Pediatrics - Exam 3 Ch. 45, 39, 41

OPIOIDS

- Analgesic for severe pain - Can be given Oral, SubQ, IM or IV - Preferred route?

VAPOTHERM IN ASTHMA

- Can reduce work of breathing during an asthma attack - Promotes bronchodilation - Promotes relaxation of smooth muscle

VAPOTHERM

- High velocity nasal insufflation (HI-VNI)

POST-OP ADMIT

- What did he get last for pain? - He's been sleeping - Hasn't cried at all

Parents are to bring their kindergarten child to the outpatient department for a venous blood sample. They have EMLA cream to apply at home prior to the procedure and have been shown two areas on the child's arms where they should place the cream. Transportation time is 15 minutes. Their appointment is for 2:45 p.m. At what time should the parents apply the cream and occlusive dressings to both arms? A. At 11:45 a.m. B. Right before leaving home for the clinic C. Between 1:15 p.m. and 1:45 p.m. D. The parents should not apply EMLA cream due to their child's age.

B. Right before leaving home for the clinic

SIGNS AND SYMPTOMS OF WITHDRAWAL

CNS: - GI: - SNS: -

EV-A71

Common cause of hand, foot & mouth disease EV-A71 can cause a mild illness that clears on its own, such as hand, foot, and mouth disease, or no symptoms at all. Rarely, it can also cause severe neurologic disease, such as meningitis, encephalitis (swelling of the brain and spinal cord) or acute flaccid myelitis (AFM). Enterovirus A71 (EV-A71) has emerged as an etiologic agent of aseptic meningitis, encephalitis, encephalomyelitis, acute flaccid paralysis, and other severe systemic disorders, including neurogenic pulmonary edema, and cardiopulmonary failure. During 2016, an outbreak of enterovirus with neurologic involvement was detected in Spain. Found in secretions and stool, like other enteroviruses Contact/droplet

When administering parenteral or epidural opioids, the nurse should always have ready access to which medication? A. Prostaglandin synthesis inhibitors B. Benzodiazepines C. Antihistamines D. Anticonvulsants E. Naloxone

E. Naloxone

PAIN ASSESSMENT SCALES: FLACC

Face Legs Activity Cry Consolability - Non-verbal Pain Assessment Scale - Location:

TOLERANCE

NOT the same as addiction or dependence

PAIN ASSESSMENT SCALES: NIPS

Neonatal Infant Pain Scale - Non-verbal Pain Assessment Scale

PAIN THERAPY

Pharmacologic vs. Nonpharmacologic

BEHAVIORAL-COGNITIVE PAIN MANAGEMENT STRATEGIES

Relaxation Distraction Imagery

REVERSAL AGENT FOR OPIOIDS

To reverse respiratory depression ONLY: - 0.01 mg/kg - Repeat as needed until respirations resume at a normal rate & quality "Even though it is one of the major fears related to the use of opioids in our study, the respondents reported that this situation is seldom experienced (incidence of 0.5%). This result is in consonance with other studies reporting that respiratory depression is a rare adverse effect, particularly when opioids are titrated for pain treatment." - (Freitas et al., 2014)

THEN WHY DOES EVERYONE DO THIS?

"Physiological indicators are now considered an unreliable measure of a child's pain and this perhaps explains why their use is not explored in studies from 2000 onwards." - (von Baeyer and Spagrud, 2007) "The errors that drew more attention were related to: • vital signs are always reliable indicators of pain intensity (34.5%) • patients usually develop respiratory depression (42.3%) • patients that can be distracted from the pain do not experience severe pain (60%)." - (Freitas et al., 2014)

NEW EVIDENCE SUGGESTS MISMANAGEMENT OF POST-OP PAIN MAY LEAD TO CHRONIC PAIN

"Researchers determined that if acute postoperative pain is not well managed, a patient is at risk of forming a "pain memory" along with experiencing chronic pain, both of which have long-term physical, psychological, social, and developmental consequences" - (Epstein, 2017, AACN)

TRUTH ACCORDING TO THE LITERATURE

- "Caring nurses delivering care that was not always explainable and children suffering pain despite orders for analgesic medications" - "some professionals hold outdated beliefs" - "nurses believe some pain is to be expected" - "nurses believed 20% or more children over reported their pain" - "nonpharmacologic interventions were seen as the parent's role" - "action was not always taken when... pain score greater than or equal to 5" - "Nurses reported struggling to reconcile children's behavior with reported pain scores if they were not behaving in a way that made it clear they were in pain" - "even when nurses have a good level of knowledge, this may not be reflected in their pain management practices" - "Nurses are morally and spiritually responsible for easing the patients' pain"

MORPHINE

- 0.1 mg/kg - Onset: 5-10 mins - Peak: 15-20 min - Duration: 2-4 hrs - Anticipate the need for Benadryl - Anticipate the need for Narcan - Anticipate N/V - Sedation - Resp depression - Pruritis - Nausea/vomiting - Urinary retention - Decreased gastric motility - Respiratory distress due to histamine release can occur if history of asthma Increased Risk of Respiratory Depression: - Altered LOC - Unstable VS - History of Apnea - Airway problems

KETOROLAC (TORADOL) AN NSAID

- 0.5 mg/kg IV Q6H - MAX 30 MG IV - No longer than 5 days - Nephrotoxic, Bleeding risk - See article - Onset: 10-30 mins - Peak: 75-150 min - Duration: 4-6 hrs - Typically prescribed for 24-48 hours - IV NSAID - Monitor urine output & Creatinine - Monitor for bleeding/GI - Minimize risk by dosing appropriately (Do not exceed 5 days) - Opioid-sparing effect: Most pronounced on Post-Op Day 1 - One adult study showed that pts receiving Toradol had a 48% decrease in the need for morphine - Monitor: H&H, platelets, surgical site bleeding, S/S GI bleeding, BUN & Creatinine, Urine output

FENTANYL

- 1 mcg/kg - Onset: 2 min - Peak: 5 min - Duration: 30-60 min - 100x more potent than morphine - Minimal effect on BP & HR - Incompatible with Zithromax - Nausea/vomiting - Respiratory depression - Prior to discontinuing PCA, consider administering oral opioid Increased Risk of Respiratory Depression: - Altered LOC - Unstable VS - History of Apnea - Airway problems

ASTHMA

- A chronic lung disease characterized by acute episodes of coughing, wheezing, chest tightness, and shortness of breath The most common triggers include: - allergens such as pollen, animal dander, dust mites & mold - irritants such as cold air, strong odors, & weather changes - tobacco smoke, cockroaches - upper respiratory infections such as a cold or flu - physical exercise, especially in cold weather

By the time a baby is 6-years-old, how many childhood diseases will they be protected from as a result of routine vaccinations?

- About 15 - There is no benefit to delaying or skipping vaccines - Receiving combination vaccines and/or multiple vaccines at the same time is safe and offers the protection against multiple diseases during one office visit

RSV: RISK FACTORS FOR SEVERE DISEASE

- Children <2 with lung disease d/t prematurity - Children <2 with significant congenital heart disease - Infants <1 born before 32 weeks gestation - Infants born at 32 - 35 weeks with either: childcare attendance OR a sibling <5 years old

UTILIZE YOUR CHILD LIFE SPECIALIST

- Decreased emotional distress - Increased understanding of procedures - Less time on narcotics - Less time in hospital - Happier parents

NURSING MANAGEMENT OF EPIGLOTTIS

- Do not attempt to visualize the throat - Do not leave the child unattended - Do not place the child in a supine position - Provide 100% oxygen in the least invasive manner - If complete airway occlusion occurs, tracheostomy may be necessary - Ensure emergency equipment is available

CONTAGIOUSNESS OF RSV

- Droplet transmission via breathing, coughing, or sneezing BUT... - Virus can survive several hours on hands and surfaces - Keep away from others until wheezing and fever is gone

HOW DOES VAPOTHERM HELP THE BABY WITH RSV?

- Educate the caregiver

REQUIRED INTERVENTIONS WHEN A CHILD IS RECEIVING CONSCIOUS SEDATION

- Ensuring that emergency equipment is readily available - Maintaining a patent airway - Monitoring the child's level of consciousness and responsiveness - Assessing the child's vital signs (especially pulse rate, heart rate, blood pressure, and respiratory rate) - Monitoring oxygen saturation levels

INTERPRETING PEAK EXPIRATORY FLOW RATES

- Green: (80-100% of personal best) signals all clear and asthma is under reasonably good control - Yellow (50-79% of personal best) signals caution; asthma not well controlled; call dr. if child stays in this zone - Red (below 50% of personal best) signals a medical alert. Severe airway narrowing is occurring; short acting bronchodilator is indicated

EPIGLOTTIS FACTS

- Haemophilus influenza type b (Hib) - Ages 3 - 7 - Dysphagia, drooling, & distress (due to severe sore throat) - High fever (102 - 104) - Sudden onset, progresses rapidly - Life-threatening!

RSV SPREAD

- Human only source of infection - Direct or close contact with secretions - Large-particle droplets <3 ft or fomites - May persist hours on surfaces or 30 minutes on hands - Viral shedding 3 - 8 days or longer - Incubation period 2 - 8 days (4-6)

TREATMENT OF RSV

- Hydration - Saline drops with bulb suction - Close monitoring - Fever control (avoid antibiotics, cough meds, decongestants) - Inhaled bronchodilators? - Nebulized 3% saline (hypertonic) - Antibiotic only if secondary bacterial infection is suspected

FYI ABOUT CODEINE

- Liver converts codeine to morphine - Some lack the CYP2D6 enzyme, which converts codeine... - Some have genetic variation of enzyme...

RESPIRATORY SYNCYTIAL VIRUS (RSV)

- Most common cause of bronchiolitis in children less than 2 years old - Season is November to March, peaks in January & February

BRONCHIOLITIS

- Most common lower respiratory tract infection in infants - Most common etiology is RSV, most cases between November and March (75% of cases under 2) - Peak incidence at 6 months of age - Breastfeeding appears to confer a protective advantage - Most severe symptoms in those under 2 (50% affected by age 1, 80-90% by age 2) - No permanent RSV immunity, reinfections common - 90,000 hospitalizations annually (80% under 1 year)

PREVENTION OF RSV

- Palivizumab (Synagis) prophylaxis for selected infants under 24 months (15 mg/kg IM monthly November - March) - Hand washing - Avoiding passive smoke exposure - Promotion of breastfeeding

RSV BRONCHIOLITIS: CRITERIA FOR ADMISSION

- Persistent hypoxia - Respiratory distress - Inability to tolerate fluids - Inability to ensure close follow-up - Infants under 2 months of age - consider - Premature infants - consider

PHYSICAL DEPENDENCE

- Physiologic adaptation - NOT ADDICTION - May have withdrawal symptoms

ARE YOU ADVOCATING FOR YOUR PATIENT?

- Predict it - Post-op - Sickle cell - Cancer - Certain diseases - Major trauma

VAPOTHERM BASICALLY...

- Reduces the work of breathing by washing out the CO2 from the upper airway - Is delivered through a small prong nasal cannula that is comfortable for the child - Is heated and humidified gas to make the high flow rates easy to tolerate - Flushes out CO2 and fills the upper airway with fresh gas - Humidifies which may also be important for helping to clear mucus from the airway

EARLY SYMPTOMS OF RSV BRONCHIOLITIS

- Runny nose/congestion - Mild cough - Fever - Decreased appetite

COMMON SIDE EFFECTS OF OPIOIDS

- Sedation - Nausea/Vomiting - Constipation - Urinary retention - Pruritis

BIOPHYSICAL INTERVENTIONS FOR PAIN MANAGEMENT

- Sucking and sucrose - Heat and cold applications - Massage and pressure

PROGRESSIVE SYMPTOMS OF RSV

- Tachypnea (600-80 bpm) with mild to severe distress - Grunting, flaring, retractions - Coughing, wheezing, crackles - Lethargy, hypoxia, air-trapping - Difficulty feeding due to congestion... dehydration

MISCONCEPTIONS

- The child's nervous system is immature, therefore pain intensity is decreased - Infants and children have no memory of pain - Children are not in pain if they can be distracted or if they are sleeping - Children are at increased risk for becoming addicted to pain medication

WHY ARE INFANTS AND YOUNG CHILDREN MORE SUSCEPTIBLE TO INFECTION?

- Their immune system is - Maternal antibodies - Immunizations are - Hygiene is - Exposure to

NURSE'S ROLE IN MANAGING PROCEDURE-RELATED PAIN

- Use topical anesthetic at site of a skin or vessel puncture - Use non-pharmacologic strategies for pain relief - Prepare child/family ahead of time about the procedure - Use therapeutic hugging to secure the child - Use the smallest-gauge needle possible - Use intermittent infusion device or PICC for multiple samples - Opt for venipuncture in newborns instead of heelsticks - Use kangaroo care for newborns before and after heelstick - Provide nonnutritive sucking before the procedure

FACTORS INFLUENCING PAIN

- What kinds of things influence a child's response to pain?

QUESTIONS TO ASK OLDER CHILDREN

- What kinds of things... - What do you tell you mom or dad... - What would you like... - Where...

METERED-DOSE INHALER WITH SPACER

- a spacer is a chamber that can be attached to a metered-dose inhaler (MDI). The spacer chamber allows the medication to be held in the chamber before it is inhaled so the child can inhale the medicine in one or many breaths, depending on ability. A spacer: - helps prevent getting a yeast infection in the mouth (candidiasis) - increases the amount of medicine delivered directly to airways - reduces the amount of medicine swallowed, which minimizes side effects

ASTHMA MEDS

- albuterol - ipratropium bromide - steroids - oxygen

COMMON SIDE EFFECTS OF VACCINES

- fever - fussy/irritable - malaise - anorexia - rash - syncope Allergic reactions most commonly seen with: •Any vaccine preventable disease can strike at any time in the U.S.; all of these diseases still circulate in the U.S. or elsewhere in the world. •Vaccine-preventable diseases that still circulate in the U.S. include: •Whooping cough •Chickenpox •Hib (a cause of meningitis) •Flu (Influenza) •Vaccine-preventable diseases can range from mild to severe and life-threatening.

SUCROSE

24% sucrose solution administered orally is believed to activate endogenous opioids through taste - Given 2 minutes prior to a procedure, pain sensation is diminished for 5 to 10 minutes - Administer with a pacifier to combine with the calming effects of non-nutritive sucking - Advocate to have this stocked in the pyxis and remind providers to write PRN orders

HOW TO USE A PEAK FLOW METER

A peak flow meter is a simple to use tool for tracking asthma. Here is what to teach: - Stand up or sit up straight - Make sure the indicator is at the bottom of the meter (zero) - take a deep breath in, filling the lungs completely - place the mouthpiece in the mouth and blast the air out as hard and as fast as possible in a single blow - remove the meter from the mouth and record the number that appears on the meter - repeat THREE times

The nurse is assessing the abdomen of a preschooler admitted for lower right quadrant pain. Which questions or requests are appropriate to use with this child? Select all that apply. A. "Choose the face that shows how you feel now." (FACES pain rating scale) B. "Touch the spot on your tummy where it hurts." C. "Is your hurt getting better?" D. "The hurt-is it sharp or dull?" E. "Does your tummy ache?"

A. "Choose the face that shows how you feel now." (FACES pain rating scale) B. "Touch the spot on your tummy where it hurts." E. "Does your tummy ache?"

The nurse is providing family education for the administration of ibuprofen. Which of the following responses indicates a need for further teaching? A. "This can be taken with other medications we have at home that didn't require a prescription." B. "This should be given with food to avoid upsetting his stomach." C. "I should monitor for signs of easy bruising or bleeding gums." D. "This medication is taken by mouth."

A. "This can be taken with other medications we have at home that didn't require a prescription."

A 12-year-old girl needs a lumbar puncture to collect cerebral spinal fluid for laboratory exam plus injection of medication into the central nervous system. She expresses great fear of the procedure because of anticipated pain and the inability to hold still. The nurse contacts the physician to make which suggestion? A. Administration of an oral anti-anxiety medication prior to the procedure. B. Include the child's parents and a child life specialist in the procedure room. C. Delay the procedure until the child can achieve better understanding and acceptance. D. The use of conscious sedation for the lumbar puncture.

A. Administration of an oral anti-anxiety medication prior to the procedure.

The adolescent receiving morphine IV for pain control needs which of the following included in his nursing care plan (NCP)? Select all that apply. A. Assessment for suppressed cough reflex B. Monitoring for itching C. High-fat diet D. Stand-by assistance when using the bathroom E. Naloxone readily available

A. Assessment for suppressed cough reflex B. Monitoring for itching D. Stand-by assistance when using the bathroom E. Naloxone readily available

An 11-year-old boy is lying quietly in bed watching a DVD. This is his first postoperative day following open reduction of an ankle fracture. One nurse concludes the child does not need his PRN pain medication; another nurse disagrees. Which of the possibilities described is likely to be true? Select all that apply. A. The 11-year-old is using the DVD to withdraw from his discomfort and is lying still to avoid movement, which exacerbates his pain. B. The boy is quiet and focused, not restless and distracted. His pain is under control. C. The child may be concerned about getting a "shot" and is avoiding the display of pain behaviors. D. At the age of 11 years, the child can be expected to let the staff know when he has pain.

A. The 11-year-old is using the DVD to withdraw from his discomfort and is lying still to avoid movement, which exacerbates his pain. C. The child may be concerned about getting a "shot" and is avoiding the display of pain behaviors.

WHICH IS APPROPRIATE?

ATC: - Predictable pain PRN: - Q 3-4H Continuous Infusion? BTP

ACETAMINOPHEN VS NSAIDS

Acetaminophen: - No anti-inflammatory effect - Can reduce prostaglandins in the brain that cause fever - No gastric effect NSAIDs: - More effective for inflammation by blocking prostaglandin formation that leads to the local inflammatory response > Inhibits the synthesis of prostaglandins by blocking the enzyme cyclooxygenase

The nurse is caring for a child who has been prescribed fentanyl (Duragesic) for pain.Which of the following actions is a priority nursing function for this child? A. Assess for oliguria or anuria. B. Assess respiratory status frequently. C. Administration of no more than five doses in a 24-hour period. D. Check for occult blood in urine or stool.

B. Assess respiratory status frequently.

The 2-month-old infant needs a capillary blood specimen obtained. In addition to having the father hold the infant, the nurse will: Select all that apply. A. Wrap the extremity in a cool towel. B. Give the baby a small amount of sucrose just prior to the procedure. C. Give the child an age-appropriate dose of ibuprofen. D. Provide a pacifier for the child.

B. Give the baby a small amount of sucrose just prior to the procedure. D. Provide a pacifier for the child.

MUMPS

Before the U.S. mumps vaccination program started in 1967, about 186,000 cases were reported each year, and many more unreported cases occurred. The disease caused complications, such as permanent deafness in children, and occasionally, encephalitis, which could rarely result in death. Since the pre-vaccine era, there has been a more than 99% decrease in mumps cases in the United States. From year to year, the number of mumps cases can range from roughly a couple hundred to a couple thousand. However, outbreaks still occur, even among highly vaccinated populations.

INDICATORS OF PAIN

Behavioral: - Grimacing - Whining - Wide eye opening/hyperalert - Restlessness - Agitation - Combativeness Physiologic: - Tachycardia - Tachypnea - Hypertension - Diaphoresis - Pallor - Pupillary dilation Complex Stress Response: - After some time of exhibiting the physiologic indicators of pain, the body will adapt... vital signs normalize, sweating diminishes, color returns...

The mother with a child following abdominal surgery holds his hand and smoothes his hair. When the nurse appears to administer a scheduled analgesic, the mother says she believes the child has been in pain the last hour or more. The nurse's best response is: A. "This is the medication he gets every 4 to 6 hours. It will control his pain for that period of time." B. "We will check every 4 hours to see if he needs the pain medicine." C. "Please tell me and all of the nurses when you believe he is in pain." D. "He looks comfortable to me and was sleeping each time I checked. The medication given earlier seems adequate." E. "His vital signs are stable, telling me he must be comfortable."

C. "Please tell me and all of the nurses when you believe he is in pain."

The nurse is preparing a 6-year-old for a venipuncture. The boy appears anxious and is crying. How can the nurse foster feelings of control to help minimize his anxiety about the procedure? A. "See how fast you can make this pinwheel whirl." B. "Mrs. Jones, why don't you have him sit on your lap?" C. "What questions do you have about what I am doing?" D. "Pick your favorite Band-Aid and show me which arm to use."

D. "Pick your favorite Band-Aid and show me which arm to use."

BRONCHIOLAR PLUGGING FROM PERTUSSIS

In 1974, Japan had a successful pertussis (whooping cough) vaccination program, with nearly 80% of Japanese children vaccinated. That year only 393 cases of pertussis were reported in the entire country, and there were no deaths from pertussis. But then rumors began to spread that pertussis vaccination was no longer needed and that the vaccine was not safe, and by 1976 only 10% of infants were getting vaccinated. In 1979 Japan suffered a major pertussis epidemic, with more than 13,000 cases of whooping cough and 41 deaths. In 1981 the government began vaccinating with acellular pertussis vaccine, and the number of pertussis cases dropped again.

HOW MIGHT A CHILD EXPRESS PAIN?

Infant: - Toddler: - Preschool: - School Age: - Adolescent: -

THE PROBLEM WITH KNOWLEDGE TRANSLATION

Is what you say the same as what you do?

PARALYTIC POLIOMYELITIS

It is very contagious and spreads through person-to-person contact. The virus lives in an infected person's throat and intestines. It enters the body through the mouth and spreads through contact with the feces (poop) of an infected person and, though less common, through droplets from a sneeze or cough. You can get infected with poliovirus if you have feces on your hands and you touch your mouth. Also, you can get infected if you put in your mouth objects like toys that are contaminated with feces (poop). An infected person may spread the virus to others immediately before and about 1 to 2 weeks after symptoms appear. The virus can live in an infected person's feces for many weeks. It can contaminate food and water in unsanitary conditions. People who don't have symptoms can still pass the virus to others and make them sick.

REMEMBER, THE PULSE OX DOESN'T MEASURE...

Manually monitor Resp rate & quality of respirations before and after administration (compare to baseline) --Utilize Capnography

MEASLES IN THE UNITED STATES

Measles was eliminated in the United States in 2000. During January 1-October 1, 2019, a total of 1,249 measles cases and 22 measles outbreaks were reported in the United States. This represents the most U.S. cases reported in a single year since 1992 (1), and the second highest number of reported outbreaks annually since measles was declared eliminated.

EV-D68

Mild or Severe Symptoms: •Runny nose •Sneezing •Cough •Body aches •Muscles aches •Wheezing •Respiratory distress •Contact/Droplet •Children with asthma may have a higher risk for severe respiratory illness caused by EV-D68 infection. First identified in California in 1962, enterovirus D68 (EV-D68) is one of more than 100 non-polio enteroviruses. during 2014 the number of people reported with confirmed EV-D68 infection was much greater than that reported in previous years In summer and fall 2014, the United States experienced a nationwide outbreak of EV-D68 associated with severe respiratory illness. From mid-August 2014 to January 15, 2015, CDC or state public health laboratories confirmed 1,395 people in 49 states and the District of Columbia with respiratory illness caused by EV-D68. Almost all of the confirmed cases were among children, many whom had asthma or a history of wheezing. About 40% tested positive for an enterovirus or rhinovirus other than EV-D68. EV-D68 can cause mild to severe respiratory illness, or no symptoms at all. Mild symptoms may include runny nose, sneezing, cough, body aches, and muscle aches. Severe symptoms may include wheezing and difficulty breathing.

DIPTHERIA: THE "STRANGLING ANGEL OF CHILDREN"

More than 15,000 Americans died from diphtheria in 1921, before there was a vaccine. Only two cases of diphtheria have been reported to CDC between 2004 and 2014. •Bacterial •Weakness, fever, sore throat, swollen glands •Possible myocarditis, heart failure •Thick coating in throat, makes it hard to breathe or swallow •Droplet & Contact In children younger than 5 years old, as many as 1 out of 5 children who get diphtheria dies. About 1 out of 10 people who get diphtheria dies. The coating in the back of the nose or throat can get so thick that it blocks the airway, so the person can't breathe. The diphtheria toxin can affect the heart, causing an abnormal heart rhythms and even heart failure. It can also affect the nerves and lead to paralysis (unable to move parts of the body).

MEASLES (RUBEOLLA)

One of the most contagious diseases known to man •Viral respiratory illness •High fever •3 "c's": cough, conjunctivitis, coryza •Rash 2 weeks after exposure •Serious illness, often requires hospitalization, can be fatal Nearly everyone in the U.S. got measles before there was a vaccine, and hundreds died from it each year. Today, most doctors have never seen a case of measles. Measles is an acute febrile rash illness with an attack rate of approximately 90% in susceptible household contacts. Measles symptoms appear 7 to 14 days after contact with the virus and typically include high fever, cough, runny nose, and watery eyes. Measles rash appears 3 to 5 days after the first symptoms. Measles can be dangerous, especially for babies and young children. Measles typically begins with: high fever (may spike to more than 104°), cough, runny nose (coryza), and red, watery eyes (conjunctivitis)

MUMPS ORCHITIS

Orchitis occurs in approximately 20-30% of unvaccinated and 6-7% of vaccinated post-pubertal male mumps patients. In 60% to 83% of males with mumps orchitis, only one testis is affected. Mumps orchitis has not been linked to infertility, but may result in testicular atrophy and hypofertility

PATIENT-CONTROLLED ANALGESIA (PCA)

PCA Pump: - Basal rate - Bolus dose - Max # of bolus/hr - Max amount in 4 hrs PCA by proxy

THEORIES OF PAIN

Pain is an unpleasant sensory and emotional experience that is associated with actual or potential tissue damage - Can be a warning sign something is wrong! - Pain is subjective - The pediatric pain experience involves the interaction of behavioral, developmental, physiologic and situational factors - Whatever the person says it is, existing whenever the person says it does - that is, pain is present when the person says that it is Gate Control Theory of pain: A gating mechanism at the level of the dorsal horn in the spinal cord can facilitate or dampen the transmission of pain impulses. Stimulation of larger afferent nerves, which carry benign sensations, can blunt the transmission of pain signals, carried by smaller afferent nerves (TENS unit)

PARALYSIS IN POLIO

Paralysis is the most severe symptom associated with polio because it can lead to permanent disability and death. Between 2 and 10 out of 100 people who have paralysis from poliovirus infection die because the virus affects the muscles that help them breathe. Note that "poliomyelitis" (or "polio" for short) is defined as the paralytic disease. So only people with the paralytic infection are considered to have the disease.

MONITORING THERAPY

Patient Parameters - Indices of work of breathing (WOB) - SpO2 - PCO2 - FiO2 - Nasopharynx patency - Feeding tolerance Documentation Patient: - Heart rate - Respiratory rate - Work of breathing (WOB) - SpO2 Device: - Flow rate - FiO2 - Temperature - Water level - Cannula size

MUMPS CASES AS OF FEBRUARY 25, 2017

People who previously had one or two doses of MMR vaccine can still get mumps and transmit the disease. During mumps outbreaks in highly vaccinated communities, the proportion of cases that occur among people who have been vaccinated may be high. This does not mean that the vaccine is ineffective. Disease symptoms are generally milder and complications are less frequent in vaccinated people.

PHYSIOLOGICAL CONSEQUENCES OF PAIN

Respiratory: shallow breathing, cough suppression Cardiac: increased myocardial oxygen consumption Immune: suppression of immune system GI: delayed return of bowel/gastric function, stress ulcer Healing: poor appetite = poor nutrition = low energy & delayed healing

PAIN ASSESSMENT SCALES: FACES (Wong-Baker)

Self Reported Scale

PAIN ASSESSMENT SCALES: NUMERIC

Self Reported Scale

VACCINE INGREDIENTS

Some people are concerned about the first ingredient on the list, thimerosal, because it contains mercury. The concern has been that vaccines that contain thimerosal might harm the babies of pregnant women or young infants. Research has shown that in vaccines containing thimerosal, the amount is not harmful. Thimerosal acts as a preservative in many medicines, including some vaccines, and has a record of being very safe. Mercury is a metal found naturally in the environment. People can be exposed to some types of mercury; methylmercury, for example, is the type of mercury found in certain some foods. If a person is exposed to a large amount of methylmercury, it can be dangerous. People can also be exposed to elemental mercury, such as when an old thermometer breaks and the mercury spills out. Thimerosal contains ethylmercury, a different kind of mercury, which does not stay in the body very long. There is no evidence of harm caused by the low doses of thimerosal in vaccines. In 1999, the Food and Drug Administration (FDA) was required by law to assess the amount of mercury in all the products the agency oversees, including vaccines. In an abundance of caution, the U.S. Public Health Service decided that as much mercury as possible should be removed from vaccines, and since thimerosal was the only source of mercury in vaccines, they recommended removing thimerosal to reduce mercury exposure. One concern has been that the thimerosal might be linked to autism in young children. However, based on a thorough review in 2004 of clinical and epidemiological studies by the National Academy of Medicine concluded that neither thimerosal, nor the measles-mumps-rubella (MMR) vaccine, is associated with autism. Even after thimerosal was removed from almost all childhood vaccines, autism rates continued to go up, which is the opposite of what would happen if thimerosal caused autism. The measles, mumps, and rubella (MMR) vaccine has never contained thimerosal. Today, the only childhood vaccines that contain thimerosal and are routinely used in the United States are flu vaccines in multi-dose vials (vials containing more than one dose). Multi-dose vials have very tiny amounts of thimerosal as a preservative to prevent the growth of dangerous microbes. When each new needle is inserted into a multi-dose vial, it is possible for bacteria from the needle to enter the vial. Receiving a vaccine contaminated with bacteria can be deadly. Thimerosal prevents contamination in the multi-dose vial when individual doses are drawn from it. Vaccines that do not contain thimerosal are in single-use vials and in pre-filled syringes.

VACCINES

The United States has very low rates of vaccine-preventable diseases, but this isn't true everywhere in the world. Only one disease — smallpox — has been totally erased from the planet. Polio is close to being eliminated, but still exists in several countries. More than 350,000 cases of measles were reported from around the world in 2011, with outbreaks in the Pacific, Asia, Africa, and Europe. In that same year, 90% of measles cases in the U.S. were associated with cases imported from another country. Only the fact that most Americans are vaccinated against measles prevented these clusters of cases from becoming epidemics.

INCIDENCE OF HAEMOPHILUS INFLUENZAE INVASIVE DISEASE, ALL TYPES: LOUISIANA, 1983-2016

The epidemiology of invasive H. influenzae disease in the United States has shifted since the introduction of the Hib vaccine. The United States began using Hib vaccine for children in 1987 and for infants in 1990. Since then, the annual incidence of invasive Hib disease in children aged younger than 5 years old decreased by 99%. Now, nontypeable H. influenzae causes the majority of invasive H. influenzae disease among all age groups in the United States. In developing countries, where routine vaccination with Hib vaccine is not widely available, Hib remains a major cause of lower respiratory tract infections in infants and children. In the United States, Hib disease is not common. It occurs primarily in underimmunized children and in infants too young to have completed the primary immunization series. Nontypeable H. influenzae also causes 30% to 52% of episodes of acute otitis media and sinusitis in children. It can be a common cause of recurrent otitis media.

KOPLIK SPOTS & RASH

Tiny white spots (Koplik spots) may appear inside the mouth two to three days after symptoms begin. Three to five days after symptoms begin, a rash breaks out. It usually begins as flat red spots that appear on the face at the hairline and spread downward to the neck, trunk, arms, legs, and feet. Small raised bumps may also appear on top of the flat red spots. The spots may become joined together as they spread from the head to the rest of the body. When the rash appears, a person's fever may spike to more than 104° Fahrenheit.

ENTEROVIRUS

Virus found in: Feces Saliva, mucus, sputum Blister fluid Exposure: Close contact with person or objects Changing diapers Drinking after person Non-polio enteroviruses can be found in an infected person's feces (stool) eye, nose, and mouth secretions (such as saliva, nasal mucus, or sputum) blister fluid You can get exposed to the virus by having close contact, such as touching or shaking hands, with an infected person touching objects or surfaces that have the virus on them, then touching your eyes, nose, or mouth before washing your hands changing diapers of an infected person, then touching your eyes, nose, or mouth before washing your hands drinking water that has the virus in it Once infected, you can shed (pass from your body into the environment) the virus for several weeks, even if you don't have symptoms.

RUBELLA

•"German measles" (3 day measles) •Viral •Serious disease rare in children •Can be devastating to unborn babies Measles, Mumps, & Rubella = MMR Before the rubella vaccine was licensed in the United States in 1969, rubella was a common disease that occurred primarily among young children. Rubella was declared eliminated from the United States in 2004. However, it is still commonly transmitted in many parts of the world. As a result, less than 10 cases (primarily import-related) have been reported annually in the United States since elimination was declared An epidemic of rubella (German measles) in 1964-65 infected 12½ million Americans, killed 2,000 babies, and caused 11,000 miscarriages. Since 2012, 15 cases of rubella were reported to CDC.

TETANUS

•Bacterial •Neck, abdomen, jaw muscles •Can be fatal if untreated •Common in soil •Enters via open wounds, deep wounds more prone to become infected Tetanus is very dangerous. It can cause breathing problems, muscle spasms, and paralysis (unable to move parts of the body). Muscle spasms can be strong enough to break a child's spine or other bones. It can take months to recover fully from tetanus. A child might need weeks of hospital care. As many as 1 out of 5 people who get tetanus dies. Tetanus bacteria are found in soil, dust, and manure. It gets into the body through a puncture, cut, or sore on the skin after a burn, or an animal bite

IF YOU CHOOSE AGAINST VACCINATION

•Be aware that your child can catch diseases from people who don't have any symptoms. For example, Hib meningitis can be spread from people who have the bacteria in their body but are not ill. You can't tell who is contagious. •If there are cases (or, in some circumstances, a single case) of a vaccine-preventable disease in your community, you may be asked to take your child out of school, childcare, or organized activities •It may not be possible to avoid exposure. For example, measles is so contagious that hours after an infected person has left the room, an unvaccinated person can get measles just by entering that room.

CONGENITAL RUBELLA SYNDROME (CRS)

•Deafness •Cataracts •Heart defects •Intellectual disabilities •Liver and spleen damage •Low birth weight •Skin rash at birth •Although specific symptoms can be treated, there is no cure for CRS. Pregnant women who contract rubella are at risk for miscarriage or stillbirth, and their developing babies are at risk for severe birth defects with devastating, lifelong consequences. Infection with rubella virus causes the most severe damage when the mother is infected early in pregnancy, especially in the first 12 weeks (first trimester). During 2005-2015, eight babies with CRS have been reported in the United States.

POLIO

•Enterovirus (Picornavirus family) •Poliomyelitis comes from the Greek terms polios and myelos, which mean "grey" and "marrow," •Viral •Can attack spinal cord & brain in rare cases Polio was once considered one of the most feared diseases in the United States. In the early 1950s, before polio vaccines were available, polio outbreaks caused more than 15,000 cases of paralysis each year in the United States. Following introduction of vaccines—specifically, trivalent inactivated poliovirus vaccine (IPV) in 1955 and trivalent oral poliovirus vaccine (OPV) in 1963—the number of polio cases fell rapidly to less than 100 in the 1960s and fewer than 10 in the 1970s. Most people who get infected with poliovirus (about 72 out of 100) will not have any visible symptoms. About 1 out of 4 people with poliovirus infection will have flu-like symptoms that may include— Common Side Effects Sore throat Fever Tiredness Nausea Headache Stomach pain These symptoms usually last 2 to 5 days then go away on their own. Rare Side Effects Parasthesia Meningitis Paralysis Most people who get infected with poliovirus (about 72 out of 100) will not have any visible symptoms. About 1 out of 4 people with poliovirus infection will have flu-like symptoms that may include— A smaller proportion of people with poliovirus infection will develop other more serious symptoms that affect the brain and spinal cord: Paresthesia (feeling of pins and needles in the legs) Meningitis (infection of the covering of the spinal cord and/or brain) occurs in about 1 out of 25 people with poliovirus infection Paralysis (can't move parts of the body) or weakness in the arms, legs, or both, occurs in about 1 out of 200 people with poliovirus infection

HAEMOPHILUS INFLUENZAE TYPE B

•Hib •Bacterial- gram negative •Invasive disease is life-threatening •Contact/droplet •Meningitis •Epiglottitis •Pneumonia •See Hib VIS Gram-negative cocci The most common types of disease caused by H. influenzae type b (Hib) include pneumonia, bacteremia, meningitis, epiglottitis, septic arthritis, cellulitis, otitis media, and purulent pericarditis. Most children with Hib disease need care in the hospital. Even with treatment, as many as 1 out of 20 children with Hib meningitis dies. As many as 1 out of 5 children who survive Hib meningitis will have brain damage or become deaf.

PERTUSSIS (WHOOPING COUGH)

•Highly contagious bacteria •Occurs mainly in children less than 4 •Most common in spring and summer •"100-day cough" (CDC, 2011) Since 2010, up to 20 babies have died each year from whooping cough in the United States. Most of these babies don't have protection against whooping cough because they are too young to get the shots. Before the whooping cough vaccines were recommended for all infants, about 8,000 people in the United States died each year from whooping cough

MUMPS

•Viral •Painful swelling of salivary glands •Deafness possible in young children •Swelling of testicles/ovaries Mumps usually involves pain, tenderness, and swelling in one or both parotid salivary glands (cheek and jaw area). Swelling usually peaks in 1 to 3 days and then subsides during the next week. The swollen tissue pushes the angle of the ear up and out. As swelling worsens, the angle of the jawbone below the ear is no longer visible. Often, the jawbone cannot be felt because of swelling of the parotid. One parotid may swell before the other, and in 25% of patients, only one side swells.

POST-POLIO SYNDROME

•begins about 15 to 40 years after the initial poliovirus infection •PPS affects between 25 and 40 out of every 100 polio survivors. Even children who seem to fully recover can develop new muscle pain, weakness, or paralysis as adults, 15 to 40 years later. This is called post-polio syndrome.

NON-POLIO ENTEROVIRUSES

•viral conjunctivitis •hand, foot, and mouth disease •viral meningitis •viral encephalitis •myocarditis •pericarditis •acute flaccid paralysis •inflammatory muscle disease (slow, progressive muscle weakness) Non-polio enteroviruses cause about 10 to 15 million infections and tens of thousands of hospitalizations each year in the United States. Most people who get infected with these viruses do not get sick or they only have mild illness, like the common cold. But some people can have serious complications, especially infants and people with weakened immune systems Infants, children, and teenagers are more likely than adults to get infected and become sick because they do not yet have immunity (protection) from previous exposures to the viruses. Newborns at risk for sepsis Non-polio enterovirus infections may play a role in the development of type 1 diabetes in children.