Pedi Test #4

Growth and development mile stones 65-70, 477-487, 507-508, 309-325, 408, 417, 458-468, 379-390

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Rheumatic fever

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Stridor

A high pitched sound generated from partially obstructed air flow or narrowing of larynx or trachea in the upper airway.

Wheezing

A musical whistling sound caused by turbulent movement of air through constricted bronchioles. Common in asthma or COPD

Epiglottis

A presumptive diagnosis of acute epiglottitis, or acute supraglottitis, is a medical emergency. It is a serious obstructive inflammatory process that occurs predominantly in c hildren 2 to 5 years but can occur from infancy to adulthood. The obstruction is supraglottic as opposed to the subglottic obstruction of laryngitis. The responsible organism is usually H. influenzae. LTB and epiglottitis do not occur together. Clinical Manifestations- The onset of epiglottitis is abrupt, and it can rapidly progress to severe respiratory distress. The child usually goes to bed asymptomatic to awaken later, complaining of sore throat and pain on swallowing. The child has a fever; appears sicker than clinical findings suggest; and insists on sitting upright and leaning forward with the chin thrust out, mouth open, and tongue protruding (tripod position). Drooling of saliva is common because of the difficulty or pain on swallowing and excessive secretions. Nursing Alert- Three clinical observations that are predictive of epiglottitis are absence of spontaneous cough, presence of drooling, and agitation. The child is irritable; extremely restless; and has an anxious, apprehensive, and frightened expression. The voice is thick and muffled, with a froglike croaking sound on inspiration, but the child is not hoarse. Suprasternal and substernal retractions may be evident. The child seldom struggles to breathe, and slow, quiet breathing provides better air exchange. The sallow color of mild hypoxia may progress to frank cyanosis. The throat is red and inflamed, and a distinctive large, cherry red, edematous epiglottis is visible on careful throat inspection. Nursing Alert- Throat inspection should be attempted only when immediate endotracheal intubation can be performed if needed. Therapeutic Management- The course of epiglottitis may be fulminant, with respiratory obstruction appearing suddenly. Progressive obstruction leads to hypoxia, hypercapnia, and acidosis followed by decreased muscle tone; reduced level of consciousness; and, when obstruction becomes more or less complete, a rather sudden death. The child who is suspected of having epiglottitis should be examined in a setting where emergency airway equipment is readily available. Examination of the throat with a tongue depressor is contraindicated until experienced personnel and equipment are available to proceed with immediate intubation or tracheostomy in the event that the examination precipitates further or complete obstruction (see Critical Thinking Case Study box). Nasotracheal intubation or tracheostomy is usually considered for the child with epiglottitis with severe respiratory distress. It is recommended that the intubation or tracheostomy and any invasive procedure, such as starting an intravenous (IV) infusion, be performed in an area where emergency airway maintenance can be easily and quickly accomplished. Humidified oxygen is administered as necessary either via mask in older children or flow-by in younger children to avoid further agitation (see Evidence-Based Practice Box, p. 727). Whether or not there is an artificial airway, the child requires intensive observation by experienced personnel. The epiglottal swelling usually decreases after 24 hours of antibiotic therapy (ceftriaxone sodium or alternate cephalosporin), and the epiglottis is near normal by the third day. Intubated children are generally extubated at this time. The use of corticosteroids for reducing edema may be beneficial during the early treatment phase. Children with suspected bacterial epiglottitis are given antibiotics intravenously followed by oral administration to complete a 7- to 10-day course. Family contacts with children younger than 4 years of age and any contacts younger than 4 years of age are treated with rifampin for 4 days (AAP, Committee on Infectious Diseases and Pickering, 2009). Nursing Care Management- Epiglottitis is a serious and frightening disease for the child and family. It is important to act quickly but calmly and to provide support without increasing anxiety. The child is allowed to remain in the position that provides the most comfort and security, and the parents are reassured that everything possible is being done to obtain relief for their child. Nursing Alert- When epiglottitis is suspected, the nurse should not attempt to visualize the epiglottis directly with a tongue depressor or take a throat culture but should refer the child for medical evaluation immediately.

Reyes Syndrome

ASPIRIN FOR VIRAL INFECTIONS IS BAD! Reye's syndrome is a disorder defined as acute encephalopathy associated with other characteristic organ involvement. It is characterized by fever, profoundly impaired consciousness, and disordered hepatic function. The etiology of RS is not well understood, but most cases follow a common viral illness, typically influenza or varicella. Definitive diagnosis is established by liver biopsy. The staging criteria for RS are based on liver dysfunction and on neurologic signs that range from lethargy to coma.Rapid progression to coma and high peak ammonia concentrations are associated with a more serious prognosis. Cerebral edema with increased ICP represents the most immediate threat to life. Care and observations are implemented as for any child with an altered state of consciousness (see p. 934) and increasing ICP. Accurate and frequent monitoring of intake and output is essential for adjusting fluid volumes to prevent both dehydration and cerebral edema. Because of related liver dysfunction, laboratory studies to determine impaired coagulation, such as prolonged bleeding time, should be monitored. Parents of children with RS need to be kept informed of the child's progress, to have diagnostic procedures and therapeutic management explained, and to be given concerned and sympathetic support. Families need to be aware that salicylate, the alleged offending ingredient in aspirin, is contained in other products (e.g., Pepto-Bismol). They should refrain from administering any product for influenza-like symptoms without first checking the label for "hidden" salicylates.

Acne

Acne vulgaris is the most common skin problem treated by physicians during patients' adolescence. Acne is not caused by dirt but by testosterone, a hormone present in boys and girls that increases during puberty. It stimulates the sebaceous glands of the skin to enlarge, or produce oil, and plug the pores. Whiteheads, blackheads, and pimples are present in teenage acne. Cleansing-Dirt or oil on the surface of the skin does not cause acne. Gentle cleansing with a mild cleanser once or twice daily is usually sufficient. Antibacterial soaps are ineffective and may be too drying when used in combination with topical acne medications. For some adolescents, hygiene of the hair and scalp appears to be related to the clinical activity of the acne. Acne on the forehead may improve with brushing the hair away from the forehead and more frequent shampooing. Medications- Treatment success depends on commitment from the adolescent. Before prescribing treatment, the practitioner should determine the adolescent's level of comfort and readiness to begin treatment. Tretinoin (Retin-A) is the only drug that effectively interrupts the abnormal follicular keratinization that produces microcomedones, the invisible precursors of the visible comedones. Tretinoin alone is usually sufficient for management of comedonal acne (Kim and Armstrong, 2011). Tretinoin is available as a cream, gel, or liquid. This drug can be extremely irritating to the skin and requires careful patient education for optimal usage. The patient should be instructed to begin with a pea-sized dot of medication, which is divided into the three main areas of the face and then gently rubbed into each area. The medication should not be applied for at least 20 to 30 minutes after washing to decrease the burning sensation. The avoidance of the sun and the daily use of sunscreen must be emphasized because sun exposure can result in severe sunburn. Adolescents should be advised to apply the medication at night and to use a sunscreen with a sun protection factor (SPF) of at least 15 in the daytime. Topical benzoyl peroxide is an antibacterial agent that inhibits the growth of P. acnes organisms. It is effective against both inflammatory and noninflammatory acne and is an effective first-line agent. This medication is available as a cream, lotion, gel, or wash. The patient should be informed that the medication may have a bleaching effect on sheets, bedclothes, and towels. The adolescent can be reassured that skin bleaching will not occur. Accommodation to the medication can be gained with a gradual increase in the strength and frequency of application. When inflammatory lesions accompany the comedones, a topical antibacterial agent may be prescribed. These agents are used to prevent new lesions and to treat preexisting acne. Clindamycin, erythromycin, metronidazole, azelaic acid, and the combination of either benzoyl peroxide and erythromycin (Benzamycin) or benzoyl peroxide and glycolic acid are all choices for topical antibacterial therapy. The combination of 5% benzoyl peroxide and 3% erythromycin is especially beneficial, although the exact mechanism of action is not understood (Kim and Armstrong, 2011). Systemic antibiotic therapy is used when moderate to severe acne does not respond to topical treatments. Oral antibiotics such as tetracycline, erythromycin, minocycline, and doxycycline are considered safe to use (Fanelli, Kupperman, Lautenbach, and others, 2011; Leyden and Del Rosso, 2011). Young women with mild to moderate acne may respond well to topical treatment and the addition of an oral contraceptive pill (OCP). OCPs reduce the endogenous androgen production and decrease the bioavailability of the woman's circulating androgens. Both of these actions result in decreased acne. Isotretinoin, 13-cis-retinoic acid (Accutane), is a potent and effective oral agent that is reserved for severe cystic acne that has not responded to other treatments. Isotretinoin is the only agent available that affects factors involved in the development of acne. However, treatment with isotretinoin should be managed only by a dermatologist. Adolescents with multiple, active, deep dermal or subcutaneous cystic and nodular acne lesions are treated for 20 weeks. Multiple side effects can occur, including dry skin and mucous membranes, nasal irritation, dry eyes, decreased night vision, photosensitivity, arthralgia, headaches, mood changes, aggressive or violent behaviors, depression, and suicidal ideation. Adolescents taking this drug should be monitored for depression, depressive symptoms, and suicidal ideation (Misery, 2011). The drug should be given only at the recommended doses for no longer than the recommended duration. The most significant side effects of this drug are the teratogenic effects. Isotretinoin is absolutely contraindicated in pregnant women. Sexually active young women must use an effective contraceptive method during treatment and for 1 month after treatment. Patients receiving isotretinoin should also be monitored for elevated cholesterol and triglyceride levels. Significant elevation may require discontinuation of the medication. Nursing Care Management Because acne is so common and its appearance may seem so mild, the health care provider may underestimate the relative importance of the disease to the adolescent. The nurse should assess the individual adolescent's level of distress, current management, and perceived success of any regimen before initiating a referral. If adolescents do not perceive the acne to be a problem, they may lack motivation to follow the treatment plan.

Pain in Children pg 144-152, 175-176

Acute pain- For infants to toddler the most commonly used behavioral pain measure is the FLACC. The FLACC Pain Assessment Tool is an interval scale that includes five categories of behavior: facial expression (F), leg movement (L), activity (A), cry (C), and consolability (C). For children ages 3 to 4 years, the most frequently used measure of pain intensity is a pictoral faces pain scale. There are many different "faces" scales. Faces pain scales provide a series of facial expressions depicting gradations of pain. They are appealing to children and easy to use because children can simply point to the face that represents how they feel. For children 8 years and older, the numerical rating scale (NRS), specifically the 0 to 10 scale, is most widely used in clinical practice because it is easy to use and document. Chronic or recurrent pain- The domains for the assessment of chronic or recurrent pain are the same for acute pain (pain intensity, global judgment of satisfaction with treatment, symptoms and adverse events, physical functioning, emotional functioning, economic factors) and two additional domains (role functioning and sleep). A pain diary is often used for these patients. Poorly controlled acute pain can predispose patients to chronic pain syndromes. The inflammation or irritation of the gingiva as the tooth erupts is responsible for discomfort during teething. Teething infants show more mouthing and drooling than nonteething infants. A topical anesthetic such as benzocaine, cold or frozen teething rings, and hard crackers or bread can alleviate pain during teething. Use EMLA before injections, perform IM's simultaneously rather than sequentially. Nitrous oxide inhalations are used frequently in children over 3 for a wide variety of procedures that require potent analgesia for a short time, such as suture insertion or removal, dressing removal or changes (including burns), drain or catheter removal, venipuncture or cannulation, lumbar puncture, physical therapy, and biopsies (skin, muscle, renal, or bone marrow).

Koplik Spots

Appear in the Prodromal (catarrhal) stage of measles outbreak, Koplik spots (small, irregular red spots with a minute, bluish white center first seen on buccal mucosa opposite molars 2 days before rash); symptoms gradually increasing in severity until second day after rash appears, when they begin to subside.

Appropriate foods pgs. 99-102, 489-490, 326-330, 417-418, 468-472, 391-392

At birth to 6 months, breastmilk is best, if not formula only. At 4-6 months, introduction of foods can be introduced staring with iron fortified cereal. Fruit juice can be offered from a cup (not a bottle because cavities) for its rich source of vitamin C and as a substitute for milk for one feeding a day. Large quantities of certain juices (e.g., apple, pear, prune, sweet cherry, peach, grape) are avoided because they may cause abdominal pain, diarrhea, or bloating in some children. White grape juice (no more than 5 oz/day) may be better absorbed and safe for infants this age without causing gastrointestinal distress. The AAP, Committee on Nutrition (2009) recommends that fruit juice intake not exceed 4 to 6 oz per day and that juices not be given to infants younger than 4 to 6 months old. Because vitamin C is naturally destroyed by heat, juice is not warmed. Juice containers are always kept covered and refrigerated to prevent further vitamin loss. The addition of other foods is arbitrary. A common sequence is to introduce strained fruits followed by vegetables and, finally, meats; however, some clinicians prefer to add vegetables before fruit. If foods are introduced early, citrus fruits, meats, and eggs are delayed until after 6 months of age because of their potential to result in allergy. At 6 months, foods such as a cracker or zwieback can be offered as finger and teething foods. By 8 to 9 months, junior foods and nutritious finger foods such as firmly cooked vegetable, raw pieces of fruit, or cheese can be given. By 1 year, well-cooked table foods are served. The introduction of solid foods into the infant's diet at this age is primarily for taste and chewing experience, not for growth. The majority of infants' caloric needs are derived from the primary milk source (human or formula); therefore, solids should not be perceived as a substitute for milk until the child is older than 12 months. Portion sizes may vary according to the infant's taste. In general, 1 Tbsp per year of age (i.e., to Tbsp for most infants under 12 months) is adequate for most infants. Preschoolers- The requirement for calories per unit of body weight continues to decrease slightly to 90 kcal/kg for an average daily intake of 1800 calories. Fluid requirements may also decrease slightly to approximately 100 ml/kg/day but depend on the child's activity level, climatic conditions, and state of health. Protein requirements increase with age, and the recommended intake for preschoolers is 13 to 19 g/day (0.45-0.67 oz/day) The recommendation for daily calcium intake for children 1 to 3 years of age is 500 mg, and the recommendation for children 4 to 8 years of age is 800 mg

ADHD

Attention-deficit/hyperactivity disorder (ADHD) refers to developmentally inappropriate degrees of inattention, impulsiveness, and hyperactivity. To be diagnosed as ADHD, the symptoms must have been present in children 4 to 18 years of age and must be present in more than one major setting

Stranger Anxiety

Between ages 4 and 8 months, infants progress through the first stage of separation-individuation and begin to have some awareness of themselves and their mothers as separate beings. At the same time, object permanence is developing, and infants are aware that their parents can be absent. Therefore, separation anxiety develops and is manifested through a predictable sequence of behaviors. During the early second half of the first year, infants protest when placed in their cribs, and a short time later, they object when their mothers leave the room. Infants may not notice the mother's absence if they are absorbed in an activity. However, when they realize her absence, they protest. From this point on, they become alert to her activities and whereabouts. By 11 to 12 months, they are able to anticipate her imminent departure by watching her behaviors, and they begin to protest before she leaves. At this point, many parents learn to postpone alerting the child to their departure until just before leaving.

Choking/aspiration pgs. 397-398, 403, 731-732

Choking-Infants and toddlers most at risk because they put things in mouth. Things to avoid: Avoid large, round chunks of meat, such as whole hot dogs (slice lengthwise into short pieces). Avoid fruit with pits, fish with bones, hard candy, chewing gum, nuts, popcorn, grapes, and marshmallows. Choose large, sturdy toys without sharp edges or small removable parts. Foreign Body Aspiration-Initially, a FB in the air passages produces choking, gagging, wheezing, or coughing. Laryngotracheal obstruction most commonly causes dyspnea, cough, stridor, and hoarseness because of decreased air entry. Up to half of all children with FB ingestion may be asymptomatic. Cyanosis may occur if the obstruction becomes worse. Bronchial obstruction usually produces cough (frequently paroxysmal), wheezing, asymmetric breath sounds, decreased airway entry, and dyspnea. When an object is lodged in the larynx, the child is unable to speak or breathe. If the obstruction progresses, the child's face may become livid, and if the obstruction is total, the child can become unconscious and die of asphyxiation. Bronchoscopy is required for a definitive diagnosis/removal of objects in the larynx and trachea. Foreign body aspiration may result in life-threatening airway obstruction, especially in infants because of the small diameters of their airways. Current recommendations for the emergency treatment of the choking child include the use of abdominal thrusts for children older than 1 year of age and back blows and chest thrusts for children younger than 1 year of age (see Airway Obstruction, p. 758). A FB is rarely coughed up spontaneously. Most frequently, it must be removed instrumentally by endoscopy. Endoscopy and bronchoscopy require sedation with an agent such as IV propofol or midazolam. The procedure is carried out as quickly as possible because the progressive local inflammatory process triggered by the foreign material hampers removal. A chemical pneumonia soon develops, and vegetable matter begins to macerate within a few days, making it even more difficult to remove. After removal of the FB, the child is usually observed for any complications such as laryngeal edema and then discharged home within a matter of hours if vital signs are stable and recovery is satisfactory. Nursing Care Management A major role of nurses caring for a child who has aspirated an FB is to recognize the signs of FB aspiration, observe for worsening of respiratory symptoms, and implement immediate measures to relieve an emergency obstruction. Choking on food or other material should not be fatal. Back blows and chest thrusts in infants and abdominal thrusts in children are simple procedures that can be used by both health professionals and laypersons to save lives. To aid a child who is choking, nurses must recognize the signs of distress. A blind sweep of the child's mouth should never be performed because it may lodge the agent farther into the airway. Not every child who gags or coughs while eating is truly choking. Nursing Alert- The child in severe distress (1) cannot speak, (2) becomes cyanotic, and (3) collapses. ***These three signs indicate that the child is truly choking and requires immediate action. The child can die within 4 minutes.

Breath Sounds

Classification of Normal Breath Sounds Vesicular Breath Sounds- Heard over the entire surface of the lungs with the exception of the upper intrascapular area and area beneath the manubrium. Inspiration is louder, longer, and higher pitched than expiration. The sound is a soft, swishing noise. Bronchovesicular Breath Sounds- Heard over the manubrium and in the upper intrascapular regions where the trachea and bronchi bifurcate. Inspiration is louder and higher pitched than in vesicular breathing. Bronchial Breath Sounds-Heard only over trachea near suprasternal notch.The inspiratory phase is short, and the expiratory phase is long. Absent or diminished breath sounds are always an abnormal finding warranting investigation. Fluid, air, or solid masses in the pleural space interfere with the conduction of breath sounds. Diminished breath sounds in certain segments of the lung can alert the nurse to pulmonary areas that may benefit from chest physiotherapy. Various pulmonary abnormalities produce adventitious sounds that are not normally heard over the chest. These sounds occur in addition to normal or abnormal breath sounds. They are classified into two main groups: crackles, which result from the passage of air through fluid or moisture, and wheezes, which are produced as air passes through narrowed passageways, regardless of the cause, such as exudate, inflammation, spasm, or tumor. Considerable practice with an experienced tutor is necessary to differentiate the various types of lung sounds.

Croup

Croup is a general term applied to a symptom complex 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. Acute infections of the larynx are important in infants and small children because of their increased incidence in these age groups and because the small diameter of the airway in infants and children places them at risk for significant narrowing with inflammation. Croup syndromes can affect the larynx, trachea, and bronchi. Table on 721, goes into detail about different syndromes.

Parallel play

During parallel activities, children play independently but among other children. They play with toys similar to those the children around them are using but as each child sees fit, neither influencing nor being influenced by the other children. Each plays beside, but not with, other children (Fig. 5-7). There is no group association. Parallel play is the characteristic play of toddlers, but it may also occur in other groups of any age. Individuals who are involved in a creative craft with each person separately working on an individual project are engaged in parallel play.

Atopic Dermatitis

Eczema or eczematous inflammation of the skin refers to a descriptive category of dermatologic diseases and not to a specific etiology. AD is a type of pruritic eczema that usually begins during infancy and is associated with an allergic contact dermatitis with a hereditary tendency (atopy). Types- 1 Infantile (infantile eczema)—Usually begins at 2 to 6 months of age; generally undergoes spontaneous remission by 3 years of age 2 Childhood—May follow the infantile form; occurs at 2 to 3 years of age; 90% of children have manifestations by age 5 years 3 Preadolescent and adolescent—Begins at about 12 years of age; may continue into the early adult years or indefinitely The major goals of management are to (1) hydrate the skin, (2) relieve pruritus, (3) reduce flare-ups or inflammation, and (4) prevent and control secondary infection. The general measures for managing AD focus on reducing pruritus and other aspects of the disease. Management strategies include avoiding exposure to skin irritants or allergens; avoiding overheating; and administrating medications such as antihistamines, topical immunomodulators, topical steroids, and (sometimes) mild sedatives as indicated.

Pinworms

Enterobiasis, or pinworms, caused by the nematode Enterobius vermicularis, is the most common helminthic infection in the United States. Infection begins when the eggs are ingested or inhaled (the eggs float in the air). The eggs hatch in the upper intestine and then mature and migrate through the intestine. After mating, adult females migrate out the anus and lay eggs. The movement of the worms on skin and mucous membrane surfaces causes intense itching. As the child scratches, eggs are deposited on the hands and underneath the fingernails. The typical hand-to-mouth activity of youngsters makes them especially prone to reinfection. Pinworm eggs persist in the indoor environment for 2 to 3 weeks, contaminating anything they contact, such as toilet seats, doorknobs, bed linen, underwear, and food. Except for the intense rectal itching associated with pinworms, the clinical manifestations are nonspecific restlessnes, irritability. Therapeutic Management The drugs available for treatment of pinworms include mebendazole (Vermox), pyrantel pamoate (Pin-Rid, Antiminth), and albendazole. The drug of choice is mebendazole, which is safe, effective, and convenient, with few side effects. However, it is not recommended for children younger than 2 years of age. If pyrvinium pamoate is prescribed, advise parents that the drug stains stool and vomitus bright red, as well as clothing or skin that comes in contact with the drug; it is available without prescription and should not be used in children younger than 2 years without consulting a primary practitioner. Because pinworms are easily transmitted, all household members are treated. The dose of antiparasitic medication should be repeated in 2 weeks to completely eradicate the parasite and prevent reinfection. Nursing Care Management Direct nursing care at identifying the parasite, eradicating the organism, and preventing reinfection. Parents need clear, detailed instructions for the 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. A convenient, commercially prepared tape is also available for this purpose. 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. Parents are instructed to place the tongue blade in a glass jar or loosely in a plastic bag so it can be brought in for microscopic examination. For specimens collected in the hospital, practitioner's office, or clinic, place the tape smoothly on a glass slide, sticky side down, for examination. To prevent reinfection, washing all clothes and bed linens in hot water and vacuuming the house may be recommended. However, there is little documentation on the effectiveness of these measures because pinworms survive on many surfaces. Helpful suggestions include hand washing after toileting and before eating, keeping the child's fingernails short to minimize the chance of ova collecting under the nails, dressing children in one-piece sleeping outfits, and daily showering rather than tub bathing. Inform families that recurrence is common. Treat repeated infections in the same manner as the first one.

Incubation, Prodromal and Desquamation period

Example: Measles Incubation period—10-20 days Prodromal (catarrhal) stage—Fever and malaise, followed in 24 hr by coryza, cough, conjunctivitis, Koplik spots (small, irregular red spots with a minute, bluish white center first seen on buccal mucosa opposite molars 2 days before rash); symptoms gradually increasing in severity until second day after rash appears, when they begin to subside Rash—Appears 3-4 days after onset of prodromal stage; begins as erythematous maculopapular eruption on face and gradually spreads downward; more severe in earlier sites (appears confluent) and less intense in later sites (appears discrete); after 3-4 days, assumes brownish appearance, and fine desquamation occurs over area Prodomal is described as the time interval between early manifestations of disease and the overt clinical syndrome

Pedi drugs used for surgery pg 642-645, 162-175

Historically, the most upsetting event for children has been the preoperative injection. An increasing number of anesthesiologists use preoperative sedative premedication, usually midazolam (Versed), and parental presence for children undergoing surgery. The goals for using preoperative medications include (1) anxiety reduction, (2) amnesia, (3) sedation, (4) antiemetic effect, and (5) reduction of secretions. When drugs are administered, they should be delivered atraumatically via oral or IV routes. Nursing Care Guidelines for Managing Opioid-Induced Respiratory Depression If Respirations Are Depressed • Assess sedation level. • Reduce the infusion by 25% when possible. • Stimulate the patient (shake his or her shoulder gently, call by name, ask to breathe). If the Patient Cannot Be Aroused or Is Apneic • Administer naloxone (Narcan): • For children weighing less than 40 kg (88 pounds), dilute 0.1 mg of naloxone in 10 ml of sterile saline to make 10 mcg/ml solution and give 0.5 mcg/kg. • For children weighing more than 40 kg (88 pounds), dilute a 0.4-mg ampule in 10 ml of sterile saline and give 0.5 ml. • Administer the bolus by slow intravenous push every 2 minutes until effect is obtained. • Closely monitor patient. Naloxone's duration of antagonist action may be shorter than that of the opioid, requiring repeated doses of naloxone

Lead poisoning 441-445

In most instances of acute childhood lead poisoning, the source is nonintact lead-based paint in an older home or lead-contaminated bare soil in the yard. Microparticles of lead gain entrance into a child's body through ingestion or inhalation and, in the case of an exposed pregnant woman, by placental transfer. There is a relationship between anemia and lead poisoning. Children who are iron deficient absorb lead more readily than those with sufficient iron stores. The Blood Lead Level test is currently used for screening and diagnosis. **Nursing Alert- Acute signs of lead poisoning include nausea, vomiting, constipation, anorexia, and abdominal pain. Additional clinical manifestations are hypophosphatemia, glycosuria, and aminoaciduria. Universal screening should be done at ages 1 and 2 years. Any child between the ages of 3 and 6 years who has not been previously screened should also be tested. All children with risk factors should be screened more often. Chelation is the term used for removing lead from circulating blood and, theoretically, some lead from organs and tissues. It is unclear whether chelation affects lead stores in bones. Although not an antidote in the truest sense, it does serve a similar purpose in that the toxic substance or poison is removed from the body. However, chelation does not counteract any effects of the lead. Multiple chelation treatments may be necessary. Adequate hydration is essential during therapy because the chelates are excreted via the kidneys.

Mononucleosis

Infectious mononucleosis is an acute, self-limiting infectious disease that is common among adolescents. Symptoms include fever, exudative pharyngitis, lymphadenopathy, hepatosplenomegaly, and an increase in atypical lymphocytes. The course is usually mild but occasionally can be severe or, rarely, accompanied by serious complications. Etiology and Pathophysiology- The herpes-like Epstein-Barr virus (EBV) is the principal cause of infectious mononucleosis. It appears in both sporadic and epidemic forms, but the sporadic cases are more common. The mechanism of spread has not been proven, but it is believed to be transmitted in saliva by direct intimate contact, although it survives in saliva for many hours outside of the body. The incubation period after exposure is approximately 30 to 50 days Clinical Manifestations of Infectious Mononucleosis: Headache Epistaxis Malaise Fatigue Chills Low-grade fever Loss of appetite Puffy eyes Fever Sore throat Cervical adenopathy Common Features Splenomegaly (may persist for several months) Palatine petechiae Macular eruption (especially on trunk) Exudative pharyngitis or tonsillitis Hepatic involvement to some degree, often associated with jaundice Diagnostic Tests The onset of symptoms may be acute or insidious and may appear anywhere from 10 days to 6 weeks after exposure. The presenting symptoms vary greatly in type, severity, and duration (Box 23-7). The clinical manifestations of infectious mononucleosis are usually less severe (often subclinical or unapparent), and the convalescent phase is shorter in younger children than in older children and young adults. Heterophil antibody tests (Paul-Brunell or Monospot) determine the extent to which the patient's serum will agglutinate sheep red blood cells; the response in these tests is primarily to immunoglobulin M, which is present in the first 2 weeks of the illness in adolescents. The spot test (Monospot) is a slide test of venous blood that has high specificity. It is rapid, sensitive, inexpensive, and easy to perform, and has the advantage over the Paul-Brunell test that it can detect significant agglutinins at lower levels, thus allowing earlier diagnosis. Blood is usually obtained for the test by finger puncture or venous sampling and is placed on special paper. If the blood agglutinates, forming fragments or clumps, the test result is positive for the infection. Therapeutic Management No specific treatment exists for infectious mononucleosis. A mild analgesic is often sufficient to relieve the headache, fever, and malaise. Rest is encouraged for fatigue but is not imposed for any specific period. Affected persons are instructed to regulate activities according to their own tolerance unless complicating factors are present. Contact sports are discouraged in the presence of splenomegaly. Antibiotics are contraindicated unless β-hemolytic streptococci are present Prognosis-The course of this disease is usually self-limiting and uncomplicated. Acute symptoms often disappear within 7 to 10 days, and persistent fatigue subsides within 2 to 4 weeks. Some adolescents may need to restrict their activities for 2 to 3 months, but the disease rarely extends for longer periods. The child is encouraged to maintain limited exercise to prevent deconditioning. Nursing Care Management- Nursing responsibilities are directed toward providing comfort measures to relieve symptoms and helping affected adolescents and their families to determine appropriate activities for the stage of the disease.

Hospitalized Children pg. 6612-633

Major stressors of hospitalization include separation, loss of control, bodily injury, and pain. Infant to Toddler- fear is separation anxiety/anaclitic depression Stages are 1. Protest-Behaviors observed during later infancy include: • Cries • Screams • Searches for parent with eyes • Clings to parent • Avoids and rejects contact with strangers Verbally attacks strangers (e.g., "Go away") • Physically attacks strangers (e.g., kicks, bites, hits, pinches) • Attempts to escape to find parent • Attempts to physically force parent to stay Behaviors may last from hours to days. 2. Despair- Is inactive • Withdraws from others • Is depressed, sad • Lacks interest in environment • Is uncommunicative • Regresses to earlier behavior (e.g., thumb sucking, bedwetting, use of pacifier, use of bottle) 3. Detachment- Shows increased interest in surroundings • Interacts with strangers or familiar caregivers • Forms new but superficial relationships • Appears happy Detachment usually occurs after prolonged separation from parent; it is rarely seen in hospitalized children.Preschoolers also suffer from SA but not as severe, may think illness or hospitalization is punishment for something bad they did School aged children- Need protection and companionship, may need support from parents but afraid to ask, want to act grown up, happiest when they have increased control, help making bed, assisting with self care, choose their own schedule Adolescents- biggest fear is loss of peer group from being different, sometimes peers visit but do not give them the support they need sometimes left with no support system. Want staff to relate to them on their own level. Nurses need to carefully assess their intellectual abilities, previous knowledge and present needs, even learn their language

External fixature

Monolateral, Taylor Spatial Frame, and Ilizarov external fixators (IEFs) are common external fixation devices. The IEF uses a system of wires, rings, and telescoping rods that permits limb lengthening to occur by manual distraction (Fig. 31-11). In addition to lengthening bones, the device can be used to correct angular or rotational defects or to immobilize fractures. The device is attached surgically by securing a series of external full or half rings to the bone with wires. External telescoping rods connect the rings to each other. Manual distraction is accomplished by manipulating the rods to increase the distance between the rings. A percutaneous osteotomy is performed when the device is applied to create a "false" growth plate. A special osteotomy or corticotomy involves cutting only the cortex of the bone while preserving its blood supply, bone marrow, endosteum, and periosteum. Capillary blood flow to the transected area is essential for proper bone growth. Cut bone ends typically grow at a rate of 1 cm (0.4 inches) per month. The IEF can result in up to a 15-cm (6-inch) gain in length. Nursing Care Management-Success of the fixation devices depends on the child's and family's cooperation; therefore, before surgery, they must be fully informed of the appearance of the device, how it accomplishes bone growth and limits bone mobility, alterations in activities, and home and follow-up care. Children are involved in learning to adjust the device to accomplish distraction. Children and parents should be instructed in pin care, including observation for infection and loosening of the pins. Cleaning routines for the pin sites vary among practitioners but should not traumatize the skin. Children who participate actively in their care report less discomfort. Because the device is external, the child and family need to be prepared for the reactions of others and assisted in camouflaging the device with appropriate apparel, such as wide-legged pants that close with self-adhering fasteners around the device. A loose sock or stockinette may also be used over the device to decrease public awareness. Partial weight bearing is allowed, and the child learns to walk with crutches. Alterations in activity include modifications at school and in physical education. Full weight bearing is not allowed until the distraction is completed and bone consolidation has occurred. Follow-up care is essential to maintain appropriate distraction until the desired limb length is achieved. The device is removed surgically after the bone has consolidated, and the child may need to use crutches or have a cast for 4 to 6 weeks after removal to reduce the risk of fracture.

Negativism

One of the more difficult aspects of rearing children in this age group is their persistent "no" response to every request. The negativism is not an expression of being stubborn or insolent but a necessary assertion of self-control. Children test limits to gain understanding of the world and to learn to modify their behavior to fit the expectations of society. Negativism begins to subside as most children prepare to enter kindergarten. One method of dealing with the negativism is to reduce the opportunities for a "no" answer. Asking the child, "Do you want to go to sleep now?" is an example of a question that will almost certainly be answered with an emphatic "no." Instead, tell the child that it is time to go to sleep and proceed accordingly. In their attempt to exert control, children like to make choices. When confronted with appropriate choices, such as "You may have a peanut butter and jelly sandwich or chicken noodle soup for lunch," they are more likely to choose one rather than automatically say no. However, if their response is negative, parents should make the choice for the child. Nurses working with children and parents can assist parents in understanding this concept by role modeling. For example, when the nurse approaches the toddler for taking vital signs, instead of asking, "Can I listen to your heart?" the nurse can say, "I am going to listen to your heart." Because of normal developmental behavior, toddlers first resist having their vital signs taken because it is an intrusion on their bodies. Second, toddlers are most likely going to answer "no," not because they necessarily fear the procedure itself but because of the tendency to answer all questions with a negative response. If the nurse asks the question and the toddler says, "No" but the nurse proceeds anyway, the toddler starts to mistrust the nurse's actions because they contradict his or her words. Several characteristics, especially negativism and ritualism, are typical of toddlers in their quest for autonomy. As toddlers attempt to express their will, they often act with negativism, the persistent negative response to requests. The words "no" or "me do" can be their sole vocabulary. Emotions become strongly expressed, usually in rapid mood swings. One minute, toddlers can be engrossed in an activity, and the next minute they might be angry because they are unable to manipulate a toy or open a door. If scolded for doing something wrong, they can have a temper tantrum and almost instantaneously pull at the parent's legs to be picked up and comforted. Understanding and coping with these swift changes is often difficult for parents. Many parents find the negativism exasperating and, instead of dealing constructively with it, give in to it, which further threatens children in their search for learning acceptable methods of interacting with others.

EMLA cream

One of the most significant improvements in the ability to provide atraumatic care to children is the anesthetic cream, EMLA (eutectic mixture of local anesthetics [lidocaine and prilocaine]) cream and anesthetic disk or LMX4 (4% lidocaine cream) • Eliminates or reduces pain from most procedures involving skin puncture • Must be placed on intact skin over puncture site and covered by occlusive dressing or applied as anesthetic disc for 1 hour or more before procedure

Types of Play

Onlooker play—During onlooker play, children watch what other children are doing but make no attempt to enter into the play activity. There is an active interest in observing the interaction of others but no movement toward participating. Watching an older sibling bounce a ball is a common example of the onlooker role. Solitary play—During solitary play, children play alone with toys different from those used by other children in the same area. They enjoy the presence of other children but make no effort to get close to or speak to them. Their interest is centered on their own activity, which they pursue with no reference to the activities of the others. Parallel play—During parallel activities, children play independently but among other children. They play with toys similar to those the children around them are using but as each child sees fit, neither influencing nor being influenced by the other children. Each plays beside, but not with, other children (Fig. 5-7). There is no group association. Parallel play is the characteristic play of toddlers, but it may also occur in other groups of any age. Individuals who are involved in a creative craft with each person separately working on an individual project are engaged in parallel play. Associative play—In associative play, children play together and are engaged in a similar or even identical activity, but there is no organization, division of labor, leadership assignment, or mutual goal. Children borrow and lend play materials, follow each other with wagons and tricycles, and sometimes attempt to control who may or may not play in the group. Each child acts according to his or her own wishes; there is no group goal (Fig. 5-8). For example, two children play with dolls, borrowing articles of clothing from each other and engaging in similar conversation, but neither directs the other's actions or establishes rules regarding the limits of the play session. There is a great deal of behavioral contagion: when one child initiates an activity, the entire group follows the example. Cooperative play—Cooperative play is organized, and children play in a group with other children (Fig. 5-9). They discuss and plan activities for the purposes of accomplishing an end—to make something, attain a competitive goal, dramatize situations of adult or group life, or play formal games. The group is loosely formed, but there is a marked sense of belonging or not belonging. The goal and its attainment require organization of activities, division of labor, and role playing. The leader-follower relationship is definitely established, and the activity is controlled by one or two members who assign roles and direct the activity of the others. The activity is organized to allow one child to supplement another's function to complete the goal.

Vital signs

Pediatric Vital Signs Aka: Vital Signs in Children Normal Body Temp 1 year old oral - 99.7°F or 37.6ºC 3 year old oral - 99.0°F or 37.2ºC 5 year old oral - 98.6°F or 37ºC Trivia: Why are lower age groups hotter? Answer: Lower age groups have higher metabolic rates. Normal Pulse Age —- Normal —- Average Newborn: 100-170 — 140 1 year: 80-170 — 120 3 year: 80-130 — 110 6 year: 75-120 — 100 10 Year: 70-110 — 90 14 Year: 60-110 — 90 Resting Respiration Age —- Normal —- Average Newborn: 30-50 — 40 1 year: 20-40 — 30 3 Year: 20-30 — 25 6 Year: 16-22 — 19 14 Year: 14-20 — 17 Blood Pressure Age —- Systolic —- Diastolic —- Average Newborn: 65-95 — 30-60 — 80-60 Infant: 65-115 — 42-80 — 90-61 3 Year: 76-122 — 46-84 — 99-65 6 Year: 85-115 — 48-64 — 100-56 10 Year: 93-125 — 46-68 — 109-58 14 Year: 99-137 — 51-71 — 118/61

Piaget Stages of Development pgs. 482, 319-320, 409, 460, 380-382

Piaget (1969) proposed three stages of reasoning: (1) intuitive, (2) concrete operational, and (3) formal operational. When they enter the stage of concrete logical thought at about age 7 years, children are able to make logical inferences, classify, and deal with quantitative relationships about concrete things. Not until adolescence are they able to reason abstractly with any degree of competence. Each stage is derived from and builds on the accomplishments of the previous stage in a continuous, orderly process. The course of intellectual development is both maturational and invariant and is divided into the following stages (ages are approximate): Sensorimotor (birth-2 years)—The sensorimotor stage of intellectual development consists of six substages (see pp. 319 and 380) that are governed by sensations in which simple learning takes place. Children progress from reflex activity through simple repetitive behaviors to imitative behavior. They develop a sense of cause and effect as they direct behavior toward objects. Problem solving is primarily by trial and error. They display a high level of curiosity, experimentation, and enjoyment of novelty and begin to develop a sense of self as they are able to differentiate themselves from their environment. They become aware that objects have permanence—that an object exists even though it is no longer visible. Toward the end of the sensorimotor period, children begin to use language and representational thought. Preoperational (2-7 years)—The predominant characteristic of the preoperational stage of intellectual development is egocentrism, which in this sense does not mean selfishness or self-centeredness, but the inability to put oneself in the place of another. Children interpret objects and events not in terms of general properties but in terms of their relationships or their use to them. They are unable to see things from any perspective other than their own; they cannot see another's point of view, nor can they see any reason to do so (see Cognitive Development, Chapter 13). Preoperational thinking is concrete and tangible. Children cannot reason beyond the observable, and they lack the ability to make deductions or generalizations. Thought is dominated by what they see, hear, or otherwise experience. However, they are increasingly able to use language and symbols to represent objects in their environment. Through imaginative play, questioning, and other interactions, they begin to elaborate concepts and to make simple associations between ideas. In the latter stage of this period, their reasoning is intuitive (e.g., the stars have to go to bed just as they do), and they are only beginning to deal with problems of weight, length, size, and time. Reasoning is also transductive—because two events occur together, they cause each other, or knowledge of one characteristic is transferred to another (e.g., all women with big bellies have babies). Concrete operations (7-11 years)—At this age, thought becomes increasingly logical and coherent. Children are able to classify, sort, order, and otherwise organize facts about the world to use in problem solving. They develop a new concept of permanence—conservation (see Cognitive Development [Piaget], Chapter 16); that is, they realize that physical factors such as volume, weight, and number remain the same even though outward appearances are changed. They are able to deal with a number of different aspects of a situation simultaneously. They do not have the capacity to deal in abstraction; they solve problems in a concrete, systematic fashion based on what they can perceive. Reasoning is inductive. Through progressive changes in thought processes and relationships with others, thought becomes less self-centered. They can consider points of view other than their own. Thinking has become socialized. Formal operations (11-15 years)—Formal operational thought is characterized by adaptability and flexibility. Adolescents can think in abstract terms, use abstract symbols, and draw logical conclusions from a set of observations. For example, they can solve the following question: If A is larger than B and B is larger than C, which symbol is the largest? (The answer is A.) They can make hypotheses and test them; they can consider abstract, theoretic, and philosophic matters. Although they may confuse the ideal with the practical, most contradictions in the world can be dealt with and resolved.

Bronchopulmonary dysplasia

Preterm infants with immature lungs damaged by positive pressure of mechanical ventilator. Pathologic process related to alveolar damage from lung disease, prolonged exposure to mechanical ventilation, high peak inspiratory pressures and oxygen, and immature alveoli and respiratory tract Dyspnea Barrel chest Inability to wean from oxygen or mechanical ventilation after course of respiratory distress syndrome (surfactant deficiency) Wheezing Prevention: Administer maternal steroids; administer exogenous surfactant postnatally. Provide early detection with pulmonary function tests. Use synchronized or volume guarantee ventilation, decreased inspiratory pressures, or nasal CPAP. Prevent air leaks. Use high-frequency ventilation. Prevent or control respiratory or systemic infections. Minimize use of high oxygen concentrations in neonatal resuscitation and on mechanical ventilation; monitor oxygen saturation and implement resuscitation according to neonate response to low oxygen administration. Diagnosis established: Support respiratory efforts. Maintain adequate oxygenation and avoid hypoxemia. Administer diuretics, bronchodilators. Provide supplemental oxygen in hospital or home. Provide individualized developmental care and enhancement. Monitor oxygen saturations closely in preterm infants and avoid hyperoxemia Provide opportunities for additional rest during feedings. Observe for signs of fluid overload or pulmonary edema.

RSV

Respiratory syncytial virus is transmitted from exposure to contaminated secretions. RSV can live on fomites for several hours and on hands for 30 minutes (AAP, Committee on Infectious Diseases and Pickering, 2009). The incubation period is 2 to 8 days. Pathophysiology- Respiratory syncytial virus affects the epithelial cells of the respiratory tract. The ciliated cells swell, protrude into the lumen, and lose their cilia. RSV produces a fusion of cell membranes, forming a giant cell. The bronchiolar mucosa swells, and lumina are subsequently filled with mucus and exudate. The walls of the bronchi and bronchioles are infiltrated with inflammatory cells, and peribronchiolar interstitial pneumonitis is usually present. The varying degrees of intraluminal obstruction lead to hyperinflation, obstructive emphysema resulting from partial obstruction, and patchy areas of atelectasis. Dilation of bronchial passages on inspiration allows sufficient space for intake of air, but narrowing of the passages on expiration prevents air from leaving the lungs. Thus, air is trapped distal to the obstruction and causes progressive overinflation (emphysema). Signs and Symptoms of Respiratory Syncytial Virus Rhinorrhea Pharyngitis Coughing, sneezing Wheezing Possible ear or eye drainage Intermittent fever With Progression of Illness: Increased coughing and wheezing Tachypnea and retractions Cyanosis Severe Illness Tachypnea, >70 breaths/min Listlessness Apneic spells Poor air exchange; poor breath sounds Clinical Manifestations- The illness usually begins with a URI after an incubation of about 5 to 8 days. Symptoms such as rhinorrhea and low-grade fever often appear first. OM and conjunctivitis may also be present. In time, a cough may develop. If the disease progresses, it becomes a lower respiratory tract infection and manifests typical symptoms (Box 23-8). Infants may have several days of URI symptoms or no symptoms except slight lethargy, poor feeding, or irritability. When the lower airway is involved, classic manifestations include signs of altered air exchange, such as wheezing, retractions, crackles, dyspnea, tachypnea, and diminished breath sounds. Apnea may be the first recognized indicator of RSV infection in very young infants (younger than 1 month old). Diagnostic Evaluation- Identification has been simplified by the development of tests done on nasopharyngeal secretions, using either a rapid immunofluorescent antibody-direct fluorescent antibody (DFA) staining or an enzyme-linked immunosorbent assay (ELISA) for RSV antigen detection (see Respiratory Secretion Specimens, Chapter 22). Hyperinflation of the lungs is generally seen on the chest radiograph. Therapeutic Management- Children with bronchiolitis are treated symptomatically with humidified oxygen, adequate fluid intake, airway maintenance, and medications. Most children with bronchiolitis can be managed at home. Hospitalization is usually recommended for children with respiratory distress and those who cannot maintain adequate hydration. Other reasons for hospitalization include complicating conditions, such as underlying lung or heart disease or associated debilitated states, or a home environment where adequate management is questionable. An infant who is tachypneic or apneic, has marked retractions, seems listless, has a history of poor fluid intake, or is dehydrated should be closely observed for respiratory failure. Humidified oxygen is administered in concentrations sufficient to maintain adequate oxygenation (SpO2) at or above 90% as measured by pulse oximetry. The administration of humidified mist may be used. Routine chest percussion and postural drainage (formerly CPT) is not recommended; infants with abundant nasal secretions benefit from periodic suctioning. Fluids by mouth may be contraindicated because of tachypnea, weakness, and fatigue; therefore, IV fluids may be used until the acute stage of the disease has passed. Nasogastric fluids may be required if the infant is unable to tolerate oral fluids and a peripheral IV is difficult to establish. Clinical assessments, noninvasive oxygen monitoring, and blood gas values may guide therapy. Medical therapy for bronchiolitis is primarily supportive and aimed at decreasing airway hyperresonance and inflammation and promoting adequate fluid intake. Bronchodilators may provide short-term benefits, yet overall significant improvement in the child's condition is not always appreciable. A single dose of bronchodilator therapy is often prescribed to assess for a clinical response. If it improves symptoms, it may be prescribed on an ongoing basis. If no response is evident, no further doses are given. Racemic epinephrine has been shown to produce modest improvement in ventilation status. Corticosteroids and antihistamines have not been shown to be effective in controlled studies and are not recommended for routine use. Antibiotics are not part of the treatment of RSV unless there is a coexisting bacterial infection such as OM (AAP, 2006). Additional recommendations in the AAP (2006) practice guideline are to encourage breastfeeding; avoid passive tobacco smoke exposure; and promote preventive measures, including hand washing. Ribavirin, an antiviral agent (synthetic nucleoside analog), is the only specific therapy approved for hospitalized children; however, use of this drug is controversial because of concerns about the high cost, aerosol route of administration, potential toxic effects among exposed health care personnel (teratogenicity), and conflicting results of efficacy trials. Prevention of Respiratory Syncytial Virus Infection-The only product available in the United States for prevention of RSV is palivizumab (Synagis), a monoclonal antibody, which is given monthly in an IM injection to prevent hospitalization associated with RSV. According to the AAP (Meissner and Bocchini, 2009), candidates for palivizumab include infants born before 32 weeks' gestation, infants with chronic lung disease, infants born at 32 to less than 35 weeks' gestation who attend daycare or have a sibling under 5 years, children younger than 2 years of age with hemodynamically significant congenital heart disease, and children with severe immunodeficiencies (e.g., severe combined immunodeficiency or acquired immunodeficiency syndrome [AIDS]).

Chicken Pox 424-430, 337-338

See Test 4 diagnosis worksheet

Rubella, mumps, measles 424-430, 332-333, 337

See Test 4 diagnosis worksheet

s/s of disease

See Test 4 diagnosis worksheet

Shaken Baby

Shaken baby syndrome (SBS) is a serious form of child abuse caused by violent shaking of infants and young children and is one form of abusive head trauma. Physicians commonly use more general terms, including abusive head trauma, inflicted head injury, or neuroinflicted brain injury; these terms do not assume the mechanism of injury but rather describe the injury itself and is most often a result of the caregiver's frustration with crying. Every year in the United States, an estimated 1200 to 1400 children are shaken, and of these victims, 25% to 30% die as a result of their injuries. The rest have lifelong complications. It is important to understand what happens in SBS. Infants have a large head-to-body ratio, weak neck muscles, and a large amount of water in the brain. Violent shaking causes the brain to rotate within the skull, resulting in shearing forces that tear blood vessels and neurons. The characteristic injuries that occur are intracranial bleeding (subdural and subarachnoid hematomas) and, in approximately 85% of cases, retinal hemorrhages, which are classic results of repetitive acceleration-deceleration head trauma (Levin, 2009). Injuries may also include fractures of the ribs and long bones. Most often there are no signs of external injury. SBS is often not an isolated event, and in one study, 45% of the children with inflicted traumatic brain injury caused by shaking showed some evidence of prior injury. Victims of SBS can be seen with a variety of symptoms, from generalized flulike symptoms to unresponsiveness with impending death. Many of the presenting symptoms, such as vomiting, irritability, poor feeding, and listlessness, are often mistaken for common infant and childhood ailments. In more severe forms, presenting symptoms may include seizures, posturing, alterations in level of consciousness, apnea, bradycardia, or death. The long-term outcomes of SBS include seizure disorders; visual impairments, including blindness; developmental delays; hearing loss; cerebral palsy; and mild to profound mental, cognitive, or motor impairments. Nurses can take an active role in prevention of SBS by teaching all caregivers about crying and techniques to cope with inconsolable crying

Otitis Media Acute and Chronic

Standard Terminology for Otitis Media Otitis media (OM)—An inflammation of the middle ear without reference to etiology or pathogenesis Acute otitis media (AOM) —An inflammation of the middle ear space with a rapid onset of the signs and symptoms of acute infection—namely, fever and otalgia (ear pain). Treatment Antibiotics or wait and watch for 72 hours. Nursing objectives for children with AOM include (1) relieving pain, (2) facilitating drainage when possible, (3) preventing complications or recurrence, (4) educating the family in care of the child, and (5) providing emotional support to the child and family.Analgesic drugs such as acetaminophen (all ages) and ibuprofen (6 months of age and older) are used to treat mild pain. For more severe pain, the AAP (2004a) guidelines recommend a stronger analgesic such as codeine. Otitis media with effusion (OME)—Fluid in the middle ear space without symptoms of acute infection Chronic Treatment- Tympanostomy tube placement and adenoidectomy are surgical procedures that may be done to treat recurrent chronic OM (defined as three bouts in 6 months, six in 12 months, or six by 6 years of age). Tympanostomy tubes are pressure-equalizer (PE) tubes or grommets that facilitate continued drainage of fluid and allow ventilation of the middle ear. They are inserted to treat severe eustachian tube dysfunction, OM with effusion, or complications of OM (mastoiditis, facial nerve paralysis, brain abscess, labyrinthitis). Adenoidectomy is not recommended for treatment of AOM and is performed only in children with recurrent AOM or chronic OME with postnasal obstruction, adenoiditis, or chronic sinusitis. Prevention- Routine immunization with the pneumococcal conjugate vaccine PCV7 (Prevnar 7) has reduced the incidence of AOM in some infants and children. Parents are encouraged to reduce risk factors for AOM by breastfeeding infants for at least the first 6 months of life, avoid propping the bottle, decrease or discontinue pacifier use after 6 months, and prevent exposure to tobacco smoke

SIDS

Sudden infant death syndrome (SIDS) is defined as the sudden death of an infant younger than 1 year of age that remains unexplained after a complete postmortem examination, including an investigation of the death scene and a review of the case history. Increased Risk Factors: • Low birth weight • Low Apgar scores • Recent viral illness • Siblings of two or more SIDS victims • Male sex • Infants of American Indian or African-American ethnicity Mother smoking, co sleeping, soft bedding, prone sleeping. History of Apparent Life-Threatening Event (near miss SIDS) Decreased Risk factors: Breastfeeding, pacifier use, sleeping supine (on back), updated immunization status

Acyclovir

The antiviral agent acyclovir (Zovirax) may be used to treat varicella infections in susceptible immunocompromised persons. It is effective in decreasing the number of lesions; shortening the duration of fever; and decreasing itching, lethargy, and anorexia. Consider oral acyclovir for immunocompromised children without a history of varicella disease, newborns whose mothers had varicella within 5 days before delivery or within 48 hours after delivery, and hospitalized preterm infants with significant varicella exposure

Upper respiratory infection

The upper respiratory tract, or upper airway, consists of the oronasopharynx, pharynx, larynx, and upper part of the trachea. Warm or cool mist is a common therapeutic measure for symptomatic relief of respiratory discomfort. The moisture soothes inflamed membranes and is beneficial when there is hoarseness or laryngeal involvement. The use of steam vaporizers in the home is often discouraged because of the hazards related to their use and limited evidence to support their efficacy. A time-honored method (albeit not evidence based!) of producing steam is the shower. Running a shower of hot water into the empty bathtub or open shower stall with the bathroom door closed produces a quick source of steam. Keeping a child in this environment for approximately 10 to 15 minutes humidifies inspired air and can help relieve symptoms. A small child can be held on the lap of a parent or other adult. Older children can sit in the bathroom under the supervision of an adult. Promote Rest- Children who have an acute febrile illness usually have limited activity. One of the cardinal signs that the child is feeling better is the increase in activity; this may, however, be temporary if a high fever returns after a few hours of increased activity. Children should be encouraged to rest or play quietly to avoid exacerbating symptoms. Promote Comfort- Older children are usually able to manage nasal secretions with little difficulty. For very young infants, who normally breathe through their noses, an infant nasal aspirator or a bulb syringe is helpful in removing nasal secretions, especially before being put to bed to sleep and before feeding. This practice, preceded by instillation of saline nose drops as needed, may clear nasal passages and promote feeding. Saline nose drops can be prepared at home by dissolving 1 tsp of salt in 1 pint of warm water. Upper Respiratory Tract Infections Acute Viral Nasopharyngitis- Acute nasopharyngitis, or the equivalent of the "common cold," is caused by the rhinovirus, RSV, adenoviruses, enteroviruses, influenza virus, and parainfluenza virus. Symptoms are more severe in infants and children than in adults. Fever is common in young children, and older children have low-grade fevers, which appear early in the course of the illness. Other clinical manifestations are listed in Box 23-3. Symptoms may last up to 10 days. Therapeutic Management- Children with nasopharyngitis are managed at home. There is no specific treatment, and effective vaccines are not available. Antipyretics may be indicated for mild fever and discomfort (see Chapter 22 for management of fever). Rest is recommended. The provision of a humidified environment and increasing oral fluids may be beneficial to some children with a cold. Decongestants may be prescribed for children and infants older than 12 months of age to shrink swollen nasal passages (they should be used with caution in infants younger than 1 year of age). Cough suppressants containing dextromethorphan should be used with caution (cough is a protective way of clearing secretions) but may be prescribed for a dry, hacking cough, especially at night. However, some preparations contain 22% alcohol and can cause adverse effects such as confusion, hyperexcitability, dizziness, nausea, and sedation. Parents should monitor the child carefully for potential adverse effects. Recent concerns regarding serious side effects of cough and cold preparations in young children, particularly infants, and lack of convincing evidence that such medications are effective in reducing symptoms have prompted recommendations by health experts to carefully evaluate the benefits and risks of recommending such preparations for children younger than 6 years of age (Ryan, Brewer, and Small, 2008). Over-the-counter cold preparation such as pseudoephedrine and some antihistamines are not appropriate for the treatment of the common cold in infants and toddlers; these may cause serious side effects in such children and have been associated with death in infants (Rimsza and Newberry, 2008; Ryan, Brewer, and Small, 2008). Antihistamines are largely ineffective in treatment of nasopharyngitis. These drugs have a weak atropine-like effect that dries secretions, but they can cause drowsiness or, paradoxically, have a stimulatory effect on children. There is no support for the usefulness of expectorants, and antibiotics are usually not indicated because most infections are viral. Prevention- Nasopharyngitis is so widespread in the general population that it is impossible to prevent. Children are more susceptible because they have not yet developed resistance to many viruses. Young infants and those with decreased resistance and pulmonary illness are subject to serious complications, so attempts should be made to protect them from exposure. Nursing Care Management- A cold is often the parents' first introduction to an illness in their infant. Most discomfort of nasopharyngitis is related to the nasal obstruction, especially in small infants. Elevating the head of the bed or crib mattress assists with drainage of secretions. Suctioning and vaporization may also provide relief. Saline nose drops and gentle suction with a bulb syringe before feeding and sleep time may be useful. Maintaining adequate fluid intake is essential. Although a child's appetite for solid foods is usually diminished for several days, it is important to offer appropriate fluids to prevent dehydration. Because nasopharyngitis is spread from secretions, the best means for prevention is avoiding contact with affected persons. This goal is difficult to accomplish in family settings, classrooms, and daycare centers. Family members with a cold should try to "keep it to themselves" by carefully disposing of tissues; not sharing towels, glasses, or eating utensils; covering the mouth and nose with tissues when coughing or sneezing; and washing the hands thoroughly after nose blowing or sneezing. The most frequent carriers of infection are the human hands, which deposit viruses on doorknobs, faucets, and other everyday objects. Children should be taught to wash their hands thoroughly and avoid touching their eyes, noses, and mouths.

Elevated Temps

To facilitate an understanding of fever, the following terms are defined: Set point—The temperature around which body temperature is regulated by a thermostat-like mechanism in the hypothalamus Fever (hyperpyrexia)—An elevation in set point such that body temperature is regulated at a higher level; may be arbitrarily defined as temperature above 38° C (100.4° F) Hyperthermia—Body temperature exceeding the set point, which usually results from the body or external conditions creating more heat than the body can eliminate, such as in heat stroke, aspirin toxicity, seizures, or hyperthyroidism Body temperature is regulated by a thermostat-like mechanism in the hypothalamus.One nonprescription NSAID, ibuprofen, is approved for fever reduction in children as young as 6 months of age. The dosage is based on the initial temperature level: 5 mg/kg of body weight for temperatures less than 39.2° C (102.6° F) or 10 mg/kg for temperatures greater than 39.2° C. The recommended dosage for pain is 10 mg/kg every 6 to 8 hours, and the recommended maximum daily dose for pain and fever is 40 mg/kg. The duration of fever reduction is generally 6 to 8 hours and is longer with the higher dose. The recommended doses of acetaminophen should never be exceeded. Acetaminophen should be given every 4 hours but no more than five times in 24 hours. Because body temperature normally decreases at night, three or four doses in 24 hours will control most fevers. The temperature is usually retaken 30 minutes after the antipyretic is given to assess its effect but should not be repeatedly measured. The child's level of discomfort is the best indication for continued treatment. The nurse can use environmental measures to reduce fever if they are tolerated by the child and if they do not induce shivering. Shivering is the body's way of maintaining the elevated set point by producing heat. Compensatory shivering greatly increases metabolic requirements above those already caused by the fever. Traditional cooling measures, such as wearing minimum clothing; exposing the skin to air; reducing room temperature; increasing air circulation; and applying cool, moist compresses to the skin (e.g., the forehead), are effective if used approximately 1 hour after an antipyretic is given so the set point is lowered. Cooling procedures such as sponging or tepid baths are ineffective in treating febrile children (these measures are effective for hyperthermia) either when used alone or in combination with antipyretics, and they cause considerable discomfort

Tonsillitis

Tonsillitis often occurs with pharyngitis. Because of the abundant lymphoid tissue and the frequency of URIs, tonsillitis is a common cause of illness in young children. The causative agent may be viral or bacterial. The manifestations of tonsillitis are caused by inflammation. As the palatine tonsils enlarge from edema, they may meet in the midline (kissing tonsils), obstructing the passage of air or food. The child has difficulty swallowing and breathing. When enlargement of the adenoids occurs, the space behind the posterior nares becomes blocked, making it difficult or impossible for air to pass from the nose to the throat. As a result, the child breathes through the mouth. Therapeutic Management-Because tonsillitis is self-limiting, treatment of viral pharyngitis is symptomatic. Throat cultures positive for GABHS infection warrant antibiotic treatment. It is important to differentiate between viral and streptococcal infection in febrile exudative tonsillitis. Because most infections are of viral origin, early rapid tests can eliminate unnecessary antibiotic administration. Tonsillectomy is the surgical removal of the palatine tonsils. Absolute indications for a tonsillectomy are recurrent peritonsillar abscess, airway obstruction, tonsillitis resulting in febrile convulsions, and tonsils requiring tissue pathology

Erickson Stages of Development

Trust versus mistrust (birth-1 year)—The first and most important attribute to develop for a healthy personality is basic trust. Establishment of basic trust dominates the first year of life and describes all of the child's satisfying experiences at this age. Corresponding to Freud's oral stage, it is a time of "getting" and "taking in" through all the senses. It exists only in relation to something or someone; therefore, consistent, loving care by a mothering person is essential for development of trust. Mistrust develops when trust-promoting experiences are deficient or lacking or when basic needs are inconsistently or inadequately met. Although shreds of mistrust are sprinkled throughout the personality, from a basic trust in parents stems trust in the world, other people, and oneself. The result is faith and optimism. Autonomy versus shame and doubt (1-3 years)—Corresponding to Freud's anal stage, the problem of autonomy can be symbolized by the holding on and letting go of the sphincter muscles. The development of autonomy during the toddler period is centered on children's increasing ability to control their bodies, themselves, and their environment. They want to do things for themselves using their newly acquired motor skills of walking, climbing, and manipulating and their mental powers of selecting and decision making. Much of their learning is acquired by imitating the activities and behavior of others. Negative feelings of doubt and shame arise when children are made to feel small and self-conscious, when their choices are disastrous, when others shame them, or when they are forced to be dependent in areas in which they are capable of assuming control. The favorable outcomes are self-control and willpower. Initiative versus guilt (3-6 years)—The stage of initiative corresponds to Freud's phallic stage and is characterized by vigorous, intrusive behavior; enterprise; and a strong imagination. Children explore the physical world with all their senses and powers (Fig. 5-4). They develop a conscience. No longer guided only by outsiders, they have an inner voice that warns and threatens. Children sometimes undertake goals or activities that are in conflict with those of parents or others, and being made to feel that their activities or imaginings are bad produces a sense of guilt. Children must learn to retain a sense of initiative without impinging on the rights and privileges of others. The lasting outcomes are direction and purpose. Industry versus inferiority (6-12 years)—The stage of industry is the latency period of Freud. Having achieved the more crucial stages in personality development, children are ready to be workers and producers. They want to engage in tasks and activities that they can carry through to completion; they need and want real achievement. Children learn to compete and cooperate with others, and they learn the rules. It is a decisive period in their social relationships with others. Feelings of inadequacy and inferiority may develop if too much is expected of them or if they believe that they cannot measure up to the standards set for them by others. The ego quality developed from a sense of industry is competence. Identity versus role confusion (12-18 years)—Corresponding to Freud's genital period, the development of identity is characterized by rapid and marked physical changes. Previous trust in their bodies is shaken, and children become overly preoccupied with the way they appear in the eyes of others compared with their own self-concept. Adolescents struggle to fit the roles they have played and those they hope to play with the current roles and fashions adopted by their peers, to integrate their concepts and values with those of society, and to come to a decision regarding an occupation. An inability to solve the core conflict results in role confusion. The outcome of successful mastery is devotion and fidelity to others and to values and ideologies.

Laryngitis

inflammation of larynx. causes hoarse voice or complete loss of voice because of irritation to the vocal folds/cords.