upper respiratory tract:* : Oronasopharynx, pharynx, larynx, and trachea > *Lower respiratory tract:* : Bronchi, bronchioles, and alveoli ETIOGLOY Infectious agents: > *Viruses:* RSV Parainfluenza > *Others:* Group A β-hemolytic streptococci Staphylococci Chlamydia trachomatis, Mycoplasma, pneumococci Haemophilus influenzae AGE: > Infants younger than 3 months—maternal antibodies > 3 to 6 months—infection rate increases > Toddler and preschool ages—high rate of viral infections > Older than 5 years—increase in Mycoplasma pneumonia and β-strep infections > Increased immunity with age SIZE: Diameter of airways plays significant role in respiratory illnesses Distance between structures is shorter, allowing organisms to rapidly move down Short eustachian tubes RESISTANCE: uImmune system uAllergies, asthma uCardiac anomalies uCystic fibrosis uDaycare SEASONAL VARIATIONS: u*Most common during winter and spring* uMycoplasmal infections more common in fall and winter uAsthmatic bronchitis more frequent in cold weather u*RSV season considered winter and spring* CLINICAL MANIFESTATIONS: uVary with age uGeneralized signs and symptoms and local manifestations different in young children: u*Fever* u*Anorexia, vomiting, diarrhea, abdominal pain* u*Cough, sore throat, nasal blockage or discharge* u*Respiratory sounds* INTERVENTIONS: uEase respiratory effort uFever management uPromote rest and comfort uInfection control uPromote hydration and nutrition uFamily support and teaching uPrevent spread of infection uProvide support and plan for home care

asthma

*ASTHMA:* - Chronic inflammatory disorder of airways - Bronchial hyper responsiveness - Episodic - Limited airflow or obstruction that reverses spontaneously or with treatment - *Lack of wheeze = severe airway; not creating enough air to create a wheeze* RISK FACTORS: - Age - Atopy (predisposition to allergic hypersensitivity) - Heredity - Gender - Mother <age 20 years - Smoking (maternal and grandmaternal) - Ethnicity (African-Americans at greatest risk) - Previous life-threatening attacks - Lack of access to medical care - Psychologic and psychosocial problems - Linkages to allergic and inflammatory genes on chromosome 5 TYPES: - Recurrent wheezing usually precipitated by a viral respiratory tract infection (e.g., RSV) - Chronic asthma associated with allergy persisting into later childhood and often adulthood - Associated with girls who develop obesity and early-onset puberty by age 11 - Cough-variant asthma CATEGORIES - *Intermittent, mild persistent, moderate persistent, and severe persistent* - *Stage I—mild, intermittent asthma* >> *Symptoms less than 2 days a week Nighttime symptoms (awakenings): None* (ages 0 to 4); less than two times a month (ages 5 to 11) - *Stage II—mild, persistent asthma* >> *Symptoms MORE than two times a week, but less than one time a day Nighttime symptoms: One or two times a month* (ages 0 to 4); three or four times a month (ages 5 to 11) >> Interference with normal activity: Minor limitation Use of short-acting β-agonist for symptom control: *More than 2 days a week but not daily* - *Stage III—moderate, persistent asthma* >> *Daily symptoms Nighttime symptoms three or four times a month* (ages 0 to 4); more than once per week but not nightly (ages 5 to 11) >> Interference with normal activity: Some limitation *Use of short-acting β-agonist for symptom control: Daily* - *Stage IV—severe, persistent asthma* >> *Continual symptoms throughout the day Frequent nighttime symptoms* >> *Interference with normal activity: Extremely limited Use of short-acting β-agonist for symptom control: Several times a day* - Clinical features of each classification CLINICAL MANIFESTATIONS: - *Dyspnea* - *Wheeze* - *Cough followed by a quiet period* - *TRIPOD* DIAGNOSTICS: - *Pulmonary function tests (PFTs)* - *peak expiratory flow rate (PEFR):* > Green (80% to 100% of personal best) signals all clear. > Yellow (50% to 79% of personal best) signals caution. > Red (below 50% of personal best) signals a medical alert. MANAGEMENT: - General - Allergen control and avoidance - Drug therapy to prevent/relieve bronchospasm - Maintain health and prevent complications - Promote self-care - Support child and family DRUG THERAPY -*Long-term control meds:* > Inhaled corticosteroids, cromolyn sodium and nedocromil, long-acting b2-agonists, methylxanthines, and leukotriene modifiers - *Quick-relief ("rescue") medications* > Short-acting b2-agonists, anticholinergics, and systemic corticosteroids are used as quick-relief (or rescue) medications - Long-term bronchodilators - Combination inhaled medications - *Theophylline—monitor serum levels* - Oral steroids - Leukotriene modifiers - Anticholinergics - Epi-pen - Magnesium sulfate - Others - Inhaled for most medications - MDI with spacer > Significance of the spacer - Nebulizer - Generally less effective in treating asthma > Oral > IV INTERVENTIONS: - Breathing exercises and physical therapy - Chest physiotherapy (CPT) - Hyposensitization - Prognosis - HELI-OX to decrease inflammatory response ; usually thru a ventilator SIGNS OF SEVERE RESP DISTRESS W ASTHMA - Remains sitting upright, refuses to lie down - Sudden agitation - Agitated child who suddenly becomes quiet - Diaphoresis - Pale - Wont see tripoded positing because asthma is more of a lower airway problem STATUS ASTHMATICUS - Respiratory distress continues despite vigorous therapeutic measures - Concurrent infection in some cases - Therapeutic intervention - *Emergency treatment—epinephrine* 0.01 ml/kg subQ (maximum dose 0.3 ml) - IV magnesium sulfate - IV ketamine - IV corticosteroids - Heliox

Acute respiratory distress syndrome (ARDS) and acute lung injury (ALI)

*Acute respiratory distress syndrome (ARDS) and acute lung injury (ALI):* - Continuum of symptoms of ALI, with ARDS the most severe form - Characterized as respiratory distress and hypoxia within 72 hours after serious injury or surgery in person with *previously normal lungs* - Sepsis, trauma, viral pneumonia, aspiration, fat emboli, drug overdose, reperfusion injury after lung transplantation, smoke inhalation, and submersion injury, among others, have been associated with ARDS and ALI - Artificial surfactant - based on body weight MANAGEMENT: - Oxygenations and pulmonary perfusion - Treatment of infection - Maintain adequate cardiac output - The child with ARDS is cared for in the ICU during the acute stages of illness. - Diuretics may be administered to reduce pulmonary fluid, and vasodilators may be administered to decrease pulmonary vascular pressure. - HOB elevated -

CROUP: ACUTE EPIGLOTTITIS

*CROUP: ACUTE EPIGLOTTITIS:* - medical emergency - *Serious obstructive, inflammatory process* - abrupt onset - 2 and 5 years of age but can occur from infancy to adulthood. - *The causative agent is usually H. influenzae type B (Hib)* - LTB and epiglottitis do not occur together. - *Epiglottitis (noninfectious) may also be caused by ingestion of caustic agents, smoke inhalation, or foreign bodies* CLINICAL MANIFESTATIONS: - *abrupt* - *sore throat* - *pain on swallowing, tripod positioning, retractions, drooling* - *Inspiratory stridor, mild hypoxia, distress* - *Fever* - *throat is red and inflamed, cherry red, large.; EDEMA* - *NO COUGH* - LOOK WORSE THAN THEY SOUND MANAGEMENT: - A lateral neck radiograph of the soft tissues is indicated for diagnosis. *(Radiology)* - *Endotracheal intubation* is usually considered for the child with epiglottitis with severe respiratory distress. Nasotracheal intubation is sometimes preferred. - For patients who are not intubated, *humidified oxygen* is administered as necessary either via mask in older children or as blow-by in younger children to avoid further agitation. - The epiglottal *swelling usually decreases after 24 hours of antibiotic therapy*, and the epiglottis is near normal by the third day. - Children with suspected bacterial epiglottitis are given *antibiotics intravenously, followed by oral administration to complete a 7- to 10-day course. Ceftriaxone/cefotaxie and vancomycin are generally the first antibiotics started.* - *DROPLET ISOLATION* until 24 hours after antibiotic administration - pulse ox, ABGS, IV infusion - Potential for complete respiratory obstruction - *Biggest type of Croup syndrome* - Position for comfort - Decrease anxiety - *No tongue blade!!!!* - *Keep suction at bedside* - Keep emergency respiratory equipment at bedside PREVENTION: - *all children receive the H. influenzae type B conjugate vaccine beginning at 2 months old (Hib vaccine)* Don't suction more than just the beginning of the mouth; nothing back on the tongue. It will trigger a spasm and obstruct airway and need emergency trach *Heliox- helium and oxygen for sedation* 24 hour droplet isolation precaution because of Hib

CYSTIC FIBROSIS

*CYSTIC FIBROSIS:* - *Autosomal recessive genetic disease* - Abnormal gene is located on the long arm of chromosome 7 - 95% known cases occur in Caucasians - Most common lethal genetic illness among Caucasian children - Approximately 3% of U.S. Caucasian population are symptom-free carriers - Genetics - Northern Europen - Lethal but now living until 40s - Must have both copies from mom and dad of the disease PATHO: - Characterized by several unrelated clinical features - *Respiratory system* - *GI system* > small intestine > Pancreas > Bile ducts > Growth patterns - Reproductive system - Skin EFFECTS OF EXOCRINE GLAND DYSFUNCTION: - Mostly exocrine dysfunction, then can develop endocrine dysfuncition - Clogs the bronchi; leads to chroncic bronchi obstruction; COPD - *GI tract thick mucus* - *Don't absorb nutrients; failure to thrive* - Lung/ liver transplant INCREASED VISCOSITY OF MUCUOUS GLAND SECRETION - *Results in mechanical obstruction* - Thick, inspissated mucoprotein accumulates, dilates, precipitates, coagulates to form concretions in glands and ducts - *Respiratory tract and pancreas are predominantly affected* DIAGNOSTICS: - Early infancy screening - DNA testing - *Sweat chloride test* - Chest radiography - History and physical exam - Can start diagnose prenatally for the gene RESP MANIFESTATIONS: - 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—obstruct bronchi/bronchioles - *Decreased O2/CO2exchange* > *Results in hypoxia, hypercapnia, acidosis* - Compression of the pulmonary blood vessels and progressive lung dysfunction lead to pulmonary hypertension, corpulmonale, respiratory failure, and death GI: - *Thick secretions block ducts → cystic dilation → degeneration→ diffuse fibrosis* - *Prevents pancreatic enzymes from reaching duodenum* - Impaired digestion/absorption of fat → steatorrhea - Impaired digestion/absorption of protein → azotorrhea - Can devlop DM - Biliary cirrhosis - *Always thirsty* - Endocrine function of pancreas initially stays unchanged - *Eventually pancreatic fibrosis occurs; may result in diabetes mellitus* - Focal biliary obstruction results in multilobular biliary cirrhosis - Impaired salivation CLINICAL MANIFESTATIONS: - *Pancreatic enzyme deficiency* - Progressive COPD associated with infection - Sweat gland dysfunction - Failure to thrive - *Increased weight loss despite increased appetite* - Gradual respiratory deterioration - *Wheezing respiration; dry, nonproductive cough* - Generalized obstructive emphysema - 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, frothy, and foul - Tissue wasting - Prolapse of the rectum - Delayed puberty in females - Sterility in males - *Parents report children taste "salty"* - *Dehydration* - Hyponatremic/ hypochloremic alkalosis - Hypoalbuminemia RESP MANAGEMENT: - *Remove excessive mucous secretions:* > *CPT: - don't do after they have eating; give fast acting broncholdialter (Albuterol), begin CPT* Tobramycin > Bronchodilator medication: Albuterol > Forced expiration - Aggressive treatment of pulmonary infections: > *Home IV antibiotic therapy* > Aerosolized antibiotics - Steroid use/nonsteroidal anti-inflammatory - *Transplantation* - *Flutter Mucus Clearance Device* GI MANAGEMENT: - *Replacement of pancreatic enzymes: Pancrealipase* - *High-protein, high-calorie, low fat diet* as much as 150% RDA - Prevention/early management of intestinal obstruction - Reduction of rectal prolapse - *Salt supplementation* - Oral glucose-lowering agents or insulin injections as needed - Diet and exercise management

Croup: Bacterial Tracheitis

*Croup: Bacterial Tracheitis:* - *Infection of the mucosa of the upper trachea* - Distinct entity, features of croup and epiglottitis in older children (5-7 yrs); may cause severe airway obstruction - Staphylococcus aureus is the most frequent bacterial organism responsible DIAGNOSTICS: - Anteroposterior or lateral *neck x-rays show narrowing (Steeple sign)*, and infiltrates may be seen. - An *endoscopy* of the airway performed in the operating room (OR) or intensive care unit (ICU) is usually indicated to remove secretions and obtain cultures. CLINICAL MANIFESTATIONS: - *Thick, purulent secretions* - *Respiratory distress* - *Stridor* - May develop life-threatening obstruction or respiratory failure MANAGEMENT: - antipyretics, fluid status, and antibiotics (10-day course), Humidified oxygen. - *Many children require endotracheal intubation and mechanical ventilation*; patients are closely monitored for impending respiratory failure if not intubated. - Early recognition to prevent life-threatening airway obstruction is essentiaL

*Diphtheria:*

*Diphtheria:* ØAgent: Corynebacterium diphtheriae ØTransmission: Direct contact ØClinical manifestations: URI-like symptoms which progress. •*"Bull's neck"' lymphadenitis* •*White or gray mucous membranes, fever, cough* ØTreatment: *Antibiotics (Equine antitoxin IV preceded by skin or conjunctival test to rule out sensitive to horse serum, penicillin G, erythromycin), bed rest, and support* Ø*Precautions: Droplet*

Otitis Media (OM)

*Otitis Media (OM):* - is the presence of fluid in the middle ear along with acute signs of illness and symptoms of middle ear inflammation - winter months - Many cases of bacterial OM are preceded by a viral respiratory tract infection. - *The two viruses most likely to precipitate OM are RSV and influenza*. - Most episodes of acute otitis media (AOM) occur in the first 24 months of life, but the incidence decreases with age, except for a small increase at age 5 or 6 years when children enter school. - *Risk factors: school, siblings, day care, passive smoking, family socioeconomic status, formula-fed infants* - *Breast-fed infants have less OM than bottle-fed infants* >> Immunoglobulin A >> Position in breast-feeding may decrease reflex in eustachian tubes PATHO: - caused by Streptococcus pneumoniae, H. influenzae, and Moraxella catarrhalis. - The two viruses most likely to precipitate OM are RSV and influenza - *OM is primarily a result of a dysfunctioning eustachian tube!!*. COMPLICATIONS: - hearing loss - ear pressure - effusion - 8th CN - damage to tympanic membrane CLINICAL MANIFESTATIONS: - *pain results from the pressure* - *fever* - lymph nodes enlarged - rhinorrhea, vomitting, diarrhea - loss of appetite - *sucking/chewing aggravates the pain* OME (Otitis Media with Effusion): >> *no pain or fever; fullness in ear, popping sensation when swallowing, feeling of motion in ear* DIAGNOSTIC: - *otoscope to differentiate AOM from OME* - AOM (acute) = is made with moderate to severe *bulging of the tympanic membrane*, acute onset of ear drainage not due to acute otitis externa, mild bulging of the tympanic membrane with onset of pain occurring less than 48 hours, and intense *erythema of the tympanic membrane* - *OME = immobile; orange colored membrane; rhinitis, cough, or diarrhea are often present.* - Acoustic reflectometry measures the level of sound transmitted and reflected from the middle ear to a microphone located in a probe tip placed against the ear canal opening and directed toward the tympanic membrane. MANAGEMENT: AOM - *Antibiotics:* Definitive diagnosis of AOM (middle ear effusion, bulging tympanic membrane, or new otorrhea not due to otitis externa) • Mild bulging of the tympanic membrane with recent erythema or ear pain >> *Amoxicillan* >> *Amoxicillin-clavulanate (Augmentin); azithromycin; and cephalosporins such as cefdinir, cefuroxime, and cefpodoxime.* - *The use of steroids, decongestants, and antihistamines, antibiotic ear drops to treat AOM is NOT RECOMMENDED.* - acteminphoen - *topical pain relief drops: benzocaine or lidocaine* - *Myringotomy*, a surgical incision of the eardrum, may be necessary to alleviate the severe pain of AOM. A myringotomy is also performed to drain infected middle ear fluid in the presence of complications - *Tympanostomy tube placement* may be indicated with chronic OM (three episodes in 6 months or four episodes in 1 year, with one episode during the preceding 6 months) - If over age 6 months—"watchful waiting" up to 72 hours for spontaneous resolution - Antibiotics if <2 years withpersistent acute symptoms of fever and severe ear pain - Antibiotics if <6 months - Topical relief—heat or cold or benzocaine drops (Rx) > First-line antibiotics >> Amoxicillin PO ×10 days > Second-line antibiotics >> Amoxicillin-clavulanate (Augmentin), azithromycin >> Cephalosporins IM >>> If highly resistant organism or noncompliant with oral doses >>> IM is painful >>>> Reconstitute with 1% lidocaine (without epinephrine) to decrease pain of injection > Analgesic-antipyretic drugs >> Acetaminophen >> *Ibuprofen (only if >6 months of age)* > No steroids, antihistamines, decongestants, antibiotic ear drops PREVENTION: - *pneumococcal vaccine PCV7 OR PCV13* - A new conjugate vaccine, Prevnar 13, replaces Prevnar (PCV 7) and is approved for use in patients 6 weeks to 17 years old - The vaccine is administered as a *four-dose series beginning at 2 months of age* - reduce risk factors for AOM by breastfeeding infants for at least the first 6 months of life, avoiding propping the formula bottle, decreasing or discontinuing pacifier use after 6 months, and preventing exposure to tobacco smoke OTITIS MEDIA WITH EFFUSION: *Prevention:* - PCV 7 vaccine - Breastfeeding - Preventing exposure to tobacco smoke WONT BE RED RED MEANS EXTERNA (SWIMMERS EAR)

Pneumonia

*Pneumonia:* - inflammation of the pulmonary parenchyma - The causative agent is usually introduced into the lungs through inhalation or from the bloodstream. - Pneumonia may be caused by histomycosis, coccidioidomycosis, and other fungi. - Other terms that describe pneumonias are hemorrhagic, fibrinous, and necrotizing. TYPES: - 1. *Lobar pneumonia—All or a large segment of one or more pulmonary lobes is involved*. When both lungs are affected, it is known as bilateral or double pneumonia. - 2. *Bronchopneumonia—Begins in the terminal bronchioles*, which become clogged with mucopurulent exudate to form consolidated patches in nearby lobules; also called lobular pneumonia. - 3. *Interstitial pneumonia*—Inflammatory process more or less confined within the alveolar walls (interstitium) and the peribronchial and *interlobular tissues.* - *Pneumonitis is a localized acute inflammation of the lung without the toxemia associated with lobar pneumonia. can give artificial surfactant* - Viral, atypical, bacterial uCausative agent introduced into lungs through inhalation or from bloodstream u"Atypical pneumonias" uCaused by pathogens other than most common and readily cultured bacteria uMycoplasma pneumoniae, chlamydial pneumonia VIRAL - occur more frequently - *cough, malaise to high fever, severe cough, fatigue* - *unproductive or productive of small amounts of whitish sputum* - oxygen, CPT, drainage, antipyretics. PRIMARY ATYPICAL: - *refers to pneumonia that is caused by pathogens other than the traditionally most common and readily cultured bacteria* (e.g., S. pneumoniae). - In the category of atypical pneumonias, M. pneumoniae is the most common bacterial pathogen of community-acquired pneumonia in children 5 years of age or older - Community acquired pneumonia occurs principally in the fall and winter months and is more prevalent in crowded living conditions - 7-10 days at home - 1 week of convalescne - incubation period 2-3 weeks, cough may last several weeks - onset is sudden or insidious - *fever, chills (in older children), headache, malaise, anorexia, and muscle pain (myalgia). These symptoms are followed by rhinitis, sore throat, and a dry, hacking cough. The cough, initially nonproductive, produces seromucoid sputum that later becomes mucopurulent or blood streaked.* - *radiology, CXR* - crackles, areas of consolidation - *Erythromycin, azithromycin, and clarithromycin are the primary agents used for treating atypical pneumonia.* BACTERIAL PNEUMONIA: - S. pneumoniae - The onset of illness is *abrupt and generally follows a viral infection* that disturbs the natural defense mechanisms of the upper respiratory tract - *fever, malaise, rapid and shallow respirations, cough, and chest pain. The older child may complain of headache, chills, abdominal pain, chest pain, or meningeal symptoms (meningism)* - vomiting, diarrhea, and abdominal distention - cyanosis, apnea - *cough is usually hacking and nonproductive; crackles and wheezing* DIAGNOSTIC: - *CXR* - labs: ram stain and culture of sputum in older children, nasopharyngeal specimens, blood cultures, and, on occasion, lung aspiration and biopsy. The white blood cell count may be elevated MANAGEMENT: - *Oral high-dose amoxicillin* - *Amoxicillin-clavulanate (Augmentin) or a second-generation cephalosporin (e.g., cefuroxime, cefadroxil) may otherwise be used.* - *Erythromycin is the drug of choice for older children and adolescents because of its activity against M. pneumoniae.* - CPT - fluids, antipyretics - Hospitalization is indicated when pleural effusion or empyema accompanies the disease PREVENTION: - *pneumococcal conjugate vaccine (PCV13; Prevnar 13) is recommended for infants and children at 2, 4, 6, and between 12 and 15 months.* COMPLICATIONS: - empyema, pyopneumothorax, or tension pneumothorax - will need a needle aspiration or thoracentesis if occurs - Continuous closed chest drainage CXR is diagnostic Supportive care May need to ventilate Long term lung damage If severe enough can be put on ECHMO - X-ray >> Pulmonary infiltrates >> Lobar consolidation >> Pleural effusion - Lab tests >> Cultures—sputum, blood cultures, lung aspiration and biopsy >> WBC NEONATAL PNEUMONA: - Group B hemolytic streptococcus may be present in the mother's vagina and asymptomatic but can cause a serious pneumonia to a newborn. - C. trachomatis - *Chlamydial pneumonia is usually an afebrile illness that occurs in the newborn between 2 and 19 weeks after delivery* - Infected mother transmits to fetus via ascending infection or during delivery - *persistent cough, tachypnea, and sometimes rales* - *Oral azithromycin given for 3 days is the treatment of choice; alternatively, erythromycin base or ethylsuccinate is administered for 14 days* - CXR

Smoke Inhalation Injury

*Smoke Inhalation Injury:* Severity depends on nature of substance, environment, and duration of contact - Inhalation injuries more deadly than flames - Local injury - Systemic injury SUSPICION FOR INHALATION INJURIES: - History of exposure to flames whether or not burns are present - *Soot around nose or in sputum, singed nasal hairs, or mucosal burns of the nose, lips, mouth, or throat* - *Hoarse voice and cough* - Increased inspiratory and expiratory stridor - *Tachypnea, tachycardia, abnormal breath sounds PULMONARY COMPLICATIONS: - Early carbon monoxide poisoning, airway obstruction, and pulmonary edema - ARDS 24 to 48 hours after injury - Late complications—bronchopneumonia and pulmonary emboli - Airway compromise from eschar after a severe burn INJURIES: - Heat injury: > Thermal injury to upper respiratory tract > Reflex glottis closure - Local chemical Injury: > Insoluble gases in the lower respiratory tract - Systemic injury: > *Carbon monoxide causing tissue hypoxia* MANAGEMENT: - Scope of the problem - *Typically 100% oxygen via nonrebreathing face mask* - Careful monitoring and support - *Bronchodilators* - Management of airway - *concern is the development of pulmonary edema; therefore accurate monitoring of intake and output is essential*

TONSILLITIS

*TONSILLITIS:* The tonsils are masses of lymphoid tissue located in the pharyngeal cavity. The tonsils filter and protect the respiratory and alimentary tracts from invasion by pathogenic organisms. They also play a role in antibody formation. CLINICAL MANIFESTATIONS: - *caused by inflammation* - *obstructs passage of air or food* - mouth breathing - dry mucous membranes - mouth odor - impaires sense of taste and smell - nasally voice / muffled - persistent cough - *Otitis media or difficulty hearing* MEDICAL TREATMENT: - *Can be bacterial or viral* - mostly viral - rapid tests can eliminate unnecessary antibiotic administration SURGICAL TREATMENT: - Controversial - *TONSILLECTOMY:* - Absolute indications are peritonsillar abcess; PFAPA: periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis; airway obstruction, chronic tonsillitis unresponsive to antimicrobials, multiple antibiotic allergies, and tonsils requiring tissue pathology - Consideration of tonsillectomy include: at least seven episodes of tonsillitis in the previous year, or at least five tonsillitis episodes in each of the previous 2 years, or at least three episodes of tonsillitis in each of the previous 3 years - *One episode = a sore throat plus at least one of the following: temperature greater than 100.9°F (38.3°C), cervical adenopathy (>2 cm or tender nodes), exudate on the tonsils, or positive culture for GABHS*. - *ADENOIDECTOMY:* (removal or the adenoids) is recommended for children who have hypertrophied adenoids that obstruct nasal breathing or a history of four or greater episodes of recurrent purulent rhinorrhea in the previous 12 months in a child under 12 years of age CONTRAINDICATIONS TO BOTH SURGERIES: (1) *cleft palate* because both tonsils help minimize escape of air during speech; (2) *acute infections at the time of surgery* because the locally inflamed tissues increase the risk of bleeding; and (3) uncontrolled systemic diseases or *blood dyscrasias.* - *can't be done until after age 3-4 because excessive blood loss* NURSING CARE; - *minimize activities that precipice bleeding* - soft to liquid diet - warm saltwater gargles, warm fluids, throat lozenges, analgesic-antipyretic drugs (acteminophen) - *Opioids, hydrocodone (Lortab) q4h* POST OP: - *Position sitting up to clear drainage* - suctioning - *don't cough frequently, clear throat, or blow nose.* - dried blood common - ice collar - Local anesthetics, such as tetracaine lollipops or ice pops, and antiemetics, such as ondansetron (Zofran), or Scopolamine transdermal patch (ages 12 and older) may be administered postoperatively. - food and fluid restricted until able to swallow with no signs of hemmorrhage - cool water, crushed ice, flavored ice pops or diluted fruit juice given - *avoid fluids that are red or brown* - avoid straws - *avoid citrus juice, ice cream, milk, pudding* - 1-2nd day post op being foods: soft foods, cooked fruits, sherbet, soup, mashed potatoes - *a cream-colored membrane visible 5-10 days post op is normal* Signs of hemorrhage: - bleeding - tachypnea, pallor, frequent clearing of throat or swelling, vomitting of bright red blood, restlessness - decreased BP - *can occur up to 10 days post op* DISCHARGE INSTRUCTIONS: - avoid highly seasoned foods - avoid use of gargles of virgours toothbrushing - no coughing or clearing the throat, no objects in mouth - use analgesic and opioids for pain - limit activity - *mouth odor, ear pain, fever are common post op* - return to normal 1-2 weeks post op

TUBERCULOSIS

*TUBERCULOSIS:* - Caused by Mycobacterium tuberculosis human and bovine varieties CLINICAL MANIFESTATIONS: - fever, cough, *night sweats*, chills, delayed growth, and *weight loss* or more specific symptoms related to the site of infection (e.g., lungs, bone, brain, kidneys) within 1 to 6 months after infection DIAGNOSTICS: - History and PE - *TB test and cultures* - *X-ray* - The Xpert MTB/RIF rapid molecular test performed on sputum is used to diagnose TB and determine Rifampin resistantance - *Bacille Calmette-Guerin (BCG) immunization can result in a positive TST*. - *The Tubercullin Skin Test should not take place within 6 weeks of administration of a live vaccine* - Recommended = *Mantoux test* >> *Uses purified protein derivative (PPD)* >> Standard dose and administration technique - Positive reaction: >> > ³5-mm induration >> > ³10-mm induration >> > ³15-mm induration - Recommendations for TB testing - A finding of *latent tuberculosis infection (LTBI) indicates infection in a person who has a positive TST, no physical findings of disease, and normal chest radiograph findings.* - *Sputum 3 mornings in a row* - *QuantiFERON-TB Gold and T-SPOT TB* TREATMENT: LTBI: - *Isoniazid (INH)—treat for 9 months* >> Daily OR alternatively 2-3 ×/wk with direct observation of therapy (DOT) - *Rifampin—treat for 6 months if INH resistant; turns urine red/orange* - Treatment not recommended for children with positive TB test result but no risk factors - Treatment to reduce risk of developing active TB TREATMENT: ACTIVE: - *First 2 months—daily INH + rifampin + ethambutol + pyranizamide(PZA)* - *Next 4 months—give 2-3 ×/wk INH + rifampin* - Alternative treatment regimens may be used by TB specialists - *DOT—direct observation of treatment* >> Decreases rates of relapse, treatment failures, and drug resistance >> Recommended for children and adolescents in the United States ISOLATION: *Airborne precautions until:* > Effective pharmacologic treatment is underway AND > Sputum smears show decrease in organisms AND > Cough is improving - All family contacts treated with airborne precautions until demonstrated to NOT have active TB

ANS: C

1. A 12-year-old child is in the urgent care clinic with a complaint of fever, headache, and sore throat. A diagnosis of group A β-hemolytic streptococcus (GABHS) pharyngitis is established with a rapid-strep test, and oral penicillin is prescribed. The nurse knows that which of the following statements about GABHS is correct? A. Children with a GABHS infection are less likely to contract the illness again after the antibiotic regimen is completed. B. A follow-up throat culture is recommended after the completion of antibiotic therapy. C. Children with a GABHS infection are at increased risk for the development of rheumatic fever and glomerulonephritis. D. Children with a GABHS infection are at increased risk for the development of rheumatoid arthritis in adulthood.

ANS: C

1. Which of the following should be used in the care of all pediatric patients to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection? A. Transmission-Based Precautions B. Airborne Precautions C. Standard Precautions D. Droplet Precautions

answer: A

1.An appropriate nursing intervention when caring for a child with pneumonia is which of the following? A.Encourage rest. B.Instruct child to avoid lying on affected side. C.Administer analgesics. D.Place in Trendelenburgposition.

ans: C

1.An infant arrives at the clinic with a persistent cough. Mother reports the infant has not been feeding well for the past day. What nursing interventions would be appropriate? A.Provide oxygen to the infant via cannula B.Undress the infant to do a complete assessment C.Suction the infant's nose with a bulb syringe D.Start an IV

ANS: A

1.The assessment process of nursing is: A.Purposeful collection B.Establishing priorities C.Interventions D.Determining outcome

ANS: B

1.The nurse is discussing the pattern of inheritance with the family. Which statement about the autosomal dominant inheritance pattern is correct? A.Only males are affected B.50% chance of inheriting if parent affected C.Requires several mutant allele to express D.Reduced chance with each pregnancy

ANS: A

1.Which of the following (after the family) is most likely to have the greatest influence on providing continuity between generations? A.Schools B.Race C.Social class D.Government

ANS: B

2.Children may feel that they are responsible for their parents' divorce and interpret the separation as punishment. At what age is this most likely to occur? A.1 year B.4 years C.8 years D.13 years

Answer(s): C

2.The single most common chronic disease of childhood is: A.Arthritis B.Cancer C.Dental caries D.Diabetes

ANS: D

2.When assessing the pain of a 15-year-old who is developmentally delayed and unable to speak, which is the appropriate pain assessment tool? A.FACES B.VAS C.CRIES D.NCCPC

ANS: C

2.When auscultating an infant's lungs, the nurse detects diminished breath sounds. The nurse should interpret this as which of the following? A.Suggestive of chronic pulmonary disease B.Suggestive of impending respiratory failure C.An abnormal finding warranting investigation D.A normal finding in infants younger than 1 year

ans: B

2.Young children are at risk for Otitis Media because: A.They are unable to clear oral and nasal secretions well due to weak cough reflexes. B.the Eustachian tube is horizontal compared to that of adults. C.young children have poor hand washing techniques. D.The immature immune system is unable to fight infection.

ANS: D

3. Which vaccine do the Centers for Disease Control and Prevention (CDC) and American College of Obstetricians and Gynecologists recommend that pregnant adolescents and women who are not protected against pertussis receive optimally between 27 and 36 weeks of gestation or postpartum before discharge from the hospital? A. DTaP B. Td C. IPV D. Tdap

ANS : C

3.To visualize the eardrum in an infant, in which direction should the nurse pull the pinna? A.Back and forth B.Up and down C.Down and back D.Up and back

ANS: D

3.What is the key measurement indicating developmental growth in infants? A.Length B.Weight C.Vital signs D.Head circumference

Answer(s): A, C, D, E Rationale: Pedestrian accidents involving children account for significant numbers of motor vehicle-related deaths. Most of these accidents occur at midblock, at intersections, in driveways, and in parking lots. Driveway injuries typically involve small children and large vehicles backing up. Freeways are not considered in pedestrian accidents.

3.When talking to parents about pedestrian accidents, the nursing students know that the top reasons involving children are related to motor vehicle-related deaths. Most of these accidents will occur in which areas? (Select all that apply.) A.Driveways B.Freeways C.Intersections D.Midblock E.Parking lots

ANS: B

3.Which nursing intervention is most effective in providing atraumatic care to a 3-year-old boy preparing for major surgery? A.Explain to the child that he will be away from his parents for only a short time. B.Allow a parent to accompany the child to the preoperative holding area. C.Give the child a teddy bear from the hospital's toy closet. D.Hold the child's hand as you accompany the child to the preoperative holding area.

PAIN - NEONATES

PAIN IN NEONATES *CRIES neonatal pain scale:* ØCrying ØRequiring increased oxygen ØIncreased vital signs ØExpression ØSleeplessness *Premature Infant Pain Profile (PIPP):* *Specifically developed for preterm infants* Gives higher pain score to infants with lower gestational age Gives higher pain score to blunted behavioral response Neonatal Pain, Agitation, and Sedation Scale (NPASS) Used in neonates from 23 weeks of gestation up to 100 days of age *Oucher pain scale:* *ØFor 3- to 12 year olds* ØValidated with African American and Caucasian children ØHispanic version of APPT scale available for children/adolescents with cancer Use body outline diagram of the APPT for non-English speaking children and adolescents *CHILDREN WITH COMMUNICATION AND COGNITIVE IMPAIRMENT:* Difficult to measure pain High risk for inadequate treatment of pain *NCCPC: Non-Communicating Children's Pain Checklist* *PICIC: Pain Indicator for Communicatively Impaired Children*

CH 4. ASSESSMENT

VITALS: PULSE: less than 2 years, measure APICAL for 1 full minute - RESP: Breathing is diaphragmatic and irregular - BP: Use correct cuff size Annually after age 3 years using auscultation Automated devices in newborns and infants INFANT AND TODDLES: VITALS: - Count respirations FIRST (before disturbing the child) - Count apical heart rate SECOND - Measure blood pressure (if applicable) THIRD - Measure temperature LAST

ASPIRATION PNEUMONIA

*ASPIRATION PNEUMONIA:* - *when food, secretions, vomitus, medications, inert materials, volatile compounds, hydrocarbons (e.g., kerosene, gasoline, solvents, lighter fluid, furniture polish, and mineral oil), or liquids enter the lung and cause inflammation and a chemical pneumonitis.* - *Risk for child with feeding difficulties* PATHO: - severity of the lung injury depends on the pH of the aspirated material, the presence of bacteria, and the volatility and viscosity of the substance. CLINICAL MANIFESTATIONS: - Acid aspiration may produce immediate pulmonary symptoms that worsen over the first 24 hours. - *Coughing and vomiting, which occur almost immediately after ingestion, contribute to the aspiration.* - CNS symptoms include agitation, restlessness, confusion, drowsiness, and coma. - The *temperature is elevated (100° to 104°F)* - After swallowing, coughing, and choking, the child becomes short of breath, and older children complain of dyspnea. - There are varying degrees of cyanosis, tachycardia, tachypnea, nasal flaring, and retractions. - Intercostal retractions, grunting, cough, and fever may appear within 30 minutes or be delayed for a few hours. MANAGEMENT: - Prevention of aspiration - Feeding techniques, positioning - Avoid these aspiration risks: > *Hydrocarbons (gasoline, lighter fluid)* >> Petroleum distillates often contain heavy metals or other toxic chemicals >> Often found in home or garage >> Severe effect even with small amount ingested >>> Spread over surface of tissues and interfere with gas exchange > *Oily nose drops and petroleum distillates (Heavy metals)* > *Solvents* > *Talcum powder* - Ensure safety in the environment - *Inducing the child to vomit is contraindicated because of the renewed danger of aspiration.* - Bronchitis or pneumonia usually develops early (within the first 24 hours) - humidity, oxygen, hydration - *endotracheal intubation* HYDROCARBON PNEUMONIA: - Coughing, vomiting, aspiration - CNS—agitation, restlessness, confusion, drowsiness, and coma - Elevated body temperature (37.8° to 40° C) - Dyspnea, cyanosis, tachycardia, tachypnea, nasal flaring, and retractions - Hemoptysis, pulmonary edema, severe cyanosis, and death within 24 hours of aspiration

Allergic Rhinitis

*Allergic Rhinitis:* - Seasonality vs. year-around - *Seasonal allergic rhinitis (also known as hay fever) usually follows a spring-fall pattern and is caused by tree, grass, and weed pollens.* - Seasonal allergic rhinitis usually does not develop until the individual has been sensitized by two or more pollen seasons. - *Year-round or perennial allergic rhinitis is more common and is triggered by household inhaled allergens such as feathers, household dust, animal dander, air pollutants, and molds.* - Allergic rhinitis is classified as seasonal allergic rhinitis (SAR) or perennial allergic rhinitis (PAR). SAR has a cyclic, well-defined course, and PAR causes year-round symptoms PATHO: - *Allergic rhinitis requires two conditions: a familial predisposition to develop allergy and exposure of a sensitized person to the allergen.* CLINICAL MANIFESTATIONS: - history of *watery rhinorrhea, nasal obstruction, sneezing, itchy throat, or nasal pruritus*. - alleviate the symptoms by rubbing the nose—the *"allergic salute"* - children may display dark circles beneath their eyes, or *"allergic shiners,"* secondary to obstruction of normal outflow from regional lymphatics and veins. - If the nasal obstruction is severe, the child becomes an obligate mouth breather and is seen with an open mouth, or *"allergic gape."* DIAGNOSTICS: - history and physical examination. - Because allergic rhinitis is often associated with atopic dermatitis or asthma, examination of the skin and chest is indicated. - Diagnostic tests include a *nasal smear to determine the number of eosinophils in the nasal secretions, blood examination for total IgE and elevated eosinophils, skin tests, and various challenge tests* TREATMENT: - Immunotherapy - OTC medications > Oral > Inhaled > Nasal sprays - second-generation *oral antihistamine such as cetrizine, fexofenadine, or loratadine is recommended.* - An antihistamine (azelastine), glucocorticoid (fluticasone), or cromolyn nasal spray could also be considered. - If the allergic rhinitis symptoms are more persistent, the *glucocorticoid nasal sprays are first-line treatment* and may even be used in combination sprays with an antihistamine twice daily. - Topical nasal corticosteroids are safe and effective therapies and are more effective than oral antihistamines for symptom relief. > First-generation agents include beclomethasone (Vancenase and Beconase), flunisolide (Nasalide), and budesonide (Rhinocort or Pulmicort). > Second-generation agents are fluticasone (Flovent) and mometasone (Nasonex). - Dry powder preparations are also available (beclomethasone furoate or ciclesonide). - *Classic first-generation antihistamines such as diphenhydramine (Benadryl) and chlorpheniramine (Chlor-Trimeton) are effective but may produce undesirable side effects such as dry mouth, urinary retention, constipation, and sedation or restlessness* - *Allergen immunotherapy may be necessary if drug therapy and avoidance of allergens are ineffective in controlling symptoms or if drugs evoke undesirable side effects; sublingual administration or by subcutaneous injection of the allergen; takes about 4 to 8 months to complete, and then maintenance treatment is continued every 3 to 4 weeks for 3 to 5 years.* DIFFERENCE BETWEEN ALLERGIES AND A COLD - Allergies occur repeatedly and are often seasonal - Allergies are seldom accompanied by fever - *Allergies often involve itching in the eyes and nose* - Allergies usually trigger constant and consistent bouts of *sneezing* - Allergies are often accompanied by ear and eye problems - *Clear secretions* - *More prone to eczema*

ANS: D

1. When caring for their infant, a parent asks you, "Is Emily in a lot of pain? How would you know since she can't really tell you?" The best answer to this question is: A. "Infants don't feel pain as we do because their pain receptors are not fully developed yet." B. "The nurses give pain medication before she really feels the pain." C. "We assess her pain using an infant pain assessment tool and give the medicine as needed." D. "Although we try to give her medicine before she feels pain, we watch her very closely and use different techniques to help relieve the pain."

ANS: B

1.The nurse attempts to obtain consent from a hospitalized 3-year-old child. This action of the nurse demonstrates which of the following? A.Appropriate understanding of the development of the 3-year-old child B.Inappropriate understanding of the child's development C.Appropriate understanding only if the parent requests the child's consent D.Inappropriate understanding because it is too time consuming

ANS: B

1.The nurse is doing a health history on a child. At the beginning of the interview, the parent says, "I brought him here because he always has diarrhea." This should be recorded under which of the following headings? A.History B.Chief complaint C.Review of systems D.Nutritional assessment

ANS: A

1.The nurse is monitoring a 3-year-old child receiving conscious sedation while undergoing a painful procedure. The child's respiratory rate is 14 breaths/min and heart rate is 64 beats/min. The child is exhibiting which of the following? A.Oversedation B.Appropriate level of sedation C.Cardiac complications of midazolam D.Respiratory complications of midazolam

ANS: C

1.When caring for a patient who has received an opioid, which of the following side effects would be the priority for the nurse? A.Moderate constipation B.Agitation C.Orthostatic hypotension D.Urticaria

Answer(s): B, C, D, E

1.When interviewing a child and parent(s) at the beginning of a visit, it will be important for the nurse to follow which of the guiding principles? (Select all that apply.) A.Address parents however you think would be appropriate B.Include children in the interaction by asking them their name, age, and other information C.Provide as much privacy as possible D.Inform the family of the limits of confidentiality E.Young children should be given play provision to keep them occupied during the parent-nurse interview

ANS: A, B, D, F

2. A 5-year-old is recovering from a tonsillectomy and adenoidectomy and is being discharged home with his mother. Home care instructions should include which of the following? Select all that apply. A. Observe the child for continuous swallowing. B. Encourage the child to take sips of cool, clear liquids. C. Administer codeine elixir as necessary for throat pain. D. Observe the child for restlessness or difficulty breathing. E. Encourage the child to cough every 4 to 5 hours to prevent pneumonia. F. Administer an analgesic such as acetaminophen for pain.

ANS: B

2. Pain scales for infants and their uses include but are not limited to: A. CRIES: Crying, Requiring increased oxygen, Inability to console, Expression, and Sleeplessness B. FLACC: child's face, legs, activity, cry, and consolability C. NCCPC: parent and health caregiver questionnaire assessing acute and chronic pain D. NPASS: neonatal pain, agitation, and sedation scale for infants from 3 to 6 months

ANS: A

2. Which childhood vaccine provides some protection against bacterial meningitis, epiglottitis, and bacterial pneumonia? A. Hib vaccine B. Hepatitis B vaccine C. Varicella vaccine D. Influenza vaccine

ans: C

2.A young child is being treated for giardiasis. Which of the following should the nurse recommend to the child's parent? A.The parasite is difficult to transmit, so no special precautions are indicated. B.The child can swim in a pool if wearing diapers. C.Diapers must be changed as soon as soiled and disposed of in a closed receptacle. D.Cloth diapers should be rinsed in the toilet before washing.

ANS: B

2.The most common nutritional problem in American children is: A.Lack of breastfeeding B.Obesity C.Access to healthy food D.Vitamins

ANS: C

2.The nurse is caring for an infant with a congenital anomaly. What strategy can the nurse use to promote parental bonding and adjustment? A.Nurse can perform all infant care B.Identify the parents' weaknesses C.Guide parents in recognizing infants cues D.Help parents recognize this is a lifetime burden

Answer(s): A

2.When a 10-year old child asks if a procedure is going to hurt, as the nurse, you know it will hurt for a little bit. The best response is: A.Be honest and answer, "Yes, for a little bit." B.Change the subject and say, "It's beautiful day outside, isn't it?" C.Say, "NO, because you're a big boy. It won't hurt a bit." D.Smile broadly and ask, "What do you think?"

ANS: C

2.Which of the following demonstrates the primary benefit of antipyretics for treatment of children with fever? A.Decrease injury to the hypothalamus B.Prevent seizures C.Provide comfort D.Decrease injury to the neurologic system

ANS: A

3. A 3-month-old infant is seen in the clinic with the following symptoms: irritability, crying, refusal to nurse for more than 2 to 3 minutes, rhinitis, and a rectal temperature of 101.8°F (38.8°C). The labor, delivery, and postpartum history for this term infant is unremarkable. The nurse anticipates a diagnosis of: A. Acute otitis media (AOM) B. Otitis media with effusion (OME) C. Otitis externa D. Respiratory syncitial virus (RSV)

ANS: B

3. As the nurse is getting Nathan ready for surgery, his doctor asked you to explain preemptive analgesic to Nathan's mother. Which response leads you to believe his mother needs more teaching? A. "I understand that preemptive analgesia is giving Nathan pain medication before he has pain and could be given before surgery." B. "This medication will control Nathan's pain so he doesn't feel anything." C. "Giving this medicine early may help prevent complications after surgery." D. "By controlling Nathan's pain, he will be more comfortable and may be able to go home sooner."

ANS: C

4. Which childhood vaccine provides protection against streptococcal infections such as otitis media, sinusitis, and pneumonia? A. Rotavirus B. Hib C. Pneumococcal D. MMR

ANS: B

4.The nurse is assigned to care for a chronically ill child who is hospitalized. The child is 14 months old, and is the youngest of 9 children ranging in age from 2 months to 17 years. Which nursing action is the best example of enhancing family-centered care? A.The nurse answers the call light promptly. B.The nurse asks the mother to describe the child's feeding history. C.The nurse offers to feed the child and allow mom to take a nap. D.The nurse allows all of the siblings to remain in the room as much as they wish.

Acute Otitis Externa

*Acute Otitis Externa: Swimmer's Ear:* - caused by Pseudomonas aeruginosa or Staphylococcus aureus - *The predominant symptom of external ear infection is ear pain accentuated by manipulation of the pinna, especially pressure on the tragus.* - *Edema, erythema, a cheesy green-blue-gray discharge, and tenderness appear as the infection progresses.* MANAGEMENT: - anaglesics - *debris is removed with gentle suction and wisp of cotton* - *Otic preparations such as polymyxin-B sulfate/neomycin sulfate, ciprofloxacin and gentamycin sulfate, with or without corticosteroids, are instilled in the canal for a 7 to 10 days.* - A gauze wick may be inserted if edema is present to facilitate the medication reaching the site of inflammation. The wick is removed after swelling and pain have subsided, but the drops are continued for at least 3 days after relief of pain. - The best management for external ear inflammation is prevention PREVENTION: - stay in water less than 1 hour - dry ears completely 1-2 hours - *Placing a combination of acetic acid (white vinegar) and rubbing alcohol (50 : 50) in both ear canals on arising, at bedtime, and at the end of each swim is effective in restoring pH and preventing recurrence. Keep in for 5 minutes* - keep ears out of water 7-10 days - can use earplugs - Caution children not to pick at the ears with a pencil, cotton swab, bobby pin, or other object

Acute Streptococcal Pharyngitis

*Acute Streptococcal Pharyngitis:* Group A β-hemolytic streptococci (GABHS) *(STREP THROAT)* AT RISK FOR: Risk for serious sequelae - acute kidney infection (glomerulonephritis) - *rheumatic fever* - *scarlet fever: pharyngitis with erythematous sandpaper-like rash* > DIAGNOSTICS: - *Rapid antigen testing (swabbing of both tonsils and pharynx)* - *throat Culture* CLINICAL MANIFESTATIONS: - pharyngitis - *fever* - headache - abdominal pain - *tonsils and pharynx are inflammed & covered with exudate* - *difficulty swallowing* - subside in 3-5 days TREATMENT: - *Penicillin, amoxicillin, for 10 days* - If allergic to Penicillin: macrolide (erythromycin, azithromycin, calrithromycin)) or cephlaosporin - warm saline gargles - rest - cool liquids, ice chips - complete all antibiotics Penicillin: Oral *Needs 10-day treatment to decrease risk of rheumatic fever and glomerulonephritis post strep* Issues with medication compliance IM: Penicillin G Resolves compliance issue (one injection) Painful injection Penicillin G procaine is less painful injection *CANNOT give penicillin G by IV route* *Erythromycin if penicillin allergy* Other antibiotics PREVENTION: - no vaccines available - *droplet precautions* - *non-infectious 24 hours after beginning antibiotics* - *replace toothbrush* - avoid sharing towels, drinking or eating items

Respiratory Syncytial Virus (RSV) and Bronchiolitis

*BRONCHIOLITIS:* - Acute viral infection— caused by RSV or other viruses - Occurs primarily at the bronchiolar level - Typically affects infants - May occur in older children with chronic illnesses - winter and spring MANAGEMENT: - at home - adequate IV fluid intake, airway maintenance, and medications. - *Heated, high-flow nasal cannula (HHFNC) has been increasingly used for hospitalized infants and young children with bronchiolitis who are at risk of respiratory failure*. - *If respiratory acidosis is present CPAP, BiPAP, or intubation may be required.* - ABGs - *Ribavirin, an inhaled antiviral agent (synthetic nucleoside analog), is the only specific therapy approved for hospitalized children.* *RSV:* - RSV occurs less frequently in breastfed infants, and more frequently in children who live in crowded conditions. - RSV infection is the most frequent cause of hospitalization in children less than 2 years old. - In addition, severe RSV infections in the first year of life represent a significant risk factor for the development of asthma that can persist into adulthood TRANSMISSION: - through direct contact with respiratory secretions (less than 3 to 6 feet), mainly as a result of inoculation from hand to eye, nose, or other mucous membranes - The incubation period is 2 to 8 days, but viral shedding can last 3 to 4 weeks. CLINICAL MANIFESTATIONS: - Higher rates occur in children who attend a day care home or day care center - Symptoms such as *rhinorrhea and low-grade fever often appear first. In time, a cough may develop.* - *infants: slight lethargy, poor feeding, or irritability* - pneumonia may occur INITIAL: Rhinorrhea Pharyngitis Coughing, sneezing Wheezing Possible ear or eye infection Intermittent fever PROGRESSION: Increased coughing and wheezing Fever Tachypnea and retractions Refusal to nurse or bottle feed Copious secretions SEVERE: Tachypnea >70 breaths/min Listlessness Apneic spells Poor air exchange; poor breath sounds Cyanosis DIAGNOSTIC: - rapid immunofluorescent antibody-direct fluorescent antibody staining or enzyme-linked immunosorbent assay techniques for *RSV antigen detection are performed on nasopharyngeal secretions.* - *hard to distinct RSV from asthma* MANAGEMENT: - The use of *3% nebulized (hypertonic) saline* is associated with an increase in mucociliary clearance in children with RSV when used greater than 24 hours, but it is recommended for use only in patients hospitalized for more than 3 days - *Antibiotics are NOOOOT part of the treatment of RSV!!!* - *Additional treatment recommendations are to encourage breastfeeding, avoid passive tobacco smoke exposure*, and promote preventive measures, including hand washing and the *administration of palivizumab (Synagis) to high-risk infants.* - *The only product available in the United States for prevention of RSV is palivizumab, a humanized mouse monoclonal antibody that is given once every 30 days (15 mg/kg/dose) between November and March. It is usually given as an IM injection but may also be given IV.* - *CONTACT AND DROPLET ISOLATION* - Risk factors: premature birth with resp illness, exposure to day cares/ other children, siblings, long term resp illness - Season = end of October - April - Not given to every infant; only specific factors ^^^ *RSV immunoglobin RSV Ig given monthly throughout the season. Given up to 3 years of age* - *Not an immunization, it's a prophylaxis* - Can lead to asthma, death, pnenumonia- destruction of lung tissue - Rhinorrhea, fever, cough, *key finding: apnea* - *Nasal swab, RSV test* - Contagious, can be with other children who have RSV - Supportive care - *ECMO* - extra corporeal membrane oxygentation- heart lung machine used when hoping it can be reversal. Up to 2 weeks. Provides and cardiac support, minimizes use of ventilator

*BRONCHITIS

*BRONCHITIS:* - Also called tracheobronchitis - is an inflammation of the large airways (trachea and bronchi) that is frequently associated with a URI. - Viral agents are the primary cause of the disease, including influenza A and B, parainfluenza, coronavirus (types 1 to 3), rhinovirus, respiratory syncytial virus, and human metapneumovirus. CLINICAL MANIFESTATIONS: - *dry, hacking, and nonproductive cough that is worse at night, lasting more than 5 days but can persist for 1 to 3 weeks* TREATMENT: - *only symptomatic treatment, including analgesics, antipyretics, and humidity.* - Cough suppressants; can interfere with clearance of secretions - 5-10 days - *Adolescents with chronic bronchitis (>3 months) should be screened for tobacco or marijuana use.* Chronic bronchitis can be associated with underlying conditions such as CF and bronchiectasis. Inflammation within the bronchioles; wont see it Will see the resp. disretress, wheezing, S/S viral or bacterial infection *More common in households with second hand smoke* *Cool midst humidifier*

CROUP SYNDROME

*CROUP SYNDROME:* - is a general term applied to a group of symptoms characterized by *(hoarseness, a resonant cough described as "barking" or "brassy" (croupy), varying degrees of inspiratory stridor, and varying degrees of respiratory distress resulting from swelling or obstruction in the region of the larynx and subglottic airway*. - attributed to viruses—namely, *Influenza types A and B, adenovirus, RSV, and measles* - more often in boys than in girls. - The number of croup cases increases in the *late autumn through early winter months.* - It occurs primarily in children *6 months to 3 years of age* and is rare after 6 years of age. - Affect larynx, trachea, and bronchi - Described by anatomic area primarily affected >> *1. Epiglottitis [or supraglottitis], 2. laryngitis, 3. laryngotracheobronchitis [LTB], and 4. tracheitis* The key differences between LTB and epiglottitis are the absence of cough, the presence of dysphagia, and the high degree of toxicity in children with epiglottitis. Children with epiglottitis usually look worse than they sound, in contrast to children with LTB, who sound worse than they look MANAGEMENT: - *Cool midst humidifier* helps to ease irritation and makes air particles move more smoothly. - If bad, hospitalized. Mostly managed at home. - IF difficult breathing, have to come into hospital. - *Drooling, hard time swallowing secretions, irritable,* - Keep nares clear, bulb syringe

CROUP: ACUTE LARYNGITIS

*CROUP: ACUTE LARYNGITIS:* - More common in older children and adolescents - Usually caused by virus - *Chief complaint: hoarseness* - accompanied by other upper respiratory symptoms (e.g., coryza, *sore throat, cough, nasal congestion*) and systemic manifestations (e.g., fever, headache, myalgia, malaise) - Generally self-limiting and without long-term sequelae TREATMENT: - humidified air - fluids SIGNS OF INCREASING RESP DISTRESS: - RESTLESSNESS - Tachycardia - Tachypnea - Retractions - Substernal - Suprasternal - Intracostal

CROUP: Acute Spasmodic Laryngitis

*CROUP: Acute Spasmodic Laryngitis:* - Also called spasmodic croup, midnight croup, twilight croup - Paroxysmal attacks of laryngeal obstruction - *Occurs chiefly at night!!!!* - Inflammation—mild or absent - Most often affects children ages 1 through 3 - Signs of inflammation are absent or mild, and there is often a history of previous attacks lasting for 2 to 5 days, followed by an uneventful recovery CLINICAL MANIFESTATIONS: - The child goes to bed well or with some mild respiratory symptoms but *awakes suddenly with the characteristic barking, metallic cough; hoarseness; noisy inspirations; and restlessness.* - The child appears anxious and frightened. - However, there is *NO FEVER, the episode subsides in a few hours, and the child appears well the next day with the exception of slight hoarseness* MANAGEMENT: - managed at home - cool mist - *Warm mist provided by steam from hot running water in a closed bathroom may be helpful.* - *if hospitalized: cool mist & racemic epinephrine, corticosteroids* - self limitting

Chicken Pox (Varicella)

*Chicken Pox (Varicella):* ØAgent: Varicella-zoster virus (VZV) ØTransmission: Direct contact and respiratory secretions ØClinical manifestations: •Prodromal stage—slight fever, malaise. •*Pruritic rash begins a macule > vesicle then erupts* •Rash is typically centripetal > *extremities, face* •*Treatment: Supportive; Antiviral acyclovir (Zovirax), varicella-zoster immune globulin; antihistamines for itching* *ØPrecautions: Standard, Airborne* ØChild is contagious a day before rash appears and until vesicles are crusted ØPrevention: Secondary skin infection and complications; immunization

Congenital diaphragmatic hernia (CDH)

*Congenital diaphragmatic hernia (CDH):* - *results when the diaphragm does not form completely, resulting in an opening between the thorax and the abdominal cavity.* - The most common type of CDH (90%) is a *left posterolateral defect, also known as a Bochdalek hernia* because the herniation occurs through the foramen of Bochdalek - With the Bochdalek hernia, the intestines and other abdominal structures, such as the stomach, liver, or bowel, can enter the thoracic cavity, compressing the lung. - *more common on the left side* CLINICAL MANIFESTATIONS: - *acute respiratory distress* in the newborn. - Infants with a CDH may be dyspneic and cyanotic and have a *scaphoid abdomen* (because of abdominal contents in the chest). - Cardiac output is impaired, and the infant exhibits signs and *symptoms of shock* DIAGNOSTICS: - *Prenatal: US* - *XR* MANAGEMENT: - *Fetal Surgery: Fetoscopic endoluminal tracheal occlusion* has been performed in cases of severe CDH to expand the lungs and push the abdominal contents back into the abdomen, thus producing larger, functional lungs. - After Birth: > *endotracheal intubation and GI decompression with a double-lumen catheter to decompress the stomach and reduce compression of the lung.* > At birth, *bag and mask ventilation is contraindicated to prevent air from entering the stomach and especially the intestines, further compromising pulmonary function.* > operative treatment > ECMO

Croup (acute laryngotracheobronchitis)

*Croup: acute laryngotracheobronchitis (LTB):* - most common type of croup experienced by children admitted for hospitalization and primarily affects children 6 to 36 months old. - Organisms responsible for LTB are the parainfluenza virus types 1, followed by parainfluenza virus types 2 and 3, adenoviruses, RSV, and M. pneumoniae. CLINICAL MANIFESTATIONS: - It is characterized by the *gradual onset of low-grade fever, and the parents often report that the child went to bed and later awoke with a barky, brassy cough and at times inspiratory stridor*. - Symptoms are typically *worse at night*, and agitation and crying tend to exacerbate the symptoms - inflammation of mucous; narrowing of airway = *inspiratory stridor and suprasternal retractions* - *COUGH, hoarseness* - *respiratory distress* - *This can lead to respiratory acidosis and respiratory failure.* MANAGEMENT: - Maintain airway - know signs of resp distress - cool mist - *Nebulized racemic epinephrine is administered as quickly as possible for moderate to severe cases; monitor for 3-4 hours for resp distress* - *Oral steroids (dexamethasone) have proven effective in the treatment of croup (as a single dose) and are considered standard treatment for this condition; IV or IM dexamethasone* may be given to children who are unable to tolerate oral dosing. - oxygen, fluids - sit up

Erythema Infectiosum (Fifth Disease)

*Erythema Infectiosum (Fifth Disease):* *ØAgent: Human herpes virus type 6* ØTransmission: Probably droplet or direct contact ØClinical manifestations: •*Persistent fever for 3 to 7 days in child who is otherwise well appearing* •*"Slapped Cheek" appearance; Do a physical exam after* •Mild URI symptoms, cough *ØTreatment: Supportive care; antipyretics, analgesics, antiinflammatory* ØPrecautions: Standard

FOREIGN BODY ASPIRATION

*FOREIGN BODY ASPIRATION:* - potential airway obstruction and inability to adequately oxygenate the body - most common in older infants and children ages 1 to 3 years CLINICAL MANIFESTATIONS: - *choking, gagging, or coughing* - Laryngotracheal obstruction most commonly causes *dyspnea, cough, stridor, and hoarseness because of a decreased air entry*. - Cyanosis may also occur if the obstruction becomes worse. - Bronchial obstruction usually produces cough (frequently paroxysmal), wheezing, asymmetric breath sounds, decreased airway entry, and dyspnea. In some cases, a FB obstruction may *be mistaken for croup or asthma* - The most common symptoms observed in children brought to medical attention are *stridor, wheezing, sternal retraction, and cough.* - When an object is lodged in the larynx, the child is unable to speak or breathe. DIAGNOSTIC: - history, physical signs - CXR - *Bronchoscopy/Endoscopy* - Fluoroscopic examination MANAGAMENT: - ABD thrust/ chest thrusts/ back blows - Bronchoscopy/Endoscopy for removal PREVENTION: - no small objects 1ST DEGREE - obstruction allows air both ways 2ND DEGREE - air able to move past the obstruction in one direction only. air passages enlarge during inspiration and diminish during expiration. COMPLETE OBTRUCTION: - Air unable to move in either direction. FB and mucous obliterate obstruction. FB IN NOSE: - unilateral nasal discharge that is foul smelling , local obstruction with sneezing, mild discomfort, and (rarely) pain - Removal usually occurs easily with either forceps, suction or inflation of a balloon catheter behind the obstruction

Infectious Mononucleosis

*Infectious Mononucleosis: MONO* Infectious mononucleos is is an acute, self-limiting infectious disease that is common among young people under 25 years old. Symptoms include fever, exudative pharyngitis with petechiae, lymphadenopathy, hepatosplenomegaly, and an increase in atypical lymphocytes. PATHO: - *The Epstein-Barr virus (EBV) is the principal cause of infectious mononucleosis* - The virus is believed to be transmitted by direct contact with oral secretions (close personal contact is needed to transmit the virus), blood transfusion, or transplantation. - It is mildly contagious, and the period of communicability is unknown. - The incubation period after exposure in adolescents is estimated to be 30 to 50 days CLINICAL MANIFESTATIONS: - *can appear 10 days - 6 weeks after exposure* - malaise - *sore throat* - fever with generalized lymphadenopathy and splenomegaly that may persists for several months - insidiously: fatigue, *lack of energy due to lack of sleep or URI*, and sore throat - *skin rash with administration of ampicillin or amoxicillin* - headache - epistaxis - severe sore throat - enlarged tonsils DIAGNOSTIC: - Clinical manifestations - increase in atypical leukotyles in a peripheral blood smear (WBC; CBC) - *Positive heterophil agglutination test (Monophil or Paul-Brunnel)* MANAGEMENT: - No specific treatment - mild analgesics - short course of corticosteroids for airway obstruction; not routinely used - *admin of ampicillin or amoxicillin contraindicated* - *avoid live vaccines* - *restrict activities 2-3 months* - increase clear fluid intake

*Influenza Flu:*

*Influenza Flu:* Agent: Influenza Virus (varies from year to year) Transmission: Direct contact Clinical manifestations: Ø*Abrupt Fever* ØURI-like symptoms which progress Ø*Malaise, anorexia* Treatment: Prevention, *antiviral Oseltamivir (Tamiflu)treatment if detected early*, supportive care *Precautions: Droplet*

Measles (Rubeola)

*Measles (Rubeola):* Agent: Viral Transmission: Direct contact from respiratory system Clinical manifestations: ØProdromal state: *fever, malaise > coryza, cough, conjunctivitis* Ø*"Koplick Spots" on mucosa* Ø*Rash appears on day 3 to 4 of illness* *Treatment: Antibiotics, bed rest, and support; Vitamin A* *Precautions: Airborne if in hospital until day 5 of rash;*

INTERVENTIONS - PAIN

*NONPHARM* *For children:* ØDistraction ØRelaxation ØGuided imagery ØCutaneous stimulation *For infants:* ØContainment ØPositioning ØNonnutritive sucking ØKangaroo holding *MEDS:* - Nonopioids for mild to moderate pain: ØAcetaminophen, NSAIDs - Opioids for moderate to severe pain ØMorphine, Codeine, fentanyl - *Morphine—Gold standard* ØDrug of choice for PCA Ø1 mg/ml typical for PCA usage - Other opioids ØHydromorphone, meperidine ØOxycodone—available with and without acetaminophen—total dose considerations ADJUVANT - Anxiolitics, sedatives, amnesics ØDiazepam (Valium) and midazolam (Versed) - Tricyclic antidepressants and antiepileptics for neuropathic pain - Stool softeners and laxatives for constipation - Antiemetics for nausea and vomiting - Diphenhydramine for itching - Steroids for inflammation and bone pain - Dextroamphetamine and caffeine for possible increased pain and sedation ANALGESICS - DOSING: *First-pass effect* Titration to desired effect Route of administration and effect on dosage - TIMING: Around the clock (ATC) versus as needed (PRN) ØContinuous versus as needed •Dosage difference and timing •Clock watching

UPPER RESP INFECTIONS (URIS)

*Nasopharyngitis—"common cold"* Caused by numerous viruses >> RSV, rhinovirus, adenovirus, influenza, and parainfluenza viruses CLINICAL MANIFESTATIONS: *Fever—varies with age of child* Irritability, restlessness *Decreased appetite and fluid intake* *Nasal inflammation* Vomiting and diarrhea Home management—varies with age - *No vaccines available* - Rest and fluids PHARM TREATMENT: *OTC pediatric cold remedies are not recommended for treating "common cold" for 6 years & younger* > *Antihistamines ineffective in most cases* > Antipyretics for comfort from fever > Cough suppressants for dry cough >> *Caution alcohol content* > Decongestant to shrink swollen nasal passages >> Nose drops more effective than oral administration PREVENTIONS: -wash hands - avoid mouth, eyes, nose NURSING CARE: - HOB elevated - suction - fluids - avoid contact with infected persons - wash hands - *frequent colds are normal throughout childhood, and by 5 years old they should be more immune* - notify HCP if no improvement in 2-3 days / dehydration

Obstructive Sleep Apnea Syndrome (OSAS)

*Obstructive Sleep Apnea Syndrome (OSAS):* - Prolonged partial upper airway obstruction during sleep - Distinctly different in children than adults CLINICAL MANIFESTATIONS: - *Snoring* - Enuresis - Interrupted sleep patterns - Neurobehavioral problems MANAGEMENT - *Adenotonsillectomy* - *CPAP* - History and physical > Growth patterns > School and social performance > Secondary enuresis - Education of diagnostic testing - Counseling and support

Pertussis (Whooping Cough)

*Pertussis (Whooping Cough):* Agent: Bordetella pertussis Transmission: Direct contact from droplets Clinical manifestations: ØCatarrhal stage: URI symptoms 1 to 2 weeks ØParoxysmal stage: *short, rapid cough bought followed by high-pitched crowing, "whoop" or gasp 4 to 6 weeks cyanosis may occur during episode* Treatment: Prevention; immunization Ø*Supportive during hospitalization with suction, humidity, careful oral feeding, and hydration* *Precautions: Droplet*

Pertussis (Whooping Cough)

*Pertussis (Whooping Cough):* - Caused by Bordetella pertussis - In the United States, *it occurs most often in children who have not been immunized & younger than 4* - Highest incidence in spring and summer - Highly contagious - Risk to young infants - Vaccines: >> *DTaP ×5 in childhood* >> *"Booster" ×1 with TDaP between ages 11 and 64 years* >> Refer to Vaccine Information Statements (VIS)www.cdc.gov/vaccines/pubs/vis/downloads/vis-tdap.pdf CLINICAL MANIFESTATIONS: - *apnea* - *persistent cough with whooop* - It persists *6 to 10 weeks and can result in encephalopathy*, seizures, pneumonia, rib fractures (adolescents), bleeding into the conjunctiva, or even death (infants). - The incubation period is 7 to 10 days but can be as long as 21 days DIAGNOSTIC: - culture or polymerase chain reaction assay using *nasopharyngeal secretions* TREATMENT: - *oral antibiotics (e.g., erythromycin, azithromycin, clarithromycin)*

Pneumococcal Disease

*Pneumococcal Disease:* Agent: Streptococcal pneumococci Transmission: Direct contact affecting *children under 2 years most commonly* Clinical manifestations: Ø*Pneumonia, otitis media, sinusitis, localized infections.* *Treatment: Prevention, antibiotics amoxillcin, supportive care* *Precautions: Droplet*

Rickettsial Infection

*Rickettsial Infection:* Disorders transmitted to humans via arthropods *ØTicks, infected fleas, mites* ØMore common in temperate and tropical climates ØBite or exposure may occur without knowledge to family and child ØIllness ranges from self-limiting to fatal *Lyme disease:* Agent: Spirochete Borrelia burgdorferi *Transmission: Infected deer tick bite* Clinical manifestations: ØStage 1: *"Bull's Eye"* •Fever, HA, malaise ØStage 2: rash on hands and feet 3 to 10 weeks after inoculation •Fever, fatigue, lymphadenopathy, cough ØStage 3: Systemic involvement 2 to 12 mo. Diagnosis: History and serologic testing Treatment: *ØDoxycycline >8 years* ØAmox < 8 years Nursing implications: ØPrevention ØTick removal and insect repellent ØSupportive care ØCompletion of ABX *Rocky Mountain Spotted Fever:* Agent: Spirochete Rickettsia rickettsii *Transmission: Infected tick bite, rodent, or dog* Clinical manifestations: ØGradual or abrupt onset of fever, malaise, HA ØRash on palms, soles of feet Treatment: *ØTetracycline* ØSupportive therapy Ø Nursing implications: ØPrevention of exposure ØEducation of family ØSupportive care *Cat Scratch Disease:* Agent: Bacteria Bartonella henselae *Transmission: Scratch from kitten or cat* Clinical manifestations: *ØPainless nonpruritic papule* ØRegional lymphadenitis Treatment: Usually supportive without need for ABX Nursing implications: ØSupport child and family without disposal of pet

Rubella (German Measles)

*Rubella (German Measles):* Agent: Rubella virus Transmission: Direct contact from droplets Clinical manifestations: *Low-grade fever, headache, malaise, sore throat, RASH* Treatment: Supportive care; antipyretics *Precautions: Droplet*

Scarlet Fever

*Scarlet Fever:* Agent: Group A Beta-hemolytic streptococci Transmission: Direct contact from droplets Clinical manifestations: Ø*Prodromal stage: Abrupt high fever, halitosis* Ø*Enanthema: Tonsils large, edematous, covered with exudate* Ø*"Strawberry tongue"* Ø*Exanthema: Sandpaper-like pink rash* *Treatment: Penicillin, or erythromycin, rest, analgesics, aniprutiics for rash and supportive care* *Precautions: Droplet until 24 hr of ABX*

Skin Infections—Bacterial

*Skin Infections—Bacterial:* Bacterial Agents: Staphylococci and streptococci MRSA on the rise Transmission: Invasion and toxicity in susceptible skin (self-inoculation is common) Treatment: ØTopical or systemic ABX ØHand washing and hygiene ØDilute bleach baths ØMay require hospitalization Disorders include: ØImpetigo (common) ØFolliculitis ØCellulitis ØScalded skin syndrome *Skin Infections—Viral:* Viral Agents: Viruses Transmission: Invasion and toxicity in susceptible skin or oropharyngeal mucosa following contact with droplets Treatment: ØAntiviral medications for HSV ØHand washing and hygiene to prevent spread ØDestruction of warts Disorders include: ØVerruca (warts) ØHerpes simplex I and II ØVaricella ØMolluscum *Skin Infections—Fungal:* Fungal Agents: Typically dermatophystoses; tinea or candidia Transmission: Invasion in susceptible skin, corneum, hair, or nails May be transmitted from infected animals DX: Microscopic exam Treatment: ØTopical or systemic antifungal Disorders include: Ø*Tinea capitis (scalp)* FUNGAL INFECTION OF SCALP HAIRS; RINGWORM OF THE SCALP. Oral griseofulvin or terbinafine. Oral ketoconazole for difficult cases. Selenium sulfide shampoos, used twice a week ØTinea corporis (body or nails) ØTinea cruris (groin) ØTinea pedis (feet) ØThrush (oral) ØCandidiasis (vaginal, diaper dermatitis)

Skin Infestations

*Skin Infestations—Scabies:* Infestation agent: Sarcoptes scabiei Transmission: Prolonged close personal contact where the mite burrows into the epidermis and deposits eggs. Clinical manifestations: ØIntense pruritus ØExcoriation and burrows ØDiscrete inflammation between finger webs, neck folds, groin Treatment: ØScabicide: Older than 2 mo. > Permethrin 5% cream × 8 to14 hr ØHygiene of linens and clothing with high heat ØSupportive care for pruritus 2 to 3 weeks. *Skin Infestations—Pediculosis Capitis: head lice* Infestation agent: Pediculus humanus capitis Transmission: Prolonged close contact when a female louse is able to obtain blood meal at scalp and deposit eggs on hair shaft at night. Clinical manifestations: *ØIntense pruritus of scalp (behind ears or nape of neck)* *ØNits attached to hair shaft* Treatment: ØPediculicide and removal of nits: *ØPermethrin 1% cream (OTC), repeat in a week, treat affected family* ØFamily may attempt other treatment regimens ØEducation and support to families ØAdvocacy and support for school attendance *Skin Infestations—Bedbugs:* Infestation agent: Cimex lectularius Transmission: Contact/sleep in infested mattress àmite burrows into the epidermis to feed on blood. Clinical manifestations: ØIntense pruritus, inflammation/rash ØMay progress to folliculitis/cellulitis ØMay trigger asthma exacerbation, anaphylaxis Treatment: ØIdentification and eradication of bedbug (professional extermination) ØTopical application of steroids ØHygiene of linens and clothing ØSupportive care for pruritus 2 to 3 weeks.

CH 6. Infectious Diseases

*Standard precautions:* ØBarrier protection from blood and body fluids ØRespiratory hygiene/cough etiquette ØSafe injection practices ØHand hygiene Transmission-based precautions: Ø*Airborne:* N95 •Small particle or evaporated droplets or dust •Negative pressure isolation room - *TB, Varicella, Measles, Chickenpox, SARS* Ø*Droplet:* •Large-particle droplets (sneeze, cough, speech, cry), - *N. meningitides, Hib B, Influenza viruses, M. pneumonia, Rubella, Mumps, B. pertussis, Diptheria, RSV, Scarlet Fever* Ø*Contact:* •Exercise judgment with gloves, gowns, masks - *MDR/ MRO, Enteric infections (C. diff, E.coli, RSV, HSV, enterovirus, parainfluenza), scabies, impetigo, non-contained abscesses/ulcers (esp for S. aureus & Gp A Strep)* SUSPECT COMMUNICABLE DISEASES?: - Obtain careful history: ØKnown exposure? ØCommunity exposure? ØProdromal symptoms: •Fever •Rash •Early clinical manifestations ØImmunization ØHistory of having disease ØHistory of comorbidity/risk factors Institute precautions, provide comfort and support, document findings

CH. 22 INTERVENTIONS AND SKILLS

- Informed consent ØAge of majority/competence - Requirements for obtaining informed consent Ø"Assent" for older children and adolescents - Eligibility for giving informed consent ØTreatment without parental consent ØEmancipated minor ØMature minor *ASSENT:* - *Meaning—Child has been informed and is willing* Developmentally appropriate awareness of the nature of his or her condition Telling the patient what to expect Assessing understanding Soliciting an expression of child's willingness to accept the proposed procedure EMANCIPATED MINOR *Legally under the age of majority but is recognized as having the legal capacity of an adult under circumstances prescribed by state law, such as pregnancy, marriage, high school graduation, independent living, or military service* *TREATMENT NOT REQUIRING PARENTAL PERMISSION OR KNOWLEDGE* - AKA "medically emancipated" conditions - All 50 states have legislation, but it varies ØSexually transmitted infections ØMental health services ØAlcohol and drug dependency ØPregnancy ØContraceptive advice

Answer(s): A, B, C, E, F Rationale: A. Obesity in children and adolescents is defined as a body mass index at or greater than the 95th percentile for youth of the same age and gender Childhood obesity is the most common nutritional problem among American children and is associated with type 2 diabetes. B. Lack of physical activity related to limited resources, unsafe environments, and inconvenient play and exercise facilities, combined with easy access to television and video games, increases the incidence of obesity among low income, minority children. C. Same as B. D. It would not be important to allow children to choose their favorite foods every day, especially sweets. Allowing children to choose their favorite healthy foods would be more appropriate. E. It is important to help parents understand how to help their child maintain a normal body weight. F. Overweight youth have increased risk for metabolic syndrome (a cluster of cardiovascular factors that include hypertension, altered glucose metabolism, dyslipidemia, and abdominal obesity) in the future.

1.When talking to parents about childhood obesity and type 2 diabetes, which topics should the nursing students discuss with the parents? (Select all that apply.) A.Obesity in children and adolescents is defined as a body mass index at or greater than the 95th percentile for youth of the same age and gender. B.Easy access to television and video games has increased the incidence of obesity. C.Lack of physical exercise contributes to obesity. D.The importance of allowing children to choose their favorite foods every day, including sweets such as dessert. E.The importance of maintaining a normal body weight. F.Overweight youth have increased risk for not only type 2 diabetes, but also high blood pressure and dyslipidemia.

ANS: A

3.Which of the following parental factors has the greatest effect on the transition to parenthood? A.Age of the parent, resources, and coping skills B.IQ of the parent, IQ of the child, and age of the parent C.IQ of the child, health care needs of the child, and age of the parent D.Resources, coping skills, and health care needs of the child

ANS: A

3.Which of the following side effects of opioid analgesics should prompt a discontinuation of the medication? A.Prevent or minimize bodily injury and pain B.Provide a caring environment that facilitates strong mental health C.Enhance the parent-child relationship D.Facilitate achievement of developmental milestones

ANS: B, C, D

4. When teaching a 6-year-old child with sickle cell disease and his family about pain management, which of the following should the nurse discuss? Select all that apply. A. When pain medications are used, all pain will be eliminated. B. Nonpharmacologic methods of pain relief, including heat, massage, physical therapy, humor, and distraction. C. It is helpful to use a "passport card" that includes information about the diagnosis, any previous complications, and the pain regimen. D. Only the physician can decide the best course of treatment, and the other health care providers follow that plan. E. Long-term medication use considers many factors.

Answer(s): B

4.The nurse makes sure that the family maintains a sense of control over their lives while their child is in the hospital when the nurse provides family-centered care and positively acknowledges their strength and helping behaviors. What concept would this nurse's actions demonstrate? A.Nonmaleficence B.Empowerment C.Atraumaticcare D.Enabling

ANS: A, C, D, F

5. A 2-month-old formerly healthy infant born at term is seen in the urgent care clinic with intercostal retractions, respiratory rate of 62, heart rate of 128, refusal to breastfeed, abundant nasal secretions, and a pulse oximeter reading of 88% in room air. The diagnosis of respiratory syncytial virus is made. The infant's oxygen saturation remains 95% in room air, and the respiratory rate is 54, with intercostal retractions; heart rate is 120 beats per minute. After 2 hours of observation and an intravenous bolus of fluids, the infant is being discharged home. The nurse provides which of the following home care instructions for this infant? Select all that apply. A. Continue breastfeeding infant. B. Discontinue breastfeeding and administer Pedialyte for 24 hours. C. Observe infant for labored breathing or apnea (cessation of breathing). D. Instill normal saline drops in both nares and suction thoroughly before feeding and before placing to sleep. E. Place infant to sleep on his side with the head of bed slightly elevated to facilitate breathing. F. Keep the infant out of day care or nursery.

ans: B, D, E

5. How can the nurse prepare a child for a painful procedure? Select all that apply. A. Be honest and use correct terms so that the child trusts the nurse. B. Involve the child in the use of distraction, such as using bubbles, music, or playing a game. C. Kindly ask parents to leave the room so they don't have to watch the painful procedure. D. Use positive self-talk such as "When I go home, I will feel better and be able to see my friends." E. Use guided imagery that involves recalling a previous pleasurable event.

ANS: B

5. One of the most common intestinal parasitic pathogens in the United States acquired from a contaminated water source such as a lake or swimming pool is: A. Tinea capitis B. Giardia intestinalis C. Pediculosis capitis D. Enterobiasis

Intestinal Parasites

:**Intestinal Parasites:* Most frequent infections worldwide Young children at highest risk Most common in the United States: ØGiardiasis ØPinworms Nursing Management: ØAssist with identification, treatment, and prevention Ø*Fecal smears are diagnostic* ØTreat family members ØProvide education and support to prevent reinfection *Giardiasis:* Agent: Protozoan Giardia intestinalis Transmission: Direct contact with *contaminated water or food* DX: stool specimen *Treatment: Flagyl or Tindamax and prevention of reoccurrence* *Enterobiasis (Pinworms):* Agent: nematode Enterobius vermicularis Transmission: Inhalation or *ingestion of eggs from contaminated hands* *DX: Tape test* > A loop of transparent (not "frosted" or "magic") tape, sticky side out, is placed around the end of a tongue depressor, which is then firmly *pressed against the child's perianal area.* > Pinworm specimens are collected in the morning as soon as the child awakens and before the child has a bowel movement or bathes. The procedure may need to be performed on *3 or more consecutive days before eggs are collected.* Treatment: *ØPyrantel Pamoate or Albendazole × 1, then again in 2 weeks.* ØTreat family members ØPrevention of reoccurrence

Nonvaccine Communicable Diseases

Nonvaccine Communicable Diseases: *Conjunctivitis:* Nursing management: Ø*Contact precautions* ØKeep eye clean and dry ØAdminister ophthalmic medications ØComfort and supportive care ØEducate caregivers ØPrevent spread of infection - Bacterial conjunctivitis has traditionally been treated with *topical antibacterial agents such as polymyxin and bacitracin (Polysporin), sodium sulfacetamide (Sulamyd), or trimethoprim and polymyxin (Polytrim).* - Infants with bacterial conjunctivitis may require systemic antibiotics - For children *1 year and older, fluoroquinolones and aminoglycosides are commonly used ophthalmic antimicrobial agents.* - Remove accumulated secretions by wiping from the *inner canthus downward and outward*, away from the opposite eye *Stomatitis:* ØTwo types: > *Aphthous stomatitis (aphthous ulcer, canker sore):* - The lesions are painful, small, whitish ulcerations surrounded by a red border. > *Herpetic gingivostomatitis (HGS):* - caused by *HSV, most often type 1,* and may occur as a primary infection or recur in a less severe form known as recurrent herpes labialis (commonly called cold sores or fever blisters). - The primary infection usually begins with a fever; - vesicles erupt on the mucosa, causing severe pain; on lips Nursing management Goal is to relieve pain ØNSAIDs Ø*Topical anesthetics: Orabase, Anbesol, and Kank-A.* Prevent spread of illness - Treatment for children with severe cases of HGS includes the use of antiviral agents such as *acyclovir* ØOral transmission ØMeticulous hand washing - *Due to herpes, or cancer with chemo*

CH 3. HEREDITARY

Numeric alterations affecting the autosomes Examples include some of the most common trisomies: ØTrisomy 21 (Down syndrome) ØTrisomy 18 (Edwards syndrome) ØTrisomy 13 (Patau syndrome)

CH 5. PAIN MANAGEMENT

PAIN ASSESSMENT TOOLS: Behavioral: ØInfants to age 4 years Physiologic *Numeric pain ratings:* *ØFor 8 years and older* Ø0 to 10 scale widely used ØEasy to use ØLittle research for reliability and validity Self-report: ØNot valid for children younger than 4 years Assessment tools *ØFLACC, CHEOPS, TPPR, and PPPRS* *COMFORT SCALE:* The only tool recommended for use with unconscious and ventilated infants, children, and adolescents. Eight indicators: Score each between 1 and 5. ØAlertness ØCalmness/agitation ØRespiratory response ØPhysical movement ØBlood pressure ØHeart rate ØMuscle tone ØFacial tension Observe for 2 minutes and add the scores of each indicator. The total scores range from 8 to 40. *Score of 17 to 26 = Adequate sedation and pain control.* FACES PAIN SCALE: *Wong-Baker FACES Pain Scale: Six cartoon faces* ØSmiling face = "no pain" ØTearful face for "worst pain" ØThe child chooses a face that describes his or her pain ØThe WB FACES widely used in United States *Bieri Faces Pain Scale—Revised: Six faces = 0 to 5* ØNo smiling face at the "no pain" end ØNo tears face at the "most pain" end ØEquivalent to a 0 to 10 metric system *VISUAL ANALOG SCALE:* *"No hurt" to "biggest hurt" are more appropriate than "least pain sensation to worst intense pain imaginable."* Requires a higher degree of abstraction than the Numeric rating scale (NRS). Recommended because of the lack of supportive evidence through psychometric studies with the NRS in children and adolescents. *Adolescent pediatric pain tool (APPT):* ØAssesses pain location, intensity, and quality •Anterior and posterior body outline on one side •100-mm word-graphing rating scale with a pain descriptor ØFacilitates assessments of pain quality + location *PEDIATRIC PAIN QUESTIONAIRRE:* *Assesses patient and PARENTAL perceptions of pain* Cognitive and developmental considerations Eight areas of inquiry: pain history, pain language, the colors children associate with pain, emotions children experience, the worst pain experiences, the ways children cope with pain, the positive aspects of pain, and the location of the child's current pain Three components of the PPQ > VASs > Color-coded rating scales > Verbal descriptors *The child, parent, and physician each complete the form separately*