meningitis patho
-inflammation of the CSF and meninges
-viral (aseptic) requires only supportive care
-bacterial (septic) is contagious and the prognosis depends on how quickly care is initiated
meningitis risk factors
-viral: cytomegalovirus, adenovirus, mumps, HSV, arbovirus
-bacterial: N. meningitidis, S. pneumoniae, H. influenzae type B, E. coli
-injuries that provide direct access to CSF (skull fracture, penetrating head wound)
-crowded living conditions
meningitis manifestations (newborns)
-no illness present w/ birth, but progresses within a few days
-vague symptoms that are hard to diagnose
-poor muscle tone, weak cry, poor suck, refuses feeding, vomiting or diarrhea, possible fever or hypothermia
-neck is supple without nuchal rigidity
-
meningitis manifestations (3 months to 2 years)
-seizures with high-pitched cry
-fever & irritability
-bulging fontanels
-possible nuchal rigidity
-poor feeding
-vomiting
-Brudzinski's & Kerning's signs not reliable for dx
meningitis manifestations (2 years through adolescence)
-seizures (often initial sign)
-nuchal rigidity
-positive Brudzinski's sign (flexion of extremities occurring with deliberate flexion of the child's neck)
-positive Kerning's sign (resistance to extension of child's leg from a flexed position)
-fever & ch
meningitis CSF analysis
BACTERIAL:
-cloudy color
-elevated WBC
-elevated protein content
-decreased glucose content
-positive gram stain
VIRAL:
-clear color
-slightly elevated WBC
-normal or slightly elevated protein content
-normal glucose content
-negative gram stain
lumbar puncture
-for definitive diagnosis of meningitis (into subarachnoid space between L3 and L4 or L4 and L5 vertebral spaces)
-have child empty bladder
-apply topical anesthetic 45 min to 1 hr prior to procedure
-place child in side-lying position with head flexed an
meningitis nursing care
-petechia or purpuric-type rash requires immediate medical attention
-isolate child as soon as meningitis is suspected, maintain droplet precautions
-monitor VS, urine output, fluid status, pain level, neurologic status, and head circumference (infants)
-
meningitis medications
-antibiotics for bacterial infections (IV up to 10 days)
-corticosteroids (dexamethasone) for bacterial; assists with initial management of increased ICP; most effective for reducing neurologic complications in children w/ Hib infections
-analgesics for p
meningitis complications
-increased ICP; can lead to neurological dysfunction
-signs of increased ICP:
INFANTS: bulging or tense fontanels, increased head circumference, high-pitched cry, distended scalp veins, irritability, bradycardia, and respiratory changes
CHILDREN: increase
Reye Syndrome patho
-life-threatening disorder that involves acute encephalopathy and fatty changes of the liver
-cause not understood
-peak incidence occurs when influenza is most common; typically january, february, and march
-early recognition & treatment necessary for be
reye syndrome risk factors
-potentially caused by using aspirin products for treating fever caused by viral infections
-typically follows a viral illness (influenza, gastroenteritis, varicella)
reye syndrome manifestations
-lethargy
-irritability
-combativeness
-confusion
-delirium
-profuse vomiting
-convulsions
-loss of consciousness
reye syndrome laboratory tests
-liver enzymes (ALT, AST) elevated
-serum ammonia level elevated
-serum electrolytes altered due to cerebral edema and liver changes
-coagulations times may be extended
reye syndrome diagnostics (liver biopsy)
-maintain NPO status prior to procedure
-monitor for hemorrhage postprocedure
-assess VS frequently postprocedure
reye syndrome nursing care
-administer IV fluids to maintain hydration
-maintain accurate I&O
-insert indwelling urinary catheter as ordered
-avoid extreme flexion, extension, or rotation
-maintain head in midline neutral position
-keep HOB elevated 30 degrees
-note unexplained or
reye syndrome medications
-osmotic diuretic (mannitol): decreases cerebral swelling
-vitamin K: improves synthesis of blood clotting factors in the liver; subQ preferred route; identify sensitivity to benzyl alcohol or castor oil
reye syndrome complications
-neurologic sequelae: sometimes includes speech and/or hearing impairment, and developmental delays based on length & severity of illness
-death
seizure patho
-abnormal, excessive electrical discharges of neurons within the brain caused by a disease process
tonic-clonic seizures (generalized)
-onset without warning
TONIC PHASE (10 to 20 seconds):
-eyes roll up
-loss of consciousness
-tonic contraction of entire body, w/ arms flexed and legs, head and neck extended
-possible piercing cry
-increased salivation
-loss of swallowing reflex
-apnea l
tonic-clonic seizures (postictal phase)
-arouses with difficulty
-confused for several hours
-impairment of fine motor movements
-lack of coordination
-possible vomiting, headache, or visual or speech difficulties
-sleeps for several hours
-no recollection of seizure
absence seizure (generalized)
-onset between 4 and 12 years and ceases by puberty
-loss of consciousness lasting 5 to 10 seconds
-minimal or no change in behavior
-resembles daydreaming or inattentiveness
-may drop items being held
-lip smacking, twitching of eyelids or face, or sligh
myoclonic seizures (generalized)
-variety of seizure episodes
-symmetric or asymmetric involvement
-brief contractions of muscle or groups of muscle
-no postictal phase
-may or may not lose consciousness
atonic or akinetic seizure (generalized)
-muscle tone is lost for a few seconds
-period of confusion follows
-loss of muscle tone frequently results in falling
infantile spasms
-most common during first 8 months of life
-sudden, brief, symmetric muscle contractions
-flexed head, extended arms with legs drawn up
-possible eyes rolling up and in
-possible loss of consciousness
-possible flushing, pallor, or cyanosis
-possible cry
aversive seizure
-eyes and head turn away from side of focus, w/ or w/out loss of consciousness
rolandic seizure
-tonic-clonic movements involving face and most common during sleep
simple partial seizure with sensory signs
-tingling, numbness or pain in one area of the body then spreading to other parts, with visual sensations
complex partial seizures
-altered behavior
-inability to respond to environment
-impaired consciousness
-confusion and unable to recall event
-complex sensory aura: stage feeling in stomach that rises to the throat, auditory or visual hallucinations, feelings or fear, distorted s
EEG for seizures
-records electrical activity and may identify origin of seizure activity
-can be monitored during sleep, when awake, and w/ stimulation & hyperventilation
-test can last 1 hr to multiple periods and days of monitoring
-can be performed w/ video monitoring
EEG education
-abstain from caffeine for several hours prior to procedure
-wash hair before and after (no oils or sprays) to remove electrode gel
-inform client that he may be asked to take deep breaths and/or exposed to flashes of light during procedure
-if prescribed
seizure precautions
-padded side rails or bed, crib, and wheelchair
-keep bed free of objects that could cause injury
-have suction and oxygen available
what to do during seizure
-protect from injury (move furniture away, hold head in lap if on floor)
-maintain position to provide patent airway
-be prepared to suction oral secretions
-turn client to side (decreases risk of aspiration)
-loosen restrictive clothing
-do not attempt t
post-seizure care
-maintain in side-lying position
-check VS
-assess for injuries, including mouth
-neurologic checks
-allow for rest if necessary
-reorient and calm client
-maintain seizure precautions (bed in lowest position, padded rails)
-note time of postictal period
antiepileptic agents (AEDs)
-diazepam (valium), phenytoin (dilantin), carbamazepine (tegretol), valproic acid (depakene), fosphenytoin (cerebyx)
-single medications is initiated at a low dose and gradually increased until seizures are controlled
-second medication can be added to ac
corpus callosotomy
-separation of the two hemispheres in the brain
status epilepticus
-prolonged seizure activity that lasts longer than 30 min or continuous seizure activity in which the client does not enter a postictal phase
-acute condition that requires immediate treatment to prevent loss of brain function, which may become permanent
status epilepticus nursing care
-maintain airway, administer oxygen, establish IV access, perform ECG monitoring, and monitor pulse ox and ABGs
-as prescribed, administer a loading dose of diazepam (valium) or lorazepam (ativan). if seizures continue after loading dose is given, fosphen
concussion
-injury to brain that altered brain function
contusion
-bruising of cerebral tissue
laceration
-tearing of cerebral tissue
late signs of increased ICP
-alterations in pupillary response
-posturing (decorticate and decerebrate)
-bradycardia
-decreased motor response
-decreased sensory response
-Cheyne-Stokes respirations
-coma
decorticate positioning
-dysfunction of cerebral cortex
-arms, wrists, and fingers flexed and bent inward onto chest and legs extended and adducted
decerebrate positioning
-disfunction of midbrain
-backward arching of head and arms w/ legs rigidly extended and toes pointing downward
expected ICP range
10 to 15 mmHg
nursing care of head injury
-ensure spine is stabilized until spinal cord injury is ruled out
-monitor VS, LOC, pupils, ICP, motor activity, sensory perception, and verbal responses at frequent intervals. use glasgow coma scale
-maintain patent airway; mechanical vent if indicated
-
interventions to decrease ICP
-keep HOB elevated to 30 degrees, which will also promote venous drainage
-avoid extreme flexion, extension, or rotation of head and maintain in midline neutral position
-keep clients body in alignment, avoiding hip flexion/extension
-minimize endotrachea
medications for head injuries
-corticosteroids: dexamethasone (decadron) and methylprednisolone (solu-medrol)- used to decrease cerebral edema
-mannitol (osmitrol)- osmotic diuretic used to treat cerebral edema
-antiepileptics: used to prevent or treat seizures
-antibiotics: in cases
craniotomy
-removal of part of the skull
-bone is replaced once edema has resolved
epidural hemorrhage
-bleeding between dura and skull
-manifestations: short periods of unconsciousness followed by normal period leading to herniation, coma, and death
subdural hemorrhage
-bleeding between dura and arachnoid membrane
-may be a result of birth injury, falls or violent shaking
-manifestations: irritability, vomiting, seizures
cerebral edema
-can develop within 24 to 73 hr posttrauma
-manifestations: increased ICP
brain herniation
-downward shift of brain tissue
-manifestations: loss of blinking, loss of gag reflex, pupils fail to react to light, coma, and respiratory arrest
visual screening tests
-using Snellen letter, tumbling E, or picture chart
-place client 10 feet from chart w/ heels on 10-foot mark
-should be wearing glasses (if appropriate), and keep both eyes open during screening
-while covering one eye, the client reads each line on the
partial visual impairment
-visual acuity of 20/70 to 20/200
legal blindness
-visual acuity of 20/200 or worse
cornmeal light reflex test
-observes ocular alignment
-flashlight is shone directly into client's eye from a distance of 16 inches
-reflected light should be observed in the same location on both corneas
cover test
-client is asked to cover each eye and observe an object at a distance of 13 inches
-cover is removed and eye is observed for movement, which should not occur
peripheral vision test
-have the client fixate on an object
-pencil is moved from beyond the field of vision into range of peripheral vision
-client is asked to say stop when the object is noted in the peripheral vision. this angle is then measured
-each quadrant of peripheral
Ishara or Hardy-Rand-Rittler test
-evaluates color vision
-client is shown a set of cars and asked to identify the number embedded in the confusion of colors
-client should identify all of the numbers on the cards with correct color vision
myopia (nearsightedness) manifestations
-sees close objects clearly, but not objects in distance
-headaches & vertigo
-eye rubbing
-difficulty reading
-clumsiness
-poor school performance
hyperopia (farsightedness) manifestations
-sees distant objects clearly, but not objects that are close
-bc of accommodation, not usually detected until age 7
astigmatism manifestations
-uneven vision in which only parts of letters on a page may be seen
-headache and vertigo
-appearance of normal vision because tilting head enables all letters to be seen
strabismus: esotropia (inward deviation of eye); extropia (outward deviation of eye) manifestations
-abnormal corneal light reflex or cover test
-misaligned eyes
-frowning or squinting
-difficulty seeing print clearly
-one eye closed to enable better vision
-head tilted to one side
-headache, dizziness, diplopia, photophobia, and crossed eyes
amblyopia (lazy eye) manifestations
-reduced visual acuity in one eye
anisometropia manifestations
-different refractive strength in each eye
-headache and vertigo
-excessive eye rubbing
-poor school performance
cataracts manifestations
-decreased ability to see clearly
-possible loss of peripheral vision
-nystagmus
-strabismus
-gray opacity of lens
-absence of red reflex
glaucoma manifestations
-loss of peripheral vision
-perception of halos around objects
-red eye
-excessive tearing (epiphora)
-photophobia
-spasmodic winking (blepharospasm)
-corneal haziness
-enlargement of eyeball (buphthalmos)
-possible pain
corrective measures for vision problems
-myopia: biconcave lenses; laser surgery
-hyperopia: convex lenses; laser surgery
-astigmatism: special lenses that compensate for refractive errors; laser surgery
-anisometropia: special lenses that compensate for refractive errors; preferably corrective
conductive hearing loss
-involves interference of sound transmission
-may result from otitis media, external ear infection, foreign bodies, or excessive ear wax
sensorineural hearing loss
-involves interference of the transmission along the nerve pathways
-may result from congenital defects or secondary acquired conditions (infection, ototoxic meds, exposure to constant noise)
central auditory imperception
-involves all other hearing losses (aphasia, agnosia [inability to interpret sounds])
hearing loss in infants
-lack of startle reflex
-failure to respond to noise
-absence of vocalization by 7 months
-lack of response to spoken word
hearing loss in older children
-using gestures rather than talking after 15 months
-failure to develop understood speech by 24 months
-yelling to express emotions
-irritability due to inability to gain attention
-seeming shy or withdrawn
-inattentive to surroundings
-speaking in monoto
oxygen saturation
-expected range is 95% to 100%
-level less than 86% is a life-threatening emergency
-use fingers, toes, ear lobe to place probe
-semi-Fowler's or Fowler's positions maximize ventilation; encourage deep breathing
metered-dose inhaler (MDI) proper use
-remove cap from inhaler
-shake 5 to 6 times
-attach spacer
-hold inhaler with mouthpiece at bottom
-hold with thumb near mouthpiece, and index & middle fingers at the top
-open-mouth method: hold inhaler approx. 2-4 cm away from front of mouth
-closed-mo
dry powder inhaler (DPI) proper use
-do not shake device
-take cover off mouthpiece
-turn wheel to prepare med
-exhale completely
-place mouthpiece between lips and take a deep breath through mouth
-hold breath for 5 to 10 seconds
-take inhaler out of mouth and slowly exhale through pursed
chest physiotherapy
-percussion, vibration, and postural drainage. gravity and positioning loosen respiratory secretions and move them into central airways, where they can be eliminated by coughing or suctioning to rid excessive secretions from specific areas of the lungs
-i
chest physiotherapy nursing care (pre-procedure)
-schedule treatments 1 hr before or 2 hr after meals and at bedtime to decrease likelihood of vomiting or aspirating
-administer bronchodilator meds or nebulizer treatment prior to postural drainage if prescribed
-offer an emesis basin & facial tissues
chest physiotherapy nursing care (intraprocedure)
-for apical secretions of upper lobes: fowler's position
-for posterior secretions of upper lobes: side-lying position
-for right lobe: position on left side w/ pillow under chest wall
-for left lobe: Trendelenburg position
-apply manual percussion using
chest physiotherapy nursing care (post-procedure)
-auscultate lungs and assess amount, color, and character of expectorated secretions
-document interventions and repeat procedure as prescribed (typically 2-4 times daily)
nasal suctioning
-use clean technique
-use mushroom tip catheter
oral suctioning
-use clean technique
-use hard catheter tip
-insert in sides of mouth
endotracheal and tracheal suctioning
-assist child into high-fowler's or fowler's position if possible
-perform through tracheostomy or endotracheal tube. obtain a suction catheter with an outer diameter of no more than 1 cm of internal diameter of tube
-hyperoxygenate child using bag-valve
nursing care of artificial airways
-do not suction routinely; this may cause mucosal damage, bleeding, and bronchospasm
-suction should be done on a PRN basis when assessment findings indicate need to do so (audible/noisy secretions, crackles, restlessness, tachypnea, tachycardia, and mucu
tonsillitis manifestations
-tonsils become inflamed and reddened
-small patches of yellowish pus may also be visible
-report of sore throat with difficulty swallowing
-may have hx of otitis media and hearing difficulties
-mouth odor
-mouth breathing
-snoring
-nasal qualities in voi
tonsillitis nursing care
-provide symptomatic treatment for viral tonsillitis (rest, cool fluids, warm salt-water gargles)
-administer antibiotics for bacterial tonsillitis
tonsillitis medications
-antipyretics: acetaminophen or ibuprofen to decrease fever and manage pain
-antibiotics: IM penicillin G, erythromycin, azithromycin, cephalosporins, amoxicillin
tonsillectomy post-op
POSITIONING:
-side-lying position or on abdomen to facilitate drainage
-elevate HOB when child is fully awake
ASSESSMENT:
-assess for signs of bleeding (frequent swallowing, clearing the throat, restlessness, bright red emesis, tachycardia, and/or pallor)
tonsillectomy post-procedure teaching
-discourage coughing, throat clearing, and nose blowing to protect surgical site
-refrain from placing pointed objects in back of mouth
-alert parents that there may be clots or blood-tinged mucus in vomitus
-contact provider if any signs of bleeding, dif
nasopharyngitis (common cold)
-self-limiting virus that persists for 7-10 days
-nasal inflammation, rhinorrhea, cough, dry throat, sneezing, and nasal qualities in voice
-fever, decreased appetite, and irritability
nasopharyngitis nursing care
-give antipyretic for fever
-rest
-provide vaporized air (cool mist)
-give decongestants in children older than 1 year
-give cough suppressants with caution (avoid over-sedation)
-antihistamines not recommended
-antibiotics not indicated
bacterial tracheitis
-infection of the lining of the trachea
-thick, purulent drainage from the trachea that can obstruct the airway and cause resp. distress
-fever, croupy cough, stridor
bacterial tracheitis nursing care
-administer oxygen as ordered
-monitor continuous oximetry
-antipyretics for fever
-IV antibiotics as prescribed
bronchitis
-associated with an upper respiratory infection and inflammation of large airways
-self-limiting and requires symptomatic relief
-persistent cough as result of inflammation
-resolves in 5 to 10 days
bronchitis nursing care
-antipyretics for fever
-give cough suppressant
-provide increased humidity (cool mist vaporizer)
bronchiolitis
-mostly caused by RSV
-occurs at bronchiolar level
-rhinorrhea: intermittent fever, cough, and wheezing
-coughing that progresses toward wheezing, increased resp. rate, nasal flaring, retractions, and cyanosis
-possible posttussive vomiting due to coughin
bronchiolitis nursing care
-provide humidified oxygen as ordered
-monitor continuous oximetry
-encourage fluid intake if tolerated
-administer IV fluids if oral intake not tolerated
-suction nasopharynx as needed
-administer nebulized bronchodilator
-corticosteroids and antihistami
allergic rhinitis
-caused by seasonal reaction to allergens most often in autumn and spring
-watery rhinorrhea; nasal congestion; itchiness of the nose, eyes, and pharynx; itchy, watery eyes; nasal quality of voice; dry, scratchy throat; snoring; poor sleep leading to poor
allergic rhinitis nursing care
-avoid allergens
-give antihistamines
-give nasal corticosteroids
pneumonia (RSV, S. pneumoniae, H. influenzae, M. pneumoniae)
-high fever
-cough that is either productive or nonproductive of white sputum
-retractions and nasal flaring
-rapid, shallow respirations
-report of chest pain
-adventitious breath sounds (rhonchi, crackles)
-pale color that progresses to cyanosis
-irrita
pneumonia nursing care
VIRAL:
-(symptom management)
-administer oxygen w/ cool mist as ordered
-monitor continuous oximetry
-administer antipyretics for fever
-monitor I&O
BACTERIAL:
-encourage rest
-promote increase oral intake
-monitor I&O
-administer antipyretics for fever
-
croup syndromes
-bacterial epiglottis (acute supraglottis)
-acute laryngotracheobronchitis
-acute spasmodic laryngitis
-influenza A and B
bacterial epiglottis (acute supraglottis)
-MEDICAL EMERGENCY
-caused by H. influenzae
-predictive signs: absence of cough, drooling, and agitation
-sitting with chin pointing out, mouth opened, and tongue protruding
-dysphonia (hoarseness or difficulty speaking)
-dysphagia
-inspiratory stridor (n
epiglottis nursing care
-protect airway
-avoid throat culture or using tongue blade
-prepare for intubation
-provide humidified oxygen
-monitor continuous oximetry
-administer racemic epinephrine, corticosteroids, and IV fluids as ordered
-administer antibiotic therapy (ceftriax
acute laryngotrachobronchitis
-causative agents: RSV, influenza A & B, and M. pneumoniae
-low-grade fever, restlessness, hoarseness, barky cough, dyspnea, inspiratory stridor, retractions
acute spasmodic laryngitis
-self-limiting illness that may result from allergens
-barky cough, restlessness, difficulty breathing, hoarseness, and nighttime episodes of laryngeal obstruction
acute laryngotrachobronchitis AND acute spasmodic laryngitis nursing care
-provide humidity with cool mist
-administer oxygen if needed
-monitor continuous oximetry
-administer nebulized racemic epinephrine as ordered
-administer corticosteroids; oral (prednisone), IM (dexamethasone), or nebulizer (budesonide)
-encourage oral i
influenza A and B
-can be mild, moderate, or severe
-sudden onset of fever and chills
-dry throat and nasal mucosa
-dry cough
-flushed face
-photophobia
-myalgia
-fatigue
influenza A and B nursing care
-promote increased fluid intake
-rest
-medications as ordered
medications for influenza
TYPE A:
-amantadine (Symmetrel): shortens length of illness; give within 24 to 48 hr of onset of symptoms
-rimantadine (Flumadine): treats manifestations; give orally 2 times daily for 7 days for children older than 1 year
TYPE A & B:
-zanamivir (Relenza)
pneumothorax
(complication)
-accumulation of air in pleural space
-s/s: dyspnea, chest pain, back pain, labored respirations, decreased oxygen sats, tachycardia
-prepare client for emergent needle aspiration w/ insertion of chest tube to closed drainage
-provide for c
pleural effusion
(complication)
-accumulation of fluid in the pleural space
-s/s: dyspnea, chest pain, back pain, labored respirations, decreased oxygen sats, tachycardia
-prepare client for emergent needle aspiration w/ insertion of chest tube to closed drainage
-provide
asthma patho
-chronic inflammatory disorder of the airways that results in intermittent and reversible airflow obstruction of the bronchioles
-the obstruction occurs either by inflammation or airway hyper-responsiveness
intermittent asthma
-symptoms occur 2 or fewer times per week
-nighttime symptoms 2 or fewer per month
-no interference with normal activity
-use short acting beta-agonist less than 2 times per week
mild persistent asthma
-symptoms occur more than twice a week, but not daily
-nighttime symptoms occur 1 to 2 times per month for 0- to 4-year-old and 3 to 4 times per month for 5- to 11-year-olds
-minor limitations with activity
-use of short-acting beta-agonists more than 2 d
moderate persistent asthma
-daily symptoms
-nighttime symptoms 3 to 4 times a month for 0- to 4-year-old and more than 1 time weekly, but not daily for 5- to 11-year-olds
-some limitation in activity
-uses short-acting beta-agonist daily
severe persistent asthma
-symptoms occur continually
-nighttime symptoms more than once a week for 0- to 4-year-olds and nightly for 5-to 11-year-olds
-limited activity
-use short-acting beta-agonist several times daily
asthma symptoms
-dyspnea
-cough
-audible wheezing
-coarse lung sounds
-mucus production
-restlessness
-anxiety
-red ears, dark red lips
-sweating
-use of accessory muscles
-decreased oxygen sats
pulmonary function tests
-most accurate tests for diagnosing asthma and its severity
-baseline test at time of diagnosis
-after treatment is initiated and child is stabilized
-yearly testing
peak expository flow rates
-measures amount of time that air can be forcefully exhaled in 1 second
-each child needs to establish personal best
short-acting beta agonists (bronchodilators)
-albuterol (Proventil)
-levalbuterol (Xopenex)
-terbutaline (Brethine)
albuterol
-watch child for tremors and tachycardia
ipatropium (Atrovent)
-cholinergic antagonist, anticholinergic med
-provides relief of acute bronchospasm
-observe child for dry mouth
-encourage older children to such hard candies to help dry mouth
corticosteroids for asthma treatment
METHYLPREDNISOLONE (SOLU-MEDROL):
-IV or oral
-children <12 years: 1 to 2 mg/kg/day divided q12h for 3 to 10 days
-children >12 years: 40 to 60 mg/day divided q12h for 3 to 10 days
PREDNISONE:
-oral
-<1 year: 10 mg q12h
-1 to 4 years: 20 mg q12h
-5 to 13
peak flow meter usage
-ensure marker is zeroed
-have child stand up straight
-close lips tightly around mouthpiece (ensure tongue is not occluding)
-blow out as hard and as quickly as possible
-read number on meter
-repeat 2 more times (wait at least 30 seconds between attempt
status asthmaticus
-life-threatening episode of airway obstruction that is often unresponsive to common treatment
-s/s: wheezing, labored breathing, nasal flaring, lack of air movement in lungs, use of accessory muscles, distended neck veins, risk for cardiac and/or respira
status asthmaticus nursing care
-monitor oxygen sats continuously
-place on continuous cardiorespiratory monitoring
-position child sitting upright, standing, or leaning slightly forward
-administer humidified oxygen
-administer nebulizer treatments of a beta-agonist 20 to 30 min apart
cerebral palsy (CP) patho
-nonprogressive impairment of motor function, especially that of muscle control, coordination, and posture
-may cause abnormal perception and sensation; visual, hearing, and speech impairments; seizures and cognitive disabilities
-manifests differently in
cerebral palsy risk factors
-existing brain anomalies, cerebral infections, head trauma (shaken baby syndrome), and/or anorexia to the brain
-maternal chorioamnionitis
-premature birth
-multiple births
-extremely low or very low birth weights in newborns
-inability of placenta to pr
cerebral palsy manifestations
-failure to meet developmental milestones
-persistent primitive reflexes (Moro or tonic neck)
-gagging or choking with feeding, poor suck reflex
-tongue thrust
-poor head control
-rigid posture and extremities, abnormal posturing
-asymmetric crawl
-hyperr
spastic (pyramidal) CP
-hypertonicity (muscle tightness or spasticity); increased deep tendon reflexes; clonus; and poor control of motion, balance, and posture
-impairments of fine and gross motor skills
-may present in all extremities (quadriplegia), similar parts of body (di
dyskinetic (nonspastic, extrapyramidal) CP
-athetoid: findings include involuntary jerking movements that appear slow, writhing, an wormlike. these movements involve the trunk, neck, face, and tongue
-dystonic: slow, twisting movements affect the trunk and extremities w/ abnormal posturing from mu
ataxic (nonspastic, extrapyramidal) CP
-evidence of wide-based gait and difficulty w/ coordination
-poor ability to do repetitive movements
-difficulty w/ quick or precise movements (writing or buttoning shirt)
-shakiness
-low muscle tone
cerebral palsy nursing care
-monitor developmental milestones
-evaluate need for hearing/speech evaluations
-promote independence w/ self-care activities as much as possible. assist child to maintain a positive self-image and high level of self-esteem
-assess developmental level
-st
cerebral palsy nutrition
-assess for possibility of aspiration
-determine ability to take oral nutrition
-ascertain correct positioning for feeding child. use head positioning and manual jaw control methods as needed
-provide foods that are similar to foods eaten at home when pos
CP skin care
-assess skin under splints and braces if applicable
-maintain skin integrity by turning child to keep pressure off bony prominences
baclofen (lioresal)
-medication for CP
-used as centrally acting skeletal relaxant that decreases muscle spasm and severe spacicity
-admin orally or intrathecally via implanted pump
-monitor for muscle weakness, increased fatigue, or less-common adverse effects (diaphoresis,
diazepam (valium) for CP
-skeletal muscle relaxant used to decrease muscle spasms and severe spasticity
-use in older children and adolescents
-monitor for drowsiness & fatigue
botulinum toxin A (Botox)
-medication used for CP
-reduces spasticity in specific muscle groups
-used primarily for clients w/ spasticity only in lower extremities
-monitor for temporary weakness
-teach family that onset of medication is 24 to 72 hr, with a peak of 2 weeks, lastin
spina bifida
-failure of osseous spine to close
-neural tube defects are present at birth and affect the CNS and osseous spine
spina bifida occulta
-mostly affects lumbosacral area and is not visible
spina bifida cystica
-has an visual sac protrusion
-meningocele: sac contains spinal fluid & meninges
-myelomeningocele: sac includes meninges, spinal fluid, and nerves
spina bifida risk factors
-meds/drugs taken during pregnancy
-maternal malnutrition
-insufficient folic acid intake during pregnancy
-exposure to radiation or chemicals during pregnancy
-prepregnancy obesity, DM, hyperthermia, low vitamin B12
spina bifida manifestations
-protruding sac midline of osseous spine
-dimpling in lumbosacral area
spina bifida lab tests
-maternal blood tests: serum alpha-fetoprotein between 16 & 18 weeks of gestation indicates possible neural tube defects
-infant blood tests: blood cultures to determine pathogen if appropriate
spina bifida diagnostics
PRENATAL:
-ultrasound may show visual defect
-amniocentesis is done following elevated alpha-fetoprotein levels to detect anencephaly or myelomeningocele
INFANT FOLLOWING BIRTH:
-MRI, ultrasonography, and CT to evaluate spinal cord and brain
spina bifida nursing care
-assess for infant-parent attachment
-assess the sac
-perform routine newborn assessment
-assess level of neurologic involvement
-obtain accurate output measures
-assess head circumference and fontanels
spina bifida surgical intervention
-closure of myelomeningocele sac is done ASAP to prevent complications of injury & infection
spina bifida pre-op nursing care
-prepare family for surgery (within first 24-48 hr after birth)
-protect sac from injury
-place infant in warmer, without clothing
-apply sterile, moist, non adhering dressing w/ 0.9% saline on sac, changing it q2h
-inspect sac closely for leaks, irritati
spina bifida post-op nursing care
-monitor VS, I&O
-assess for signs of infection
-provide pain management as ordered
-provide incision care as ordered
-assess for CSF leakage
-maintain prone position until other positions are ordered
-resume oral feedings
-provide ROM to extremities
spina bifida discharge care
-depending on disability teach ROM techniques
-assess head circumference
-assess skin integrity
-assess for allergies such as latex allergy
-assess cognitive development
-assess bladder & bowel function
-assess motor development
-monitor for infection
-ad
skin ulceration (spina bifida)
-caused by prolonged pressure in one area
-monitor skin for breakdown
-reposition frequently to prevent pressure on bony prominences
-monitor skin under splints and braces
latex allergy (spina bifida)
-child may have high risk of allergy to latex. allergy responses range from urticaria to wheezing, which may progress to anaphylaxis. there also may be an allergy to certain foods (bananas, avocados, kiwi, chestnuts)
-reduce exposure
-provide family w/ li
down syndrome patho
-chromosomal abnormality
-trisomy 21
-many conditions accompany down syndrome (congenital heart malformation, hypotonicity, dysfunction of immune system, thyroid dysfunction, leukemia)
-risk factor: maternal age greater than 35 yr
down syndrome manifestations
-separated sagittal suture
-enlarged anterior fontanel
-small, round head
-flattened forehead
-upward, outward slant to eyes
-small nose w/ depressed nasal bridge
-small ears w/ short pinna
-high-arched narrow palate
-protruding tongue
-short, broad neck
down syndrome diagnostics
-prenatal: testing for alpha-fetoprotein in maternal serum
-infant: chromosome analysis and echocardiography
down syndrome ongoing care
-teach family how to aspirate nasal secretions
-teach family to rinse mouth after feedings
-tach family to use cool mist in room to assist in moistening secretions
-encourage family to reposition infant frequently
-teach family pulmonary hygiene by perfor
complications of down syndrome
-respiratory infections are common
-teach family ways to prevent occurrence
juvenile idiopathic arthritis (JIA)
-chronic autoimmune inflammatory disease affecting joints and other tissues
-the chronic inflammation of the synovium of the joints leads to wearing down and damage to articular cartilage
-rarely life-threatening, and may subside overtime, but it can resu
JIA manifestations
-joint swelling, stiffness, redness, and warmth that tend to be worse in morning or after naps
-mobility limitations
-fever
-rash
-limp in morning
-enlarged lymph nodes
-delayed growth
JIA lab tests
-anticyclic citrullinated peptide (anti-CCP) antibodies can be detected before symptoms or disease occur
-ESR may or may not be elevated
-CBC w/ diff may demonstrate elevated WBCs, especially during exacerbation
-antinuclear antibodies (ANA) indicate incr
JIA nursing care
-care is primarily outpatient
-assist client w/ exercise program
-teach relaxation techniques and nonpharmacological pain management
-evaluate child's pain and responses to analgesics
-encourage support groups
-encourage child to participate in physical t
JIA medications
-NSAIDS (ibuprofen, naproxen, and tolmetin) to control pain and inflammation
-methotrexate (rheumatrex): a cytotoxic disease-modifying anti rheumatic drug (DMARD) that slows joint degeneration and progression of rheumatoid arthritis when NSAIDs to not wor
muscular dystrophy
-group of inherited diseases w/ progressive degeneration of symmetric skeletal muscle groups
duchenne muscular dystrophy (DMD) (manifestations)
-fatigue
-muscle weakness beginning in lower extremities
-unsteady gait, with a waddle
-lordosis
-delayed motor skill development
-frequent falling
-difficulty getting out of bed, rising from seated position, or climbing stairs
-learning difficulties
-mil
DMD lab tests
-serum polymerase chain reaction (PCR) to detect the dystrophin gene mutation
-serum creatine kinase (CK)- elevated and can be elevated prior to clinical manifestations
DMD diagnostics
-muscle biopsy
-EMG
DMD nursing care
-encourage & provide for genetic counseling
-assess & monitor: ability to perform ADL's, respiratory function, cardiac function, understanding of long-term effects, and coping/support
-maintain optimal physical function for as long as possible
-encourage
medications for DMD
-corticosteroids (prednisone): increases muscle strength
-other medications can include bronchodilators, amino acids, vitamins, and mineral supplements
congenital heart disease (CHD)
-anatomic defects of the heart prevent normal blood flow to pulmonary and/or systemic system.
-increased pulmonary blood flow (ASD, VSD, PDA)
-decreased pulmonary blood flow (tetralogy of fallot, tricuspid atresia)
-obstruction to blood flow (correction o
ventricular septal defect (VSD)
-hole in septum between right and left ventricle that results in increased pulmonary blood flow (left-to-right shunt)
-s/s: loud, harsh murmur auscultated at left sternal border; heart failure
-many VSD's close spontaneously
atrial septal defect (ASD)
-hole in septum between right and left atria that results in increased pulmonary blood flow (left-to-right shunt)
-loud, harsh murmur w/ fixed split second heart sound; heart failure
-asymptomatic (possibly)
patent ductus arteriosus (PDA)
-condition in which the normal fetal circulation conduit between the pulmonary artery & the aorta fail to close and results in increased pulmonary blood flow (left-to-right shunt)
-machine hum murmur
-wide pulse pressure
-bounding pulses
-asymptomatic (po
pulmonary stenosis
-narrowing of pulmonary valve or pulmonary artery that results in obstruction of blood flow from ventricles
-systolic ejection murmur
-asymptomatic (possibly)
-cyanosis varies w/ defect, worse with severe narrowing
-cardiomegaly
-heart failure
aortic stenosis
-narrowing of aortic valve
INFANTS:
-faint pulses
-hypotension
-tachycardia
-poor feeding tolerance
CHILDREN:
-intolerance to exercise
-dizziness
-chest pain
-possible ejection murmur
coarction of aorta
-narrowing of lumen of aorta, usually at or near the ductus arteriosus, that results in obstruction of blood flow from ventricle
-elevated BP in arms
-bounding pulses in upper extremities
-decreased BP in lower extremities
-cool skin of lower extremities
transposition of great arteries
-condition in which the aorta is connected to the right ventricle instead of the left, and the pulmonary artery is connected to the left ventricle instead of the right; a septal defect or PDA must exist in order to oxygenate the blood
-murmur depending on
tricuspid atresia
-complete closure of tricuspid valve that results in mixed blood flow. an atrial septal opening needs to be present to allow blood to enter the left atrium
INFANTS: cyanosis, dyspnea, tachycardia
OLDER CHILDREN: hypoxemia, clubbing of fingers
tetralogy of fallot
-four defects that result in mixed blood flow: pulmonary stenosis, VSD, overriding aorta, and right ventricular hypertrophy
-cyanosis at birth- progressive cyanosis over first year of life
-systolic murmur
-episodes of acute cyanosis and hypoxia (blue spe
truncus arteriosus
-failure of septum formation, resulting in a single vessel that comes off of the ventricles
-heart failure
-murmur
-variable cyanosis
-delayed growth
-lethargy
-fatigue
-poor feeding habits
hypoplastic left heart syndrome
-left side of heart is underdeveloped. an ASD or patent foramen oval allows for oxygenation of blood
-mild cyanosis
-heart failure
-lethargy
-cold hands & feet
-once PDA closes, progression of cyanosis and decreased cardiac output result in eventual cardi
manifestations of heart failure (HF)
-impaired myocardial function: sweating, tachycardia, fatigue, pallor, cool extremities w/ weak pulses, hypotension, gallop rhythm, cardiomegaly
-pulmonary congestion: tachypnea, dyspnea, retractions, nasal flaring, grunting, wheezing, cyanosis, cough, or
manifestations of hypoxemia
-poor weight gain
-tachypnea
-clubbing
-polycythemia
tet spells
-(blue spells) manifest as acute cyanosis and hyperpnea
cardiac catheterization (pre-procedure)
-perform nursing hx and physical exam. evidence of infection, such as severe diaper rash, may necessitate canceling the procedure if femoral access is required
-check for allergies to iodine & shellfish
-describe how long the procedure will take, how the
cardiac catheterization (post-procedure)
-provide for continuous cardiac monitoring and oxygen saturation to assess for bradycardia, dysrhythmias, hypotension, and hypoxemia
-assess heart & respiratory rate for full minute
-assess pulses for equality & symmetry
-assess temp and color. a cool ext
nursing care of congenital heart defect
-remain calm when providing care
-keep child well-hydrated
-conserve child's energy by providing frequent rest periods; clustering care; providing small, frequent meals; bathing PRN; and keeping crying to minimum in cyanotic children
-monitor HR, BP, seru
digoxin (lanoxin)
-improves myocardial contractility
-monitor pulse and withhold med as ordered. generally, if an infant's pulse is less than 90/min, the med should be withheld. in children, the med should be withheld if pulse is less than 70/min
-monitor for toxicity AEB
captopril (capoten) or enalapril (vasotec)
-ACE inhibitors reduce afterload by causing vasodilation, resulting in decreased pulmonary and systemic vascular resistance
-monitor BP before and after administration
-monitor for hyperkalemia
metoprolol or carvedilol (coreg)
-beta-blockers, which decrease heart rate and BP and promote vasoconstriction
-monitor BP and pulse prior to admin
-monitor for adverse effects such as dizziness, hypotension, and headache
furosemide (lasix) or chlorothiazide (diuril)
-potassium-wasting diuretics rid the body of excess fluid and sodium
-encourage diet high in potassium
-monitor I&O
-monitor for adverse effects such as hypokalemia, nausea, vomiting, dizziness
-monitor weight daily
VSD interventions
-closure during cardiac catheterization
-surgical: pulmonary artery banding OR complete repair with patch
ASD interventions
-closure during cardiac catheterization
-surgical: patch closure
PDA interventions
-administer indomethacin
-insertion of coils to occlude PDA during cardiac catheterization
-surgical: thoracoscopic repair
pulmonary stenosis interventions
-balloon angioplasty w/ cardiac catheterization
-surgical: Brock procedure (infants); pulmonary valvotomy (children)
aortic stenosis interventions
-balloon dilation w/ cardiac catheterization
-surgical: Norwood procedure OR aortic valvotomy
coarction of aorta interventions
-infants & children: balloon angioplasty
-adolescents: placement of stents
-surgical: repair of defect recommended for infants less than 6 months
transposition of great arteries interventions
-surgery to switch arteries within first 2 weeks of life
tricuspid atresia interventions
-surgery in 3 stages: shunt placement, Glenn procedure, modified Fontan procedure
tetralogy of fallot interventions
-shunt placement until able to undergo primary repair
-completer repair within first year of life
truncus arteriosus interventions
-surgical repair within first month of life
hypoplastic left heart syndrome interventions
-surgery in 3 stages starting shortly after birth: Norwood procedure, Glenn shunt, and Fontan procedure
digoxin administration
-give q12h
-direct oral elixir toward side and back of mouth when administering
-give water following administration to prevent tooth decay if child has teeth
-if dose missed, do not give extra dose or increase next dose
-if child vomits, do not re-admini
diuretic administration
-mix the oral elixir in small amount of juice to disguise bitter taste and prevent intestinal irritation
-observe for manifestations of serum potassium level imbalances (muscle weakness, irritability, excessive drowsiness, increased or decreased HR)
-enco
complications of cardiac catheterization (potential)
-nausea, vomiting
-low-grade fever
-loss of pulse in catheterized extremity
-transient dysrhythmias
-acute hemorrhage from entry site
INTERVENTIONS:
-apply direct continuous pressure at 2.5 cm (1 in) above catheter entry site to localize pressure over loc
hypoxemia
-hypercyanotic spell can result in severe hypoxemia, which leads to cerebral hypoxemia, and should be treated as an emergency
-immediately place child in knee-chest position, attempt to calm child, and call for help
bacterial endocarditis or subacute bacterial endocarditis
-bacterial endocarditis prophylaxis includes receiving prophylactic antibiotic therapy prior to dental and surgical procedures
-causative organisms include S. viridian's and S. aureus
-administer antibiotics parenterally for extended length of time usuall
rheumatic fever
-inflammatory disease that occurs as a reaction to group A beta-hemolytic streptococcus (GABHS) infection of the throat
-usually occurs within 2-6 weeks following an untreated or partially treated upper respiratory infection (stereo throat) with GABHS
rheumatic fever manifestations
-fever
-tachycardia
-cardiomegaly
-prolonged PR interval
-new or changes heart murmur
-muffles heart sounds
-pericardial friction rub
-report of chest pain (may indicate carditis)
-nontender, subQ nodules over bony prominence
-large joints (knees, elbows,
rheumatic fever lab tests
-throat culture for GABHS
-serum ASO titer- elevated or rising titer; most reliable diagnostic test
-C-reactive protein (CRP): elevated in response to inflammatory reaction
-ESR: elevated in response to inflammatory reaction
rheumatic fever diagnostics
-ECG to reveal presence of conduction disturbances & to evaluate function of heart & valves
-diagnosis made on the basis of modified Jones criteria. child should demonstrate presence of 2 major criteria or presence of 1 major and 2 minor criteria followin
rheumatic fever nursing care
-encourage bed rest during acute illness
-give antibiotic as ordered
-encourage nutritionally balanced meals
-assess for chorea
hyperlipidemia
-excess lipids in circulating blood
-cholesterol is part of lipoprotein complex in blood
-triglycerides com from 2 sources: naturally made in body from carbs, and the end product of fat ingestion
-high-density lipoprotein cholesterol (HDL): "good" cholest
hyperlipidemia lab tests
-lipid profile: fasting for 12 hr prior to test
-fasting blood glucose
nursing care for hyperlipidemia
-assess client for febrile illness 3 weeks prior to screening (illness will alter results)
-teach client to keep diet hx for review by dietician
-teach diet to lower cholesterol: low fat, whole grains, fruits and veggies
-encourage use of olive oil and ca
cholestyramine (questran) and colestipol (colestid)
-for hyperlipidemia
-used in clients who fail conventional treatment
-used in children 8 yr and older who have LDL of 190 mg/dL or higher or 160 mg/dL in clients who have risk factors
-powdered med mixed in 4 to 6 oz water or juice, then administered imme
kawasaki disease
-acute systemic vasculitis
-acute phase:
furosemide (lasix) or chlorothiazide (diuril)
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