PEDS ATI Part II

Meningitis Inflammation of CSF and meninges, which are the CTs that cover the brain and

spinal cord Types:

o Viral (aseptic) meningitis Usually only requires supportive care

o Bacterial (septic) Contagious infection Prognosis depends on how quickly care initiatied Risk factors:

Infections caused by bacterial agents:o Neisseria meningtitidis (meningococcal),

streptococcus pneumoniae (pnemococcal), haemophlus influenzae type B (Hib), E. coli)

o Injuries with direct access to CSF (skull fracture, penetrating head wound)

o Crowded living conditionso Subjective: photophobia, nausea, irritability, headacheo Newborns

Poor muscle tone, weak cry, poor suck, refuses feeding, vomiting or diarrhea, possible fever or hypothermia

Neck supple without rigidity Bulging fontanels late sign

o 3 mos-2 years seizures with high pithched cry fever and irritability bulging fontanels possible nuchal rigidity poor feeding vom brudzinski and kernig’s signs not reliable for dx

o 2 years through adolescence seizures (often initial sign) nuchal rigidity + brudzinskis sign (flexion of extremities occurring with

deliberate flexion of childs neck) + Kernigs sign (resistance to extension of childs leg from flexed

position fever and chills H/A V Irritablility and restlessness that may progress to drowsiness,

delirium stupor and coma Petechai and purpuris type rash Involvement of joins

Chronic draining earo Labs

Bacterial Cloudy color Elevated WBC Elevated protein Decreased glucose + gram stain

Viral Clear Slightly elevated WBC Normal or slightly high protein Normal glucose content - gram stain

o Droplet precautions Lumbar puncture

o Measures spinal fluid pressures and collects CSFo Empty bladdero Topic anesthetic may be applied over area 45 min to one houro Side lying position with head flex and knees drawn up toward chesto Remain in bed 4-8 hours flat post op to prevent leakage and resulting

headache

Reye Syndrome Life threatening disorder that involves acute encephalopathy and fatty changes

of the liver

Patient with head injury S/S of increased ICP

o Infants: bulging fontanel, separation of cranial sutures, irritability, increased sleeping, high pitched cry, poor feeding, sun setting sign

o Children: nausea, HA, vomiting, blurred vision, increased sleeping, inability to follow simple commands, seizures

o Late signs: alteration in papillary response, posturing (decorticate and decerebrae), bradycardia, decreased motor response, decreased sensory response, cheyne-stokes respirations, coma

o Expected reference range 10-15 mmhGo Implement to decreased ICP:

Keep HOB 30, promotes venous drainage Avoid extreme flexion, extension, or rotation of head and

maintain in midline neutral position Keep body in alignment, avoid hip flexion/extension Minimize suctioning Instruct to avoid coughing and blowing nose, because this

increases ICP

Promote fluids

How to use inhaler Remove cap Shake five to six times Attach spacer Hold mouthpiece at bottom Hold inhaler with thumb near mouthpiece and index and middle finger at top Instruct on MDI technique

o Opening mouth method: hold approx 2-4 cm away from front of mouto Closed: placebetween lips and instruct to form seal around MDI

Take deep breath then exhale Tild head back slightly and press inhaler. While pessing begin a slow, deep

breath that lasts for 3-5 seconds to facilitate delivery to air passages Hold breath for approx 10 seconds to let med deposit in airways Take inhaler out of mouth and slowly exhale through nose

Digoxin (Lanoxin) Improves myocardial contractility Monitor pulse and withhold medication as ordered Generally if infants pulse is less than 90/min the med should be withheld In children, med held If pulse less than 70/min Monitor for toxicity: bradycardia, dysrhythmias, N/V, or anoerxis Monitor serum dig levels

Furosemide (Lasix) Potassium wasting diuretics rid body of excess fluid and sodium Encourage diet high in K (bran cereals, potatoes, tomatoes, bananas, melons,

oranges, organge juice) Monitor I and O Monitor for adverse affects hypokalema, N/V, dizziness Weight daily

HDL- goodLDL- bad

Iron deficiency anemia Most common type in US Ages 12-1§ at risk due to consuming diet high in cows milk without adequate

intake of iron Nursing actions

o Provide iron supplements for preterm and LBW infants by age 2 months

o Provide iron supplements to infants exclusively breastfed by age of 4 months

o Recommended iron fortified formula for infants who are not breastfedo Modify infants diet to include high iron, vit C and protein contento Monitor milk intake

Limit to 32 o (950 mL) per day Delay giving milk til after meal Do not let carry bottles or cups of milk

o Iron supplements Give one hour before or two hour after milk or antacid to

prevent decreased absoption GI upset normal at start of therapy Administer on empty stomach Give with vit C Use straw to avoid staining teth Z track; don’t massage after Tarry green stool normal

Sickle cell anemia Group of diseases in which abnormal sickle hemoglobin S replaces normal adult

hemoglobin (Hgb A) SCA- Homozygous & most common form; autosomal recessive; African

Americans Vaso-occlusive

o Painful episodeo Usually lasts 4-6 dayso Manifestations

Acute Severe pain in bones, joints and abdomen Swollen joints, hands and feet Anorexia, vomiting, fever Hematuria Obstructive jaundice Visual disturbances

Chronic Increased risk of resp infections and osteomyelitis Retinal detachment and blindness Systolic murmurs Renal failure and enuresis Liver cirrhosis; hepatomegaly Seizures Skeletal deformities; should or hip avascular necrosis

Dehydration: fatigue, malaise, change in behavior, change in stool pattern, poor appetite, weight loss, pain Isotonic

o Water and sodium lost in equal amountso Major loss of fluid from ECF leads to a reduced volume of circulating

fluid

o Hypovolemic shock may resulto Serum sodium WNL (130-150)

Hypotonico Electrolyte loss greater than water losso Water changes from extracellular fluid to intracellularo Physical manifestations more severe with smaller fluid losso Shock likelyo Serum sodium less than 130

Hypertonico Water loss greater tan electrolyte losso Fluid shifts from intra to extrao Shock is les likelyo Neuro changes may occuro Serm sodium greater than 150

Tape test Performed to check for enterobius vermicularis Education

o Tell parents to place transparent tape over child’s anus at nighto Remove tape following morning prior to child toileting or bathingo If possible, have parents apply take after child has gone to bed and

remove before wakenso Bring specimen to lab

Cleft lip & Palate Lip

o Done between 2-3 monthso Infants should be at least 10 weeks old, weigh 10 ilbs and Hgb 10g/dlo Revisions usually required in severe defectso Postop

Position infant upright, on back, or on her side to maintain integrity of repair

Elbow restains Saline on sterile seab to clean Gently aspirate secretions of mouth and nasopharynx to

prevent respiratory complications Palate

o Between 6-12 monthso Majority require second surgeryo Post op

Change position frequently to facilitate breathing. May be placed on abdomen immediate post op period

Maintain IV fluids until infant able to eat and drink Monitor packing, usually removed 2-3 days

Avoid objects in mouth Elbow restraints may be used to prevent infant from injuring

repair

Expected findings with renal disorders Throat culture to ID streptococcus infection (usually – by time of diagnosis) Urinalysis- proteinuria, smoky or tea colored uring, hematuria Renal function- elevated BUN and creatinine ASO titer- positive indicator for presence of strep antibodies AHase ADnase- B step enzymes may be present Serum complement (C3) decreased initially, increases as recover takes place

normal 8-10 weeks

Compartment syndrome Compression of nerves, blood vessels, and muscle inside confined place If untreated tissue necrosis can result Findings:

o Increased pain not relieved with elevation or analgesicso Intense pain when passively movedo Paresthesia or numbnesso Pulselessess or numbnesso Pulselessness distal to fractureo Inability to move digitso Warm digits with skin tight and shinyo Pallor

Clubfoot Positional clubfoot( occurs from intrauterine crowding), syndromic (in

associaion with other syndromes) and congenital (idiopathic) Talipes varus- inversion (being inward) Talipes valgue- eversion (bending outward) Talpes calcaneaus- dorsiflexsion (toes higher than heels) Talipes equinus- plantar flexion (toes lower than heels) Talipes eqinovarus- toes facing inward and lower than heel

Duchenne Muscular Dystrophy (DMD) Genetic hx S/S

o Fatigueo Muscle weakness beginning in lower extremitieso Unsteady gait, with waddleo Lordosiso Delayed motor skill developmento Fallingo Hard to get out of bed

o Learning difficultieso Mild cognitive delayso Progressive diff walking by 12o Progressive muscle atrophyo Resp and cardiac probs by age 20

Tinea coporis- round erythematous scaling path; speards peripherally and clears centrally

Head lice pediculosis capitus Shampps containing 1% permethrin as prescribed Remove nits with nit comb repeat in 7 days after shampoo tx Wash clothes and bedding in hot water with detergent Difficult cases: use malathion 0.5% in isopropanol

Diaper rah contact dermatitis Diaper rash may be caused by detergents, soaps, chemicals that come into

contact with genital area May be result of candida albicans Contant derm-Red bumbs that may form moist, weeping blisters, skin

warm and tender to touch, presence of oozing, drainage, or crusts, skin becomes scaly, raw, or thickened

Diaper derm- bright red rash that extends gradually, fiery red and scaly areas on scrotum and penis or labia, pimples blisters ulcers large bumps or pus illed sores, smaller red pathches that blednd together

Nursing care diaper:o Remove wet diapero Clean urine off periineal area with nonirritating cleanser.

Cleanse perineal area of feces with warm water and milk doapo Wash skil folds and genital area frequently with watero Expose affected area to airo Superabsorbent disposable dispers to reduce skin exposureo Aply skin barrier such as zinc oxide. DO NOT wash off with

each diaper changeo Use cornstarch to reduce friction bet diaper and skin

Diabetes Hypo <60 Hyper >250: thirst, poly uria, oliguia, N/V, Abd pn, skin that is warm, dry and

flushed with poor turgor, dry MM, confusion, weakness, lethary, weak pulse, diminished reflexes, rapid deep resirations with acetone/fruity odor due to ketones (Kussmaul respirations)

Diagnostic Criteria An 8 hour fasting blod glucose level of 126 or more A random blood glucose of 200 or more with classic signs of diabetes An orgal glucose tolerance test of 200 or more in 2 hours sampleTYPE TRADE NAME ONSET PEAK DURATION

Rapid acting Insulin lispro (humalog)

Less than 15 min

0.5-1 hr 3-4 hr

Short acting Regular insulin (humulin R)

0.5-1 hr 2-4 hr 5-7hr

Intermediate actig

NPH (humulin N)

1-2 hr 4-12 hr 18-24 hr

Long acting Insulin glargine (lantus)

3-4 hr None 10/4-24 hr