Health problems of the Preschooler
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What are the different types of hearing loss a preschooler may experience?
- Conductive hearing loss (such as from OME)
- Sensorineural due to damage to the cochlea and inner ear (cochlear implant for treatment)
- Central (problem with sound interpretation in the brain)
How is hearing loss evaluated in the preschooler?
- Audiologic assessment can be done in children as young as 3 years
- Infants tested differently at birth for referral
- Treatment and education are key
- conductive loss: hearing aids 2-2.5 yrs
- Conchlear Implant: sensorineural 8-12mo
- Vision also needs to be assessed as they will be relying more heavily on other senses (deficits will need to be corrected)
What nursing care can be done for the preschooler with hearing loss?
- Rooming in with the primary care giver
- Let the client see you before you touch them
- Use adequate lighting
- Promote other methods of communication, such as signing, lip reading, picture boards
- Teach care of hearing aids
What are some common vision impairments experienced by the preschooler?
- Refraction: light does not bend properly in eye and does not focus on the retina
- Myopia: near sightedness
- Hyperopia: far sightedness
- Astigmatism: Uneven corneas
- * A child's vision is essential in the their learning development, social development, coordination and safety
How is vision assessed? What is considered blindness?
- Can be assessed by a snellen chart, e-chart, or picture chart
- Ishihara test for color blindness
- Blindness can be caused by maternal infection during pregnancy or delivery
- Blindness is legally defines as 20/300 or less or peripheral vision less than 20 degrees
How is a vision impairment treated and what teaching can be done?
- The earlier vision impairment is treated, the better the outcome
- Corrective lenses may be used
- Large print, tapes, magnifying glasses, typewriters or computers, talking books and braille
- Identity self when coming into the room and before touch
- Other senses are heightened due to impairment
- Encourage independence
What is Reyes syndrome?
- Acute encephalopathy and fatty degeneration of liver and abdominal organs
- Often occurs in young school age
- Occurs after viral illness or URI (often varicella)
- Administration of ASA during virus has been implicated and should not be given during viral infections
What are the s/s of Reye's syndrome?
- Generally appear 1-3 weeks after initial illness
- Severe vomiting
- Lethargy, change in LOC
- Personality changes
- *Immediate intervention needed to prevent serious insult to brain
How is Reye's syndrome diagnosed and treated?
- History of recent viral illness is the immediate clue
- Elevated liver function studies with elevated ammonia levels
- Liver biopsy is the only definitive test for diagnosis
- Treated: ICU care determined by staging of symptoms, frequent neuro assessments, resp assessments, control hypoglycemia, watch for cerebral edema
- *liver function may return, but any brain damage will be permanent
What causes tonsillitis? What are the s/s?
- Results from pharyngitis and is frequently caused by viruses, but may be B-hemolytic streptococcal
- Diagnosed by throat culture
- May be the palatine tonsils (back of throat) or adenoid tonsils (above uvela)
- S/S include swelling of tonsils that can lead to obstruction of airway
What is the treatment for tonsillitis?
- Analgesics, antipyretics, antibiotics
- Soft to liquid diet
- Adequate fluid intake
- Cool Mist Vaporizer
- Tonsillectomy/Adenoidectomy: controversial, usually does after age 4-5 if 3x or more infections per year. There must be no active infection during surgery
What interventions and teaching can be done for tonsillitis?
- Prevent aspiration
- Monitor for hemorrhage (persistent swallowing)- do not feed red colored food as it can mask blood
- 5-10 days post op is highest risk for hemorrhage
- Monitor VS, fluid intake, soft foods only
- Provide comfort measures
- Discourage coughing
- No milk or dairy products (risk for infection)
What is acute leukemia? What is the most common kind in childhood?
- Acute Lymphatic Leukemia accounts for 85% of childhood leukemias and is considered the most curable
- Peak onset between 3-5 yrs old
- Uncontrolled reproduction of immature white blood cells (lymphoblast)
- Rapid increase in lymphoblasts leads to a decrease in RBCs and platelets
What are the clinical manifestations of acute leukemia?
- Abrupt onset
- Pallor, low grade fever, easily fatigued due to anemia
- Faintness (lassitude)
- Bone/joint pain
- Petechiae (pinpoint)
- Purpura (hemorrhage into skin and mucus membranes)
- Anorexia, n/v, headache, diarrhea
- Abd pain due to enlarged liver/spleen
How is acute leukemia diagnosed?
- History and Physical, symptoms
- Immature leukocytes and low RBCs and Platelets
- Bone marrow aspiration from iliac crest (put pressure at site 10-15min, pressure dressing)
- Lumbar puncture to evaluate CNS involvement (must then lay flat for 4-8hrs)
How is acute leukemia treated?
- 90% long term survival (5yrs+)
- Intensive chemotherapy with central line in 4 phases
- 1. Induction: 4-6 weeks
- 2. Sanctuary pr CNS prophylactic therapy; intrathecal
- 3. Intensification or consolidation; to eradicate residual cells
- 4. Maintenance; to preserve remission (2-3yrs)
- *If there is a second relapse, bone marrow transplant will be necessary
What is hematopoietic stem cell transplantation (HSCT) and what risks are involved?
- Stem cells used may be peripheral or from umbilical cord blood
- Donors may be relatives or non-relatives, antigens may be matched or mismatched
- There is a significant risk of morbidity and mortality
- Graft vs host disease (GVHD)
- Risk of overwhelming infection
- Severe organ damage
- Cure after HSCT up to 60-70%
What is the prognosis for a child with acute leukemia and what factors influence the prognosis?
- If there is a relapse after HSCT, the prognosis is dismal
- Prognosis is determined by:
- Initial WBC count
- Age at time of diagnosis
- Type of cell involvement
- Gender (boys have a higher mortality rate)
- Karyotype analysis
What infection control precautions should be taken for a child on chemotherapy?
- Neutropenic precautions
- Keep away from other sick kids, live vaccines
- Proper and frequent hand hygiene for all family members and medical personel
- Visitor restrictions
- Neupogen may be given to stimulate mature lymph cells
- ANC (absolute neutrophil count) eval frequently taken. if <500, do not leave home for high risk of infection
What are some common side effects and complications of chemotherapy?
- Mucosal ulceration
- Neuropathy (foot drop)
- Hemorrhagic cystitis
- Mood changes (steroids), mood face
What is Idiopathic thrombocytopenic purpura (ITP)?
- Blood disorder associated with deficit of platelets usually preceded by a viral infection with an acute onset
- S/S include bruising and a generalized rash which may disappear spontaneously within a few weeks
- ITP may become chronic, rule out all other diseases
What us the treatment and nursing care for ITP?
- Corticosteroids (must rule out leukemia via bone marrow aspiration)
- IV immune globulin (IVIG) increases the production of platelets
- Anti-D antibody prolongs the survival time of platelets (used only if no active bleeding)(watch for adverse reactions and keep benadryl on hand)
When would a splenectomy be done for ITP and what else needs to be done?
- If ITP persists for longer than one year
- Removes the risk of hemorrhage but increases the risk of infection
- Usually wait until age 5
- Pneumococcal and meningococcal vaccines must be given prior to removal
What teaching should be done after a splenectomy?
- Protect from injury- no contact sports
- Monitor for signs of bleeding
- No ASA or NSAIDS (bleeding)
- Give soft diet
What is hemophilia A?
- Classic Hemophilia
- Deficiency of factor VIII
- Accounts for 80% of hemophilia cases and occurs in 1 out of 5000 males
- X-linked: males are affected and females are carriers
- Degree of bleeding depends on amount of clotting factor and severity of given injury
- 1/3 of cases have no family history
What is hemophilia B?
- Christmas Disease
- Deficiency in Factor IX
- Accounts for 15% of hemophilia cases
What are the clinical manifestations of hemophilia?
- Hemarthritis: bleeding into the joint spaces leads to limited mobility
- Bleeding after procedures and injuries
How is hemophilia diagnosed?
- Genetically through amniocentesis
- Genetic testing of family members to identify and educate carriers
- Labs: low levels of factor VIII or IX, prolonged PTT (normal platelets, PT, and fibrinogen)
How is hemophilia medically managed?
- DDAVP (synthetic vasopressin) given IV increases 2-4x factor VIII
- Can be given after an episode or prophylactically
- Bleeding precautions with safe environment
- For superficial injury, hold pressure for 15 min and put ice
- For significant injury, transfuse for factor replacement
How is hemarthosis managed?
- During bleeding, elevate and immobilize joint
- ROM after bleeding stops to prevent contractures
- PT and physical activity
- Avoid obesity to minimize joint stress
What is von Willebrand disease?
- A hereditary bleeding disorder involving deficiency of von Willebrand Factor necessary for platelet adhesion
- Autosomal dominant trait occurring in both males and females
- Gene is located on chromosome 12
What interventions can be done for von Willebrand disease?
- Avoid ASA and NSAIDs
- Manage bleeding episodes with prompt infusion therapy
- Children with von Willebrand have normal life expectancy if well managed
What are the manifestations of nephrotic syndrome?
- Decreased UO
- Edema and Wt Gain
- Massive urinary protein loss
- *often occurs in conjunction with a bacterial or viral infection
What changes occur in nephrotic syndrome?
- Glomerular membrane become permeable to proteins, esp albumin, which is then lost in the urine (hyperalbuminemia)
- Serum albumin is then decreased (hypoalbuminemia)
- Fluid shifts from plasma into the interstitial spaces leading to hypovolemia, ascites, and edema
How is nephrotic syndrome managed?
- Supportive Care
- Diet: low to moderate protein and sodium restriction (with edema)
- Steroids: 2mg/kg bid with prednisone being the first choice, followed by Cytocan (immunosuppressant)
- Diuretics if edema s great (furosemide)
- IV Albumin for replacement
What nursing assessments and interventions should be done for nephrotic syndrome?
- Eval of edema, check for skin breakdown, turning q2hr
- Daily weights, I/O, bedrest, 6 small meals/day
- Aseptic technique for all catheterization
- Standard precautions to prevent nosocomial infections
- Thorough perineal are
- Avoid incontinent episodes by answering call light and offering bed pan at frequent intervals
- Insure adequate fluid intake to dilute urine and flush bacteria
- Avoid bladder irritants such as caffeine alcohol, citrus juices, chocolate, and highly spiced foods
What discharge to home instructions should be given for Nephrotic syndrome?
- Follow up urine cultures will need to be done
- Recurrent symptoms may appear 1-2 weeks after therapy
- Encourage adequate fluids even after infection
- Low dose, low term antibiotics may be given to prevent relapse or reinfection
- Always explain rationales to increase compliance
What is glomerulonephritis and what may it be related to?
- Usually appears 1-3 weeks after pneumococcal, streptococcal, or viral infections
- Can be a distinct entity
- May point to another disease such as systemic lupus erythematosus (SLE), sickle cell disease, or others
What are the symptoms of glomerulonephritis?
- Due to decreased glomerular filtration
- Begins with periorbital edema then progresses to the lower extremities and ascities
- Hypertension due to increased extracellular fluid
- Hematuria in the upper urinary tract leads to smoky, tea like urine
- Proteinura (higher the protein, worse the disease)
What is acute poststreptococcal glomerulonephritis (APSGN)?
- Autoimmune renal disease
- Onset 5-12 days after other infection, often an A beta-hemolytic streptococci (like scarlet fever)
- Most common in kids ages 6-7
How is APSGN managed?
- manage edema with daily weights, accurate I/O, daily abdom girth measurements
- Low sodium, low to moderate protein
- Antibiotics due to susceptibility of infections
- Diuretics and antihypertensive meds may be ordered
- Bed Rest is not necessary
What is the difference between Nephrotic syndrome and Glomerulonephritis?
- Nephrotic Syndrome:
- -ages 2-6yrs
- -increased permeability of glomerulus
- -Generalized dependent edema with an increase in weight and a decrease in BP
- -Proteinuria, decreased serum albumin, increase H/H, increased cholesterol
- -Treated with diuretics, protein infusion, corticosteroids
- -Risk for fluid volume excess or deficit
- -school age
- -post strep infection
- -Decreased glomerular filtration and renal insufficiency
- -Hematuria and proteinuria
- -Descending Edema
- -Decreased UO, increased BP, increased ASO titer
- -Treated with antihypertensives
- -Risk for fluid volume excess
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