NP3: Module 7

Acetaminophen; Aspirin

o Acetaminophen (Tylenol) is most common analgesic for mild-moderate pain, also Tx for fevers in children. Minimal anti-inflammatory effects; ST use is safe, even w/ neonates; does NOT have gastric irritation & GI bleeding effects associated w/ other analgesics. Hepatic damage can occur, usually w/ overdosage. RN must monitor the amount given bc often combined w/ other prescription & OTC meds to Tx pain, fever, & s/s URT infection & flu. o Aspirin (acetylsalicylic acid) is not used in children bc of Reyes syndrome--causes confusion, brain swelling, & liver damage.

Morphine sulfate

o Morphine sulfate: opioids bind to the CNS opioid receptors & control pain by depressing pain impulse transmission. Used to control moderate-severe acute & chronic pain—post-Op, post-traumatic, SCD vaso-occlusive crisis, & cancer pain. o Effects: analgesia, sedation, respiratory depression, constipation, pruritus, n/v, cough suppression, & urinary retention. Pruritus, nausea, sedation, & urinary retention usually resolve in 1-3 days; Tx w/ antipruritic & antiemetic meds. Constipation does not resolve, RN advocate for laxatives & stool softeners. § Morphine is the preferred drug for kids; IV peaks at 10-20 min, PO peaks at 1hr. If sedation occurs, max respiratory depression will occur 7min after IV admin. Nausea is common, report if vomiting occurs. Dizziness & lightheadedness can occur, so supervise ambulation & initiate safety precautions. Assess respiratory status frequently & carefully; assess CNS changes & implement safety measures. Monitor I&O rt urinary retention & constipation. Begin w/ lowest dose, titrate up or down to max pain relief & minimize adverse effects. --Hypercyanotic Episode: AKA tet spells; seen w/ cyanotic heart dz, esp. unrepaired tetralogy of fallot. Exact cause unknown but acute spasm of the RV outflow tract as result of agitation (cry, feed, BM) or another AE that dramatically decreases pulmonary BF; causing hypoxia & metabolic acidosis. -S/S: episode is a few min to hrs; rapid/deep respirations; irritability & crying; periperal vasodilation; increased systemic venous return; increasing cyanosis can be severe; decrease in systolic murmur, reflects decreased pulmonary BF. As cyanosis, hyperpnea, & tachypnea increase, R-L shunting increases. -Morphine sulphate admin to suppress the resp. center & decrease degree of hyperpnea (which contributes to vasodilation).

Bronchodilators

o SABAs (Short-acting bronchodilators: albuterol, levalbuterol, terbutaline), relax bronchial smooth muscle & inhibit release of mediators from mast cells, admin w/ MDI or nebulizer 3-4x/day when symptomatic or before exercise. Rescue med for asthma. o Long-acting bronchodilator/LABAs (Long-acting B-2 adrenergic agonists: Serevent/Salmeterol, Foradil/Formoterol). Routine asthma med.

Corticosteroids

o Systemic corticosteroids (prednisone, prednisolone), decrease airway inflammation, admin in short-burst courses of 5-7 days. Rescue med for asthma. o INH corticosteroids (Pulmicort/Budesonide, Flovent/Fluticasone, Azmacort/Triamcinolone), admin topical anti-inflammatory action directly to the airway. Routine med for asthma. o Topical corticosteroids: anti-inflammatory; through vasoconstriction & inhibiting the movement of inflammatory cells from blood stream to local tissue. Used for inflammatory dz, atopic dermatitis. Best absorbed after taking a bath (w/in 5min). NEVER use for chicken pox or on diaper rash. Never occlude area being Tx; more potent= shorter Tx time. Adverse rx can occur w/ ST use high-potency or LT use low-potency; suppression of HPA axis causes growth suppression; immunosuppression; moon-face; osteoporosis; obesity. Local skin thinning, striae, telangiectasia, atrophy, purpura.

Allergic Rhinitis

Allergic Rhinitis: AKA intermittent allergic rhinitis or hay fever, persistent allergic rhinitis. • Inflammatory disorder of the nasal mucosa; usually seasonal, recurrent, & triggered by specific allergens; usually a family Hx; some children have symptoms year-round. • S/S: occur as long as exposed to allergen; clear rhinorrhea, itching (nose, eyes, ears, palate), and paroxysmal sneezing that's not associated w/ URT infection. Allergic salute- crease below bridge of nose from upward rubbing. Allergic shiners- dark circles under eyes from congestion & edema. • RN: Early ID w/ therapeutic management; differentiate from viral nasopharyngitis (common cold). Nasal smear & CBC indicate elevated eosinophils—associated w/ allergies. RAST used when skin testing is difficult bc of dermatitis, young age, or illness. • Tx of choice is to eliminate the allergen from their environment; sometimes impossible. Teach patient & family about ordered meds, environmental control, & immunotherapy. • Place toys in the freezer to kill allergens. • Warm H2O or NS solution irrigation of nasal passages; moisten membranes, soften crusted secretions, wash out irritants. • W/ immune-Tx [or any new med] monitor child closely after medications for reactions (20-30min after). Keep emergency epinephrine ready in the event of anaphylaxis. W/ antihistamines, main SE is drowsiness—admin at night to reduce effects; some children are affected by dry mucus membranes & excitability. • S/S of dz can impair functioning, esp. if effected by another dz too—watch for depression & anxiety.

Amoxicillin

Amoxicillin: is a commonly prescribed aminopenicillin; used to treat infections caused by susceptible organisms in the ears, nose, throat, GU tract, skin, and skin structures. Pediatric dosages are sometimes higher than in the past because of the development of increasingly resistant Strep-tococcus pneumoniae organisms. The drug is available only for oral use and can be given with or without food. -Route: PO; Onset: 0.5-1 hr; Peak: 1-2 hr; Elimination Half-Life: 1-1.5 hr; Duration: 6-8 hr. -Ask patients about drug allergies to penicillin before beginning drug therapy because allergies to this drug category are common. -Teach patients to take the drug with food to reduce the risk for GI upset. -Instruct patients to call the primary health care provider if severe or watery diarrhea develops to recognize the complication of pseudomembranous colitis, which may require discontinuing the drug. -Suggest that women who take oral contraceptives use an additional method of birth control while taking this drug because these drugs may reduce the effectiveness of estrogen-containing contraceptives. -Caution patients to complete the drug regimen even if the symptoms improve or disappear sooner to prevent bacterial resistance and infection recurrence.

Asthma

Asthma: is a reversible obstructive airway disease. -S/S during an episode: wheezing is the classic sign (difficulty exhaling), dry cough (nonproductive), SOB, dyspnea on exertion; retractions, nasal flaring, or stridor; nonproductive cough w/ or w/o wheezing that later becomes productive; tachypnea, orthopnea; restless, apprehensive, diaphoretic; ABD pain from straining muscles during labored breathing; tripod position; fatigue & difficulty w/ ADLs bc of SOB; chest tightness followed by dry cough, wheezing, & dyspnea; s/s are worse after going to bed at night bc increased narrowing of airways & pooling of secretions; also worse in cold weather. --Beginning of episode- wheezing heard only w/ stethoscope; increasing severity- wheezing audibly heard; severe respiratory distress- no wheezing heard bc of decreased air movement & child will not show s/s of clinical improvement, ominous s/s (silent chest)—increased wheezing can indicate improvement (increased air movement). Emergency Management of Asthma: • Worsening wheeze, cough, or shortness of breath. No improvement after bronchodilator use (short acting). Difficulty breathing, respiratory distress. Trouble with walking or talking. Feeling of chest tightening. Discontinuation of play. Listlessness or weak cry. Gray or blue lips or fingernails. Not hearing wheezing or previously heard wheezing has stopped—may be due to decreased movement of air - ominous sign. If you weren't hearing wheezing & after Tx wheezing starts—may indicate improvement bc the airway is starting to open. • Admin of meds & Tx: Acute - bronchodilator (SABA: short acting beta-adrenergic agonist, ex. Albuterol), O2 therapy, short course of corticosteroid. • Education for the child & family: ST & LT management, meds & how to admin correctly, emotions effect on asthma episodes, avoidance of triggers (type of exercise, animals, grass, pollen, smoke, perfumes, viral resp. infections, etc), exercise should not be discouraged- avoid sports that require sustained exertion, rapid breathing of large vL of cold/dry air can trigger episode. How to use a peak flow meter (measures the air flow during forced exhalation); can ID start of an episode before the child feels the s/s. • Recognize early s/s of an episode: itchy chest or chin, cough, irritable or tired, increased RR, dry mouth, dark circles under the eyes; then use the individualized Tx plan. • Prevent an asthma attack: Use SABA (Albuterol) 30min before exercise. Warm air by breathing through nose, or place scarf over mouth & nose when exercising in the cold. Decrease hyperventilation by keeping them calm & teach methods to help them stay anxiety-free (ex. progressive muscle relaxation, diaphragmatic breathing).

Bronchiolitis: respiratory syncytial virus

Bronchiolitis- respiratory syncytial virus: - Inflammation of the bronchioles. RSV is the causative agent in 50% of cases; it is a significant cause of hospitalization in kids <1yr old; for adults & older kids it's the 'common cold'. Highly communicable; contact isolation & scrupulous hand hygiene needed. Peak times during winter & early spring. • URT infection from RSV; leads to edema, mucus, & cell debris that obstructs bronchioles; bronchiole constriction during expiration causing hyperinflation of lungs; atelectasis occurs when obstruction is complete & trapped air is absorbed; normal gas exchange impaired; hypoxemia occurs; metabolic acidosis & mild resp. alkalosis results. o Leads to hypoxemia then metabolic acidosis and mild respiratory alkalosis. Lots of mucus; child goes home w/ significant amounts still, even if O2sat is better. • S/S: tachypnea (RR 60-80), tachycardia (HR >140); wheezing, crackles, or rhonchi; intercostal or subcostal retractions w/ or w/o nasal flaring; cyanosis. Feeding difficulties bc of increased RR, interferes w/ sucking & swallowing. Temp. varies from hypothermia to as high as 105.8 (41 C). Lots of mucus. • Respiratory Distress: restlessness (early s/s), nasal flaring, retractions. • Feeding Difficulty: w/ thick nasal secretions, the baby will have difficulty feeding/sucking, spitting out the nipple, RR increasing. Due to the posterior soft palate covering the oropharynx and the tongue's proximity with the hard & soft palate, infants this age are obligate nose breathers. When the nose is congested, they cannot form a seal to suck. Their respiratory effort increases as they attempt to breathe through congested nasal passages & suck at the same time. • Tx: mild case Tx at home w/ fluids, humidification, & rest. Resp. distress Tx in hospital; cool humid O2 admin when O2sat <90% on room air—relieves dyspnea, hypoxemia, & insensible H2O loss from tachypnea. Suction kept at bedside; suction nasal passageways. INH NS 3% may improve resp. status & decrease hospital stay. IV fluids for dehydration. Position infant w/ head & chest at 30-40 degrees w/ neck slightly extended to maintain airway & decrease diaphragm pressure. Antibiotics given only for secondary bacterial infection. • IV dextrose 5% and sodium chloride 0.45%. Patient is NPO & likely to experience insensible losses due to increased RR or fever. Infants have a higher metabolic rate—dextrose is typically administered with IV fluids to meet metabolic demands. • Nebulized 3% hypertonic sodium chloride. Admin this solution prior to suctioning can help thin mucous secretions, aid their removal. • Salbutamol: Medical Tx for bronchiolitis is primarily supportive. Bronchodilators may prove of some ST benefit to those w/ underlying respiratory disorders that can result in exacerbation of bronchoconstriction due to viral infection; attempt 1 dose then assess for desired effect. • Contraindicated: PO Prednisone. Corticosteroids are not indicated for a client who has bronchiolitis. The appropriate use of corticosteroids remains controversial.

Bronchitis

Bronchitis: Acute bronchitis is viral in origin; Bacterial infections occur secondary or from foreign body aspiration; Rhinoviruses most common agent. Occurs with other conditions like URT/LRT infections. Seen in young children & boys. - S/S: gradual onset of rhinitis & a cough that is nonproductive, but may change to a loose cough w/ increased mucus production. Inflammation of the trachea and major bronchi; course & fine moist crackles, high-pitched rhonchi on auscultation. Also malaise, low-grade fever, increased mucus that may be purulent. • Bronchitis vs Asthma: • Bronchitis is characterized by a dry hacking cough that becomes productive over 2-3 days; the cough associated with asthma is nonproductive. Typically bronchitis is caused by a virus & is accompanied by a low-grade fever & a sore throat; fever is not associated with asthma. Bronchitis resolves in 5-10 days & chronic exercise intolerance is not a feature; it is a feature of poorly controlled asthma. As a viral illness, bronchitis responds to s/s Tx: antipyretics, analgesics, & humidity; in young children, response to β2-agonists is often used as a Dx tool for asthma. • Chronic bronchitis: May indicate underlying respiratory dysfunction. • Tx: mainly symptomatic; rest, humidification, increased fluid intake. Avoid exposure to cigarette smoke. Avoid cough suppressants unless cough interferes w/ rest; avoid antihistamines bc of drying effect. Only give antibiotics if bacterial infection confirmed w/ C&S, or if s/s support the Dx.

Burns

Burn Injuries: Ranges from a small painful area to most of the body; Infants and toddlers at greater risk; Unintentional or intentional; A leading cause of death and injury in children. -Depth of Burn Injury: • Superficial: Destruction of epidermis; physiologic function intact • Superficial partial thickness: Destruction of epidermis and some dermis • Deep partial thickness: Destruction of epidermis and dermis • Full thickness: Destruction of epidermis, dermis, and underlying tissue • Extent: TBSA; To calculate TBSA the Lund and Browder chart is used; Corrects for age of the child. • Severity: Local or systemic reaction • Calculating total body surface area (TBSA) burned in children. The standard "rule of nines" and standard body surface charts must be adapted because of the difference in body proportions between adults and children. • Therapeutic Management: • Wound cleaning: Burns should receive care at least daily until closure. Hydrotherapy - NO >20min, to prevent electrolyte loss through osmosis. • Debridement: Removal of dead material (eschar) • Protection: Application of antimicrobial agents and dressings. Burn dressings can be changed in the hydrotherapy room. The room is kept warm because children who have been burned have poor body temperature control. The child life therapist reads a book to the child to distract her from the discomfort associated with the procedure. -Pediatric Differences: Children who sustained burn injuries are at increased risk for the following • Higher mortality rate; More severe burns; Fluid & heat loss; Hypertrophic scarring; CV problems; Infection; Protein & calorie deficiency. Conditions with Sever Burns: Burn Shock • Hypovolemic (>15 - 20% of TBSA in children): All capillaries lose their capillary seal resulting in leakage into interstitial spaces; 24-48hrs. Tx: aimed at supporting until integrity is restored; fluid resuscitation. UO reflects end-organ tissue perfusion so insufficient urine indicates insufficient fluid replacement.

Case Study: Burns

CS Burns: • Admission Priorities: Establish and maintain an open airway; the burns on client's trunk can cause constriction leading to a restricted airway. Additionally, smoke inhalation is always a concern following a fire. Remember Maslow's Hierarchy of Needs: ensuring an open airway is always the highest priority nursing intervention. • Percent of BSA: 45%; According to the Rule of Nines, lower extremities are 18% each. The front trunk is 18%, with the upper torso receiving 9% and the abdomen receiving 9%. Therefore, if the abdomen (9%) and both legs (36%) are burned, the total percentage is 45%. • Client grimaces in pain as the nurse assesses his red and blistered wounds that are affecting his epidermis and dermis; Partial thickness or second degree burns. Partial thickness wounds are painful, red, and moist and are known for their blistering appearance. o A first degree is usually minor, painful, but only involves the upper laying of the skin. o Full thickness or third degree burns; Full thickness burns extend through every layer of the skin. The skin may appear leathery and stiff. o A fourth degree burn normally involves the muscle, tendon, and bone. • A client with a burn injury is at significant risk for hypovolemia from fluid loss and fluid movement from increased capillary permeability and vasodilation. The ED HCP inserts a central venous catheter via the subclavian vein and prescribes sodium lactate/Hartmann's solution (RL) at 1,000 mL/hr. Fluid volume requirements are calculated using an accepted formula such as the Parkland Formula to adequately hydrate client: The nurse administers the first half of the fluid from the time the burn occurred over 8 hours, and the second half over the following 16 hours. o The first half is given over the first 8 hours from the time the burn occurred, and the second half over the following 16 hours. • UO during fluid replacement: o 0.5 mL to 1 mL/kg (1 mL/2.2 lbs) in children weighing less than 30 kg (66 lbs) is ideal. o A child who weighs more than 30 kg (66 lbs) should produce 30 mL/kg (30 mL/2.2 lbs) to 50 mL/kg (50 mL/2.2 lbs) per hour.

Cellulitis

Cellulitis: Bacterial infection of the subcutaneous tissue and dermis. Associated w/ break in the skin, but cellulitis of head/neck can follow URT infection, OM, sinusitis, tooth abscess. Most common in LE, buccal mucosa, & periorbital region. Mostly seen in children 2 years and younger. o Complications: septic arthritis, meningitis and brain abscess; Periorbital can cause blindness. -Patho: bacteria overwhelms defense cells that normally contain inflammation to local areas; results in more extensive invasion as infection moves from superficial to deeper SQ tissue. o S/S: Red, hot, tender and indurated; H. influ.= purplish tinge to the area; Periorbital= purple color & edema of eyelids, & decreased eye movement; Lymphangitis= red streaking of area w/ enlarged nodes (lymphadenitis). Fever, malaise, headache. o Tx: Antibiotics (until the full prescription is completed) initial dose IM/IV ceftriaxone, then 10 days at home PO (cephalosporin, cloxacillin, dicloxacillin); Warm soaks several times a day; Know signs and symptoms of sepsis. -Face, joint, s/s acute febrile illness- hospitalize & IV ABs; incision & drainage of area.

Cerebral Palsy

Cerebral Palsy: chronic, nonprogressive disorder of posture & movement; one of the most common neuro-impairments in kids. Characterized by difficulty controlling muscles bc of abnormality in the motor cortex, basal ganglia, & cerebellum (extrapyramidal or pyramidal motor system). Alteration in voluntary muscle control rt cerebral insult; area of brain affected determines type of neuromuscular disability. ½ of CP kids have other disabilities—epilepsy, cognitive disabilities, learning problems, poor attention span, hyperactivity, hearing or visual impairment, & emotional problems. GERD can occur; intense movement can cause high expenditure of kCals along w/ feeding challenges, leading to kCal deficit & poor nutritional status. • Comorbidities are cognitive, hearing, speech, & visual impairments, & seizures—vary widely between cases. Intelligence may be intact but often overlooked because of the physical limitations. • 5 Classifications: o Dyskinetic (athetoid) palsy: disorder of basal ganglia; slow, writhing, uncontrolled, involuntary movements in all extremities. o Spastic CP: most common type; cortex is affected; increased DTR, hypertonia, flexion, & sometimes contractures. Muscles are very tense; any stimuli can cause sudden jerking movement; child must make conscious effort to relax. Scissors gait, hip flexion w/ adduction & internal rotation, or toe walking bc of tight heel cords may be present. o Ataxic CP: cerebellum is affected; loss of coordination, equilibrium, & kinesthetic sense; appears clumsy. o Rigid (tremor, atonic) CP: rare in kids; rigidity of flexor & extensor muscles. If tremors present, they are seen at rest & during movement. Px is poor bc of associated deformities & lack of active movement. o Mixed: more common; >1 type of CP; common combination is spastic & dyskinetic. • Factors Associated with CP: damage prenatally, perinatally or postnatally. o Prenatal: Maternal Diabetes; Rubella in 1st trimester; CMV; Toxoplasmosis; Precipitous delivery; PIH; Birth trauma; Anoxia. o Perinatal: Asphyxia; Low birth weight; Prematurity. Babies born <1000g are at highest risk due to intracerebral hemorrhage or periventricular leukomalacia—veins in brain are very thin & easily burst/hemorrhage w/ simple ADLs (diaper change). o Postnatally: Infections; Trauma; Stroke; Poisoning. Not usually Dx <2yrs of age; if <2yrs= static encephalopathy, which is permanent brain damage. • S/S rt difficulty controlling muscles: Persistence of primitive reflexes; Delayed gross motor development; Lack of progression through developmental milestones; Abnormal muscle tone; Abnormal posturing w/ inability to maintain normal posture & balance; Spasticity (uncontrollable movements) in the extremities; Gait disturbances (esp. ataxia & toe-walking); Seizures; ADD; Sensory impairment; Failure of automatic reactions (equilibrium); Speech & swallowing impairments. • Comorbidities: Cognitive impairment; Hearing and speech impairment; Visual impairment; Seizures. • Dx: EEG, CT or MRI, electrolytes, metabolic workup, thorough Hx, complete neuro-exam; genetic evaluation for kids w/ congenital malformations. Must assess for developmental disorders bc of increased incidence in CP patients. CP often not Dx before 2yrs old; if <2yrs, Dx w/ static encephalopathy= nonspecific term for permanent brain damage. • Tx: goal is early ID & intervention to max the child's abilities; requires multidisciplinary team to meet child's needs. o Repetition of Motor Activities: facilitates G&D of new brain pathways through alternative receptor sites, enhances appropriate motor function. Early on, ensure you are doing Tx that increase motor function to limit contractures. § RN: reinforce PT to strengthen & help w/ coordination of muscles; early & consistent Tx facilitates proper posture & prevents contractures. Encourage parents to be active in the child's PT/OT, empowers the parents. Observe & record the response to PT; changes can be made sooner to increase success. o Cognition: child may be intellectually intact, but this can be overlooked bc of physical limitations; appearance makes you assume they aren't aware of surroundings but this may be false. RN: Assess for delays in developmental milestones, need for learning adaptations in school. Consider the use of assistive devices; collaborate w/ school RN. o Meds: Intrathecal Baclofen- skeletal muscle relaxant, admin w/ infusion pump; Tx severe spasticity. Benzodiazepines- Tx spasticity. Botulinum Toxin A- admin IM; used w/ non-ambulatory kids, helps w/ comfort & care. RN: closely monitor for infection, pump malfunction, correct pump assembly & programing.

Coarctation of the aorta

Coarctation of the aorta: Obstructive or stenotic lesions; or lesions that decrease cardiac outflow. Narrowing of the aorta obstructs LV output, increasing afterload to LV; blood supply is decreased in the ABD organs & lower periphery; LV pressure increases; aortic pressure is high proximal to the constriction & low distal; pulmonary edema can occur. If mild, collateral blood supply ca develop to channel blood past. -Lt HF w/ low CO, poor LE perfusion, metabolic acidosis, shock. -If PDA present: R to L shunting w/ differential cyanosis (color & O2 difference between UE & LE). -Asymptomatic kids: pulse & BP difference between UE & LE (systolic HTN); weakness, tingling, cramps in LE. -Systolic murmur w/ ejection click (w/ bicuspid aortic valve) or thrill. -Assess BP in all 4 limbs in newborn; BP will be higher in arms vs legs in CoA. -Tx: admin Prostaglandin e1 infusion to open DA & improve LE perfusion. Diuretics & Dig to improve CO. -Cardiac Cath- balloon dilation w/ placement of stent for reoccurances. -OP: usually shortly after Dx; end-to-end anastomosis, prosthetic patch, Lt subclavian artery patch (post-op absent palpable Lt pulse).

Croup

Croup: Children 6mo-6yrs; often begins at night; may be preceded by several days of s/s of URT infection. Laryngotracheobronchitis most common form; Acute spasmodic croup in 1-3 yrs; bacterial tracheitis, epiglottis [unique s/s & Tx, bacterial infection]. • S/S: Sudden onset of harsh, metallic, barky (seal-like) cough & varying degrees of resp. distress; sore throat; inspiratory stridor; hoarseness; use of accessory muscles to breathe; frightened appearance, agitation, cyanosis. • RN: must stay calm around the child & help them remain calm; crying increases the obstruction. Increased PO fluids when no resp. distress present; cool, humid night air can soothe mucosal swelling; dexamethasone for mild croup or INH budesonide to decrease airway inflammation. Management of Croup: • Use calm approach; crying aggravates the dz & makes it sound worse. • Assess respiratory status & O2 sat; cap refill • Increased oral fluids; may be needed if they had an URT infection & decreased intake, they may be dehydrated. • Cool humidity is soothing; night air or shower steam; cool is best. • Racemic epi. neb Tx if severe; stay in hospital until Tx is effective, they are maintaining their O2sats for 3hrs. Hospitalization is rare. • Teach to avoid large groups & have good health habits.

Cystic Fibrosis

Cystic Fibrosis: an inherited multisystem disorder characterized by widespread dysfunction of the exocrine glands; CTFR mutated gene encodes a defective Cl channel in epithelial cells. Deadly genetic disease, predominantly found in whites; survival age is 40yrs—dz of children & young adults. Ends in CHF or RF/death; no cure just management. - Adults: as the female grows, thick cervical mucous can make it difficult to become pregnant—but don't use this as a method of birth control. Increased incidence of fetal loss, preterm birth, neonatal mortality. 95% of males w/ dz have sterility (lack of sperm). - Peds: Meconium ileus in the neonate is the earliest clinical manifestation. If child progresses beyond infancy w/o being Dx, parents complain the child taste salty. • Dx: Pilocarpine iontophoresis/Sweat test is just 1 Dx procedure; measures the Na & Cl in sweat—simple, painless, & reliable if infant it >2wks old. 50mg of sweat is required; Cl >60mEq/L Dx for CF; Cl 40-60mEq/L suggests CF & requires a repeat test. • Manifestations: • Respiratory: Wheezing, dry, non-productive cough (earliest pulmonary s/s); thick sticky secretions obstruct small & large airways; Repeated bouts of respiratory infections; Respiratory symptoms progress to emphysema and atelectasis, as the airway obstruction increases; Cor pulmonale & CHF result from fibrotic lung changes in the later stages; Spontaneous pneumothorax or hemoptysis in late stages; Nasal polyps, sinusitis; Digital clubbing can be an indication of hypoxia—normal nail is curved, w/ firm base & 160 degree angle; Barrel chest (increased anteroposterior diameter). o Digital clubbing = hypoxia from resp. disorders or CF: normal nail is curved, w/ firm base & 160-degree angle; early clubbing shows a springy sensation of nail on palpation & a reduced angle; late clubbing shows matchstick appearance, springy base, swelling of the base, loss of angle, rounding & enlargement. • Digestive: Steatorrhea - frothy foul-smelling stools; Malnutrition & growth failure, usually small size—caused by an inability to absorb fats & fat soluble Vit A, D, E, & K. • Exocrine Glands: High concentrations of Na and Cl in sweat—leads to +Dx w/ sweat test & the salty taste; Electrolyte imbalance—hyponatremia, hypochloremia, dehydration (esp. in hot weather); Dry mouth & susceptible to infection. • Reproduction: Average 2-yr delay in secondary sex characteristics; Difficulty becoming pregnant; Lack of sperm in males. • Therapeutic Management: Maintaining a patent airway; Admin bronchodilators (Albuterol) & nebulizer Tx (O2); Performing, teaching, or supervising respiratory Tx; Admin intermittent or continuous antibiotics & life-long pancreatic enzymes (starch & heat inactivate it, acid & protein also avoided; mix w/ apple sauce, pudding); Increased exercise tolerances; Teaching the child and family about cystic fibrosis & its Tx; Preventing & Tx pulmonary infections, maintain optimal nutrition status, & promoting psychological adjustment [refer to CF support groups]. o ACT: Airway Clearance Techniques, which are segmental percussion & postural drainage; preceded by INH Tx, done several x/day to loosen secretions & move them from peripheral to central airway for expectoration. o Flutter device: same device used w/ asthma patients.

Differences in the Child's Respiratory System

Differences in the Child's Respiratory System: • Lack of or insufficient surfactant in premature; infant <37wks gestation, higher risk of RDS. Surfactant (ex. Curisurf) can be replaced directly w/ ET tube into the lungs; weight-based dose, greatly improves resp. system. • Smaller lower airways & undeveloped supporting cartilage—predisposed risk of obstruction by mucus, edema, & foreign body. Neonate airway is 50% smaller than an adult. Premature have a more compliant chest wall & weaker resp. muscles than term. • Obligatory nose breather (infant); difficulty breathing through mouth. If infant has nasal congestion, breathing is more difficult. • Less developed intercostal muscles in infants; diaphragm is their major resp. muscle. Retractions more common in infant than older kids or adults. • Brief periods of apnea common (newborn); 10-15sec; resp. pattern may be irregular, RR irregular—why we do the RR assessment for a full 1min. • Children's normal RR is higher than an adult; increased RR = increased metabolic needs; lung size is proportional to body height—thus lung vL & capacities do not vary from age to age, they vary w/ height. • Alveolar development is gradual; 20mil to 200mil by 3yrs old; gradually decreases after 3yrs old, few develop after 8yrs old. • Lung surface increases till 5-8yrs old; actual lung growth continues into teen yrs. • Eustachian tubes relatively horizontal; increases risk of bacterial entering in the middle ear—ex. acute otitis media. • Tracheal size triples by adulthood. • Tonsillar tissue is normally enlargemed in early school-age kids—why they have problems w/ tonsilitis. • Child's flexible larynx is more susceptible to spasm. • Infants & children are ABD breathers (use ABD muscles for inhale) until 5-6yrs old; assess RR by placing hand on ABD.

Digoxin/Lanoxin

Digoxin/Lanoxin: cardiac glycoside; slows the HR & Tx HF; helps the heart pump more effectively (increases CO by increasing strength of contractions), improves circulation, & promotes normal elimination of excess fluid. Baseline ECG before admin; admin loading (digitalizing) dose over 12-18hrs--first 3-5 days, monitor ECG to ID toxicity, levels can be inaccurate at this time. o Prior to admin dose: obtain the client's apical pulse to determine if it is within the guidelines of the written prescription. It is important to 1st check the prescription for a withholding pulse rate because the drug is not given if the apical pulse <90-110 beats/min in infants. It is important to know the baseline heart rates for different age groups. o Digoxin is administered in very low doses such as 0.625 mg or 1.25 mg; admin 2x/day for several mo-yrs. o Therapeutic levels range from 0.8 to 2ng/mL. Observe for signs of toxicity, especially bradycardia and vomiting. Give the child the medication at the scheduled times; the medication should always be verified and given at the appropriate times to maintain therapeutic blood levels. o Frequent vomiting, poor feeding, or slow heart rate can be signs of digoxin toxicity; if they occur, contact the physician. Hypomagnesmia & hypokalemia can increase risk fo toxicity. Dose should be decreased if altered renal function present. o Client will need to have blood drawn Q6mo while taking the med. Instruct the parents to give a regular dose of medication at least 6 hours prior to the test. Levels are obtained to determine medication compliance and assess for toxicity. The effectiveness of the medication is determined by the client's signs/symptoms. A falsely elevated level will be obtained if there is not a min. of 6hrs between the last dose of digoxin and blood collection. o Admin 20-30min before feeding. Give digoxin at regular intervals, usually every 12 hours, such as at 8 AM and 8 PM; adjust to meet your scheduling needs w/ in ordered intervals. Measure w/ syringe, NOT dropper; admin few drops in child's mouth, let them swallow, then admin more. --If you forget a dose, admin when your remember, then resume normal schedule. If they vomit, don't admin more, just wait till next dose. Miss/vomit 2 doses in a row, call the cardiologist. Keep in a place out of reach of kids; accidental dosing, call poison control or take person & Dig to ED. Get refills 1wk before you run out; ask for new prescription PRN.

Dx & Tx increased ICP

Dx & Tx increased ICP: • Dx: CT, MRI, lumbar puncture, serum & urine electrolytes, ABGs, CBC, EEG, radiography. Normal ABGs: w/ normal ICP O2 >80, CO2 <45. o Lumbar Puncture: if child is old enough explain the process, show them on a doll. Position them on their side w/ body bent, knees & chin touching; help them hold position be hugging knees to chin. Allow the child to practice if time permits. The infant will be in a side-lying or sitting position; they will face you &your thumbs will be across their scapulae, steady their head against your body. HCP will wash back w/ "cool liquid", after they might feel a pinch/sting as needle is inserted; use a topical anesthetic whenever possible. The child MUST remain still. Encourage the child to relax, sing, take DB, use guided imagery (decrease anxiety). The collection of CSF & pressure measurements takes several minutes. Child will feel light pressure as needle is withdrawn, & the application of a dressing. § RN: monitor cardiorespiratory status throughout procedure. Maintain child's position w/ shoulders & hips aligned to prevent spinal rotation. Help the parents comfort the child during/after. Positioning: child is in a side-lying knee to chin posture; place one hand under the child's neck, w/ your forearm behind their head, supporting the neck. Other arm is under their upper thighs, curl their body by bringing knees to head. RN supports her own weight on the edge of the table, lean slightly over the child & control their legs & arms. Position limits your direct visibility of their resp. status, so a cardiorespiratory monitor MUST be worn. • Tx: the underlying cause, reduce vL of CSF, preserve cerebral metabolic function, avoid situations that increase ICP. o Elevate HOB 30 degrees w/ midline head position; maintain normothermia. May be given an osmotic diuretic (mannitol) or hypertonic saline, sedation & analgesia, & anticonvulsants. Monitor BS closely to maintain normal levels & prevent further increases in metabolic demands. IV NS bolus are given for hypovolemia. Hyperventilation used if there are s/s of cerebral herniation. Corticosteroids are NOT used to Tx increased ICP bc of TBIs. o Intraventricular catheter: measure ICP, drain CSF, &/or admin meds; placed in the lateral ventricular or subarachnoid space; measure pressure, drain excess fluid into bag. Manometer & drainage bag are part of a sterile, closed system. o Subarachnoid Bolt: end of bolt placed in the subarachnoid space; top of bolt attached to a transducer to conduct a waveform to the monitor. Neurosurgeon adjusts the transducer to produce a waveform on the monitor.

Epiglottitis (Supraglottitis)

Epiglottitis (Supraglottitis): severe form of pharyngitis; emergency medical situation. Usually bacterial - H. influenzae. • Cardinal s/s: Drooling, Dysphagia (difficulty swallowing), Dysphonia (difficulty talking), Distressed respiratory efforts. Abrupt onset & rapid progression—complete obstruction w/in few hrs; child was well when put to bed & woke w/ sore throat & difficulty swallowing. Epiglottis looks cherry red & edematous; high fever of 39-40C (102.2-104F); appears toxic & very ill; anxious & frightened, irritable or lethargic; classic s/s insistent on sitting in tripod position, w/ chin thrust out & open mouth; nasal flaring, retractions, pale to cyanotic color, tachycardia. • DO NOT: Leave child unattended if epiglottitis is suspected. Examine or attempt to obtain culture; any stimulation by tongue depressor or culture swab could trigger complete airway obstruction. • Tx: • Have emergency equipment available at the bedside; intubation tray & suction tray. • Achieve a patent airway (usually intubation); all other tests can wait until airway is obtained & stabilized; don't do anything that will increase the child's stress. If in mild distress, you may be able to do an x-ray. • A sudden decreased respiratory effort (slowing RR) is a sign of exhaustion and impending cardiorespiratory arrest. • Never force the child to lie down; usually sitting in tripod position, let them sit however is most comfortable for them. • Humidified O2 in high concentrations. • Progresses rapidly; parents and child have high anxiety levels. Provide support, once stable reassure parents that it rarely reoccurs & won't happen every time the child gets sick.

Epstein-Barr (Infectious Mono)

Epstein-Barr (Infectious Mono): EBV is a herpes-like virus; double stranded DNA can occur in any season. Incubation = 4-7wks; Infectious = unknown but commonly shed before onset of dz untl 6mo—then intermittently for life, asymptomatic carriers are common. Transmission = saliva, blood, intimate contact; Immunity = natural dz. • Typically occurs in healthy individuals, usually older children & young adults, highest in 15-19yr old kids. Acute illness lasts 2-4wks, followed by a gradual recovery. Can remain dormant after infection & recur during times of suppressed immunity. Px usually excellent if no complications occur. • S/S: fever, exudative pharyngitis, lymphadenopathy (cervical, axial, inguinal), & hepatosplenomegaly. Ranges from asymptomatic & mild to severe & fatal. Some develop a maculopapular rash, esp. after Tx w/ aminopenicillin antibiotics (ampicillin or amoxicillin). Children may report malaise, fever, headache, fatigue, nausea, & ABD pain. o Teens: parents may not notice s/s of fatigue & report of 'not feeling well'—may misinterpret as normal teen behavior. Once Dx, parents may be frustrated w/ long recovery period & assume their teen is just 'lazy'. RNs must educate them that this is a very long recovery period, & to be patient w/ their teen. • Dx: Mono Spot test done in hospital setting, may check liver enzymes or do a CMV test—CMV can mimic Mono. • Tx: generally self-limiting; address complications w/ medical Tx. Steroids for acute tonsillar swelling & other inflammation s/s. Avoid contact sports & strenuous activity during acute illness & for >1mo, or as long as the spleen is enlarged to avoid rupture; prolonged rest is needed, need parents support because of the lengthy recovery period; homebound school. o Rest, throat soothing measures, acetaminophen or ibuprofen, low energy impact activity that is gradually increased.

5th disease (Erythema Infectiosum, Parvovirus B19)

Fifth's Disease: AKA Erythema Infectiosum, Parvovirus B19; late winter & early spring; Incubation = 4-17 days, up to 28 days; Infectious = shedding of virus between days 5-12 of the infection—usually from prodromal until rash is seen; Transmission = airborne particles, respiratory droplets, blood/products, transplacental. Immunity = natural dz may provide antibodies. • S/S: Most common in children 5-15yrs but can occur in adults, relatively mild systemic dz—child appears well but w/ fiery red, edematous rash on cheeks, "slapped cheeks"; or may have a Hx of a rash that "comes & goes". Before rash, children are asymptomatic w/ non-specific s/s headache, runny nose, malaise, mild fever. Then 1-4 days after facial rash, an erythematous, maculopapular rash appears on trunk & extremities; fades w/ central clearing causing a lacy appearance; rash lasts 2-39 days but can be aggravated by environmental factors like heat, exercise, warm baths, rubbing of skin, & stress. • Complications: Watch around pregnant women, risk for intrauterine infection; notify potential exposed pregnant women—she should call HCP & have serial US done by OBP. SCD & beta-thalassemia patients at risk for anemia & aplastic crisis. Poor immune system also at risk of anemia. • Tx: Benign and self-limiting, so Tx is supportive & symptomatic.

Foreign Body Aspiration

Foreign Body Aspiration: Seen most frequently in children 6mo-5yrs. Children's curiosity, oral needs, & lack of supervision all contribute to FBA. Latex balloons contribute to a significant number of deaths; balloon pops & kid is startled, so they inhale & a piece goes into lungs—death or brain damage may result. • S/S: sudden violent coughing, gagging, wheezing, vomiting, brief episodes of apnea, possibly cyanosis. • Most foreign bodies become lodged in the bronchi (right); can be removed mechanically or surgically; watch for edema after removal & ensure patent airway. - Tx: Heimlich for baby >1yr; <1yr perform back & chest thrusts till it comes out; code= CPR. Direct laryngoscopy or bronchoscopy; remain in hospital post-op for assess for laryngeal edema & resp. distress. Cool mist & admin of bronchodilators or corticosteroids for 24-48hrs after OP. - Post-Op: Liquids are held until gag reflex returns from anesthesia. Parents have anxiety & guilt about their child swallowing the foreign body. Teach parents preventative measures for aspiration. -Preventative measures are very important to teach; done at every well-child visit. Avoid common items: latex balloons, coins, seeds, grapes, nuts, pins, bones, earrings, small toys, chunks of food, toy parts, hard candy, popcorn, hotdogs, carrots.

Griseofulvin

Griseofulvin is an anti-fungal medicine that is used to treat infections such as ringworm, athlete's foot, jock itch, and fungal infections of the scalp, fingernails, or toenails. -Tinea Capitis: med must penetrate the hair follicles; topical alone won't work. PO Griseofulvin admin daily for 6wks+= Tx of choice. Its insoluble in H20; absorption increased if taken w/ high fat meal or milk. -Tinea Pedis: Tx first w/ topicals; if non-responsive, then use PO Griseofulvin for 1mo+, to promote healing. --Take PO meds as ordered; stopping too soon can allow infection to reappear. Call HCP if condition doesn't improve w/in 4wks or if it keeps spreading after 1wk of Tx.

Guillian Barre' Syndrome

Guillain-Barré Syndrome: GBS is an autoimmune neurologic disorder of the PNS characterized by rapidly progressing limb weakness & loss of DTRs; rarely, motor & CNs can be affected. S/S result from acute demyelinization of the nerves. ½ of cases illness originates as an URT or GI viral infection 2-4wks prior; May originate as a viral infection—rubella, enterovirus, Epstein-Barr, CMV, mycoplasma, varicella; most commonly Campylobacter jejuni. Can also be a toxic response to the flu vax. Can affect any age; average of 5yrs old; more often in boys. • Patho: infiltration of lymphocytes into peripheral nerves, causing inflammation. Initially myelin sheath becomes edematous, further inflammation causes segmental demyelinization—occurs along the membrane surrounding the Schwann cells. Inflammation continues casing increased myelin loss & results in axonal degradation. • S/S: Limb paresthesia and/or pain; causing numbness, tingling, weakness of LE w/ ascending loss of DTR, leading to flaccid paralysis. Autonomic instability; BP fluctuations, cardiac arrhythmias, postural hypotension, & incontinence (UO, BM). CN dysfunction; facial nerve paralysis, dysphagia, & inadequate cough, gag, swallow reflexes (resp. function impaired). Respiratory failure; results from the progressive motor paralysis of the intercostal & phrenic nerves, major cause of death. Neuromuscular impairment; bilateral ascending weakness or paralysis, usually progresses upward from feet to head. As healing occurs, neuromuscular function gradually returns in reverse order (head to feet). • Dx: bilateral ascending weakness or paralysis occurring 2-4wks after URT or GI infection; paralysis can quickly affect resp. muscles—s/s of resp. distress need prompt elective intubation. CSF has high protein levels. Nerve conduction studies, LP, MRI can confirm Dx. • Tx: spontaneous recovery in 2-3wks w/ full regain of strength; most regain full muscular strength. Kids w/ rapid paralysis Tx w/ high-dose IV Immune globulin (IVIG) for several days; some may benefit from a 2nd course. Failure to recover w/ IVIG, Tx w/ plasmapheresis. Med-management is supportive; focus on neuro, resp., CV systems. Resp. support is critical bc most deaths attributed to resp. failure.

CHF in children

Heart Failure: Reasons for the cause in kids are different than adults, congenital defect; could also be due to metabolic disorders, drugs or toxins during fetal G&D. Kids have respiratory related s/s. • Manifestations: Difficulty feeding (sweat on head), poor weight gain; Mild tachypnea, SOB, grunting, tachycardia; Cardiomegaly; Galloping rhythm; Poor perfusion, edema; Liver and spleen enlargement; Mottling, cyanosis, pallor. • Therapeutic Management: correct underlying problem as soon as possible. o Medical Management: § Decrease workload/improve output § O2 (caution with left to right shunting); increases O2sat but is also a vasodilator & can increase pulmonary BF. § Inotropes (digoxin), diuretics, ACE inhibitors § Good nutritional intake to meet metabolic demands § Digoxin - cardiac glycoside; strengthens the force of myocardial contractions; increases CO & cardiac effectiveness. Slows the HR—so check HR before admin & know normal ranges for that age. Check serum levels as ordered by HCP. Can admin PO or IV. Watch for hypokalemia & hypomagnesemia—can indicate digoxin toxicity. o Diuretic - furosemide (loop diuretic); eliminates excess H2O & Na through urine; reduces pulmonary congestion. Preferred drug for initial diuretic Tx. o Additional meds: vasodilators- hydralazine, captopril, enalapril—relax vascular smooth muscle & reduce afterload. • Feeding the Infant w/ HF: o Feed the infant or child in a relaxed environment; frequent, small feedings may be less tiring. o Hold the infant in an upright position. This may provide less stomach compression and improve respiratory effort. o If the child is unable to consume appropriate amount during 30-minute feeding every 3 hours, consider nasogastric feeding. Feeding <30min & cluster care to conserve energy. o Monitor for increased tachypnea, diaphoresis, or feeding intolerance (vomiting). When tachypneic don't feed PO bc risk of aspiration. o Consider nutritional needs of the infant, normal formula is 20kcal/oz; concentrating formula to 30 kcal/oz may increase caloric intake w/o increasing vL & infant's work. • Educating Parents: some babies will be D/C home & have to wait until they are older/bigger in order to get an OP. Teach the s/s of HF; Increased cyanosis, Dehydration, Infection, Dysrhythmias - feeling pulses for change in rhythm (irregular, galloping), Decreased nutritional intake.

Herpes infection

Herpes infection: HSV 1= Herpes Labialis- cold sore or corneal lesions; HSV 2= anal-genital area, rare before 14yrs assess for sexual abuse. HSV 1 & 2 can affect any area of the body. In neonate, transmit through birth canal in infected mom; RN can transfer w/ improper hand hygiene. Children w/ break in skin or immunosuppression are susceptible. -HSV 1: virus is alive but dormant; stress, trauma, fever, sun exposure, period, immunosuppression can reactivate it. Regardless of s/s being present, it is just as contagious when active. Recurrent infections are usually less severe. Infection in neonate or immunocomp. can be fatal; common cause of viral encephalitis in kids. -Tx: symptomatic, no cure; HSV 1 Tx at home, if dehydrated then Tx in hospital w/ IV fluids. Topical or PO acyclovir (Zovirax) if given early can reduce recover time; also given to immunocomp. kids, neonates, & kids w/ encephalitis to reduce severity of infection. AB ointment for secondary infections. Steroids NOT used bc worsen dz. Acetaminophen for pain, w/ or w/o codeine; topical anesthetics can be used. PO rinse Benadryl, kaopectate, lidocaine can decrease pain & help them eat. Topical anesthetics (lidocaine) used w/ caution bc depresses gag reflex in small children (aspiration). -Intake: Frequent small feedings of soft, bland food; ensure fluid intake w/ popsicles, non-citrus juice, milk, non-carbonated drinks or flattened drinks

Hydrocephalus

Hydrocephalus: can be acquired, congenital, or unknown etiology; develops as the result of an imbalance of production & absorption of CSF. As CSF accumulates in the ventricular system, ventricles dilate & brain compresses against the skull; open sutures= enlarged skull, fused sutures= s/s of increased ICP. Most often congenital (developmental deficits), caused by Arnold-Chiari malformations, arachnoid cysts, tumors, or aqueductal stenosis; hydrocephalus is often associated w/ Myelomeningocele. o Infancy - congenital or rt prematurity, intrauterine infection, or perinatal hemorrhage. Premature- neonatal meningitis or subarachnoid hemorrhage. o Older children - usually acquired, due to complication of meningitis, tumor, or hemorrhage. o Obstructive (noncommunicating): accounts for nearly all cases in children. o Communicating: in the premature infant, usually due to subarachnoid hemorrhage. o S/S: rt increased ICP; enlarged ventricles & ICP; head circumference abnormally large. § Infant: Rapid head growth; Bulging anterior fontanel; Irritability, poor feeding; Distended scalp veins, wide sutures. · Late signs: Setting-sun sign; Bossing of frontal bone; Vomiting; BP increase, Decrease HR; Sluggish pupillary response. § Child: Strabismus; Frontal headache in a.m. relieved by vomiting; Diplopia; Ataxia; Irritability; Sluggish pupils; Confusion; Lethargy. · Late signs: Seizures; BP increase, HR decrease; Blindness; Posturing. § BP increase, HR decrease: s/s of increased ICP; consistent in all patients, regardless of age. o Tx: prevent further CSF accumulation & reduce disability & death. Ventriculoperitoneal (VP) shunt- tube leading from ventricles out of the skull & passing under skin to the peritoneal cavity, drains the CSF where it can be reabsorbed. Ventriculoatrial shunt- alternative for older kids, drains fluid from ventricles to RA of the heart. Shunt infection or malformation can occur; must monitor closely, esp. for fever; antibiotic coated shunts are decreasing rates of infection. Shunt may need to be revised as child grows, LT follow-up is essential. RN: monitor for infection, obstruction, & pain; admin antibiotics & pain meds as ordered; teach family how to change dressings, & how to ID shunt blockages & other problems.

Impetigo

Impetigo: bacterial; often occurs as a secondary infection from another skin lesion, ex. insect bite. Begins in an area of broken skin (bite, scabies, atopic dermatitis). Highly contagious, spread by close contact (daycare, school, camp, teen athletes at increased risk). Incubation= 7-10days, can spread to other parts of skin or others who touch it, use the same towel, or drink from same glass. Spread fostered by poor hygiene, crowded living, hot/humid environment. -S/S: Lesions are usually located around the mouth & nose but may be located on the extremities (or anywhere). Resolve in 12-14 days w/ Tx. Inflammation results in pustular lesion; honey colored fluid from lesions becomes crusted. Infected nasal discharge can erode skin above the upper lip, allowing for its entry. -Bullous: small vesicles progress to bullae; filled w/ serous fluid that becomes pustular. Rapidly rupture, leaving shiny lacquered lesions surrounded by a scaly rim. -Crusted: vesicle or pustule that ruptures into an erosion w/ overlay of honey-colored crust; bleed easily when crust is removed; mildly pruritic. Scaring can occur if child picks or scratches. Post-inflammatory hyperpigmentation can occur in dark-skinned kids. -Dx: by s/s; failure to respond to Tx= MRSA. C&S is obtained from beneath the crust or from fluid inside the lesion. Caring for a Child with Impetigo: • Can be spread merely by touching another part of the skin after scratching infected areas. • Keep the child's fingernails short, and wash the child's hands frequently with antibacterial soap. • Emphasize good hand washing and careful hygiene for the entire household. • Discourage family members from sharing towels, combs, or eating utensils with the infected child. • Often occurs as a secondary infection from another skin lesion. Highly contagious. Incubation period is 7 to 10 days. Spread poor hygiene, crowded living conditions, and a hot, humid environment. Resolve in 12 to 14 days with treatment. Topical and oral antibiotics. Bactroban or Bacitracin for 7 - 10 days. If severe, IV antibiotics.

Increased ICP

Increased ICP: reflects pressure exerted by the blood, brain, CSF, fluid, or mass. Results from a disturbance in autoregulation; defined as a pressure sustained at >20mmHg for >5min. • Causes: brain Tumor, hematoma; brain swelling from trauma, infection, hypoxic episode; overproduction of fluid, malabsorption of fluid; communication problem w/in the system disrupting CSF dynamics; brain aneurysms, acute liver failure. • Patho: increased ICP results from alterations in the brain, CSF dynamics, & CBF. To maintain CPP & vl w/in normal range, changes in 1+ contents of cranium must be compensated by changes in the others—Monro-Kellie Doctrine. o Compensatory Mechanisms: reduction in CSF production, increase in CSF absorption, reduction in cerebral mass as result of fluid displacement; once these limits are reached any increase in pressure or vL will cause a sudden increase in ICP & decline in clinical status. Ultimately increased ICP will compromise cerebral perfusion & produce shifting of brain tissue, causing herniation. Consequences of herniation depend on severity & location. o Infants can compensate somewhat bc of open cranial sutures; craniosynostosis is premature closure of sutures, abnormal skull G&D results in abnormal shape of skull—craniectomy needed to manage the increased ICP. • Manifestations: dependent on developmental age; confusion & altered MS/LOC. • S/S Infant: poor feeding or vomiting; irritability, restlessness, or lethargy; bulging fontanel; high-pitched cry; increased head circumference; separation of cranial sutures; distended scalp veins; eyes deviated downward ("setting sun" sign: see whites of eyes above iris); increased or decreased response to pain. • S/S Child: headache; diplopia; mood swings; slurred speech; papilledema (edema of optic disk; after 48hrs); altered LOC; N/V (esp. in the morning). o LOC: assess w/ modified GCS; 15= no change, <8= aggressive management & monitor ICP, 3= deep coma. o Behavior: changes may be an early s/s of increased ICP; parents are 1st to notice change in normal behavior, take their observations seriously; further assess irritability, mild confusion, & agitation. S/S of deterioration- child doesn't recognize parents, can't follow commands, minimal response to pain. Decreased responsiveness to pain is a significant s/s of alteration in LOC. o Pupils: as ICP rises, 3rd CN is compressed, causing pupil dilation w/ sluggish or absent constriction in response to light. Transtentorial Herniation- herniation of center section of brain; s/s fixed dilated pupil ominous sign in an unconscious child. o Motor Function: purposeful movement decreases & abnormal posturing may be seen. § Flexion/decorticate posturing: flexion of the UE (elbows, wrists), extension of the LE, w/ possible plantar flexion of the feet. Implies injury to the cerebral hemispheres. § Extension/decerebrate posturing: extension of the UE w/ internal rotation of the upper arm & wrist, LE extend w/ some internal rotation at the knees & feet. Indicated damage to more areas f the brain, like the diencephalon, midbrain, or pons. § Progression from flexion to extension: indicates deteriorating neuro function, must report to HCP. § Flaccid Paralysis: further deterioration of the child's condition. o VS: temp. elevation may occur. § Cushing's response: increased systolic BP w/ widening PP, bradycardia, & change in RR & pattern (development of apnea); indicates alteration in brainstem perfusion, body is attempting to improve CBF by increasing BP; the response is a late s/s of increased ICP in kids; occurs at or just before brainstem herniation. § Cheyene-Stokes respirations: increasing RR & depth, then decreasing RR & depth w/ a pause of variable length; cycle keeps repeating. § Central Neurogenic Hyperventilation: rapid RR despite normal ABG values; usually indicates midbrain or pontine involvement. § Apneustic Breathing: prolonged inspiration & expiration. § Late S/S: tachycardia that leads to bradycardia, apnea, systolic HTN, widening PP, & flexion or extension posturing.

Endocarditis

Infective Endocarditis: IE occurs most commonly in the presence of CHD; inflammation resulting from infection of the cardiac valves and endocardium—bacteria, fungus, or viral agent; infection can result from poor hygiene or an invasive procedure of the RT. Most common organisms are Streptococcus and Staphylococcus aureus. Prevention is the most important therapeutic intervention. • Manifests: non-specific complaints, fever, anorexia, nausea, fatigue, malaise, arthralgias, chest pain, progress to HF, petechia, neuro-impairment from embolic events, presence of/or change in murmur (present in CHD, so detect the change in quality). • Prophylaxis for IE: admin antibiotics (amoxicillin) 1hr before procedure. Maintain optimal dental hygiene to decrease periodontal infections; go to the dentist frequently for dental procedures, including cleaning; risk- may induce gingival or mucosal bleeding offering a port of entry for infection. Invasive RT OP- Tonsillectomy and/or adenoidectomy or biopsy. Surgery and/or biopsy involving RT or GI mucosa- admin antibiotics for RT OP; GI or GU OP if infection present. Amoxicillin given PO 1hr prior to the procedure is the recommended prophylaxis.

MMR

MMR vaccine: is an immunization vaccine against measles, mumps, and rubella. It is a mixture of live attenuated viruses of the three diseases, administered via injection. -2 doses needed for full protection; 1st at 1yr old; 2nd at 4-6yrs but can be admin at any visit if its >4wks since the 1st dose & both doses are admin at or after 1yr old. Kids who havent received 2nd dose, should get it at or before 6yrs old. -Combined MMR+Varicella: slight increased risk of fever & febrile seizures 7-10 days after vax in kids 12mo-24mo; compared to the separate MMR & varicella vax.

Methicillin-Resistant Staphylococcus aureus

MRSA: contact transmission; Hospital Acquired—ventilated pneumonia, catheter related bloodstream infections (CLABSI); all admissions tested for MRSA via nasal swab. Community Acquired—more often the case today, from skin & soft tissue infections, UTIs. CA-MRSA most common infections through skin & soft tissue, less often from UTIs, pneumonia, & bacteremia. • Complications: osteomyelitis, endocarditis, necrotizing fasciitis. • Risk factors [community acquired]: Hx of chronic illness, immunocompromised status, close-contact team sport, daycare settings. • Tx: difficult to treat, hence "resistant"; Vancomycin, Clindamycin, peaks/troughs; Bactroban/Mupirocen (intranasal) used; contact precautions.

Major changes in the circulatory system occur at birth after the first breath; CHD & the underlying mechanisms/defects.

Major changes in the circulatory system occur at birth after the first breath: Gas exchange is transferred from the placenta to the lungs; Fetal shunts close; Resistance to flow in the pulmonary system decreases as systematic resistance increases; Pulmonary vascular resistance decreases; Marked increase in pulmonary blood flow follows. Gas exchange occurs in the lungs, blood pumped back to the heart & towards the rest of the body. • Left-to-right shunting lesions; increase pulmonary BF. A shunt is when there is an abnormal opening or connection between the cardiac chambers or great arteries; shunts are open in the fetus but should close in the neonate. Pressure is higher on one side of the heart, & an increase in O2sat in blood where there should be decreased O2; mixing of blood occurs. Volume overload in the Rt-side of the heart & pulmonary artery, cardiac workload increases—can lead to heart failure, pulmonary vascular disease, & pulmonary hypertension. Ex. ASD, VSD, PDA, AVSD. • Obstructive or stenotic lesions; or lesions that decrease cardiac outflow. Stenosis - narrowing or constricting of an opening in a vessel or a valve; pressure rises behind the obstruction. If on Lt-side of heart, decreases amount of blood for systemic perfusion. Leads to increased cardiac workload, ventricular strain - eventually may cause HF, decreased CO & pump failure. Ex. Pulmonary Stenosis, Aortic Stenosis, CoA. • Cyanotic lesions with decreased pulmonary BF: an error in fetal development; hypoplasia (incomplete development) on the right side of the heart; decreases BF to the lungs—may need PDA to stay open, admin PGE; hypoxemia w/ cyanosis—even w/ supplemental O2, does not always help saturations. Limited pulmonary BF & marked exercise intolerance; w/ babies when you move them or when they cry. Chronic hypoxia leads to polycythemia. Ex. Tetralogy of Fallot, Tricuspid valve anomalies, Pulmonary Atresia w/ intact ventricular septum. • Cyanotic lesions with increased pulmonary BF: Fail to develop separate pulmonary & systemic circulations during fetal growth- cyanosis occurs (mixed lesions- desaturated & saturated blood); Increased cardiac workload, decreased CO; Cardiogenic shock S/S increased respiratory effort; dusky or gray. Ex. Truncus arteriosus, Hypoplastic left heart syndrome, Transposition of the great arteries.

Mantoux test

Mantoux test: initial method of testing & screening for TB; performed on kids w/ known risk factors. Skin test will be + 2-10wks after initial infection; once +, reactivity continues for life, even w/ Tx. -Skin text w/ 5 tuberculin units of purified protein derivative (PPD); admin intratermal into forearm. Read 48-72hrs later. - >15mm induration in child >4yrs= +TB, regardless of risk factors. ->10mm induration if risk factors present= +TB; immigrant (<5yrs) in country w/ high rates, IV drug user, in high-congregate setting, mycobacteriology lab personel, w/ high-risk clinical condition, <4yrs old, child exposed to adults in high-risk categories. - >5mm induration in child <4yrs or w/ risk factors= +TB; for kids w/ HIV, recent contact w/ TB, fibrotic changes on CXR, & immunosuppressed (>15mg/day prednisone for 1mo+; taking tumor necrosis factor-A antagonists) -Negative TB test does NOT rule out TB, esp. in infants.

Scoliosis & Spinal fusion

Musculoskeletal Developmental Disorders: • Scoliosis: lateral deviation or curvature of the spine, >10-degrees; the vertebrae rotate pulling the ribs along. Measured w/ Cobb angle. -Requires LT Tx including the following: • Splinting; Traction; Bracing; Casting; Surgery; A combination of any of these. -Curve <25: observation. -Curve 25+: custom made braces w/ pads. -Curve 40-50: posterior down the length of the spine to be fused. -Spinal Fusion: implants (hook, screw) places in/on the vertebral body; implants then attached to2 rods that correct the deformity. To achieve solid fusion of the corrected curvature, additional bone is needed to graft the fixed portion of the spine.

NIX

NIX: OTC pediculocide (Tx pediculosis), permethrine 1%; kills head lice, pubic lice, & eggs w/ 1 application & has residual activity for 10 days (stays in hair after application). -Tx: apply Nix creme rinse to hair after shampooing; apply to pubic hair as a lotion. Rinse out after 10min. Do NOT shampoo hair after Tx for 24hrs. Kill rate is high & it has residual action, but still Tx hair after 7-9 days.

Neonatal Sepsis

Neonatal Sepsis: Bacteria in bloodstream; serious bacterial illness in neonates, can occur in infants >3mo old too. Bacteria or their endotoxins gain access to the bloodstream & cause systemic s/s. • Systemic s/s: primary s/s is fever, Temperature 100.4 (38 C) or higher up to 3 months of age; low temp. can also be a s/s, esp. if in the hospital. Manifestations are vague, nonspecific, "just not right". Respiratory distress could be early sign as well. • Dx: "Septic workup"; based on hx, s/s assessment, & labs—cultures (blood, urine, CSF-if indicated or w/ +blood culture, nasopharyngeal), CBC (I:T for infection) w/ differential (determines left shift), CRP- C Reactive Protein (elevated w/ inflammation or stress of birth, few days old+ should be normal). • Tx: Antibiotics started as soon as cultures done; usually Amp & Gent until pathogen/sensitivity is done. o Monitoring Gent: peaks & troughs; Gent is an aminoglycocide, its ototoxic & nephrotoxic. o RN Dx: are risk for injury rt effect of sepsis on all body systems; ineffective thermoregulation r/t stress of infection; imbalanced nutrition, less than body requirements rt lack of interest in feeding & not feeding effectively. o Low risk: infant is well, no infection site, lab tests rule out serious infection; Tx at home as outpatient w/ long-acting antibiotics (ceftriaxone). Follow-up w/in 24hrs is essential. o High risk: require hospitalization for IV antibiotics. & observation. RN: management similar to that of febrile infants.

Neurovascular Assessment

Neurovascular Assessment: • CSM (circulation, sensation, and motion): Assess every <2hrs during first 48hrs. Assess strength of the pulse distal to the site, compare to the pulse in the unaffected extremity. Sluggish capillary refill time suggests neurovascular impairment. Touch the skin proximal & distal to the device to check temp.; ask them to move fingers & toes. o S/S of circulatory impairment: coldness, pallor, blueness of extremity, swelling, loss of motion, & numbness & tingling of the extremity. § Paresthesia, or numbness, burning, & tingling; assess by touching the fingers or toes & noting any decrease or loss of feeling. Serious concern bc can result in paralysis if not corrected. Report child's complaints of pins-&-needles or the extremity 'falling asleep'. W/ young children, may not be able to describe sensation; avoid questions like, "Do you feel like this?"—instead ask to wiggle fingers or toes & ID motor impairment. • CSM (circulation, sensation, and motion): Assess every <2hrs during first 48hrs. Assess strength of the pulse distal to the site, compare to the pulse in the unaffected extremity. Sluggish capillary refill time suggests neurovascular impairment. Touch the skin proximal & distal to the device to check temp.; ask them to move fingers & toes. o S/S of circulatory impairment: coldness, pallor, blueness of extremity, swelling, loss of motion, & numbness & tingling of the extremity. § Paresthesia, or numbness, burning, & tingling; assess by touching the fingers or toes & noting any decrease or loss of feeling. Serious concern bc can result in paralysis if not corrected. Report child's complaints of pins-&-needles or the extremity 'falling asleep'. W/ young children, may not be able to describe sensation; avoid questions like, "Do you feel like this?"—instead ask to wiggle fingers or toes & ID motor impairment.

Osteomyelitis

Osteomyelitis: Bacterial infection of the bone that involves cortex or marrow cavity; high mortality & morbidity rate; classified as acute, subacute, chronic, or chronic recurrent multifocal. Effects boys more than girls. o Route/cause: endogenous (skin, RT, abscessed/impacted tooth, AOM) or exogenous (injury or OP); usually the result of vascular spread of bacteria. Result of direct injury (open fracture), injury to surrounding soft tissue (cellulitis), external fixation device, & skeletal traction. Staph aureus is the most common organism. o Acute or subacute; Chronic or chronic recurrent multifocal: Chronic if persists >1mo or doesn't respond to initial antibiotic protocol. o S/S: in older child pain, warmth, erythema, & tenderness over the site of infection; favoring the affected extremity; limited ROM; systemic s/s fever & lethargy. Pain is localized but can radiate pain to adjacent areas; radiation to an adjacent joint indicates need for assessment of septic arthritis. Infant s/s vague & non-specific—fever, lethargy, irritability, & feeding difficulties. o Tx: IV high-dose antibiotics, preferable through a PICC. Type/length chosen based on probable organism & changes PRN according to C&S results; obtaining the Hx is a key component to Tx. • RN care: o Assessment & documentation of the child's status o Pain control: assess Q4hrs or more if indicated; ask parents when child is preverbal or unable to explain; acute phase- severe pain, assess pain level & Tx before activities are performed. o Admin of antibiotics w/o iatrogenic injury: usually LT admin through IV—complications of IV site, PICC site; assess response to antibiotic Tx; peak & trough serum levels closely monitored; if aminoglycosides used- assess for ototoxicity & nephrotoxicity; assess renal & hepatic function, measure BC counts to ID bone marrow activity.

Otitis Media

Otitis Media: bacterial pathogens; may be precipitated by viral infections or allergies. • Otitis media: Effusion (fluid) & infection or blockage of the middle ear. • Acute otitis media (AOM): Effusion & inflammation in the middle ear that occurs suddenly & is associated w/ other s/s of illness. Considered 'persistent' if still have s/s during Tx or w/in 1mo after Tx is done; 'recurrent' if >3 episodes over 6mo, or 4 episodes w/in 1yr. - S/S AOM: otalgia- earache, infant may pull ears or roll head; bulging, opaque tympanic membrane, looks red w/ decreased motility, diffuse light reflex, & obscured landmarks; yellow-green, purulent, & foul drainage (perforation of tympanic membrane); may be accompanied by irritability, sleep disturbances, fever, vomiting, anorexia, or diarrhea (esp. infants). • Otitis media w/ effusion (OME): The presence of fluid behind the tympanic membrane w/o s/s of infection; often follows an episode of AOM & usually resolves in 1-3mo. - S/S OME: tympanic membrane is retracted & dull gray or yellow; may see air-fluid level or bubbles behind the membrane; membrane mobility reduced & landmarks distorted; may have tinnitus or popping sounds, hearing loss (conductive); older child may show behavioral problems, poor school performance, disturbed sleep, irritability, decreased responsiveness; mild balance disturbances may cause delayed motor skills. • Etiology: daycare (esp. <1yr old), bottle feeding, & reflux—while feeding in supine position when formula flows into eustachian tube. • Incidence: peaks at age 6mo-2yrs; at 6mo old maternal antibodies decline. Boys effected more than girls; incidence is highest in winter & spring, lowest in summer. - Infant/Toddler Patho: drainage is inhibited by shorter & more horizontal eustachian tube; tube is more distensible in infant; tube collapses easily bc lack supporting cartilage, restricts drainage. • Tx AOM: >6mo to <24mo, antibiotics if AOM is w/ pain & fever (>39c) for 48hrs, or bilateral AOM w/ mild s/s; if unilateral AOM & mild s/s collaborated w/ parents, "watch & wait" for 48-72hrs & follow-up. Older kids, admin antibiotics if severe; if unilateral or bilateral & mild s/s, collaborate w/ parents & "watch & wait" for 48-72hrs. • Tx Recurrent AOM or OME: if child is unable to clear the fluid, may indicated need for a myringotomy w/ insertion of tympanostomy tubes (pressure equalizing & draining); tube falls out in 6-12mo; some need repeat OP bc of eustachian tube dysfunction.

Pavlik harness

Pavlik harness: the most common tool used in treating early (<6mo old) Developmental dysplasia of the hip (DDH), maintains the infant's hips in a flexed, abducted, & externally rotated position; allowing for proper hip development. Chest & shoulder straps, & foot stirrups. -Worn for about 3-5 months or until the hip joint is stable. The straps are adjusted periodically by the health care provider to account for infant growth. -Instructions on care for the infant wearing a Pavlik harness are as follows: -Position & fasten the chest halter w/ room for 2 fingers to rotate under the strap; straps are fastened in the back & crossed over the shoulders w/ 1-finger of room over the shoulders; place leg & foot in stirrup & strap, connect straps to chest halter. Leg straps are secure enough to keep hips flexed w/o being tight. Harness worn for 23hrs a day. Hold & cuddle infant as much as possible; feed in normal positions. Protect the skin & legs under the harness. A long tee or onesie under the halter reduces harness rubbing. Put a diaper under the harness; teach to inspect skin frequently for breakdown & reposition often. -Double diapered; may need to pad where ever the harness hits; skin care; massage the skin.

PDA

Patent ductus arteriosus (PDA): L-R shunting lesion; DA is open in utero but should close 24-72hrs after birth bc of decreased PG & BP in ductus lumen. Bc of drop in pulmonary BV resistance & failure of DA to close, increased systemic pressure moves O2sat blood from the aorta into pulmonary arteries (L to R shunt), lungs, & Lt side of the heart—causing increased Lt-sided cardiac workload & increased pulmonary BF. -S/S of HF rt lesion size & amount of L-R shunting; continuous murmur (machinery sound); widened PP; bounding pulse, cardiac enlargement. -Tx: address HF. -Admin indomethacin (Indocin), PG inhibitor, constricts the ductus (only used in preterm). Monitor resp. status, renal function, & growth. -Cardiac cath- std. of care; nonsurgical occlusion via coil; tissue grows around coil= permanent occlusion. -OP: litigation of ductus via Lt thoracotomy; usually w/in 1st yr of life.

Whooping cough (Pertussis)

Pertussis (whooping cough): Bordetella pertussis, a G- bacillus; occurs in any season but usually summer & fall; Incubation = 6-20 days; Infectious = Catarrhal from 1-2wks until the 4thwk; Transmission = direct contact or resp. droplets from coughing; Immunity = bacteria or vaccine. Manifests as 3 classic stages, that last 6-12wks. o 3 stages: 1. Catarrhal- 1-2wks, s/s of URT infection. 2. Paroxysmal- 2-6wks, severe cough that is repetitive during a single expiration, followed by massive inspiration w/ a whoop (not often in older children); cyanosis, protrusion of tongue, salivation, JVD, coughing spell may be triggered by yawning, sneezing, eating, drinking; cough may cause vomiting. 3. Convalescent- 1-2wks, episodes of coughing, whooping, & vomiting that decrease in frequency & severity; cough may persist for several months. Classic stages not seen in infants <3mo old. o Complications: pneumonia, atelectasis, emphysema, pneumothorax; hypoxemia can lead to CNS involvement. o Preventable by vaccine; primary prevention of Pertussis is 5 dose of DTaP with a booster Tdap (11-12yrs); immunity wanes approx. 2-5yrs after admin of vax. o Tx: Antibiotics (Erythromycin, azithromycin or clarithromycin) depending on age—also should be given to those in close contact to the child (kids >13yrs bc of waning immunity); if given in Catarrhal, eliminates bacteria in the nasopharynx in 5 days. Older kids usually cared for in the home. o May need hospitalization for respiratory support (esp. infants <6mo= mortality) & monitoring of airway patency; watch O2sat & cardiopulmonary monitor during the Paroxysmal episodes; droplet precautions.

Pharyngitis and Tonsillitis: Tonsillectomy

Pharyngitis and Tonsillitis: • Tonsillitis: Inflammation and infection of the two palatine tonsils; function as a filter for the resp. system. • Adenoiditis: Infection and inflammation of the pharyngeal tonsils or adenoids • Surgical Tx: often when tonsillectomy is indicated, T&A is performed—tonsillectomy & adenoidectomy. • Incidence peaks during middle childhood • Caring for the Child who Has Had a Tonsillectomy: may be kept overnight for evaluation or if AM OP may get to go home in the evening after stable. • Assessing the child for post-op bleeding: Excessive swallowing (swallowing blood); Elevated HR & decreasing BP = hypovolemia [s/s shock]; Signs of fresh bleeding in back of throat; Vomiting bright red blood; Restlessness not associated w/ pain. • RN Management: place in prone or side-lying position; normal to vomit old blood; avoid straws bc sucking may remove the scab & start fresh bleeding; non-aspirin analgesia; give clear, cool liquids—no citrus or carbonated, & no extremely hot or cold liquids bc it can irritate the throat; limit milk bc it coats the throat, causing the need to clear the throat which can cause bleeding. Avoid giving anything red to drink; can make you think bleeding is occurring when it's not. Keep suction at the bedside & make sure it's set up for when they come to you post-op; suction PRN not on a schedule.

Pneumonia

Pneumonia: inflammation of the lung parenchyma. Viral more frequent than bacterial. Seen in children of all age groups and associated w/ URIs. • Primary or secondary disease; Viral or bacterial; Community acquired. Marked decrease since the introduction of routine vax. Dx or ID based on the location in lung (ex. RUL). Kids w/ chronic & acute conditions (ex. cystic fibrosis, congenital defects) are at risk of pneumonia. Secondary-from aspiration of hydrocarbons in household products, or lipids. • RN Care: Airway, respiratory status; Rest; Fluids (admin w/ all airway dz); Decrease pain from coughing (help w/ splinting); Anxiety occurs w/ resp. conditions, help them stay calm. • Tx: antipyretics, antibiotics, oral or IV fluids (depends on tolerance of PO route), avoid cigarette smoke bc it exacerbates the condition. Teach to finish entire course of antibiotics.

Primary hypertension

Primary HTN: Average systolic or diastolic BP that >95th percentile—know the ranges for each age group (adolescent= >120/80 is prehypertensive; normal BP = S&D <90th% for age/sex/ht); w/ no underlying disease - considered "essential HTN", just like adults. If CoA is present, it is the primary CV cause; Endocrine cause is DM; DM2 increasing in children due to being overweight. • Tx: Weight reduction; Physical conditioning; Dietary modification (regardless of wt)—low Na, teens should avoid alcohol; Relaxation techniques; Pharm Tx—diuretics, Beta adrenergic receptor blockers, vasodilators. RN must teach diet modifications, esp. w/ obese kids. • Infusing IV Anti-HTN Meds: Infuse very slowly & follow manufacturer guidelines; Maintain an arterial line for monitoring (most likely in Peds ICU); Watch for sudden hypotension, may result after initiation of anti-HTN meds.

Pulmonic stenosis

Pulmonary stenosis: Obstructive or stenotic lesions. Obstruction causes resistance to BF at RV outflow track; increased pressure in RV causes RN hypertrophy. Critically severe pulmonary artery obstruction elevated RV pressure severely, blood regurgitates into the RA—rising pressure forces foreman ovale open, causing BF from R to L-side of the heart. -S/S: many asymptomatic; if s/s present- exercise intolerance, s/s Rt HF, systolic ejection murmur w/ possible palpable thrill, cardiomegaly, cyanosis (severe). -Tx: admin PGE (prostaglandin) to keep the DA patent. Cardiac observation & prophylactic ABs for asymptomatic. -Cardiac Cath- ballon valvuloplasty; dilate valve to decrease pressure. -OP: Valvuotomy for unsuccessful valvuloplasty or for supravalvular stenosis; also placement of a shunt.

RN Considerations for OM

RN Considerations for OM: • Sometimes when children are crying & have illness w/ fever, the middle ear may look red on exam—doesn't always mean it's an infection. • Antibiotics: when +Dx of ear infection confirmed; admin med, teach about taking the med at the right time & finish the full course (even if they feel better)—explain about relapse, provide written & oral instructions & a med record to track the doses, calibrated measuring devices are helpful for liquid meds. • Pain relief: acetaminophen given; increase fluids if fever is present. • Analgesia for temperature: antipyretic to Tx temp. & pain. • Encourage a reduction of risk factors: don't smoke near the child, 2nd hand has an effect. • Feeding that decreases risk for OM: breastfeed infants; stop formula feeding ASAP. Feed in upright position; don't prop bottles or give a bottle while in bed. • If surgery indicated: done after 1yr+ of OM; myringotomy and insertion of tubes—cut into membrane to insert. Prepare for outpatient surgery; describe OP in simple/clear terms & answer questions simply/honestly. Post-op, monitor drainage—small reddish amount is normal for 1st few days; parents should report heavier bleeding or if it occurs after 3 days; report any fever or increased pain; avoid blowing nose for 7-10 days. - Avoid too much water in the ear: small amount is okay, dry is best; Avoid baths & lakes bc bacteria, avoid pools bc chlorine is irritating. Place plugs or cotton w/ petroleum jelly in ears during bathing. Swim only w/ plugs & HCP approval; NO diving & deep swimming. - Describe the tube size & appearance to parents; reassure that it's not an emergency if they fall out but call the HCP. • OM/AOM are common problem & may reoccur: infection & effusion; teach parents s/s of ear infection & importance of seeking HCP appt. Hearing impairment from middle ear infusion is hard for parents to detect; child w/ chronic OM needs periodic evaluations of hearing.

Reye's Syndrome

Reye's syndrome: exposure to virus or toxin in at-risk kids, leads to liver damage w/ rising serum ammonia; toxic ammonia levels lead to cerebral dysfunction (encephalopathy, cerebral edema); F&E imbalance; coagulopathies. Average age of onset 6-7yrs. May be rt admin of aspirin in kids w/ viral dz. o S/S: prior viral infection- malaise, n/v, progressive neuro deterioration. Elevated ammonia, liver dysfunction on biopsy, hypoglycemia, altered coag times, increased ICP w/ resp. dysfunction. o Clinical Staging: I= lethargy, V= coma w/ flaccidity/extension posturing. o Tx: hospitalization to monitor neuro-status, increasing ICP, hydration & A/B balance, cardiorespiratory status. o RN: Similar to care of increased ICP w/ possible mechanical resp. support. Accurate & continuous monitoring of neuro & cardiorespiratory status bc sudden deterioration can occur. Fluid replacement w/ IV hypertonic solutions, if ICP is NOT increased. Protect from coagulopathy injury. -Give patents info regarding the ABSOLUTE avoidance of aspirin & OTC meds containing salicylates bc of risk for Reye's syndrome.

Rheumatic fever

Rheumatic Fever: Inflammatory condition of connective tissue involving the heart, joints, SQ tissues, brain, & BVs; often seen 2-6wks following an untreated GBS (Group-Beta Strep) infection of the RT. Serious complication is Rheumatic Heart disease; peaks in 5-15yr old range. • S/S: Arthritis or polyarthritis- painful, tender joints, warm; Carditis- all of the myocardium but esp. the mitral valve; Chorea- involuntary movement of extremities, effects face & speech, not seen when sleeping (shows brain involvement); Erythema marginatum- rash that starts on the trunk & spreads peripherally; SQ nodules- small, tender swellings over the joints. • Tx: 10-day course of PO penicillin.

Rocky Mountain spotted fever (Rickettsial Infections)

Rickettsial Infections: Small, parasitic bacteria occurs in April-September; Incubation = 2-14 days (average 7); Transmission = blood-sucking arthropods (ticks); Reservoir = dogs & wild rodents. Replication w/in human host cell causes cell death—can lead to vasculitis w/ thrombocytosis, increased permeability, tissue edema, hemorrhage, circulatory failure, &meningoencephalitis. Cannot spread from person to person. • Rocky Mountain Spotted Fever: S/S headache, fever, anorexia, restlessness; Day 3 - maculopapular or petechial rash on extremities—wrists, palms, ankles, soles & spreads to the rest of the body; then progresses to hemorrhagic & necrotic lesions. 2/3 of cases are <15yrs old (peak 5-9yrs) • Tx: no vax available. Doxycycline used for 7-10 days, but it stains the teeth for life—use preventative measures like using a straw, or rinse/wash mouth; if vascular damage already present, drug may not alter the dz; Px is excellent if Tx w/in first 5 days.

Compartment syndrome

Risk for Compartment syndrome: Swelling causes pressure to rise within the closed fascia compartments, compromising vascular perfusion to the muscles and nerves. Seen w/ halo traction; immobilizing devices. o Compartment syndrome is the compression of structures, such as arteries and nerves, w/in a closed compartment in an extremity. This complication typically occurs within 24hrs of a fracture. It should be reported to the HCP immediately bc permanent damage can occur w/in 12hrs of ID of the syndrome. Cast removal is often necessary to relieve the pressure, and surgical fasciotomy is sometimes needed as well. Don't elevate higher than the heart, apply ice, or encourage the patient to keep wiggling fingers or toes. o S/S: severe pain often unrelieved by analgesia (differentiates it from pain of a fracture) & signs of neurovascular impairment. Report to the HCP if extending the fingers or wiggling the toes produces pain, &/or the quality of the radial or pedal pulse is poor-absent. Also assess for pallor, paresthesia, pulselessness; paresis & paresthesia are late s/s, indicate permanent damage. Pain distal to the site may be the 1st s/s of a complication. o Tx: RN should immediately elevate the extremity only to the level of the heart, loosen restrictive bandages or dressings, split the cast, notify the HCP immediately, & admin pain meds as ordered; keep them NPO for possible emergency OP.

Rubella (German Measles, 3-day rash)

Rubella - German Measles: RNA virus seen in late winter-early spring; incubation = 14-21 days; infectious = 7 days before onset of s/s to 14 days after rash seen; transmission = airborne particles, direct contact w/ droplets, transplacental can cause fetal death or abnormalities (congenital rubella- some infants shed virus for months after birth); Immunity = natural dz or live-attenuated vax. • AKA 3- day or German Measles Rash: usually a mild dz in children & adults, resolves in 5 days; virus enters host, rash occurs after 14-21 days. Young child usually asymptomatic until rash is seen; older may have profuse nasal drainage, diarrhea, malaise, sore throat, headache, low grade fever, polyarthritis, eye pain, aches, chills, anorexia, & nausea. All ages have impressive posterior cervical, posterior auricular, & occipital lymphadenopathy. • Rash: pinkish rose maculopapular exanthem; begins on face, scalp, & neck, then spreads downward to entire body in 1-3 days; usually pruritic. Fades on face as it spreads to trunk. Petechiae (red or purple pinpoint spots) may occur on soft palate—"Forchheimer's sign". • Complications: maternal infection during pregnancy (usually first 12wks/1st Tri), causes Congenital Rubella Syndrome, crosses the placenta & results in fetal death or abnormalities; results in intrauterine growth retardation—typically weight <2,500g, & failure to thrive in infancy. Mortality is highest in 1styr; common COD are pneumonia, heart defects, encephalitis, & immune deficiency. • Tx: Supportive & symptomatic treatment; dz is self-limiting, resolved in 5 days. Child can go back to school or daycare 7 days after rash begins.

Sinusitis

Sinusitis: Inflammation and infection of the sinuses; can be chronic or acute. Although not serious may lead to life-threatening complications if left untreated (periorbital edema, orbital cellulitis, CNS s/s). Can occur in infancy & childhood; frequently in preschoolers & school-age kids fro group exposure to URT infection. • Acute: often follows an URT infection • Chronic: often have allergic rhinitis or otitis media w/ effusion (OME). • S/S of a cold w/ no improvement after 10 days; low-grade fever, nasal congestion w/ purulent discharge, halitosis, cough (increases when lying down), headache, & tenderness & feeling of fullness over affected sinus. W/ chronic, same s/s but cough is chronic & headache recurrent; possible taste & smell impaired & feel fatigued. • RN: Analgesics (Tylenol; NEVER aspirin), hydration, moist heat (humidifier); Warm, moist compresses; nasal sprays. • Tx: most acute self-resolve but amoxicillin (Augmentin) may be used when it doesn't. For orbital cellulitis- hospitalize immediately & admin IV antibiotics.

Soft Tissue Injuries

Soft Tissue Injuries: common in kids; usually from play or athletic activities. Trampoline use is associated w/ cause of soft tissue injury & fractures in kids, on admit to the ED. • Sprains: result of trauma to a joint in which ligaments are stretched or partially/completely torn. Not often in young kids bc of poorly developed epiphyseal plate; twisting or turning injury will more likely cause a fracture at the weak plate. • Strains: AKA pulls, tears, or ruptures; result of excessive stretch of a muscle. Sprains & strains are common in teens, usually from athletic injuries. ACL tears are a common type of knee injury, esp. in teen athletes. • Contusions: occurs when soft tissue, muscle, or SQ tissue is damaged. Strains & contusions often accompany one another. See bruising. • Dislocation: joint is disrupted so that articulating surfaces are no longer in contact. • S/S: pain, swelling, localized tenderness, limited ROM, poor wt bearing, & a pop or snapping sound (sprain). Dx made based on s/s, X-ray can rule out fracture, MRI or arthroscopy sometimes needed to Dx knee-ligament tears. Tx the Child with a Soft Tissue Injury: • RICE: R= rest; I= ice; C= compression; E= elevation • ICES: I= ice; C= compression; E= elevation; S= support • Primary Goal: First 6-12hrs after soft tissue injury are most important in controlling swelling & reducing muscle. o External pressure (compression) is best before edema has accumulated; swelling can inhibit healing by keeping ligament ends separated & increasing fibrous scaring. Immediately wrap the site w/ a compression bandage to support the joint & control swelling. o Ice reduces swelling; apply for no >20min at a time - effective for 5-6hrs; apply repeatedly for several days. NSAIDs can reduce pain & inflammation. o More severe injuries should have no weight bearing for 3 days; crutches may be needed; air-cast (plastic, air-filled pressure cuff) can be used over the elastic wrap to support the joint & reduce swelling. Air-cast or compression bandage should be worn for several wks while healing. o Begin stretching & isometric exercises to improve joint stability once the pain & swelling have diminished. o Immobilization of the injured joint & cold application are effective for incomplete ligament tears. Complete rupture may need surgery to prevent excessive scar formation & LT joint stability problems; cast or splint for 4-5wks may ne needed, esp. knee injuries.

Spina Bifida

Spina Bifida: congenital neural tube defects (NTD) classified by incomplete closure of the vertebrae & NT during fetal life; cause unknown, possibly genetic or lack of maternal folic acid. Depending where the deficit is on the spine will determine the degree of deficit. Preventative: admin 0.4mg folic acid to women of childbearing age, or 4mg if mom had a child w/ NTD. Occurs during 4th wk gestation (days 24-28), ventral induction of the NT fails to occur. 90% of spinal cord lesions are at or below L2. Lesion results in total or partial paralysis, or varying sensory defects. Clubfeet, scoliosis, & contracture & dislocation of the hips often seen. § Spina bifida occulta: usually between L5 & S1 vertebrae w/ failure of vertebrae to completely fuse; no herniation of spinal cord or meninges. Some kids will have no sensory or motor impairment; only s/s is a dimple, small tuft of hair, hemangioma, or lipoma in the lower lumbar or sacral area—ID accidentally by routine x-ray. § S/S Occulta: small tuft of hair or dimple in the lower lumbar sacral area § Spina bifida cystica: more extensive defect w/ a range of sensory & motor impairments; results from incomplete closure of the vertebra & NT, AEB sac-like protrusion in the L or S area w/ varying degrees of NS tissue involvement.

Spina bifida cystica: Meningocele & Myelomeningocele

Spina bifida cystica: Meningocele & Myelomeningocele § Meningocele= sac-like protrusion containing meninges & CSF. § Myelomeningocele= most severe form; saclike protrusion filled w/ CSF, meninges, nerve roots, & spinal cord. Clubfoot often seen bc defect presents normal intrauterine movement, interferes w/ G&D of the extremities. Legs may be flaccid, normal neonatal flexion is absent; may constantly dripple urine & stool. Hydrocephalus & Arnold-Chiari malformations occur in 80% of these patients. Mortality rate 10-15%. 80% of these infants require shunting to Tx hydrocephalus. § S/S: lesion appearance varies w/ type; manifestations rt degree of deficit, determined by the level of the lesion on the spinal cord & the size. T12- flaccid LE, decreased sensation, & bowel & bladder incontinence. L1-L3- hip flexion, flail feet. L2-L4- hip adduction. L3-S2- hip adduction, hip extension, knee flexion. S3 & below- no motor impairment. Sacral roots- plantar flexion. § Dx: tests the serum AFP at 16-18wks; if elevated, perform amniocentesis & fetal US; after delivery, may have a CT scan or myelography. § Tx: may perform prenatal microsurgical closure of the myelomeningocele at 19-25wks in utero, depending on situation; reduces malformations & risk of hydrocephalus. After delivery, almost immediate surgical closure of the defect reduces risk of infection, morbidity, & mortality; also improves Px w/o further cord deterioration, & earlier/easier physical handling & bonding between newborn & parent. § Lifelong management of neuro, orthopedic, & urinary problems; best done in a multispecialty O.P. setting; urodynamic studies done early & bladder emptying program is started w/ close monitoring of UTI status. Usually require orthopedic bracing & possible surgery to max mobility. Spina Bifida clinics have best outcomes; coordinate care w/ multiple HCP, implement care in 1 visit, have fewer complications & hospitalizations, improved communication between HCPs & patient/family. § High risk of latex allergies bc of frequent exposure to latex during catheterizations, shunts, & other operations; 73% affected by latex allergy, range from mild to anaphylactic shock; test kids for latex allergy, take precautions from birth to decrease exposures; check equipment & supplies & select non-latex alternatives.

Standard Terms for LOC

Standard Terms for LOC: § Full consciousness: awake, alert, oriented, interacts w/ environment. § Confused: lacks ability to think clearly & rapidly; usually oriented to person. § Delirious: not oriented (x3); impairment of reality w/ hallucinations possible. § Disoriented: lacks ability to recognize place or person. § Lethargic: very drowsy & needs increased stimulation to awaken. § Obtunded: sleeps unless aroused; once aroused has limited interaction w/ environment; answers questions w/ minimal response. § Stupor: vigorous stimulation required to arouse. § Coma: vigorous stimulation produces no motor or verbal response.

Sudden Infant Death Syndrome

Sudden Infant Death Syndrome: SIDS; Sudden and unexplained death of an infant <1yr old; exact cause is unknown; referred to as crib death by the public. Usually occurs during sleep; 95% cases <6mo (peak 2-4mo); more common in boys & low-birth-weight infants. Racial disparity- lower SES groups; American Indians and Alaskan Natives. Most common in winter months. -Prevent: Since "Back to Sleep" program adopted the AAP, decrease of SIDS by 44% in the US. -Place on back not prone; Avoid bed sharing (rolling over onto baby is another problem, not counted in SIDS numbers); Firm mattress w/ fitted sheet (no blankets, toys, bumpers; just put baby in a sleeper); Provide pacifier after breastfeeding well established; Do not put to sleep (for the night) in swing, car seat or carrier.

Tetralogy of Fallot

Tetralogy of Fallot: Cyanotic lesions with decreased pulmonary BF. Most frequent cyanotic lesion; constellation of lesions results from misalignment of ventricular septum during fetal G&D: VSD, RV outflow tract obstruction (pulmonary stenosis), overriding of the aorta (RV), RV hypertrophy. -Equal R & L ventricle pressures rt the pulmonary artery obstruction & size of the VSD; desaturated blood enters systemic system by shunting R to L across the VSD, or into the overriding aorta. -Onset & severity of s/s rt extent of pulmonary BF obstruction. Mild= sat mildly low, pink tet. S/S worse in neonate when DA closes; cyanosis, extreme fatigue, hypercyanotic episodes, chronic hypoxemia. Harsh systolic murmur w/ palpable thrill; boot-shaped heart rt poor G&D of pulmonary artery. Difficulty feeding, poor wt gain, tachypnea. Chronic hypoxia leads to polycythemia -Tx: manage tet-spells w/ knee/chest position (C-position) helps dilate the RV which decreases the obstruction, morphine, O2. PG1 maintain patency of DA & BF to the lungs. OP at 3-4mo old w/ CP bypass machine. o Hyper-cyanotic Episode: Occur more often with children <2yrs. Last a few min-few hrs. Caused by feeding or crying. -"tet spells": unrepaired (OP) Tetralogy of Fallot; Acute spasm of the RV; Hypoxia & can lead to metabolic acidosis; Rapid respirations, irritability, crying, peripheral vasodilation, severe cyanosis. -Tx: Calming child, place in knee-chest position ("C", or squat down); Administer oxygen; Morphine to decrease respiratory center and hyperpnea—helps them settle down & allows O2 to occur.

Triscuspid Atresia

Tricuspid atresia: desaturated blood enters the RA, shunts R to L through a patent foramen ovale into the LA—mixing of blood in the LA, then goes to the LV & aorta; some blood shunts through the VSD to the RV & into the pulmonary artery to the lungs; if the DA is open, some blood will flow from the aorta to the pulmonary artery; lesser pulmonary stenosis can contribute to pulmonary congestion. -S/S: profound cyanosis w/ decreased pulmonary BF; single 2nd heart sound bc tricuspid valve doesn't close; systolic murmur from VSD or PDA murmur if ductus remains open. -Tx: PGE to keep DA open. Balloon Atrial Septostomy creates opening by tearing the septum. OP goal is to stop mixing of blood & optimize vent function by decreasing workload of the heart (Palliative Systemic-to-pulmonary artery shunt; create connection between SVA & PA; then a Modified Fontan in early childhood)

Tuberculosis (TB)

Tuberculosis: not often in US children but can come in contact w/ TB; contagious disease w/ high morbidity & mortality worldwide. Foreign born 2/3s higher incidence. Airborne precautions used. • TB: Acid-fast bacillus; Contamination through INH—children are infected by family members, babysitters, etc. Chronic illness, immunosuppression, HIV infection, malnutrition can contribute to the ease of getting TB. Ages most seen are infancy & adolescence; Nonwhite racial, ethnic groups; immigrants from areas with high TB incidence (2/3 are foreign born). • S/S: age 3-15yrs are mostly asymptomatic in the beginning w/ normal chest x-ray & Dx only through +skin test; then malaise, fever, night sweats, a slight cough, weight loss, lymphadenopathy, or more specific s/s rt the site of extrapulmonary infection (ex. kidneys, brain, bone). • Therapeutic Management: meds/chemotherapy are priority. • Understand the difference between TB exposure, infection (+skin test), & disease (CXR changes w/ s/s & +skin test). Admin & evaluating TB skin tests. • Admin anti-TB meds as ordered: • Infection - admin INH for 9mo (or admin 4mo course of rifampin alternate for Tx-resistant: may affect efficacy of birth control pills, need an alternate method). • Disease - 6mo course of combined regime (first 2mo: INH, rifampin, ethambuterol, & pyrazinamide; next 4mo: INH & rifampin). • Instructing the child & family regarding: Importance of adequate rest; Nutritionally adequate diet; Adherence to med regime—this is LT admin & they might get tired of taking meds; Ways to prevent transmission of TB infection.

Valproic Acid (Depakene)

Valproic Acid (Depakene): -Tx: generalized, focal, absent, myoclonic seizures. -SE: lethargy, sedation, double vision, ataxia, N/V, tremor, wt gain, hair loss, menstrual cycle irregularities, thrombocytopenia, liver failure, transient hair loss. Most serious adverse effects are hepatotoxicity and pancreatitis. -RN: monitor for general weakness; do NOT cut/crush pills or sprinkles; can cause stomach ulcers; take w/ food; monitor blood tests for theraputic levels. -Route PO, IV; Onset 15-30 min; Peak 1-4 hr; Elimination Half-Life 6-16 hr; Duration 4-6 hr. -Used primarily in the tx of generalized seizures (absence, myoclonic, and tonic-clonic). It is also used for bipolar disorder and has been shown to be effective in controlling partial seizures. -Contraindications: known drug allergy, liver impairment, and urea cycle disorders (genetic disorders of urea metabolism). -Valproic acid can interact with many meds. Valproic acid is highly protein bound and competes with other highly protein-bound medications for binding sites. It also is metabolized by hepatic microsomal enzymes and competes for metabolism with other drugs. In contrast to phenobarbital and phenytoin, it is not a hepatic enzyme inducer. -Valproic acid itself is chemically the simplest dosage form and is available as an oral liquid. -Long-acting oral dosage forms are also available as divalproex sodium (Depakote), which comes in delayed-and extended-release tablets as well as capsules with long-acting granules (Depakote Sprinkles) that can be opened and sprinkled onto food. -The injectable form is the salt valproate sodium (Depacon)

Varicella-Zoster (Chicken Pox, Shingles)

Varicella-Zoster (Chicken Pox, Shingles): double stranded DNA virus, common during late winter-early spring; Incubation = 10-21 days; Infectious = 1-2 days before the rash appears, until all lesions are dried/crusted over—takes 5-7 days; Transmission = contact, droplet, & airborne particles. Immunity = natural dz of varicella/chicken pox, can then later cause zoster/shingles, & varicella vax. • Varicella: primary infection in children 5-9 years old; adults can also get it. First 24-48hrs [before the lesions appear], may have a slightly elevated temp., malaise, headache, anorexia. o Rash: varies between children; macular rash "crops" 1st seen on trunk & scalp (move sparsely to extremities), followed by papular rash, then lesions that quickly become teardrop vesicles w/ erythematous base; vesicles become pustular, afterwards they dry & develop crust. Over 3-4 days the lesions appear in crops (x3), seen in different stages on the body; approx. 300 lesions. Children in house w/ secondary case are worse than the child w/ primary. Lesions can be on mucous membranes of mouth, genitals, & rectum. 2nd attacks rare, more often in immunocompromised; breakthrough attack in vax child rare, but dz is mild w/ few lesions. • Zoster: reactivation of the latent virus more often in the elderly population but can occur in children & adults; in primary dz, enters the sensory nerve ending & the dorsal root ganglion & goes latent. o Rash: tenderness along involved nerve & surrounding skin for 2wks before rash appears. Pain can be mild to severe knife-like prickling. Unilateral crops of lesions appear along a single dermatome of 1+ sensory nerves. Lesions go through same stages as varicella; may be enlargement & tenderness of regional lymph nodes. • Risks: Hx of Chicken pox, >50yrs old, weak immune system, stress/trauma, & Tx for cancer. • Complications: Concern with virus is secondary infection; esp. w/ chickenpox in children—itching results in Staph infection. • Tx: symptomatic & supportive for healthy children; oatmeal bath &antihistamines, control itching & prevent bacterial secondary infections; acetaminophen to control fever. Private room w/ airborne & contact isolation, strict isolation for 8-21 days in hospital; very contagious. Acyclovir, not recommended for healthy kids but for severe cases, chronic illnesses, LT aspirin Tx, kids on ST corticosteroid Tx; for immunocompromised, give IV; good Px when started early bc antivirals have limited window of opportunity.

Neurologic Exam

• Neurologic Exam: o LOC: Glasgow Coma Scale (for infant vs child); assess eyes 1-4, motor 1-6, verbal 1-5; 15 is no change - 3 is deep coma. § Modified GCS: objective measure of a child's LOC & severity of the injury; detect brain injury early & prevent permanent damage. Total of 15pts; 3= deep coma & poor Px, 15= no change in LOC. Score of <8 requires aggressive management & monitoring of ICP. · Eye Opening (4): same for infant & child; 4=spontaneously, 3= to speech, 2= to pain, 1= no response. · Motor (6): 6= spontaneous/obeys commands, 5= withdraws to touch/localizes, 4= withdraw to pain/withdraws, 3= flexion (decorticate)/flexion, 2= extension (decerebrate)/extension, 1= no response. · Verbal (5): 5= coos & babbles/oriented, 4= irritable cry/confused, 3= cries to pain/inappropriate words, 2= moans to pain/incomprehensible words, 1= no response. o Behavior: alterations in normal pattern of behavior o Pupil evaluation: assess for PERRLA; sluggish or absent restriction - compression of 3rd CN; fixed & dilated - herniation in the center of the brain, ominous s/s. o Motor function: assess for flexion & extension posturing; head injuries can cause different types of posturing. o VS: temp. elevation may occur w/ increased ICP. Cushing's response- increased systolic BP w/ widening pulse pressure, bradycardia, & change in RR & pattern—usually apparent just before or at time of brainstem herniation—s/s of alteration in brainstem perfusion w/ body trying to improve cerebral BF by increasing BP; in kids this is a late s/s of increased ICP.