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What is SIDS? age of leading cause and incidence peak at what age?
- Sudden unexplanned death syndrome of an infant younger than 1 year oldMost death associated with sleep" Crib death"First leading cause of postneonatnal death btw 1& 12 mos
- Peak age of incident: 2-3 mon
- 3th leading cause of infant deaths (birth-12 mos)
Etiology of SIDS?
- UNKNOWN. Other unexplaned apnea and factors are:
- Sleep prone (Respirator muscle are constricted)
- Viral respiratory or botulism infection
- Pulmonary edema
- Brain stem abnormality. Deficiency of neurotransmitter
- HR abnormalities
- Distorded famalial breathing pattern
- Decrease arousal responses
- Possible lack of surfactant in alveola
- Low social economic status
- Highly incidence of male than female
What groups that are high risks of SIDS?
- Preterm Babies; Multiple birth rate
- Babies who are placed to sleep prone position
- Infants of adolescent mother or close spaced pregnancies
- Underweighted infants
- Infants with apnea, brochopulmonary dysplasia, twins, CNS & respiratory disorders
- Greater incidence: N-A, A-A, Hispanic
- Infants of narcotic-dependent mother
- Subsequent siblings of 2 or more SIDS victims
What are the findings of SIDS Babies?
- Dishelved bed, with blankets over head & huddled in a corner
- Mouth and Nostril: Forthy, blood tinge fluid
- Position: Lying down in secretions
- Complete bowel & bladder incontinence
What are Nurse's response when parent have SIDS arrived at the ED?
- ASK only FACTUAL questions (When, How?)
- AVOID any remarks suggestion responsibility
- LET the perents HOLD, TOUCH, & ROCK the baby
- ALLOW them to say good-bye
- STRESS that death isn't their fault
What diagnostis that confirms SIDS?
What are reveal pathology findings of SIDS?
- Pulmonary edema
- Petechiae in lungs
- Chronic hypoxia dues to Inflammation and Other minor changes
- R/O suffocation and aspiaration as a cause of death
What are the behaviors and COPING PHASES of Parents returning home post death of SIDS baby?
- Turmoil Phase: 1 week post death
- (behavior: structure thinking is common)
- Impact Phase: disorganized thought
- Home visit RN as soon as after death
- Reassure other children in the family
- Frightening of the birth of another child
- Referrals to support group for a year or more
What Does American Academy of Pediatrics (AAP) Recommended to reduce SIDS occur?
All newborns should be put to sleeps on their back (supine position) (AAP, 1992)
Home monitoring to prevent SIDS?
- Infants: Appearant Life-Threatening Event (ALTE)
- New baby: sleeping study precaution within first 2 weeks of life
- --Child placed on home apnea monitoring/or cardiopulmonary monitor machine
How to reducing risks of SIDS in Infants?
- Supine position
- Firm sleep surface
- No Soft objects, Toys, Loose Bedding near sleeping area
- Avoid letting the baby overheated during sleeping
- Think about using a clean, dry pacifier when placing baby down to sleep
Nursing Diagnosis for parents with SIDS baby?
What are Nursing Implications to parents of SIDS child?
- Educating family of newborns: risk for SIDS
- Educating regarding PRONE sleep positions in infants from birth-6mos age
- Use of appropriate bedding and dangers of co-sleeping (pet, stuffed animals)
- Modeling appropriate behavior in hopsital
- Provide emotional support
- Recommended attending support groups
- Recommended learning CPR in the future
- Prevention of Positional Plagiocephaly: vary infants head positions
What are nursing alerts for SIDS?
- Infant: Apneic, gently stimulate the trunk by patting or rubbing it
- Infant prone: turn to back and flick the feet
- No response: begin CPR and activate EMS-call 911
- NEVER vigoriously shake the child
- No more than 10-15 seconds are spent on stimulation before implementing CPR
Spring for SIDS?
National Fundraiser & SIDS awareness day
Test for accommodation?
- • Pupils
- • Equal
- • Round
- • Reactive
- • Light
- • Accommodation
- Shows the structures of the back
- of the eyeball or (fundus)
- • Fundus apparent as “Red
- • Optic disc: creamy pink
What is Macula?
Area with greatest concentration of visual receptors
Area of most perfect vision?
What is Red Reflex? and what does it should look like?
- It is vital for early detection of vision and life threatening abnormality: cataract, gloscoma, abnormality with retina and any systemic
- Red Reflex should be: Brilliant, uniform reflection of red
- Older children’s RR are deepper pigmented and Infant is ighter
What are Abnormality that need to be refer to ophthalmologist immediately? "LAB"
- Absent RR
- Bruckner reflex: symmetry of the reflex
Random dot E Test for which eye disorders?
Tests for Amblyopia & Strabismus
At what age does Routine Vision screening start?
- 3 years old
- (AAP recommended as early as possible)
Children who cannot read the alphabet or numbers is using which test?
Preschool E Chart (Tumbling E)
What is Ambylopia common name?
Lazy eye: Reduced visual acuity in one eye
Pathology of Ampylopia?
- One eye does not receive sufficient stimulation
- Child uses only “one” eye while “resting” other
- Central vision fails to develop if prolonged; or if developed, it fades
What are Clinical Manifestations of Ampylopia?
- Poor vision in affected
- Misaligned eye
What are Assessment & Management of Ampylopia?
- Correctable if treated early
- Ambylopia: before age 6
- After age 6: correction is diminished
Treatments for Ampylopia?
- Good eye: cover by patch
- (force the child to use the poor eye)
- Remove patch one hour each day
- (prevent the good eye become ambylopia)
What is Strabismus?
“Squint” or “Cross eye”—Misalignment of eyes
What is the pathology of Strabimus?
- Unbalanced muscle control
- Visual axes are not parallel so the brain receives 2 images and ambylopia results
- Resting position of one eye:
- Divergent (turned out)
- Convergent (turned in)
What age is considered to be normal for the infant to have crossed eye?
Infants eyes are may crossed occasionally until 6 weeks of ages = normal but eventually disappear but if they continue pass these age needs for referral. However, if infant demonstrate constant Strabimus then better referral immediately)
What does the child with Strabismus see?
- See double
- Anomalous retinal correspondence
What is the Clinical Manifestations of Strabismus?
- Squinting of eyelids together or frowning
- Difficulty with focusing one distance to another
- Inaccurate judgment in picking up objects
- Inability to see print or moving objects clearly
- Tilts head to one side
How often Assessment is needed for strabismus?
Constant Assessment strabismus before 6 weeks of age older than that need immediate referral
Definite deviations of strabimus?
- Exotropia (eye turning out)
- Esotropia (eye turning in)
- Hypertropia (eye turning up)
Best time to detect Strabimus is when?
- Best detected when child examine’s a nearby object
- Cover test (if pseudostrabismus)
- Corneal light reflex (Hirshberg’s)
- Strabismus: most usual typefound in children
What are Therapeutic Managements for Strabimus?
- Eye exercise (orthoptics)
- Occlusion therapy
- Injections of botulinum
What happened after Post Op Care of Strabismus Surgery?
- Soreness 1-3 hr post
- Antibiotic oint 2-3 days post
- Pain on eye movement: 1st post-op day >2 yr: pain
- and antiemetics
- “Foreign body sensation”
- Red eyes: 1-2 weeks post
Penetrating wounds vs. Non-penetrating wound
- Penetrating wounds
- Result of sharp instruments
- Propulsive objects
- Powerful contusion (blunt trauma)
- Non-penetrating wounds
- Foreign object
- Blow from blunt object
What is Hematoma?
“Black Eye” result of Trauma
What are applications for “Black Eye”
- Use flashlight to check for gross hyphema
- Apply ice 1st 24 h if nohyphema present: decreases swelling
- Refer to opthalmologist stat if hyphema
- Have child rest with eyesclosed
What is Conjunctivitis? and which bacteria that cause it?
- Is Inflammation of conjunctiva
- Newborns: chlamydia trachomatis (inclusion conjunctivitis)
- N. gonorrhea (ophthalmis neonatorium: most serious)
- HSV-- ocular damage
- Recurrent conjunctivitis-- nasolacrimal duct obstruction
- Chemical conjunctivitis-- instillation
What is the usual causes of conjunctivitis:
- Bacterial: PINKEYE
- Allergic (allergy season)
- Foreign body conjunctivitis
Clinical Manifestation: PINKEYE
- Crusting: waking-up in the morning
- Matting: crustiness and stuck/matted or glue together
- Flame and swollen-
- Burning and itching
What are the treatment for PINKYEYE?
- Fluoroquinolones: Best ophthalmic antibiotic agent. Approved for children 1yr & older
- Ciloxan, Ocuflox, Quixin
- Vigamox-- new 4th gen
- No corticosteroids-- reduces ocular resistance to bacteria
What are Nursing Care Management for PINKEYE?
- Keep eye clean
- Administer ophthalmic agents
- Eye care
- Warm, moist compresses
What are Nursing Alerts for PINKEYE?
- Signs: serious conjunctivitis
- Reduction or loss of vision
- Ocular pain
- Decreased ocular mobility
- Corneal ulceration
- Unsual patterns of inflammation
- Refer to ophthamologist immediately
Inner Ears include what parts of the ear?
- Semicircular canal
- Oval Window
- Round window
- Tympanic membrane: eardrum
- Auditory Ossicles (Incus, Malleus, Stappe)
- Middle Ear Cavity
- Eustachian Tube
Ear Assessment? How?
- -Proper alignment
- - Opening to ear canal
- - Area in front of the ear forderma sinus or skin tag
- -Ear lobes for redness ordrainage
- Assess ear for hygiene
- Touch the pinna & Watch for evidence ofpain
Correct way of Examine of ear canal in children?
- Straighten ear by
- Pulling pinna gently down &back in children <3
- Pulling pinna gently up and back >3
How should the Tympanic Membrane look?
Translucent, light pearly pinkish to greyish
What position Light reflex: “Cone of light” should reflect at?
should reflect at about the 5 or 7 o’clock position
What are Ear Disorders?
- External Otitis
- Otitis Media
- – Acute (AOM)
- – with Effusion (OME)
- – Chronic OM
- Greater than 3 months=Can lead to hearing loss/delayed speech
What is Otitis Media (OM)
- Inflammation of the middle ear
- Incidence: highest in winter months
- Bacterial OM: Preceded by a viral respiratory infection
- Viruses most likely to precipitate OM: RSV and influenza
- Age: 6-36 months of age & again at 4-6 yrs
- High incidence: homes where parents smoke
What is the predeposition reason for the child to be at high risk for OM?
Eustachian tube is short, wide, straight and lies in a horizontal plane
Etiology of Acute OM?
- Three most common bacteria causing AOM:
- 1. Strep pneumoniae,
- 2. H. influenza &
- 3. Moraxellacatarrhalis
- Relationship b/w OM & infant feeding methods
Acute OM Risk Factors?
- Secondary smoke
- Formula feeding [positioning]
- Day care
- Pacifier: > 6 mos
Clinical Manifestations/Assessment findings of Acute OM?
- Follows an URI
- Acute ear pain “Otolgia
- Pull or tug at affected ear (Infant or very young)
- Yellow, red, inflammed, full/bulging TMFever, n/v /d
- Cold “rhinitis"
- Irritability & fussiness
Complication of Chronic OM?
Ear drum perforation
What Diagnostic Examination found TM in OM?
- TM-- reddened, inflammed, purulent discolored effusion and a bulging, full, opacified immobile membrane
- Decreased mobility on pneumatic examination
Therapeutic Management for OM?
- Fever/Analgesic (acetaminophen (Tylenol),
- ibuprofen (Motrin) [>6 mos.]
- Topic anesthetic drops
- Antibiotics: Amoxicillin (Amoxil): DOC
- IM ceftriaxone (Rocephin)
- – Myringotomy
- – Tympanostomy tube [PE tubes] placement
- -- Adenoidectomy
Nursing Implications for OM?
- Identification of symptoms
- Pain and fever mgmt.; medications; instillation of topical anesthetic
- Parent & child teaching
- Administration of IM antibiotics (some cases)
- Emotional support
- Nursing care following myringotomy, tympanostomy tube placement &adenoidectomy
How to instillation Ear Drops in children?
- Pull the ear down and back to instill eardrops in infants/toddler (↓3 years pull ↓)
- Pull the ear up and out (back) to instill inolder children (↑ 3 years pull ↑)
- Have medication at room temperature
What is External Otitis?
- Inflammation of external ear canal
- “Swimmer’s ear”
- Causative organism: Pseudomonas and Candida
What are Assessments in External Otitis?
- Itching of canal
- Small amt. drainage
- Sensation that ear: blocked or full
- Fungal infection-- brown or black (entire canal)
- Inflammation from foreign object--white or graydebris around object
- skin under object-- moist, red and eroded.
- TM visualization
- Weber test
EO Therapeutic Management?
- Ear drops: hydrocortisone
- Burow’s or acetic acid solution
- Ear plugs for swimming
- No foreign objects into ear
What does Nursing Teach child/parent about External Otitis?
- Keep ear dry
- Avoid swimming and hair wetting
- Insert ear plugs (showering)
- Do not use Q-tips
- Reinforce complete antibiotic therapy
What is ear disorder OM with Effusion (OME)?
- Fluid in the middle earspace without symptoms ofacute infection
- Occurs as a result ofchronic OM
- Fluid in ear-- sterile, thick, tenacious: “glue-like”
- Peaks spring & fall allergies
Assessment for OME?
- Muffled hearing
- Feeling of pressure in ear
- Light reflex: distorted
- TM: tends to retract
Therapeutic Management for OME
- Mild: antihistamine/nasaldecongestant
- Tubal myringotomy
What does Nursing Teach parents about OME?
- Medication compliance as ordered
- Emotional support
- Encourage parents to notify school nurse of problem
- Remind child/parent that water should not enter theear
- Hair washings with ear plugs in place
- Swimming-- depends
Impacted Cerumen eardrop Tx?
What is Skinfold thickness and which sites are most common sites for mesurement?
- Measures body fat with Lange calipers
- Most common site for measuring skinfold thickness--
- Apper thigh
Prepare to exam a child has to be pleasant & educational. How? be specific
- Detailed drawing or anatomically correct doll: preschoolers/older children learn about body
- Paper-doll technique: teach children about bodypart being examined
Proceed to exam the body in a head-to-toe fashion
- Examine PAINFUL AREAS LAST–
- In emergency situation:
- Examine vital functions (Airway, Breathing &Circulation) & Injured area FIRST
What are Developmental Milestones in Children
- Holding up head steadily (6 mos head lag well established or not)
- Sitting alone without support
- Walking without assistance
- Meaningful speech
- Present grade in school
- Scholastic performance
- Friends/interactions with others (Loner children are not healthy)
Growth Measurements included what?
- Physical growth parameters
- Height (length)
- Arm/ Head circumference
- Skinfold thickness
Growth chart is most commonly use by whom?
- National Center for HealthStatistics (NCHS): most commonly used
- – Percentile curves that illustrate distribution of selected body measurement in children.
What are nursing alerts regarding BMI in chlidren?
- > 95 percentile: overweight
- > 85th & <95percentile: at risk for being overweight
What percentile are Questionable Growth?
- Ht & wt percentiles widely disparate:
- Ht in 10th percentile
- Weight in 90th percentile, esp. with above average skinfold thickness
Measurment of Height?
- Wall-mounted stadiometer: most accurate measurement
- Measurement taken when child is standing upright
Length Measurements taken in children at which position?
- Supine (recumbent length)
- Until 24 mos. old (or 36 mos. if using the chart for birth-36mos)
- Children measured for recumbent length: weighted on an infant platform scale in lying position.
Plot on growth chart measurement by what?
What percentile considered outside expected parameter of HWH circumferrence
- By gender and prematurity if appropriate
- <5th or >95th percentile
- Measure with appropriate size balance beam scale that measures wt to the nearest 10 g (0.35 oz.) for infants & 100g (0.22 lb) for children.
- Balance scale before weighing by setting at 0
- Birth-36 mos charts used: weight nude
- Older children: wearing underpants or a light gown(*remember respect privacy of all children)
- Children measured for recumbent length--weighted on aninfant platform scale in lying position
- Maximum asepsis--cover scale with a
Correct Head Circumference measurement?
- Measure up to 36 months
- In any child whose head is questionable
- Measure at its greatest circumference, slightly Above the eye brows
- Pinna of ears
- Around occipital prominence at the back of the skull
Recommended screening routes in children?
- Birth-2y: (AR) axillary; rectal (if definitive one is needed for infant over 1month)
- 2-5 y: (OATR) oral, axillary, tympanic, rectal (if definitive temp needed)
- 5 y: (OAT) oral, axillary, tympanic
In Infants & children, which pulse is more reliable?
Blood Pressure Measure annually/routinely?
Children > 3 y through adolescent
What Blood pressure Cuff reading if it either too small or too large?
- If cuff too small: falsely High
- If cuff too large: falsely Low
What are normal and abnormal B/P percentile in infants and children?
- Below 90th percentile: Normotensive BP
- Between 90th & 95th percentile: prehypertension
- Over 95th percentile: Hypertension
What is Postural hypotension?
- Systolic B/P decrease of at least 20 mm Hg
- Diastolic B/P decrease of at least 10 mm Hg within three minutes of standing
How does Postural hypotension Manifested as?
- Syncope (fainting)
- Vertigo (dizziness) or lightheadedness
- Decreased blood flow to the brain: (cerebral hypoperfusion)
- Occurs with sudden changes from sitting to standing to lying
Common causes of Postural Hypotension?
- Hypovolemia (diuretics)
- Prolonged immobility or bedrest
- BP measurements: child supine then standing
What is "SIMIAN CREASE"?
Palmar crease with line of V shape, may indicate/associate with mental challenge or down syndrome
Stiff neck terminology?
What are Nursing Alerts while Evaluate ROM in children?
Hyperextension of the head (opisthotonos) w/pain on flexion: serious sign of meningeal irritation => Refer for medical evaluation immediately
What are Nursing Alerts while Head & Neck Evaluate for nodes or masses in children?
- Any masses detected in the neck, report them for further investigation.
- Large masses can block the airway.
Correct Examination of Mouth & Throat?
- Encouraging opening of mouth
- – Perform examination in front of mirror
- – Let child first examine someone else’s mouth & then examine child’smouth
- – Instruct child to tilt head back slightly, breathe deeply via the mouthand hold breath.
Inspect Chest for what? SSS-MBB
- Breast development
- Bony landmarks formed by theribs and sternum.
Specific Chest landmarks?
- Anterior axillary line (vertical from anterior axillary fold
- Mid axillary line (vertical from apex of axillary)
- Posterior axillary line (vertical from posterio axillary fold)
- Scapular line
- Vertebral line
How many Lung Lobes and Segments are there?
- 2 lungs: 1 Left & 1 Right
- 2 Right lobes
- 3 Left lobes
- 10 Segments on Right lung
- 8 Segments on Left lung (less segment b/c of the heart)
What are normal breath sounds? and locations?
- Normal = BBV
- Bronchial: over trachia
- Bronchiovesicular: over main bronchi
- Vesicular: over lesser bronchi, bronchioles, and lobes
Breath sounds Classification?
- Vesicular: Heard over entire surface of lung except major bronchi
- -- Anteriorly over mainstem bronchi on either side of the sternum(manubrium)
- -- Posteriorly (b/w upper intrascapular) regions where trachea & bronchi birfurcate
- Bronchial: Heard over trachea near suprasternal notch
- Abnormal breath sounds (ABS):
- Adventitious sounds: heard along with ABS are
- -- Bronchi: snoring in the chest
- --Crackle: air , moist, russling of leaves
- --Wheeze: musical sound
- --Stridor: crowling sound, repiratory obstruction
Apical impulse (AI) location?
Most lateral cardiac impulse that may correspond to the apex.
Where Apical Impulse located in children < or > 7yrs?
- Lateral to the LMCL & 4th ICS in children: < 7 yrs
- At the LMCL & 5th ICS: children > 7 yr
Where is Point of Maximum Impulse (PMI)?
At Area of most intense pulsation. LMCL at 5th ICS
How to Assess capillary refill?
Brisk: less than 2 seconds
Heart sounds produced by: opening & closing of valves & vibrations of blood against wall of heart & vessels
What is S1 & S2 of heart sounds?
- S1 & S2: normal heart sounds: “lub-dub”
- S1: closure of tricuspid and mitral valve(Atrioventricular valve (AV)
- S2: closure of the pulmonic and aortic valve(Semilunarvalve)
During inspiration, how does Split of both sounds in S2 to be heard over apical ausculatiton?
- Split of both sounds in S2 is distinguishable and widens during inspiration
- (physiologic splitting: normal finding)
What Alert is important about fixing splitting of boths sounds in S2?
Fixed splitting in which S2 does not change during inspiration, is an important diagnostic sign of atrial septal defect.
Which areas of the heart sounds can be heard louder in S1 & S2?
- S1: louder at apex in mitral & tricuspid area
- S2: louder near base of heart in pulmonic & aortic area
Which positions the child should be when auscultated of heart?
2 positions: sitting & reclining
Heart Auscultation anatomy
Genu Varum (toodlers who have bowleg)
- Dorsiflexion: big toe and Fanning toes
- During Infancy: Normal
- After one year: Abnormal
Neurologic Assessment test Cerebellar function?
- Tests for cerebellar function:
- – Romberg test
- – Finger-to-nose test
- – Heel-to-shin test
Important Crania Nerves for eye movements and hearing?
- CN III: Oculomotor
- CN IV: Trochlear
- CN VI: Abducent
- CN VIII: Vestibulocochlea
Six Cardinal Gazes [Fields of Gaze]?
- Tests extraocular eye movements
- Indicates functioning of CN III, IV, VI
Six Cardinal Gazes [Fields of Gaze](Positions)?