Health Problems of the Toddler
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What is Autism spectrum disorder?
- Complex neuro-developmental disorders of brain function: autistic disorder, asperger syndrome, pervasive developmental disorder not otherwise specified
- Can range from mild to severe
What are the possible causes of ASD?
- Currently recognized as a genetic disorder of prenatal and postnatal brain development
- Immune and environmental factors may increase ASD incidence
- High risk for reoccurance in families
- Not apparently caused by MMR or Thimerosal containing vaccines
How is ASD Diagnosed?
- May use the CHAT (checklist of autism in toddlers)
- Qualitative impairment in social interaction
- Qualitative impairment in communication
- Restricted repetitive and stereotyped patterns of behavior (such as echoalia), interests, and activities
- Delays or abnormal functioning with onset prior to 3rd birthday
- American Psychiatric Association DSM IV TR
What nursing considerations should be taken for a child with ASD?
- Wide variation in individual client response to treatment efforts
- No cure for ASD, but many therapies
- Most promising results seem to be through highly structured routines and intensive behavior modification programs
What are some goals for children with ASD?
- Promotion of normal development
- Language development
- Social Interaction
How can you support a family with a child that has ASD?
- ASD often becomes a "family disease"
- Help alleviate parents' unwarranted feelings guilt and shame
- Stress importance of family counseling
- Autism Society of America (ASA) is good source of information
- Encouraging home care for children; assisting with long-term placement later in life
What are some common eye conditions of the toddler?
- Cataracts: Dm, galactosemia, eye injury. Requires surgical removal and possible post op contacts
- Glaucoma: congenital if developed <3yrs
- Strabismus: lazy eye or cross eyed leading to double vision. Often corrected before school age with eye patch on good eye
- Eye Injury: if penetrating, patch both eyes prior to intervention (ophthalmic emergency)
- Infections: conjuctivitis
How is conjunctivitis treated?
- Ophthalmic antibiotics
- System antibiotics in some cases
- Caution with the use of steroids because they can worsen viral infections
- Infection control concerns
What are some eye emergencies and how are they treated?
- Foreign body: removal
- Hematoma: check for hyphema
- Penetrating injuries: both eyes patched
What is important to consider in the visually impaired, hospitalized client?
- Safe Environment
- Orient the child to surroundings
- Encourage independence
- Consistency of team members
What is celiac disease and what are some common s/s?
- Gluten induced enteropathy- defect of metabolism when gluten is ingested (wheat, rye, barley, oats)
- General malnutrition (FTT), secondary vitamin deficiencies, steanorrhea (fatty, foul stools), abdominal distention
- S/S generally not seen before 6mo
What is a celiac crisis and how is celiac disease managed?
- Explosive n/v/d leading to dehydration, electrolyte imbalance, and hypovolemic shock
- Often precipitated by other infection
- Needs f/e replacement
How is celiac disease managed?
- Managed by excluding gluten from diet
- Important to consider different cultures and the meaning behind food, such as at holidays (may lead to a diet change in the entire family)
- Educate about reading labels and choosing approp foods
What are croup syndromes?
- Characterized by hoarseness, barking cough, inspiratory stridor, and varying degrees of respiratory distress
- Croup syndromes affect the larynx, trachea, and bronchi: epiglottitis, laryngitis, laryngotracheobronchitis (LTB), tracheitis
Describe acute epiglottitis
- Most common in 2-7 y/os
- Clinical manifestations include sore throat, pain, tripod positioning, retractions, inspiratory stridor, mild hypoxia, distress
- 3 Ds: dysphagia, hyspnea, drooling (dysphonia)
- No spontaneous cough- frog like sound
- Fever 102-104
- Therapeutic management: Edema of the upper airway (DO NOT USE TONGUE BLADE TO INITIATE GAG REFLEX). Prepare to intubate
Describe acute laryngitis
- More common in older children and adolescents
- Usually caused by a virus
- Chief complaint is horseness
- Generally self-limiting and without long term sequalae
- Treatment: symptomatic
Describe Acute Laryngotracheobronchitis (LTB) and it's clinical manifestations
- The most common croup syndrome
- Generally affects children <5yrs
- Organisms responsible include RSV, parainfluenza virus, mycoplasma pneumonia, and influenza A & B
- Clinically manifested by inspiratory stridor, suprasternal retractions, barking or seal-like cough, increasing respiratory distress and hypoxia, can progress to respiratory acidosis, respiratory failure, and death
What is the therapeutic management for LTB?
- Airway management/O2
- Maintain hydration (PO or IV)
- High humidity
- Nebulizer treatments: racemic epinephrine,
- steroids, heliox
What is acute spasmodic laryngitis?
- Also called spasmotic croup or midnight croup
- Praoxysmal attacks of laryngeal obstruction
- Occurs chiefly at night
- inflammation: mild or absent
- Most often affects children ages 1-3yrs old
- treatment includes humidity such as placing in shower or cool night drives
What is bacterial tracheitis and how it therapeutically managed?
- Infection of the mucosa of the upper trachea
- Distinct entity with features of croup and epiglottitis
- Clinical manifestations simulation to LTB
- May be a complication of LTB
- Thick, purulent secretions result in respiratory distress
- Therapeutic management: humidified oxygen, antipyretics, antibiotics, may require intubation
What is cystic fibrosis?
- Hereditary autosomal recessive trait- if both parents carry, there is 1 in 4 chance
- Basic defect related to abnormal secretions of exocrine glands (mucus producing)
- Lead to obstruction of secretory ducts of pancreas, liver, reproductive organs
- Thick mucus obstructs respiratory passages leading to air trapping and overinflation
What are the s/s of cystic fibrosis?
- Meconium ileus
- Intestinal malabsorption
- Pancreatic enzyme deficiency
- Atelectesis, lung abscess, pneumonitis
- Clubbed fingers
- FTT, weight loss
- Non-productive cough
- fatty stools
- barrel chest
How is cystic fibrosis diagnosed?
- s/s in the newborn include meconium ileus
- Salty taste, hard nonproductive cough,bronchial infections, barrel chest, clubbing, malnutrition (ftt and bruising)
- Newborn screening for CF
- Stool analysis may show increased fat and decreased albumin with an absence of trypsin
- sweat-chloride test induces sweat and measures sodium chloride. >60 meq/L on 2 tests is diagnostically positive
How is cystic fibrosis treated and managed?
- newborn: meconium ileus treated user hyperosmolar enemas or surgery
- Older child: aimed at correcting pancreatic deficiency, improving pulmonary function, preventing respiratory disease, maintaining physical activity
- Diet is high in complex carbs and proteins with no fat restriction (may need 1.5-2x cal requirements to promote growth)
- No salt restriction due to loss of salt (increase salt intake in hot weather)
- Pancreatic enzymes (such as pancrealase) to increase digestion and absorption of fat
- ADEK Vitamin supplements (fat soluble)
- Prophylactic antibiotics (may be parenteral)
- Postural drainage/qvest/flutter device
- Inhalation therapy: pilmonzyme/albuterol, mucomyst for acute infection, humidified environment
- Physical activity is essential!!!
What are some good resources for cystic fibrosis?
- Home care and an interdisciplinary team
- Compliance to treatment is key!
- Cystic Fibrosis Foundation
What is the emergency treatment for ingesting a toxic substance?
- Remove obvious remnants of the substance and maintain airway
- Call poison control (keep number handy!)
- Follow directions PER SUBSTANCE as to how to prevent further absorption
- When possible, bring container to ER with you
- Administer general supportive and symptomatic care
What are some commonly ingested toxic substances?
- Ibuprofen (motrin, advil)
- Ferrous sulfate
- Corrosives (such as lye, bleach, drain and toilet cleaners, iodine, silver nitrate)
- Hydrocarbons (kerosene, gasoline, furniture polish, turpentine)
What should be done if a child ingests a foreign object?
- Many objects pass safely through the intestinal tract
- Occasionally lodge in esophagus or bowel (including foods)
- Unless choking, gagging, or pain is present, it is usually safe to wait and see if it passes
- For choking- abdominal thrusts can be used for children older than1 y/o
What should be done if a child puts a small object in their nose or ear?
- May irrigate ears to remove (not paper)
- Risk for infection and aspiration if object is in ears
- May use speculum to remove
- S/S of infection in nose due to object includes one sided purulent drainage
What are two common types of heavy metal poisoning?
- Lead poisoning
- Mercury Poisoning
What are common methods of lead poisoning?
- Common by peeling lead based paint
- Microparticles in the air can be inhaled or ingested
- Lead can also be found in soil and water that has been contaminated by Microparticles
- May also come in contact with hobbies that use lead, near by industries that use lead, and foreign made toys that contain lead
Describe lead screening for children
- Screening is done at well check up at 1 & 2 yrs of age
- Screen any child between 3-6 who has not been screened
What are the s/s of lead poisoning in children?
- Insidious symptoms! Often misdiagnosed for ADHD
- Early signs: irritability, hyperactivity, aggression, impulsiveness, short attention span, mild learning disabilities
- Late Signs: encephalopathy r/t increased ICP, degeneration of brain, MR, blindness, paralysis, seizures, coma, death
- Acute signs: n/v, constipation, anorexia, abd pain, anemia (lead prevents iron from binding to the heme molecule)
What are the ABCDEFG of lead poisoning?
- Basophillic stripping
- Collicky pain and constipation
- Difficulty concentrating/developmental delays
- Foot Drop
- Gums (lead line)
How is lead poisoning diagnosed?
- Diagnosed with a blood test
- 5-14mcg/dL: educate and retest
- 20-44mcg/dL: chelation therapy, environmental investigation, lead hazard control
- 45-69 mcg/dl: chelation within 48 hrs
- >70 mcg/dL: needs immediate chelation therapy
What medications are used with chelation therapy?
- EDTA: Ca edetate disodium, given IV for levels >45 mcg/dL
- BAL: dimercaprol, given deep IM for levels >70 mcg/L
- Succimer (chemet): given PO for levels >45 mcg/dL
- D penicillamin: given PO for levels <45 mcg/dL
What are some common intestinal parasites and how are they diagnosed?
- Common intestinal parasites are roundworm, hookworm, threadworm, and whipworm
- Commonly transmitted by ora/fecal route, or direct contact with contaminated objects
- Diagnosed by stool sample
- Nurses most important role is education
How can intestinal parasites be prevented and how are they treated?
- Treated by medications such as flagyl
- Prevented by frequent hand washing!!
- Short finger nails
- Wear shoes outside
- Proper Diaper disposal
- Safe drinking water
- Keep pets out of play areas
- Disinfect bathrooms, diaper areas
Describe Giardiasis, how it is dx and how it is treated
- Giardiasis is the most common intestinal parasite
- Cysts are passed in stool for months
- Contracted through person to person contact or contaminated water
- S/S include abdominal cramps and diarrhea
- May require mult stool samples to dx
- Treated with flagyl, alinia, tindamax, or albendazole (mix with juice or sweet food)
- Also called pinworms, it is the most common helminthic infection
- Ingest (oral fecal rt) or inhale eggs (floating in the air)
- Common in day cares
- Diagnosed by a tape test on anus where eggs are laid
- Main symptom is intense anal itching
- Reinfects self from eggs on hands or under fingernails
How is enterobiasis treated and prevented?
- Treated with vermox, antimith, or albendazole in 1 dose with a repeat dose in 2 wks
- Wash clothing and bedding in hot water
- Promote hand washing
- Cut nails short and possible 1 piece pjs
- Reoccurrence is common
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