NS2P1: Peds Mod 3

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Radhika316
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294523
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NS2P1: Peds Mod 3
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2015-02-01 15:27:31
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NS2P1 NS2 Peds Linda Respiratory Cardiac
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Acute Respiratory Problems Cardiac Issues
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  1. **Upper airway
    tonsillitis:  
    adenoiditis:
    tonsillitis: usually don't take out tonils, just give broad spectrum antibiotics

    adenoiditis: kids, one is cdap, removing adenoids decreases sleep apnea
  2. otitis media:
    • Middle ear infection,
    • 80% viral and 20% baceria
    • bulging of the ear canal-mastoiditis
  3. **otitis externa
    • -external ear infection
    • -basically blowdryer in ear or alcohol and vinegar
    • -medical emergency for diabetic adults
    • -treated broad spectrum antibiotics
    • -closeness of upper airway and ear, URI can go up ear because ear canals are more lateral.

    Any oral infection can go to up to ear canals.
  4. **Croup
    --laryngotracheobronchitis (croup)

    • -Croup is breathing difficulty and a "barking" cough. Croup is due to swelling around the vocal cords. It is common in infants and children.
    • -very young kids

    =>Causes: Croup is most often caused by viruses, such as parainfluenza RSV, measles, adenovirus, and influenza. It tends to appear in children between 3 months and 5 years old, but it can happen at any age. Some children are more likely to get croup and may get it several times. It is most common between October and March, but can occur at any time of the year.

    More severe cases of croup may be caused by bacteria. This condition is called bacterial tracheitis.

    Croup may also be caused by:Allergies, Breathing in something that irritates your airway, Acid reflux

    Symptoms: The main symptom of croup is a cough that sounds like a seal barking.

    Most children will have mild cold symptoms for several days before the barking cough becomes evident. As the cough gets more frequent, the child may have trouble breathing or stridor (a harsh, crowing noise made when breathing in).

    Croup is typically much worse at night. It often lasts 5 or 6 nights. The first night or two are most often the worst. Rarely, croup can last for weeks. Talk to your child's doctor if croup lasts longer than a week or comes back often.

    => Shower helps (moisture)
  5. **bacterial tracheitis:
    -in kids with permanent traches

    -because you have an upper airway that filters into your lungs and they don't have this option, so susceptible to this..copious amounts of yellow/thick drainage.

    -respiratory infection
  6. **epiglottis & Epiglottitis
    -kid who didn't feel good in morning and in the evening, it was a bacterial infection so they could barely move air-

    HIBB vaccine (Hemo..Influenza type B)

    • -leading cause of meningitis and epiglotitis
    • -Send in OR, had to trach because it can occlude their airway and they'll die..tracheostomy and broad spectrum antibiotics

    -keep them calm, don't visualize throat or agitate them-don't close off their airways--> death!

    -decadron Decreases inflammation
  7. **Lower Airway Health Deviations & Bronciolitis
    Lower Airway-a little more serious

    Bronchiolitis - affects children < 6 mos, inflammation and blockage of alveoli, less space to breathe..

    Leading Cause RSV (respiratory systemic virus), VERY expensive vaccine ($2000) so only NICU gets them

    -no antibiotics because it's a viirus, instead give them oxygen and IV fluids, expectorate stuff in thier lungs.
  8. **Cystic Fibrosis
    • Autosomal recessive: both parents are carriers and they give it to the child;
    • stetorrheas: is the presence of excess fat in feces. Stools may also float due to excess lipid, have an oily appearancefrequent respiratory infectionsbody produces viscous secretions specifically lungs and pancreas

    • Frequent lung infections
    • Failure to Thrive; die into early 20's
    • .Pancreas unable to produce digestive enzymesRequire fat
    • -soluble vitamins, CPT and pancreatic enzymes with all meals-affects exocrine system; don't produce digestive enzymes and pancrease donn't make fat-> freq respiratory infections.

    The first sign: -colonic illeus: child has not passed stool within 24 hours because muscles stop working and so they have to have a temporary colostomy

    • -body produces viscous secretions of digestive portion of pancreation they can't exxpectorate so they develop a chronic cough, pancrease can't produce digest enzymes
    • -douse pancreatic enzymes in lipase
    • -salwater seems to help CF; hypotonic saline but no cure. Identified the chromosome that has the defect.
    • -tends to affect the caucasian population
  9. **Pertussis
    • -very serious disease
    • -oxygen doesn't go to lungs, stays in blood
    • -kids die
    • Acute respiratory infection caused by bordetella pertussis, there's a vaccine.In past occurred in children < 4y not immunized

    Highly contagious and dangerous for infants

    Incidence highest in spring and summer

    • =>Resurgence
    • The increase in pertussis among children > 10 makes CDC to believe booster is needed

    • Currently epidemic in several states and until recently in California
    • -pertussis vaccine wears around around 7, TDAP booster needed.
  10. **Asthma
    • Chronic inflammatory disorder of airways in which many cells play roles
    • Inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness and cough especially at night and early morning
    • -very serious, you can die during an asthma attack.
    • -keep them as active as possible.

    • => 4 Categories
    • Intermittent-inhalers and nebulizers, inhaled steroids
    • Mild persistent
    • Moderate persistent Severe persistent

    • =>Increase in USE
    • specially among African Americans
    • Worsening air pollution
    • Poor access to medical care
    • Under diagnosis and under treatment

    • =>Most frequent chronic disease of childhood
    • Allergies influence both persistence and severity of the disease
    • Other substances can act as triggers: Biochemical, genetic, immunologic, environmental, infections, endocrine and psychological factors & Viral respiratory infections play significant role
  11. => 4 Categories of Asthma
    Intermittent-inhalers and nebulizers, inhaled steroids

    Mild persistent: more than twice a week

    Moderate persistent: Daily symptoms with nightime symptoms three to four times a month

    Severe persistent: continual symptoms throughtout the night with frequent nightime symptoms, extremly limited normal activity
  12. Asthma Patho, Diagnosis & Managment
    • **Asthma Pathophysiology
    • Inflammation contributes to airway reactionBronchospasm Smooth muscle causes narrowing and shorteningIncreased resistance causes air trapping (almost like bronchiolitiis)

    • **Asthma Diagnosis
    • Dyspnea, wheezing and cough
    • Can be abrupt or develop gradually
    • The first attack usually occurs <5y
    • =>Pulmonary function tests 5 or 6 y; Do every 1-2 years to assess airway function & Each child needs to assess best over 2-3 wks
    • -send parents with Volume of forced expiration in 1 sec
    • Green 80-100%, yellow 50-79%,    red < 50%Check for GI reflux can exacerbate symptoms

    • **Asthma Management
    • Goal: Maintain normal activity levels
    • National Asthma Education and Prevention Program 2007
    • Health care visits every 1-6 monthsPrevent exacerbations avoid allergens and medications as needed
    • Reduce underlying inflammationPatient education, environmental control, medication management, and use of objective measures to monitor severity of disease
  13. **Asthma Drug Therapy  & Medications
    • => Long term control medications: Inhaled corticosteroids, cromolyn sodium and nedocromil, long action B2 agonists, methylxanthines, and luekotriene modifiers as long term control
    • -inhaled steroids stund growth
    • -teach controlled breathing
    • -smell roses and blow out the candles

    • =>Rescue medications
    • bronchodilators B agonists, methylxanthines, and anticholinergics can be used for long term and rescue

    • =>Frequently used in combination
    • => Given by inhalation with nebulizer or metered dose inhaler should always be attached to spacer

    • **Asthma Medications
    • Corticosteroids > 5 years: Long term use can cause slowed growth
    • Cromolyn sodium NSAID
    • B2 agonists Short action Albuterol
    • Salmeterol long acting B2 Agonist BIDLeukotrienes mediators of inflammation(Montelukast)
    • Anticholinergic relief bronchospasm (Ipratropium)
    • Omalizumab block IgE to mast cells Injected
  14. **Asthma Exercise
    Exercised-Induced Bronchospasm 5-10 minutes into exercise

    Problem with activities that require short bursts: Baseball, sprints, gymnastics

    Less common: Soccer, basketball, distance running

    Swimming well tolerated
  15. **Chest Physiotherapy
    -the treatments generally performed by physiotherapists and respiratory therapists whereby breathing is improved by the indirect removal of mucus from the breathing passages of a patient.

    • Techniques include clapping or percussion: the therapist lightly claps the patient's chest, back, and area under the arms. Percussion, while effective in the treatment of infants and children, is no longer extensively used in Australia in adults due to the introduction of more effective and self-management focused treatments. These include, but are not limited to, the use of "flutter" or oscillating positive pressure devices, PEP masks or devices (positive expiratory pressure) as well as specific exercise regimes.
    • Breathing exercises

    • Improve posture
    • Breathing exercises and controlled breathing
    • http://www.youtube.com/watch?v=lDplcbllr1c
  16. **Asthma Prognosis
    Varies widelySome have symptoms that improve at pubertyRare, but deaths have been increasing since 1980’s due to albuterol?Most deaths in children 11-17 y Mortality and morbidity and death rates for African Americans 3 times higherRisk factors for death include: Early age at onset, frequent attacks, difficult to manage disease, adolescence, history of respiratory failure, psychological problems
  17. **Heart Disease In Children
    The two types of heart disease in children are "congenital" and "acquired"' , Mostly congentital

    Congenital heart disease (also known as a congenital heart defect) is present at birth.

    About 40,000 children are born with a heart defect each year. At least 8 of every 1, 000 infants born each year have a heart defect
  18. **Congenital Heart Disease
    The normal heart is a strong, muscular pump a little larger than a fist. It pumps blood continuously through the circulatory system. Each day the average heart "beats" 100,000 times and pumps about 2,000 gallons of blood.
  19. **Cyanotic Heart Defects Tetrology of Fallot
    A heart defect present at birth consisting of four different abnormalities. It usually results in insufficiently oxygenated blood being pumped to the body causing cyanosis (bluish discoloration of the skin).

    • **Anatomy of Defect Tetrology of Fallot
    • Ventricular septal defect (hole between the right and left ventricles)
    • Narrowing of the pulmonic outflow tract (tube that connects the heart with the lungs)
    • An aorta (tube that carries oxygenated blood to the body) that arises from both ventricles, rather than exclusively from the left ventricle A thickened muscular wall of the right ventricle (right ventricular hypertrophy)
  20. **Heart Disease Symptoms
    • Difficult feeding
    • Failure to gain weight
    • Poor development
    • Cyanosis which becomes more pronounced during periods of agitation
    • Passing out
    • Sudden death
    • Clubbing of fingers (skin or bone enlargement around the finger nails)
    • Squatting during episodes of cyanosis
  21. ** <3 Disease Treatment
    Surgery to repair the defects in the heart is always performed relatively early in life. Sometimes a preliminary surgery to create increased blood flow to the lungs is done before definitive corrective surgery. Corrective surgery widens the narrowed pulmonary valve, and the ventricular septal defect is closed.
  22. **Transposition of Great Vessels
    -another cyanotic defect

    => Transposition of the great vessels is a cyanotic heart defect. This means there is decreased oxygen in the blood that is pumped from the heart to the rest of the body.In normal hearts, blood that returns from the body goes through the right side of the heart and pulmonary artery to the lungs to get oxygen. The blood then comes back to the left side of the heart and travels out the aorta to the body.

    In transposition of the great vessels, the blood goes to the lungs, picks up oxygen, returns to the heart, and then flows right back to the lungs without ever going to the body. Blood from the body returns to the heart and goes back to the body without ever picking up oxygen in the lungs.

    => Transposition of the great vessels is a congenital heart defect in which the 2 major vessels that carry blood away from the heart -- the aorta and the pulmonary artery -- are switched (transposed)In transposition of the great vessels, there is no communication between the pulmonary circulation and the systemic circulation
  23. ** Transposition of Great Vessels Treatment
    Immediately after diagnosis, a medication called prostaglandin is started intravenously to maintain the small connection (the ductus arteriosus) between the pulmonary and systemic circulations. Surgery to temporarily adjust the vessels may be required shortly after birth, with permanent correction postponed until the child is older. However, a surgical technique known as an arterial switch procedure allows permanent correction within the first month of life
  24. **Trucuspid Atresia
    A type of congenital heart disease in which blood is unable to flow from the right atrium to the right ventricle because the tricuspid valve is missing or abnormally developed.

    • **Trucuspid Atresia Treatment
    • Surgery is necessary to repair the abnormal circulation created by tricuspid atresia. Approaches vary depending on the severity of the defect, but usually a series of operations is required.Surgical treatment initially involves a shunt (or bypass) from the aorta to the pulmonary arteries. Definitive treatment is with a Fontan operation, where the systemic venous return is connected to the pulmonary arterial tree.
  25. **Hypoplastic Left Heart load eventually causes the heart to fail.
    -"half a heart"; need heart transplant immediately.

    -Hypoplastic left heart describes the underdevelopment of the left side of the heart (left ventricle, aortic valve, and aorta

    • => Physiology
    • In patients with this condition, the left side of the heart is unable to maintain blood circulation for the body. As a result, the right side of the heart must maintain the circulation for both the lungs and the body. This extra work
  26. **Hypoplastic Left Heart Surgical Approach
    In patients with this condition, the left side of the heart is unable to maintain blood circulation for the body. As a result, the right side of the heart must maintain the circulation for both the lungs and the body. This extra workload eventually causes the heart to fail.

    There are two surgical approaches to hypoplastic left heart syndrome. One is to do a heart transplant early in life. This means that a small donor heart, which is very rare, must be available. It also means that the patient will have to take a number of medicines to prevent rejection of the new heart.

    The other option is a series of operations done over the first 3 years of life; this option is called the Norwood procedure.

    Stage I of the Norwood procedure is done within the first few days of life and consists of attaching the functioning right ventricle to the aorta (vessel that delivers blood to the body). Because the lungs must still receive blood, a surgically created conduit (tunnel) is created to attach the a large artery in the chest to the pulmonary arteries (the vessels that lead to the lungs). This conduit is called a Blalock-Taussig (BT) shunt.

    In the stage II operation, called the Glenn or Hemi-Fontan procedure, the superior vena cava (the vessel that removes deoxygenated blood from the head and arms) is attached to the pulmonary arteries and the BT shunt is removed.

    During stage III, called the Fontan procedure, the inferior vena cava (the vessel that returns deoxygenated blood from the lower half of the body) is also attached to the pulmonary arteries. This is usually performed between the ages of 2-3 years. After the third stage the patient is no longer blue (cyanotic).

    The Norwood procedure is relatively new, but outcomes have been good so far. While it is possible that these patients' hearts eventually will fail and they will need a heart transplant, it is much easier to transplant an older patient than an infant.
  27. **Assessment of the Child with Cardiovascular Abnormalities
    • check b/p all extremitiesobserve color when crying become cyanotic
    • may have audible murmur
    • Children difficult feeders usually failure to thrive
    • EKG, Echo Cardiogram and Cardiac Catheterization
    • -polycythemia compensated for lack of oxygen soo too many RBC's and thick blood

    • **Assessment
    • Echocardiogram
    • An echocardiogram is a test in which ultrasound is used to examine the heart. no special preparation is necessary

    • **Information Obtained
    • Size of the chambers of the heart, including the dimension or volume of the cavity and the thickness of the walls. Pumping function of the heart can be assessed by echocardiography.
  28. **Cardiac Catherization
    • Considered Gold Standard for Diagnosis
    • Provide age appropriate preparation depending on developmental level

    observe post cath for bleeding, circulation to extremity (go through fem artery so check legs, cap refil, circ, pulses, site for bleeding!!

    => A thin plastic tube (catheter) is inserted into an artery or vein in the arm or leg. From there it can be advanced into the chambers of the heart or into the coronary arteries. This test can measure blood pressure within the heart and how much oxygen is in the blood. It's also used to get information about the pumping ability of the heart muscle. Catheters are also used to inject dye into the coronary arteries.
  29. **Classifications of Congenital Heart Disease
    Cyanotic: TGV, TOF, Aplastic L heart blood flows from R to L

    Acynotic: PDA, VSD, ASD blood flows from L to R -> Heart must pump faster!!
  30. ** Acquired Cardiac Disease
    • Rheumatic Fever Causative Agent Beta Streptococcus, make sure they don't have strep throat.
    • -do strep test, if postive

    • => 10 days of pencillin
    • Bedrest
    • Complication Mitral Valve Insufficiency so that heart must pump harder and faster, making it enlarge because it's a muscle, if it's big enough it'll create a cardiomyopathy.
  31. **Kawasaki Disease
    Vascular Inflammation complication coronary artery anyurisms

    Child will have high fever x at least 5 days, reddened palms, red lips, red tongue

    High dose ASA "ringing in the ears", and IVIG

    Monitor child for ASA toxicity, and coronary artery anyuerisms
  32. **Sickle Cell Anemia
    • Group of diseases referred to as Hemoglobinopathies
    • Most Common Forms
    • Sickle Cell C disease Heterozygous variant of SCD
    • Sickle Cell Hgb E disease variant of SCD where glutamic acid has been substituted for lysine in number 26 position of B chain
    • Sickle Thalassemia combination of sickle cell trait and B thalassemia trait

    • **Sickle Cell
    • SS is the most severe form individuals with this form susceptible to strokeLife expectancy males 42
    • Females 48
    • SC is less severe but these individuals are susceptible to retinopathy
    • Males 60 Females 68
    • 50% of SCD children have evidence of cerebrovascular disease by 14
    • In 1990 Sickle Cell testing was expanded to the newborn screening in
    • This screening identifies 2000 individuals with Sickle Cel
    • lBabies are placed on penicillin from ages 3 to 5 years
    • At 3 months of age fetal hemoglobin disappears
  33. **SCA Patho & Clinical Manifestations
    • Incidence 1 in 375 births of African Americans, 1 in 1200 Hispanics
    • Although the defect is inherited it is usually not apparent until later in infancy due to presence of fetal Hbg
    • As a result most states include this test in newborn screening

    • =>Pathophysiology
    • Results in obstruction caused by sickled RBCIncreased RBC destruction because normal cell last 3 months but sickle cells don't last long. -Hydrourea increases length of life of sickle cells. The abnormal adhesions, entanglement, and enmeshing of rigid sickle-shaped cells with one another intermittently block the microcirculation results in hypoxia and ischemia distal

    • **Clinical Manifestations
    • Vary in severity and frequency
    • Acute symptoms occur during periods of exacerbation called CRISIS
    • Several types vaso-oclusive, spleenic sequestration, aplastic, hyperhemolytic, CVC, Acute Chest and infection
    • Spleenic Sequestration
    • Pooling of blood in the liver and spleen with decreased blood volume and shock; aplastic crisis, diminished RBC production results in severe anemia

    Accelerated destruction of RBC’s results in anemia, jaundice and reticulocytosis
  34. **CVA
    • CVA is a sudden and severe complication often with no illness
    • Sickled cells block blood flow to the brain
    • Repeated CVA’s can cause brain damage

    • =>Diagnostic Evaluation
    • Newborn screening is mandatory in most states
    • Early diagnosis enables initiation of appropriate interventions to minimize complications
    • The family is taught to administer prophylactic antibiotics and the early signs of infections and to seek medical care early in illness
  35. **CVA Management
    • Goal to prevent sickling
    • Prompt medical treatment of illness
    • Rest to minimize energy expenditure and oxygen use
    • Hydration through oral and IV hydration
    • Electrolyte replacement electrolyte imbalance causes sickling
    • Analgesia for acute pain
    • Blood replacement to treat anemia Antibiotics to treat infection
    • Pneumococcal and meningococcal vaccine plus all other vaccines
    • Oral penicillin prophylaxis is recommended by 3 months of age to reduce the chance of pneumococcal sepsisOxygen therapy for children with respiratory difficulty
    • Exchange transfusions reduces the number of circulation sickle cells
    • Transcranial Doppler identifies children with SCD that are at high risk for CVA
    • For children with recurrent spleenic sequestration a spleenectomy
    • RBC transfusion for spleenic sequestration Most common problem vaso-occlusive pain
    • Priapism continuous or intermittent a painful erection of the penisTylenol used initially, opiods and methadone for severe pain
  36. **Children with severe SSD
    • SS may have to receive blood transfusions to prevent strokes.
    • If an individual receives 20 units of blood over their lifetime they will need chelation therapy
    • Once Children Grow up and Become Adults
    • If they go to ER’s they know what medications they need to relieve there pain.Most hematology adult physicians know nothing about SSD
    • With the high doses of medication the patient they need they are often labeled as drug seekers
    • Pain is a major factor of a sickle cell patients life, they have acute episodes but because of the damage to their body from the chronic sickling that occurs within their bodies they experience chronic pain

    • **Children that grown into adulthood need to learn to advocate for themselves
    • Hallmark acute painful vaso-occlusive crisis*know*
    • This disease affects 1/400 African American People in the US
    • =>Dactylitis
    • =>Fish Mouth Deformity: This is a Defect in the Spinal Column=>Other Sickle Cell Problems: Acute Chest
  37. **SSD Prognosis  & Nursing Care
    • Most of the time children are without symptoms
    • Tylenol is used initially and as for moderate to severe pain opiods are used. Children during crisis are on PCA’s
    • Children receiving Hydroxyurea have a 40% decreased in mortality and fewer vaso-occlusive occurrences
    • Bone marrow transplant effective for some

    • **SSD Nursing Care
    • Family education of disease and it’s consequences
    • Seek early intervention in illness for example with temp > 38.5C 101.3F
    • Recognize signs of splenic sequestration
    • Treat children normally
    • Emphasize importance of hydration to prevent sickling
    • Promote supportive Therapies during Crisis
    • Success of medical therapies relies heavily on nursing implementation
    • Pain program should be combined with psychologic support to help the children deal with depression and compliance of treatment
    • Warm compresses
    • Be aware of size of spleen and vital signs
    • OxygenHydration especially IV hydration
    • Nurses must be alert for Acute Chest and CVA and educate parents of symptoms
    • Support the family and refer them for genetic counseling

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