peds bone resp cardio

8/20/2019 PEDS Bone Resp Cardio

1/23

1

Exam 3 PEDS study guide

Chap 34- Fractures p1159

Complete fracture- fragments are completely separated Incomplete- remain intact

Transverse: crosswise, at right angles to the long axis of one Obliue-slanting y straight

Spiral! slanting and circular twisting around one shaft

Simple"closed fracture- does not rea! s!in Compound-open wound, one protrudes

Complicated- if one fragments damages organs"tissues Comminuted- small fragments

lying in surrounding tissues

#ro$t% plate" p%yseal- wea!est point of long ones# fre$uent site of in%ury# close monitoring &

early treatment are essential to pre'ent long("angular deformities# may re$uire surgical

treatment w" open reduction & internal )xation# *ealing is usually rapid in the epiphyseal plate

area( Complete immoili+ation is not necessary

Immediately after fracture occurs: muscle contract splinting the area# muscle

pulling"contracting pulls onesout of alignment# muscle can e o'ercome y traction or complete relaxation with

anesthesia in order to realign Salter-Harris classifcation of growth plate in%uries

ype 1 slip"separation of . w"o one fracture

ype /: separation of . & ro!en metaphysic

ype 3: fracture of physis extending through the epiphysis into the %oint surface

ype 4: fracture of growth plate, epiphysis, and metaphysic

ype 5: crushing, comminuted fracture of the physis

Cast purpose: %oints ao'e and elow the site of in%ury are immoili+ed to eliminate the

possiility of mo'ement that might cause displacement

Consist of gau+e strips and andages impregnated with: .laster of .aris, Fierglass,

polyurethane resin, waterproof liners

0oth types of cast produce heat from a chemical reaction acti'ated y water

oa! ca!ed s!in in tu after cast remo'al

.laster- used for molding closely to ody part"hea'ier"not light weight

Cast removal- explain to pt( that heat and 'irations occur during remo'al

Plaster -/4-42 hrs to dry# support with pillow in plastic# a'oid indenting cast, creating pressure

points# turn plaster cast $/hr to help dry e'enly# hair dryer cool setting# ma!es hollow sound

when dry


2/23

/

&iberglass-dries within minutes"must remain unco'ered to dry from inside out

Chief concern- compartment syndrome: cast ecomes tourni$uet, cutting o circulation causing

neuro'ascular complications during )rst hr after applying cast

'obili(ation devices- lighter etter )tting de'ices leading to greater usage compliance

Ort%otics- races, )tting and farication# used to pre'ent deformity, increase energy

eciency of gait and control alignment

)&O-an!le foot S'O- supramalleolar

*)&O- !nee an!le foot orthosis- use to pre'ent uc!ling of !nee, mar!ed $uad

wea!ness, protect wea! one structure

Care of !in: F6, 7F6, *7F6

• decreased sensation in the legs, chec! the s!in condition more fre$uently

than e'ery 4 hours(• urning sensation under the race, remo'e the race and oser'e the s!in

for any reddened areas( 8f the child complains of urning se'eral times,

contact the pro'ider or orthotist(

• small lister or open area de'elops, co'er it with a sterile andage and chec!

the s!in more often( o not put alcohol on open areas# a'oid wearing the

de'ice until the s!in heals(

• 8f no sign of healing occurs after 3 days, contact the pro'ider or orthotist(

• otions and creams will soften the s!in and should e used only if the s!in is

dry(

T+SO

• 0ecause the de'ice wor!s y pressing against the ody and is !ept 'ery snug

y straps and uc!les, some s!in pin!ness is to e expected( he s!in at the

race edges and under the pads should e inspected carefully and

fre$uently, especially in the initial period when the child or adolescent is

getting accustomed to the de'ice( ny red mar! that does not fade within /;

minutes, or any area that appears raw and sore, should e reported to the

orthotist(

• *a'e the child wear a cotton undershirt under the race to protect the s!in#

!eeping it clean, dry, and free of wrin!les will help pre'ent s!in prolems(

Prost%etics- arti)cial lim )tting & farication

Sprain- %oint trauma stretching ligament# often accompanied y 'essel, muscle, tendon and

ner'e damage

seldom are sprains painful# rapid swelling immediate disaility reluctance to use in%ured

%oint


3/23

3

Strain- microscopic tear to tendon# painful to touch swollen# happens o'er time# the more rapid

it occurs the more se'ere

Scoliosis- complex spinal deformity in three planes, usually in'ol'ing lateral cur'ature, spinal

rotation causing ri asymmetry, and when in the thoracic spine, often thoracic hypo!yphosis

?ost common deformity

Congenital- fetal de'elopment Infantile-irth-3yrs ,uvenile- 3-1;yrs )dolescent 1;@

?ay e caused y a numer of conditions and may occur alone or in association with other

diseases, particularly neuromuscular conditions Aneuromuscular scoliosisB(

Idiopat%ic scoliosis: no apparent cause# identi)ed during preadolescent growth spurt, anormal

school screening, poor )tting clothes"%eans

6 & . scoliosis screening y school, physician oce, & nurse clinic# screener must e

educated in the detection of spinal deformity

#irls screen at 1;-1/ yrs old oys 13-14 yrs old

T%erapeutic '.# of Scoliosis- oser'ation w" regular clinical, radiographic 'al, race

Aorthotic intr'nt(B and surgical spine infusion

reatment ased on magnitude, location type of cur'e age s!eletal maturity & any

underlying disease processes

Bracing- moderate curves 25-45 degrees; not curative, slows progression to allow growth

& maturity

.ursing care of the adolescent who is facing scoliosis surgery, potential social isolation,pain, and uncertainty, not to mention misunderstood emotions and ody image issues, must

e e'aluated from the adolescentDs perspecti'e

he management in'ol'es the s!ills and ser'ices of a team of specialists, including the

orthopedist, physical therapist, orthotist Aa specialist in )tting orthopedic racesB, nurse,

social wor!er, and sometimes a thoracic or pulmonary specialist(

Developmental %ip dysplasia-

• normal de'elopment of the hip that may de'elop at any time during fetal life, infancy,

and childhood• Eis! factors: reech irth, female gender, family history of *, left hip, )rst-orn child,

and positi'e clic!ing hips with clinical examination

• female gender, )rst pregnancy, family history, reech intrauterine position, high irth

weight, %oint laxity, and postnatal positioning

Pat%op%ysiology of DD/- cause is un0no$n

.redisposing factors associated with * may e di'ided into three road categories:

• p%ysiologic maternal hormone secretion, intrauterine positioning#


4/23

4

mec%anical reech presentation, multiple fetuses, oligohydramnios, large infant si+e, as

well as continued maintenance of the hips in adduction and extension that with time can

cause dislocation

• #enetic silings of aected infants and e'en greater incidence of recurrence if a siling

and one parent were aected( 6ne study found a twel'efold increase in ris! of * for

indi'iduals with a )rst-degree relati'e aected

* can e categori+ed into two ma%or groups:Idiopat%ic, in which the infant is neurologically intactTeratologic: neuromuscular defect such as arthrogryposis or myelodysplasia( he

teratologic forms usually occur in utero and are much less common

hree degrees of *:1( )cetabular dysplasia: his is the mildest form of *, in which there is a delay in

acetaular de'elopment e'idenced y osseous hypoplasia of the acetaular roof that is oli$ueand shallow( he femoral head remains in the acetaulum with no uluxation ordislocation(

/( Subluxation: he largest percentage" most common of *, sulxation impliesincomplete dislocation( he femoral head remains in contact with the acetaulum, ut astretched capsule and ligamentum teres cause the head of the femur to e partially displaced(.ressure on the cartilaginous acetaulum inhiits ossi)cation and produces a attening ofthe soc!et(

3( Dislocation: his is the most se'ere form of *( he femoral head loses contact withthe acetaulum and is displaced posteriorly and superiorly(* iagnostic 'al

reatment initiated efore / months of age for highest success rate# G in neworn periodif possile

Heworn- hip laxityIhip dysplasia

6 & 0 tests for sulxation and the tendency to dislocate# most reliale from irth -4w!s#dduction contractures occur at J-1;w!s 6 sign disappears# then limited hip aduction test ismost sensiti'e

Ortolani test-1( 8nfant supine on )rm plat surface#/( *ips and !nees exed at right angles3( .lace middle )nger of each hand o'er the greater trochanter4( hums on the inner side of the thigh opposite of lesser trochanter5( 6ne at a time !nees are carried to midaduction, and each hip %oint is sumitted, one at a

time, )rst to forward pressure exerted ehind the trochanter and then to ac!wardpressure exerted from the thums in front as the opposite %oint is held steady

J( 8f the femoral head can e felt to slip forward into the acetaulum on pressure fromehind, it is dislocated

arlo$ test-1( 8f, on pressure from the front, the femoral head is felt to slip out o'er the posterior lip of

the acetaulum, the hip is said to e dislocatale or =unstale>

T%erapeutic 'anagement of DD/ reatment egins .# treatment 'aries with age

.e$born 1 2mont%s: pa'li! harness worn continuously until stale clinically & 'ia ultrasound#J-1/w!s2-4 mont%s: surgical closed reduction# spica cast for 1/w!s


5/23

5

Older c%ildren- operati'e reduction- preoperati'e traction, tenotomy of contracted muscles,pel'ic osteotomy

.S# Care 'anagement- DD/ he primary nursing goal is teaching parents to apply and maintain the reduction de'ice.arents should e instructed not to ad%ust the harness(

!in care is an important aspect of the care of an infant in a .a'li! harness( he followinginstructions for pre'enting s!in rea!down are stressed:K Chec! at least two to three times per day for red areas under the straps and at s!in folds(K ently massage healthy s!in under the straps once a day to stimulate circulation(K 8n general, a'oid lotions and powders ecause they can ca!e and irritate the s!in(K lways place the diaper under the straps(

Clubfoot- talipes euinovarus- TE5- one deformity and mal position" soft tissuecontracture

• Eeadily apparent at irth & prenatally# if you canDt straighten it itDs deformed(

• he aected foot Aor feetB is usually smaller and s%orter, with an empty %eel pad and atransverse plantar crease(

• Lhen the deformity is unilateral, the aected lim may e shorter, and calf atrophy is

present(

• enerally, imaging such as radiographs or ultrasonography is not necessary for diagnosis(

• thorough hip examination should e performed for all infants with a clufoot# an

increased ris! of hip dysplasia is associated with clufoot deformities

T%erapeutic 'anagement- TE5 oal is to achie'e painless, plantigrade and stale foot#3 Stages:1( Correct deformity/( ?aintenance of the correction until normal muscle alance is regained

3( Follow-up oser'ation to a'ert possile recurrence of the deformity

.S# Care 'anagementHursing responsiilities include

• reinforcing and clarifying the orthopedic pro'iderDs explanations and instructions,

• teaching parents aout care of the cast or racing Aincluding 'igilant oser'ation for

potential prolemsB, and

• ncouraging parents to facilitate normal de'elopment within the limitations imposed y

the deformity or therapy6

Osteogenesis Imperfecta OI- rittle bones faulty bone

minerali(ation7 abnormalbone arc%itecture7 and increased susceptibility to fracture

• ?ost common syndrome in children#

• excessi'e fractures and one deformity#

• moderate"se'ere growth restriction

Clinical features include 'arying degrees of one fragility, deformity, and fracture# lue sclera#hearing loss# and dentinogenesis imperfecta Ahypoplastic discolored teethB, utosomal dominant"recessi'e: C611, C61/ genes- precollagen Acollagen precursorBClassi)cation ased on clinical


6/23

J

• Type 8- most common# wide 'ariaility of one fragility# some aected family memers

ha'e signi)cant deformity and disaility, whereas others lead agile, acti'e li'es

• Type - 'ariants are the most se'ere and are considered lethal in infancy

• Type 3- multiple fractures, one deformity, and se'ere disaility# aected indi'idualsrarely li'e to 3; years of age

• Type 4- similar to type 8 with lue or white sclera

• Type 9- hyperplastic callus, a radiodense metaphyseal and, and calci)cation of theinterosseous memrane of the forearm# no collagen mutations are noted in this group

T%erapeutic 'anagement- OI- primarily supporti'e# one marrow transplant,Focus on

1( decreasing the numer of fractures/( decreasing pain3( increasing growth4( impro'e one metaolism5( optimi+ing function

isp%osp%onate t%erapy with pamidronate, risedronate, olpadronate, neridronate, or

alendronate to promote increased one density and pre'ent fractures has ecome standard

t%erapy for many children with 68( 0isphosphonate therapy reportedly is more ene)cial for

increasing 'erteral one density# considered less eecti'e for long ones( 6thers report

eecti'eness of pamidronate in children with moderate to se'ere 68(

.S# Care 'anagement- OI-rittle bone-upported when turned, mo'ed, held, positioned#

ne'er hold at the an!le gently lift uttoc!s or support with pillows# need compassion# otain 0.

with manual cu

:pper resp6 tract infections- includes rhino'iruses, EM, adeno'irus, inuen+a 'irus, and

parainuen+a 'irus, cause acute nasopharyngitis Athe e$ui'alent of the =common cold>

Clinical 'anifestations-Nasopharyngitis more se'ere in infants & children# fe'er is common(

3 mo-3 years: sudden fe'er, irritaility, restlessness, decreased appetite uid inta!e,

decreased acti'ity( Hasal inammation may lead to ostruction of passages, producing open-

mouth reathing( Momiting and diarrhea may also e present

Older c%ildren dryness and irritation of nasal passages and the pharynx, followed y

chilling sensations, muscular aches, an irritating nasal discharge, and, occasionally,

coughing or snee+ing( Hasal inammation may lead to ostruction( Continual wiping away of

secretions causes s!in irritation to nares(

elf limiting# resol'es w"in 4-1; days without complications# prescrie cough suppressant w"

caution as coughing is encouraged

.S# Care 'ang6

mall infants- most discomfort from nasal ostruction# ele'ate *60 to assist drainage#

saline drop & suction prior to feeding, 'apori+ation,

?aintain ad$( Fluid inta!e, a'oid contact with aected persons


7/23

N

)cute Strept6 P%aryngitis- 0*- group eta-hemolytic streptococcus not serious itselfut can cause acute rheumatic fe'er Ainammation of the heart %oints and CHB and acute H#

impetigo & pyoderma

Scarlet fever- " .haryngitis, erythematous sandpaper-li!e rash

Clinical 'anifestations: rief, suclinical- se'ere# arupt onset, pharyngitis, headache,

fe'er, adominal pain( he tonsils and pharynx may e inamed, co'ered with exudates y

day / A5;O to 2;O of casesB, which usually appears y the second day of illness(

T%erapeutic 'anagement- 1;days of penicillin if sore throat, /4hr response# moxicillin

for 1; days# must complete entire med therapy

.S# Care 'anagement- swa throat for culture, ntiiotics, analgesic during acute

phase

Tonsillitis: mass of lymphoid tissue encircling the nasopharynx, oropharynx, !nown as the

Laldeyer tonsillar ring

• Palatine, or faucial, tonsils are located on either side of the oropharynx, ehind and

elow the pillars of the fauces Aopening from the mouthB surface of the palatine tonsils is

usually 'isile during oral examination(

• P%aryngeal tonsils, AadenoidsB are located ao'e the palatine tonsils on the posterior

wall of the nasopharynx( heir proximity to the nares and eustachian tues causes

diculties in instances of inammation(

• +ingual tonsils at the ase of the tongue(

• ual tonsils- near the posterior nasopharyngeal opening of the eustachian tues are not

part of the Laldeyer tonsillar ring(

onsils )lter & protect the respiratory and alimentary tracts, antiody formation# children

generally ha'e larger tonsils


8/23

2

T%erapeutic 'anagement- Tonsillitis self-limiting, treatment of 'iral pharyngitis is

symptomatic( hroat cultures positi'e for 0* infection re$uire antiiotic treatment( 8t isimportant to dierentiate etween 'iral and streptococcal infection in ferile, exudati'etonsillitis( 0ecause the ma%ority of infections are of 'iral origin, early rapid tests can eliminate

unnecessary antiiotic administration(

Surgical treatment- Tonsillitis

onsillectomy Asurgical remo'al of the palatine tonsilsB may e indicated for massi'e

hypertrophy that results in diculty reathing or eating(

denoidectomy Athe surgical remo'al of the adenoidsB is recommended for children who

ha'e hypertrophied adenoids that ostruct nasal reathing# additional indications for

adenoidectomy include recurrent adenoiditis and sinusitis, 6? with eusion, airway ostruction

and suse$uent sleep-disordered reathing, and recurrent rhinorrhea

.S# Care 'anagement- pro'iding comfort and minimi+ing acti'ities or inter'entions that

precipitate leeding soft to li$uid diet is generally preferred( cool mist 'apori+er !eeps themucous memranes moist during periods of mouth reathing( Larm saltwater gargles, warm

uids, throat lo+enges, and analgesic-antipyretic drugs such as acetaminophen are useful to

promote comfort( 6ften opioids are needed to reduce pain for the child to drin!( Comination

nonopioid and opioid elixirs such as hydrocodone AortaB relie'e pain# e'ery 4 hours while

symptoms persist( 8f surgery is needed, the need pain medication at regular inter'als for at least

the )rst /4 to 42 hours# any longer thereDs another prolem

Food and uid are restricted until children are ale to swallow them and are alert with no signs of

hemorrhage( Cool water, crushed ice, a'ored ice pops, or diluted fruit %uice is gi'en# uids with

a red or rown color are generally a'oided to distinguish fresh or old lood in emesis from the

ingested li$uid( traws should e a'oided, since these may damage the surgical site and causesuse$uent leeding( Citrus %uice may cause discomfort and is usually poorly tolerated( ?il!, ice

cream, or pudding is not usually oered until clear uids are retained ecause mil! products coat

the mouth and throat, causing the child to clear the throat, which may initiate leeding(

Otitis 'edia- ear infection# presence of uid, inammation in the middle ear along with acute

signs of illness# winter months, most pre'alent in early childhood due to eustachian tues

'ertical wider shorter

Etiology- 0acteria: treptococcus pneumoniae, *( inuen+ae, and ?oraxella catarrhalis# Miruses:

EM and inuen+a

.atho- primarily a result of a dysfunctioning eustachian tueApart of a contiguous system

composed of the nares, nasopharynx, eustachian tue, middle ear, and mastoid antrum and air

cells(

Eustac%ian tubes 3 functions relative to t%e middle ear!

1( protection of the middle ear from nasopharyngeal secretions,/( drainage of secretions produced in the middle ear into the nasopharynx, and


9/23

9

3( Mentilation of the middle ear to e$uali+e air pressure within the middle ear and

atmospheric pressure in the external ear canal and replenishment of oxygen that has een

asored(

Clinical manifestations-6?

T%erapeutic 'anagement- 6?-reatment for 6? is one of the most common reasons for

antiiotic use in the amulatory setting

• .rescrie antiiotics to children J mos @ older with se'ere otalgia for at least 42 hours or

temperature P1;/(/Q F R39Q CSB(

K .rescrie antiiotics for bilateral )O' T /4 months $it%out se'ere otalgia for at least 42

hours or temperatureU1;/(/Q F R39Q CSB(

K ither prescrie antiiotics or oer oser'ation with close follow-up for unilateral 6? in

children 2 mo- 3 mo of age $it%out se'ere otalgia for at least 42 hours or temperature

U1;/(/Q F R39Q CSB# if child does not impro'e within 42 to N/ hours, egin antiiotic therapy(

• ither prescrie antiiotics or oer oser'ation with close follow-up for unilateral or

bilateral /4 mo old or older $it%out se'ere signs and symptoms otalgia for at least 42

hours or temperature U1;/(/Q F R39Q CSB(

.S# Care 'anagement-)O' relieving pain, facilitating drainage when possile, pre'enting

complications or recurrence, educating the family in care of the child, and pro'iding support to

the child and family(

)cute Epiglottitis- is a non infectious medical emergency# /-5yrs ut can occur to adulthood#

re$uires immediate medical attention# usually Caused y /6 in;uen(a, can e cause y hot

foods"li$uids, smo!e inhalation, foreign odies, crac! cocaine# 0 and epiglot( o not occurtogether

Clinical manifestations: arupt, precede y sore throat, can rapidly progress to se'ere resp(

distress# children insist on sitting upright and leaning forward with chin out mouth open and

tongue protruding, drooling, diculty and pain swallowing, irritale and extremely restless and

has an apprehensi'e frightened expression( he 'oice is thic! and muVed, with a frogli!e

croa!ing sound on inspiration( T%e c%ild is not %oarse( uprasternal and susternal retractions

may e 'isile( he child seldom struggles to reathe, and slow, $uiet reathing pro'ides etter

air exchange( he sallow color of mild hypoxia may progress to fran! cyanosis if treatment is

delayed( he throat is red and inamed, and a distincti'e, large, cherry red, edematous epiglottis

is 'isile on careful throat inspection(

NSG Alert- Absence o spontaneous cough, drooling & agitation

T%erapeutic 'anagement- Epiglottitis- may de'elop suddenly, with respiratory

ostruction appearing rapidly( .rogressi'e ostruction leads to hypoxia, hypercapnia, and

acidosis, followed y decreased muscular tone, reduced le'el of consciousness, and, when

ostruction ecomes more or less complete, sudden death(


10/23

1;

.re'ention: 8t is recommended that all children recei'e the *( inuen+a type 0 con%ugate 'accine

eginning at / months of age since administration of the 'accine has ecome a routine part of

the immuni+ation schedule# the incidence of epiglottitis has declined( .atients now tend to e

older and ha'e disease caused y 'iral agents(

.ursing Care 'anagement- Epiglottitis- serious and frightening disease for the child, family,

and health professionals it is important to act $uic!ly ut calmly and pro'ide support withoutunduly increasing anxiety( he child is allowed to remain in the position that pro'ides the most

comfort and security and parents are reassured that e'erything possile is eing done to otain

relief for their child( roplet isolation precautions are indicated for /4 hours after initiation of

eecti'e antiiotic therapy to control spread of respiratory organisms( .rophylactic antiiotic

treatment of household and other contacts may e indicated

.S# )+E


11/23

11

• 8t is essential to allow children with mild croup to continue to drin! e'erages they li!e

and to encourage parents to use comforting measures with their child Ae(g(, holding,

roc!ing, wal!ing, and singing, reading oo!sB( 8f the child is unale to ta!e oral uids, 8M

uid therapy and 8M steroids may e indicated(

.ursing Care 'anagement- he most important nursing function in the care of children

with 0 is continuous, 'igilant oser'ation and accurate assessment of respiratory status


12/23

1/

T%erapeutic 'anagement- bronc%iolitis- pali'i+uma, a humani+ed mousemonoclonal antiody that is gi'en once e'ery 3; days A15 mg"!gB# Ho'emer and ?arch# 8?" 8M(

• Wncomplicated cases of ronchiolitis are treated symptomatically with supplemental

oxygen as re$uired, ade$uate uid inta!e, airway maintenance, and medications(• ?ostly managed at home(

• *ospitali+ation for respiratory distress"cannot maintain ade$uate hydration(

The American Academy o Pediatrics practice oygen i the inant ails to

maintain oygen saturation o at least !"# ater nasal suctioning and

repositioning

• Eoutine chest physiotherapy AC.B is not recommended

$andidates or this drug include% palii'umab%

K T 3/ wee!sD gestation

K T / yrs A/4moB with ronchopulmonary dysplasia who ha'e recei'ed supplemental

oxygen, ronchodilator, diuretic, or corticosteroid for the condition w"in J months efore EM

season

(et)een *+ - * )ee.s/%

K T 3 months efore the onset of or during the EM season

K 1 out of / ris! factors present: attends day care, at least one other child younger than

age 5 in the householdB

K T 3 months of age

.ursing Care 'anagement

• separate rooms or rooms with other EM-infected children(

• Wse roplet, $ontact , and tandard .recautions

• *and washing, not touching the nasal mucosa or con%uncti'a, and using glo'es, gowns,

and mas!s when entering the patientDs room(

• Eeduce contact with patient hospital personnel, 'isitors, uninfected

&I-&oreign ody Ingestion > )spiration

8st degree- ostruction allows air to pass in bot% directions

nd degree- air can pass only in one direction

Complete Obstruction- F0 & edematous mucosa loc! passage

NSG Alert - igns of truly cho!ing: canDt spea!, cyanotic, collapses# re$uires immediate action#

c%ild can die $"in 4min# Follow-up care after the F0 is remo'ed includes monitoring for

respiratory distress and educating the parents(


13/23

13

86 Cannot spea0 6 Cyanotic 36 Collapses

)st%ma-

a chronic inammatory disorder w" recurring symptoms, airway ostruction, and ronchial

hyper responsi'eness

• hee'ing, "reathlessness, chest tightness, and cough, especially at night or in the early

morning(

• airow limitation or ostruction that is re'ersile either spontaneously or with treatment#

increase in ronchial hyperresponsi'eness to a 'ariety of stimuli

)st%ma triggers

llergens: OutdoorXrees, shrus, weeds, grasses, molds, pollens, air pollution, spores

IndoorXust or dust mites, mold, coc!roach antigen

IrritantsXoacco smo!e, wood smo!e, odors, sprays

xposure to occupational c%emicals, Exercise, Cold air: Changes in weather or temperature

Environmental c%angeXmo'ing to new home, starting new school

Colds and infections

)nimalsXCats, dogs, rodents, horses

'edicationsXspirin, nonsteroidal anti-inammatory drugs, antiiotics, eta loc!ers

Strong emotionsXFear, anger, laughing, crying

ConditionsXastroesophageal reux, tracheoesophageal )stula

&ood additivesXul)te preser'ati'es

&oodsXHuts, mil! and dairy products

Endocrine factorsX?enses, pregnancy, thyroid disease

Pat%op%ysiology- inammation causes heightened airway reacti'ity in asthma# 8t is unli!ely

that asthma is caused y either a single cell or a single inammatory mediator(

Chronic inammation may also cause permanent damage 0air)ay remodelingB to airway

structures# this remodeling cannot be preented by and is not responsie to current

treatments

Clinical 'anifestations-)st%ma: dyspnea, whee+ing, coughing(


14/23

14

Children: acute episodes of shortness of reath, whee+ing, and cough followed y a $uiet period

to a relati'ely continuous pattern of chronic symptoms that uctuate in se'erity(

Diagnostic Evaluation: .ulmonary Function est- o%ecti'e e'al of the presence and degree

of lung disease & the response to therapy

pirometry: for children 5-Jyrs, traditional"simple mechanical done at the time of initial

assessment, after treatment when symptoms are staili+ed e'ery 1-/ years to assess airway

funx( ?aintenance

.FE- Pea0 expiratory ;o$ rate Amax air ow forcefully exhaled in 1 sec and measured in

"minB can e measured using .F? pea0 expiratory ;o$ meter

K reen A2;O to 1;;O of personal estB signals all clear( sthma is under reasonaly good

control( Ho symptoms are present, and the routine treatment plan for maintaining control can e

followed(

K Yellow A5;O to N9O of personal estB signals caution( sthma is not well controlled( n acute

exaceration may e present( ?aintenance therapy may need to e increased( Call the

practitioner if the child stays in this +one(

K Eed Aelow 5;O of personal estB signals a medical alert( e'ere airway narrowing may e

occurring( short-acting ronchodilator should e administered( Hotify the practitioner if the

pea! expiratory ow rate does not return immediately and stay in yellow or green +one

)st%ma drug t%erapy

)C:TE!

Anticholinergic Aatropine and IpratropiumB help relie'e acute bronc%ospasm( *owe'er,

these drugs ha'e ad'erse side eects that include drying of respiratory secretions, lurred

'ision, and cardiac and central ner'ous system stimulation( he primary anticholinergic drug

used is 8pratropium: which does not cross the 000, therefore elicits no CH eects Aas does

atropineB(

1agnesium sulate, a potent muscle relaxant that acts to decrease inammation and impro'es

pulmonary function and pea! ow rate, may e used in pediatric patients treated in the

emergency department or 8CW with moderate to se'ere asthma( he drug is administered

intra'enously at /5 to N5 mg"!g

2-Adrenergic agonists Ashort actingB Aprimarily aluterol, le'aluterol RGopenexS, and

terutalineB are used for treatment of acute exacerations and for the pre'ention of 80( i'en

)rst 8n emergency treatment

3ong term treatment%

$orticosteroids are anti-inammatory# reduce ronchial hyperresponsi'eness in chronic

asthma( 8nhaled corticosteroids should e used as )rst-line therapy in children o'er 5 years of

age(


15/23

15

$romolyn sodium maintenance therapy age / years@# staili+es mast cell memranes# inhiits

acti'ation, release of mediators from eosinophil and epithelial cells# inhiits the acute airway

narrowing after exposure to exercise# cold, dry air# and sulfur dioxide( H6 immediate relief of

symptoms# minimal side eects Aoccasional cough from inhalation of the powder formulationB#

only available as an oral preparation or 'ia neuli+er( Cromolyn sodium and nedocromil sodium

inhaler preparations discontinued /;1;

3eu.otrienes: mediators of inammation that cause increases in airway hyperresponsi'eness(

(a?rlu0ast @)ccolateS yr4 & montelu0ast sodium AsingularB 5+mo4 loc! inammatory

and ronchospasm eects( hese drugs are N6T used to treat acute episodes ut are gi'en

orally in comination with Z-agonists and steroids to pro'ide long-term control and pre'ent

symptoms in mild persistent asthma(

P%arm6 oo0 Info

nti inammatory- glucocorticoids- gi'en on )xed scheduled

0ronchodilators- beta- agonists- acute ronchospasm# .EH")xed"long term schedule

1( .rophylaxis & maintenance 1/mos@/( .re'ention of 80 15yr@3( Eelief of allergic rhinitis

Cystic &ibrosis- C&

• stimated that 1 in /9 Caucasians in the Wnited tates is a symptom-free carrier(

• utosomal recessi'e trait#

Pat%op%ysiology

e'eral clinical features characteri+e CF:

• increased 'iscosity of mucous gland secretions, a

• stri!ing ele'ation of sweat electrolytes, an

• increase in se'eral organic and en+ymatic constituents of sali'a, and

• normalities in autonomic ner'ous system function

• primarily a result of anormal chloride mo'ement# the CFE appears to function as a

chloride channel

Primary actor, responsible or many o the clinical maniestations o the disease% is

mechanical obstruction caused by the increased iscosity o mucous gland secretions

The goals o $7 therapy are to preent or minimi'e pulmonary complications, ensure

ade8uate nutrition or gro)th, encourage appropriate physical actiity, and promote

a reasonable 8uality o lie or the child and the amily

.ancreas issues

9iagnosed 'ia: s)eat test - positi'e J;m$"# fat in stools, patchy atelectasis"ostructi'e

emphysema on $hest :-ray

$linical 1aniestations: he most common symptoms are


16/23

1J

A1B .rogressi'e chronic ostructi'e lung disease associated with infection

A/B ?aldigestion from exocrine pancreatic insuciency

A3B rowth failure from malasorption and anorexia

A4B iaetes symptoms of hyperglycemia, polyuria, glycosuria,

": growth failure Afailure to thri'eB, increased weight loss despite increased appetite, gradual

deterioration of the respiratory system( may not e readily apparent, especially when there is no

familial e'idence of CF


17/23

1N

+eu0emia - p 1392

road term for malignant diseases of the one marrow & lymphatic system

?orphology- 8n children, two forms are generally recogni+ed:

Acute lymphoblastic leu.emia 0A33> three sutypes: 1- most common /, and 3(

Acute myelogenous leu.emia 0A13> 2 sutypes

C%romosome Studies-Chromosome analysis of leu!emic cells has ecome an important tool in

the diagnosis and management of patients with and ?( For example, children with trisomy

/1 ha'e /; times the ris! of other children for de'eloping

Pat%ologic and


18/23

12

A3B 'aintenance- which consists of further chemotherapy to ensure the disease stays in

remission(

one 'arro$ Transplantation! successfully in treating some children with and ?(

• 0? is not recommended for children with during the ?rst remission ecause of

the excellent results possile with chemotherapy( (est result )? (1T during second

remission(poorer prognosis with ?, transplantation considered during the )rst remission

Prognosis- he ma%ority of children with newly diagnosed leu!emia who recei'e eecti'e

multiagent chemotherapy will sur'i'e# reported o'erall sur'i'al is more than 2;O

.ursing Care 'anagement- Hursing care of the child with leu!emia is directly related to the

regimen of therapy( ?yelosuppression, drug toxicity, and leu!emic in)ltration cause secondary

complications that necessitate supporti'e physical care

/emop%ilia- p839

• he term hemophilia refers to a group of leeding disorders resulting from congenital

de)ciency, dysfunction, or asence of speci)c coagulation proteins or factors

• 2;O of all cases F-lin0ed recessive inheritance pattern

?ost common- factor M888 2 de)ciency Ahemophilia , or classic hemophiliaB most pre'alent

1"5;;;# abnormal PTT labs• factor 9 8G de)ciency Ahemophilia 0, or Christmas diseaseB# 1"/;-3;,;;;

• he most fre$uent pattern of transmission is through the union of an una@ected male

)ith a trait-carrier emale

'odes of Transmission

• G-lin!ed recessi'e disorder, ut only aout J;O of aected children ha'e a positi'e family

history for the disease(

• Wp to 1"3 gene mutation(

• he most fre$uent pattern of transmission is through the union of an unaected male with

a trait-carrier female(• 0"c treatments for hemophilia ha'e impro'ed the results of a union etween an a=ected

male and a normal or carrier female must also e considered( For example, the chances

are e$ual Ae(g(, 1 in 4B that an ospring of an aected male and a carrier female will e an

aected son, an aected daughter, a carrier daughter, or a normal son( uch parentage is

one of the few ways in which a female inherits the disorder( Female carriers may ha'e low

le'els of factor M888 and e symptomatic(

Pat%op%ysiology and Clinical 'anifestations- %emop%ilia

• he asic defect of hemophilia is a de)ciency of factor M888 Aantihemophilic factorB(


19/23

19

• Factor M888 is produced y the li'er and is necessary for the formation of thromoplastin in

phase 8 of lood coagulation(

• he less factor M888 that is found in the lood, the more se'ere the disease

• ucutaneous and intramuscular hemorrhages are common

• *emarthrosis, leeding into the %oint ca'ities, especially the !nees, elows, and an!les, is

the most fre$uent form of internal leeding(

• 0ony changes and crippling deformities occur after repeated leeding episodes o'er

se'eral years(

• Early signs of %emart%rosis: stiness, tingling, or ache in the aected %oint, followed y

a decrease in the aility to mo'e the %oint( 6'ious signs and symptoms are warmth,

redness, swelling, and severe pain, with considera"le loss o movement%

Sic.le $ell Trait-p5*"

Pathophysiology and $linical 1aniestations

he clinical manifestations of C are primarily the result of:

A1B 6struction caused y the sic!led E0Cs

A/B Mascular inammation

A3B 8ncreased E0C destruction(

(he a"normal adhesion, entanglement, and enmeshing o rigid sic)le-shaped cells accompanied

"y the infammatory process intermittently "loc)s the microcirculation, causing asoocclusion;

(he resultant a"sence o "lood fow to ad.acent tissues causes local hypo!ia, which leads to

tissue ischemia and inarction #cellular death$

Normal adult hemoglo"in is partly or completely replaced "y a"normal hemoglo"in

/utosomal recessive

Sic0le Cell Crises- Masoocclusi'e crisis AM6CB, preferaly called a painful episode or e'ent, is

the most common type of non-life-threatening crisis( 8t is characteri+ed y ischemia that causes

mild to se'ere pain that may last from minutes to days(

Screening of .e$borns-creening for C in the neworn period can identify children with

hemogloinopathies( Wni'ersal screening of neworns for C has ecome standard in all 5; W(

states and territories

T%erapeutic 'anagement- he aims of therapy are to

1( pre'ent the sic!ling phenomenon, which is responsile for the pathologic se$uelae/( o treat the medical emergency of sic!le cell crisis(

(he successul achievement o these aims depends on prompt nursing interentions and

medical therapies, child and amily preentie measures, and innovative treatment

interentions(

.ursing Care 'anagement- ?inimi+e issue eoxygenation, promote hydration, minimi+e

crises, promote supporti'e therapy


20/23

/;

'inimi(e Tissue Deoxygenation-nything that increases cellular metaolism also results in

tissue hypoxia(

A1B a!ing fre$uent rest rea!s during physical acti'ities

A/B 'oiding contact sports if the spleen is enlarged

A3B 'oiding en'ironments with low oxygen concentration, such as high altitudes ornonpressuri+ed airplane ights# and A4B a'oiding !nown sources of infection( 8f the child has e'ena mild infection, the parents must see! medical attention at once(

Promote /ydration- importance of ade$uate hydration to pre'ent sic!ling and delay the

'asoocclusion and hypoxia ischemia cycle( Approximately 1J;; ml"m/"dayB, which is the

minimum daily uid inta!e( he nurse also assesses the childDs usual uid consumption to

e'aluate its ade$uacy and ma!es ad%ustments ased on this !nowledge( 8t is not sucient to

ad'ise parents to =force uids> or =encourage drin!ing(> hey need speci)c instructions on how

many glasses or ottles of uid are re$uired# chec! mucus memranes

'inimi(e Crises-0ecause infection is the ma%or cause of death due to the odyDs inaility to

resist infection, the nurse stresses to parents the importance of ade8uate nutrition, re8uent

medical superision, proper hand )ashing, and isolation rom .no)n sources o

inection; 7eep in mind that children also need to li'e a normal life( 6'erprotection can e as

de'astating emotionally as an infection is physically( .arents need to e aware of the need to

see! prompt medical care at the )rst sign of any infection( each the family the signs and

symptoms of crises and ad'ise them to see! medical attention immediately when any are

present( eaching parents spleen palpation for earlier detection of splenic se$uestration can

reduce mortality from this serious complication(

Promote Supportive T%erapies he success of many of the medical therapies relies hea'ily

on nursing implementation( ?anagement of pain is an especially dicult prolem and oftenin'ol'es experimenting with 'arious analgesics, including opioids, and 'arious schedules efore

relief are achie'ed( Wnfortunately, these children tend to e under medicated, which results in

=cloc! watching> and demands for additional doses sooner than might e expected( 6ften this

incorrectly raises suspicion o drug addiction, when in act the pro"lem is one o inadeuate pain

control

Drug )lert - ?eperidine Apethidine RemerolSB is not recommended ( Hormeperidine, a

metaolite of meperidine, is a central ner'ous system stimulant that produces anxiety, tremors,

myoclonus, and generali+ed sei+ures when it accumulates with repetiti'e dosing( .atients with

C are particularly at ris! for normeperidine-induced sei+ures

$hildren/s Bnderstanding and =eactions to 9ying-pC!C

ges and stages may e helpful as a general guide, ut communication should e ased

on the cogniti'e de'elopmental capailities of the indi'idual child and his or her readiness for

such discussion

0y apprx( Nyrs most children understand the !ey io-scienti)c components of death# 4-

1/yrs ha'e an adult li!e understanding of death

Infants and toddlers:


21/23

/1

Concept of Deat%: oddlers are egocentric and can only thin! aout e'ents in terms of

their own frame of reference: li'ing( heir egocentricity and 'ague separation of fact and fantasy

ma!e it impossile for them to comprehend asence of life( 8nstead of understanding death,

this age-group is aected more y any change in lifestyle(


22/23

//

Sc%ool age! may still associate misdeeds or ad thoughts with causing death and feel intense

guilt and responsiility ut ecause of their higher cogniti'e ailities, they respond well to logical

explanations and comprehend the )gurati'e meaning of words etter

Concept of eath: hese children still associate misdeeds or ad thoughts with causing

death and feel intense guilt and responsiility for the e'ent( 0ecause of their higher cogniti'e

ailities, they respond well to logical explanations and comprehend the )gurati'e meaning ofwords( hey ha'e a deeper understanding of death in a concrete sense( hey particularly fear

the mutilation and punishment they associate with death( hey personify death as the de'il,

a monster, or the ogeyman( hey may ha'e naturalistic-physiologic explanations of death( 0y

age 9 or 1;, children ha'e an adult concept of death, reali+ing that it is ine'itale,

uni'ersal, and irre'ersile


23/23

/3

shame( hey are li!ely to see de'iations from accepted eha'ior as the reason for their

illness(

peds bone resp cardio

Documents