peds mini 5 | Coconote

Neuro Alterations # **Pediatric Variations** - Complete but immature nervous system – until 4 years old - Brain and spinal cord develop from neural tube - Large head and poor developed neck muscles - Thin cranial bones – skull expands until 2, sutures unfused - Excess spinal mobility – immature muscles/ligaments, incomplete vertebral ossification - Risk of cervical injury or vertebral compression fractures with falls *Pediatric Assessment* - CT – may need sedation; lesions, tumors, edema, structures - EEG – r/o seizures, continuous brain activity, wear for different amounts of time - LP – ICP/CSF, may need sedation; spinal infection, meningitis - MRI – tissue and structure, requires longer sedation; lesions, tumors, edema, structures - XRAY – skull fractures - EVM – lower is worse, want score of 15, used for nonverbal and “A&O” assessments **ADULT** **PREVERBAL & INFANTS** - Time & Place (5) - Confused (4) - Inappropriate words (3) - Incomprehensible words (2) - No response (1) - Smiles, coos, cries - Irritable - Cries in pain - Moans in pain - No response # **Intracranial Pressure (ICP)** *General IPC & Posturing* - Force exerted by tissue, CSF, blood – decreased perfusion with increase in ICP - Low EMV, neuro, LOC - Meningitis, seizure, trauma, substance, stroke, brain tumors, electrolyte imbalance - Treat ASAP, assess head circumference 1x/shift - Posturing – LATE SIGNS of serious brain injury - Decorticate = towards the body, rigid flexion from trauma ABOVE brainstem - Decerebrate = away from the body, extension from brainstem injury Infants VS. Child SX - Infant = bulging fontanel, separate sutures, irritable then lethargic, increased sleeping, high pitch scream, distended veins, setting sun (sunken eyes) - Child = HA, N/forceful vomiting, diplopia, blurry vision, seizures, indifference, drowsy, decline in activity/school, cannot follow simple commands, lethargy Late Signs of Increased ICP - Posturing, low HR/high BP, fixed large pupil, decreased motor/sensory, Cheyne-Stokes breathing, GCS <8, coma - Cushing’s Triad = increased systolic with wide pulse pressure, low HR, irregular RR Treatment of ICP - Evacuate cranial, Mannitol, elevate HOB 30 - O2 with ventilation if needed – stabilize airway - Antibiotics (meningitis), fluids or blood - Norepinephrine – increase perfusion and CO, serious cases - Ventricular catheter – accumulated CSF from tumor # **Seizures** *Types, Stages, Manifestations* General - Brief paroxysmal behaviors from excessive abnormal neuron firing - Diagnosed around 2, MOST idiopathic unless family hx - Primary = absence of abnormality; epilepsy - Secondary/Symptomatic = structural or metabolic dx; hydrocephalus - Subtle signs if <1yr – eye opening, fluttering, smacking, drooling, swimming or pedal movements instead of shaking Types of Seizures - Focal/Partial – one hemisphere from tumor or lesion - Generalized – entire brain, epilepsy - Febrile – rapid temperature from acute, risk of epilepsy in future, brief or 15 mins at 6m - Tonic – rigidity of muscles - Clonic – jerking movements - Tonic Clonic – tonic first; excess drool or foaming, random noises, incontinence; postictal - Absence – NO sx, brief LOC change, NO postictal, cluster or multiple a day, looks like zoning out or daydreaming Stages of Seizures - Aura = sensation alerting to oncoming seizure, NOT everyone has this - Tonic - Clonic - Postictal = sleepy, confused, slurred speech, arousal only to pain *Status Epilepticus (EMERGENCY)* - Seizure >30 minutes or multiple with NO return to normal LOC between - Maintain airway, assist if needed (O2 through Ambu), turn onto side, DON’T restrain - Administer medications (midazolam), respiratory assessment, prevent injury and falls *Management & Nursing Care* Seizure Precautions - Padded side rails up, Ambu/suction working - Emergency medications if >5 minutes - Midazolam (IN, home), Lorazepam (secondary), Diazepam - Outpatient – swim buddy, showers, driving regulations, medical bracelet, medication adherence/safety, NO fire Medications **Emergency** Midazolam – IN, 1st line Lorazepam – IV push 2-3mins, secondary Diazepam – IV or rectal Phenytoin/Fosphenytoin or Phenobarbital – IV 2nd round **Maintenance** Try to stay on only one, follow-ups with neuro, need routine dental for gum AEs (gingivitis) Phenytoin – monitor levels (neurotoxic), IV dose in NS Fosphenytoin – less AEs Valproic – monitor levels, PO Levetiracetam – psych impulsivity, monitor gross motor, IV/PO Phenobarbital – monitor levels, withdrawal sx if abrupt, sedation or hyperactive if toxic, drug interactions Nursing Care - Maintain appointment for levels - DON’T suddenly stop taking the medication - Birth control less effective - Decreased seizure threshold with alcohol, weed, and street drugs - Try keto or high fat diet - Check driving regulations for recent seizures - IF medication and diet NOT working… - Vagal nerve stimulation – implant that sends impulses to increase perfusion and decrease number of seizures # **Hydrocephalus** *General* - Imbalance in production and absorption of CSF - Common in spina bifida, acquired from trauma/abuse - Production > absorption = accumulates, increasing ICP, dilation of ventricles - DX: CT/MRI In Infants - Head grows abnormally, fontanels bulging, dilated scalp veins, separated sutures - IF SEVERE – frontal bossing or protrusion, setting sun, sluggish fixed pupils *Ventriculo-Peritoneal Shunt* - Shunt in the ventricle to direct and reabsorb excess CSF - Internal and end in the abdomen or RA of the heart - Can be for life if congenital - Needs revisions with growth – breakdown or length - Risk of malfunction, infection, or occlusion - May need to remove and place externally until infection treated - Monitor ICP, head circumference, elevate HOB, keep calm (less crying) # **Meningitis** *General* - SX: poor feeding, crying, V/D, poor muscle tone, temperature changes, apnea in clusters, seizures - Infant = fever (bacterial), bulging fontanels, lethargy, irritability - Child = signs, severe HA, photophobia, drowsy, altered LOC - Kernig – lift leg but cannot extend at knee, pain prevents flexion in supine - Brudzinski – flex head causes involuntary knee/hip flexion Management - Private room if viral, droplet precautions – quiet rest periods to decrease ICP, cluster care - VS/neuro/I&O – pupils, EMV, fontanels, head circumference, eating or drinking - Antibiotics – broad until C/S - Seizure precautions and medications – risk from high ICP and meningitis - Alter for progressive sepsis – purpura, petechiae, low BP, mental status changes - Vaccine – 12yrs to prevent severe, can lessen if given at diagnosis *Bacterial Meningitis* - Inflammation of meninges -> cerebral edema -> elevated ICP - NEED antibiotics, more serious for newborns because immature immunity - DX: lumbar puncture; high WBC/protein, low glucose, +gram stain # **Acute Head Injury** *General* - Complication of head trauma – seen with shaken baby - SX: changes in LOC, transient confusion, somnolence, listless, irritable, pallor, 1+ episodes of projectile vomiting - Progress = altered mental/difficult arousal, mounting agitation (behavior), focal neurological (movement), high BP, apnea - Severe = increased ICP, bulging fontanel, retinal hemorrhage (SBS), hemiparesis, quadriplegia, elevated temp, unsteady gait Medications - Mannitol/Hypertonic 3% - pull off fluid and decrease pressure - Steroids (dexa or methyl) – decrease ICP/pressure - Anticonvulsants (pheno/y) – decrease seizure risk - Sedative – caution with children, hard to tell if med or progression - Ventricular drain if needed # **Infant Botulism** *General* - Soil, honey <1yr, improperly canned foods - Progressive so catch early - SX: HA, V/C, neurological impairment, weak descending paralysis and tone in respiratory muscles, hypotonia - Seen in 12-36 hours after contamination - TX: IV antitoxin, supportive or respiratory/nutritional - MOST recover, but can lead to death if untreated Endocrine & Metabolic Dysfunction # **Pediatric Variations** - Immature but similar to adults – sex differentiation as fetus, growth/development, puberty - Release of hormones controls cellular activity that regulates growth and metabolism # **Disorders of the PITUITARY** *Diabetes Insipidus – Dry Inside* - LOW ADH – cannot HOLD water, concentrate urine, or sustain hydration - Inadequate production = central; autoimmune, tumor, trauma - Ineffective action = nephrogenic; medication AEs or medication toxicity - SX: polydipsia, polyuria, enuresis in kids (dehydration) - HIGH serum Na/osmolarity, dilute urine - TX: DDAVP to decrease UOP and thirst - Nursing – daily weight, I&O, cold fluids, assess dehydration *SIADH – Soaked Inside* - HIGH ADH from feedback failure – HOLDS water, water toxicity, cellular edema - Brain tumors/trauma, CNS, pulmonary disorders, positive pressure ventilation - SX: FVO, HTN, JVD, crackles, weight gain WITHOUT edema, concentrated urine - LOW serum Na, HIGH urine Na, LOW BUN (cellular expansion) - TX: diuretics, vasopressin - Nursing – restrict fluids, monitor fluid balance, I&O, daily weights *Precocious or Early Puberty* - Sexual development before 9 (males) and 8 (females) – more in females - HPA axis has premature activation - Results in premature skeletal maturation and short stature - TX: leuprolide IM or nafarelin acetate IN 2x/day to slow progress # **Disorders of the THYROID** *Congenital Hypothyroidism* - MOST from organ abnormality or genetics, acquired is RARE, 3 months best prognosis - C = few signs; thick tongue, hypotonia, umbilical hernia, hoarse cry - A = like adult; cold, dry, constipated, thin hair, small height, delay bone/dental age - Decreased hormones = delayed growth and developmental/intellectual delay - Complications – retarded skull, delayed teeth eruption, ataxia, strabismus - DX: newborn screening, LOW T3/T4, HIGH TSH - TX: lifelong levothyroxine (10-15mcg/kg/day), T4/TSH checks - Nursing – routine newborn screening before discharge, length/weight each visit (delays) # **Disorders of the PANCREAS** *Diabetes Mellitus* - Disorder of hyperglycemia from insulin secretion or production deficiencies leading to metabolism problems - MOST children have type 1 – only difference from adults is treatment Types of DM - Type 1 = autoimmune, abrupt, NO insulin production - DX – fasting >126, random >200, A1C >6.5 - SX – hyperglycemia, polyuria, polyphagia, polydipsia, weight loss, fatigue, enuresis - Undiagnosed and leads to DKA - TX – insulin; basal 1x/day, bolus with each meal or snack **Carbohydrate Counting** x grams/x units **Glucose** glucose - >x, divided by ratio **Total Insulin** Carbs + Glucose (round at end) Insulin Pump Therapy - Glycemic control especially in kids – continuous basal, like normal pancreas - Can get disconnected, change site 2-3 days, risk of infection and pump failure (DKA) Blood Glucose Monitoring - 4x/day and A1C every 3 months - Before meals, bedtime, any hypoglycemia sx, before activity, illness (more) Sick Days - Monitor glucose q.1-4 hours – more frequently, increased DKA risk - Test urine ketones if BG >200 or q.2-4 hours - Increase usual insulin dose but DON’T skip doses - Maintain hydration - Notify if cannot tolerate fluids, ketones, BG out of target, sx of dehydration Developmental Considerations - Toddler = funny feelings - Preschool = reports lows and shaking - School Age = supervise for mistakes with insulin, can inject and monitor carbs/sx self - Adolescents – compliance; activity, substances *Hyperglycemia* - Causes – high carbs, too little insulin, incorrect administration, illness, injury, stress, decreased activity, eating too close together - Gradual onset - SX: lethargy, confusion, Kussmaul, thirst, hunger, dehydration, weak, fruity breath, fatigue *Diabetic Ketoacidosis (DKA)* - Relative or absolute insulin deficiency – new dx, noncompliance, stress, trauma, infection - Glucose too low = breakdown of fats = ketones and metabolic acidosis/osmotic diuresis - DX: >200, positive ketones, pH <7.3, HCO3 <15, urine glucose, high BUN/Cr, electrolytes - SX: abdominal pain, N/V, polydipsia, polyuria, fruity acetone breath, dehydration, Kussmaul respiration, mental status changes Treatment - Fluid restriction -> NS bolus (10-20mL/kg) -> dextrose (if drop or <250 rapidly) - Slowly replace electrolytes - Insulin therapy for 12-24 hours then titrated and transition to SQ when stable - Oral feedings when stable - Monitor (q.1hr) – BG, neuro, VS, perfusion, RR Prevention - Monitor for abdominal pain, N/V, anorexia, 1-2 days with polyuria/polydipsia, illness without being able to eat - Still need insulin when not able to eat - Educate about the symptoms - Check BG and ketones frequently, extra insulin or fluids *Hypoglycemia* - Low blood sugar between 70-80; MUST be symptomatic - Kids at increased risk from growth, activity, insulin mistakes, eating patterns - SX: irritable, nervous, shaky, difficulty concentrating, HA, dizzy, blurry vision, pallor, sweating, shallow respirations, high HR, palpitations - Rule of 15 = test, 15 grams of carbs, retest and repeat until 70 - If unstable or unconscious glucagon kit, sugar gel, glucose paste # **Inborn Errors of Metabolism** - Inherited RARE, biochemical – urea, protein, metabolism *Phenylketonuria (PKU)* - Mutation disorder of amino acids that affects the body’s use of protein - Results in CNS damage from toxic levels of phenylamine - DX: newborn screening - SX: restricted ht/wt, musty urine, hypopigmentation, vomiting, irritable, seizures, hypertonia, cognitive \`delays - Irreversible brain injury if left undiagnosed - NO CNS concerns if diet managed - Dietary – formula low in phenylalanine, low protein diet that meets needs, NO aspartame - Nursing – restricted throughout life, avoid in formula or in mom’s diet if breastfeeding *Galactosemia* - Disorder of carb metabolism – cannot convert glucose, galactose accumulates - Leads to organ dysfunction, sepsis, brain and kidney damage - DX: newborn screening - S/S – poor sucking, no weight gain, V/D, hypoglycemia, hepatomegaly, ascites, jaundice, lethargy, seizures, coma - TX: lactose or galactose free formula or diet, watch for added milk (antibiotics, etc.) Cardiac Dysfunction # **Pediatric Considerations** *Fetal Circulation* - Ductus Venosus/Arteriosus, Foramen Ovale - Fetal shunts close shortly after birth - Permanently in 10-21 days *Pediatric Variations* - Can have congenital or acquired cardiovascular concerns - SVR increases and right atrial pressure falls - RV > LV – less use in utero from placenta, slowly grows - Higher HR to maintain CO, metabolic rates, O2 demands - Higher risk of HF – immature until 5, sensitive to volume and pressure overload *Cardiovascular Disease in Children* Manifestations - Heart murmur is 1st sign - Can be symptomatic after cord cutting or asymptomatic with a murmur - If undiagnosed – exercise intolerance, CP, arrhythmias, syncope, sudden death Diagnostics - Chest X-Ray – anatomy, heart shape/size - ECG – electrical activity, arrhythmias - Echocardiogram – structure, flow, pressure - MRI – anatomy, severity of defect - Cardiac Cath – invasive to diagnose or treat; O2, CO, pressure, correct arrhythmias - Bedrest for 4-6hrs with legs straight, minimal exercise for first 24hrs - Monitor distal pulse (weak initially, loss of feeling/pulse), coolness or blanching (clot), HR/BP, bleeding, hematoma, F&E (IVF dextrose if low glucose, flush dye) - Exercise Testing – stress test to monitor during exercise - Labs – ABGs, SpO2, H&H Assessment & Management - Respiratory (more tired/WOB when eating), pulses (compare sides), BP between extremities, color of skin, murmurs, edema/distension (FVO and HF), cap refill, exercise tolerance, growth (higher O2 and metabolic demand, decreased with WOB) - GOALS - Improve resistance – vasodilators, ACEI, beta blockers, antihypertensives - Remove excess fluid and Na – furosemide - Decrease demands and SVR - Improve oxygenation – CAREFUL supplementation of cyanotic defects Digoxin Administration - Used to improve strength, contractility, rate, rhythm, flexibility - 2x/day, 1 hour before or 2 hours after eating, DON’T mix with food or fluids - DON’T repeat dose if vomiting or double dose - <4hrs give dose, >4hrs hold dose, miss 2 call provider - Hold if HR <100 – educate about counting pulses - IF toxicity occurs – N/V, bradycardia, anorexia, yellow vision # **NANDA Considerations for ALL Cardiovascular Disorders** *Ineffective Tissue Perfusion* - Administer Digoxin (monitor HR), diuretics, antihypertensives - Monitor telemetry, I&O (fluid restrictions), daily weights, electrolytes - Observe for circulation changes – pulses, edema, HR, skin, cap refill - Rest periods – easily tired, heart cannot keep up, cluster care *Activity Intolerance* - Promote rest and utilize cluster care - Prevent crying, encourage short play, prevent fevers – decrease O2 demands - Supplemental O2 – CAREFUL administration with cyanotic disorders *Altered Nutrition* - Anticipate hunger to prevent crying - Small frequent feedings - <30-45mins, relaxed environment, semi-erect position - Burp before, during, after or every ounce - Increased calories in formula – burn more calories from O2 demands - Soft preemie nipple with large opening – decreased WOB to suck *Ineffective Breathing Patterns* - Assess respiratory – WOB, O2 stats, RR, retractions, belly breathing, nasal flaring - Position to encourage maximum expansion - NO tight clothes or tight swaddling - Supplemental O2 during crying or invasive UNLESS cyanotic duct dependent # **Acyanotic Lesions** *Summary* - Left to right = increased pulmonary flow - Higher lung resistance pressure creates right hypertrophy overtime - NO cyanosis but murmurs with ALL - SX: tachypnea, diaphoresis, eating exhaustion, pulmonary edema, rales, rhonchi *Types of Acyanotic* Patent Ductus Arteriosus (PDA) - Left is open and patent - Shunts from aorta to pulmonary arteries like in utero - Can be NO sx or pulmonary - TX: surgical ligation, Indomethacin (decrease prostaglandins to close) Atrial Septal Defect (ASD) - Opening between atria – blood to lungs - Can close on own or patch surgically - Can live with until sx, NOT immediate surgery - Can involve tricuspid if large enough Ventricular Septal Defect (VSD) - Opening between the ventricles - MOST common heart defect in children - Can close on own or patch surgically *Obstructive Defects* Coarctation of Aorta (COA) - Block in aorta – impaired flow to the body - Increased WOB/pressure in left or abnormality in aortic valve leaflets - Different BP in upper and lower extremities – low in lower with PDA close - TX: prostaglandins, EMERGENCY heart cath or stent to stretch, anastomosis Aortic Stenosis (AS) - Narrowing of aortic valve – 2 leaflets instead of 3 - Increased WOB/CP from work on left – hypertrophy, injury - Can have sudden death if only mild or asymptomatic - TX: balloon, Ross, valve replacement - Balloon – can renarrow, need valve replacement - Ross – take own pulmonary valve to replace aortic - Replacement – mechanical, will eventually need, lifelong anticoagulants # **Cyanotic Lesions** *Summary* - Right to left = decreased pulmonary flow - Deoxygenated blood through aorta to the body – CAREFUL with supplemental O2 - SX: clubbing, HF, cyanosis, TET/hypercyanotic spells (common when crying), polycythemia - Risk of decreased end-organ perfusion and hypoxemia *Types of Cyanotic* Transposition of the Great Arteries - Pulmonary artery (leaves left) and aorta (leave right) connected to wrong chambers - Oxygenated blood goes to the lungs, NO O2 reaching body - MUST have VSD/PDA open to gets O2, ductal-dependent - SX: cyanosis (increased as ducts close) - TX: arterial switch of vessels, prostaglandins or balloon if delayed surgical at birth Tricuspid Atresia - Tricuspid valve doesn’t work or exist – small RV from not working, hypoplastic - ASD/VSD to get O2 – ductal-dependent - Can lead to CHF, arrhythmias, stroke, clots – eventually need heart transplant - Requires 3 surgeries in phases - 1st = VT shunt to connect pulmonary artery and aorta, like PDA right flow, outgrows - 2nd (Glenn) = superior vena cava to pulmonary artery to get pulmonary flow - 3rd (Fontan) = connect superior and inferior vena cava to pulmonary artery Tetralogy of Fallot - 4 separate heart defects together - Pulmonic stenosis – narrowing, hard to get blood to lungs, open or remove block - RV hypertrophy – overworked from stenosis, remove tissue to decrease work - Ventricular septal defect – large VSD, patched surgically to close - Overriding aorta – enlarged about VSD, too much poor O2 blood, NO surgery - Need VT shunt and then complete repair in few months with sx - Tet spells – blue skin during crying or feeding - Squat or knee to chest to increase pressure and send blood to pulmonary artery - THEN O2 supplementation, surgery with increased frequency in episodes # **Acquired Heart Conditions** *Kawasaki’s Disease* - Acute systemic vasculitis that affects coronary arteries – possible virus component - Common in younger children, boys <2 yrs - MOST recovery, few progress to HF - can get arthritis and thrombocytopenia Criteria (Crash & Burn) - **C**onjunctivitis, **R**ash (chest/genitals), **A**denopathy, **S**trawberry tongue, **H**ands/feet swollen and peeling **+** 5 days of fever Treatment - High ASA and antiplatelets – fever and clots - Immunoglobulin – prevents LT damage; consent, 2 nurses, hydrated, check renal before - Nursing –cardiac, I&O, daily weight, fluids, monitor for MI (coronary involvement) *Dysrhythmias* - DX: 24hr Holter, ECG, Transesophageal (picture of heart) - Brady – atropine or epi if symptomatic, check if HR normal for them first - Tachy – can be normal in fever or shock - SVT – MOST common; 200-300 bpm with narrow QRS - Vagal/Valsalva first, adenosine (IV push fast), cardioversion, pacing (if reoccurring), ablation of source, digitalis, education (digoxin, maneuvers) Respiratory Dysfunction # **Eyes, Ears, Nose & Throat** *Anatomical Differences* Eyes - Decreased visual acuity (8 inches) until 6-7 years - Cannot distinguish eye color initially – can change - Eyes smaller and more easily injured Ears - Tube smaller, narrower, horizonal - Sucking, yawning, swallowing allows free air, more prone to ear infections - Membrane close to surface - Hearing begins at 20 weeks’ gestation, tested at newborn screening Nose, Mouth & Throat - Nose breathers – prone to mucus accumulation - Large tonsils - Teeth in first six months *Nose & Throat Disorders* Nasopharyngitis - Viral common cold, contact/droplet precautions - SX: fever, clear drainage, sore red throat, sneezing, V/D (draining secretions) - Risk of hospitalization in young from inability to clear secretions – NEED to clear for airway - TX: supportive; hydrate, antipyretics, rest, cool mist, saline/suction, smaller frequent meals Acute Streptococcal Pharyngitis - SX: fever, enlarged tonsils, sore throat, SOME have tonsil exudate - IF strawberry tongue or sandpaper rash – progressed to Scarlet Fever (NOT always) - TX: antibiotics; contagious until 24hrs post - Nursing – oral intake (cold, non-acidic), pain management, full AB - If difficulty breathing, excess drooling, sx of respiratory distress see provider, can lead to abscess of epiglottitis Tonsillitis & Adenoiditis - Inflammation or infection of tonsils and adenoids from virus or bacteria - SX: red tonsils, enlarged nodes, sore throat, fever, exudate, nasal stuffiness/discharge - IF swollen enough, can obstruct airway - TX: antibiotics, tonsillectomy/adenoidectomy if 7+/year or sleep concerns - Nursing – fluids, pain control, monitor for post-op hemorrhage - Scabs falling off -> excess swallowing or throwing up blood -> ligate vessels Otitis Media - Inflammation and/or infection –allergies, smoke, daycare, URI - Can be with effusions if sx of infection and fluid in middle ear - SX: otalgia pulling at ears, fever, crying/fussy, loss of appetite, hearing loss, vertigo - TX: high dose antibiotics then ear drops, supportive if NO infection - Tubes if 3+/6 months or 4+/year to allow continuous drainage # **Respiratory System Variations** *Anatomical Differences* - Grows and changes until 12 years old - Shorter neck and narrower nostrils – higher risk of obstruction and congestion - Less effective alveoli to ventilate Upper Airway - Shorter and narrower – size of pinkie finger - Cartilage in trachea more flexible and easily compressed - Increased airway resistances – narrow, increased effort with inflammation Lower Airways - <36 weeks’ – immature lungs, bronchi/bronchioles highly sensitive to inflammation - Children <6 use diaphragm instead of intercostal muscles to breath - Rib cartilage immature and flexible - Higher metabolic rate – need more oxygen, little reserve, fatigue quickly *Airway & Breathing* - NEED to determine airway patency – clear secretions/objects, provide airway - Adequate rise and fall – auscultate, retractions (sternal, subcostal/ribs, intercostal) Interventions - Patency – suction, sitting up HOB up, pillow or neck roller, tripod - Oxygen supplementation if needed - NC = colds, 10-15L/min - Non-Rebreather = bag reservoir, high O2 quickly, emergency - Venturi Mask = specific amount of O2 - High Flow NC = different machine, positive high pressure to open airway - Medication – bronchodilators (asthma), hypertonic saline (secretions) Worsening Conditions - Distress – high RR, use of accessory, nasal flaring, grunting, tense face, irregular breathing patterns, bobbing of the head - Worsening condition – increased O2 need >50% FiO2/>2L, periods of apnea, decreased breath sounds (any is BEST), decreased RR (high initially then fatigue), parental perception # **Respiratory Distress & Upper Airway Disorders** *Foreign Body Aspiration* - Inhalation of object into the respiratory tract – severity based on size, composition, age - Leading cause of unintentional death <5 years old - SX: choking, coughing, SOB, muffled or absent voice sounds, dyspnea, hypoxia, cyanosis - TX: back blows (higher) or chest thrusts (lower, severe) 5x or until unresponsive - Bronchoscopy in mouth or nose to remove if lower *Sudden Infant Death Syndrome (SIDs)* - Leading cause of infant mortality <1 year (2-4 months) - Prevention is key – sleep on back, NO bed sharing, limited objects in bed, 1 layer of clothes, decreased secondhand tobacco smoke exposure - If roll on stomach during sleep, OKAY if rolling milestone met - Often found morning later because NO symptoms of distress, blood-tinged frothy sputum *Acute Respiratory Tract Infections* - Swelling of the epiglottis and larynx – can extend to trachea and bronchi - Contact and droplet precautions - SX: 103-105 fever, poor feeding, vomiting from coughing, swollen abdominal lymph nodes, nasal blockage, cough, advantageous respiratory sounds, sore throat - TX: supportive; hydration, antipyretics, saline/suction, cool mist, AB if bacterial (rare) *Acute Epiglottis* - Inflammation and obstruction of tissue in back of larynx - Rapid progression, can be life-threatening if airway lost – MEDICAL EMERGENCY - Prevention with HIB vaccine - SX: drooling, sudden sore throat, absence of spontaneous cough, dystonia (thick muffled voice), dysphagia, stridor, high HR/RR, cherry red edematous epiglottis - TX: intubation, constant VS in ICU, O2, cultures, suction, fluids, IV AB and steroids - NOTHING in the back of the throat – tongue depressor, throat cultures or exam can cause sudden loss of airway *Laryngotracheobronchitis (Croup)* - Viral inflammation of the larynx, epiglottis, bronchi, and trachea - Any virus can trigger - SX: barky brassy seal-like cough, hoarseness, stridor, mild fever, runny nose, irritable - Only inpatient if stridor present - TX: racemic epinephrine 1-2x then monitor, steroids for LT - Nursing – O2 if hypoxic, monitor respiratory and airway, cool mist, PO fluids or NPO/IVFs depending on distress - NEED to maintain the airway *Influenza* - A/B most common, C is more mild - Contact and droplet precautions - SX: sore throat, dry cough, rhinitis, fever, chills, HA - TX: supportive if uncomplicated, IV AB if pneumonia, oseltamivir within 48hrs for 5 days # **Lower Airway Disorders** *Bronchiolitis* - Infection of bronchioles from RSV – NOT the same as bronchitis (URI) - Common in winter and <12 months, contact and droplet precautions - 2nd/3rd days worse, recover in 5-7 days - SX: runny nose, cough, wheeze, fever, high RR (>70), retractions, cyanosis, dehydration, listless, apnea, respiratory failure, diminished breath sounds Treatment & Nursing Care - Symptomatic treatment - Humidified oxygen (high flow NC), fluids, airway maintenance, saline drops or hypertonic saline, AB if bacterial - NO inhalers or bronchodilators unless asthma dx or hx - Synagis vaccine if increased RSV risk - $$$, NOT everyone - Nursing – suction, saline/suction education, monitor WOB/O2/NC patency *Pneumonia* - Inflammation or infection of the bronchioles and alveolar spaces - Community common, hospital acquired from vents - SX: URI 1st, high RR, crackles, wheezes, increased WOB, CP, poor appetite, fever - TX: IV AB and supportive, chest tube if pus/complicated # **Chronic Lung Disorders** *Asthma* - Reversible constriction, inflammation, hyperresponsive airway resulting in bronchospasms - DX: PFT - Triggers – exercise, temperature, air pollutants, allergens, tobacco, emotions, GERD, aspirin/NSAIDS, viral infections, stress, chemicals, fragrance, pet dander, genetics - NEED to determine and remove triggers - SX: dry hacking cough at night, chest tightness, wheezing, SOB, dyspnea, restless, fatigue, anxiety, tripod position, retractions, nasal flaring Medication Treatment - Albuterol – bronchodilator, use spacer, hold breath for 10 seconds after use - Beclomethasone – inflammation, 1x/day; inhaler first, wash components, rinse mouth after - Montelukast – relax muscle, decrease edema/mucous, PO in evening (sedation) Acute Episodes - Access ABCs, monitor response - Bronchodilator, O2, steroids (burst/maintenance), IV mag/terbutaline (inflammation) Long-Term Management - Inform school and provide medication access - Peak flow meter – home management of respiratory function; push air out, used for 2 weeks to determine normal and progression (lower number) - Asthma action plan - Education – medication use/how to, nebulizers, cleaning, identifying/removing triggers *Cystic Fibrosis* - Multisystem recessive– defective protein causing mucus obstruction in pancreas, GI, lungs - Low life expectancy from complications and lung transplant needs - DX: sweat test; medication to induce sweating and test for chloride (GOLD) - NO cure only prevention of progress - GOALS = facilitate airway/exchange, prevent infection, provide nutrition, promote exercise for lung function, meet emotional needs Manifestations - Respiratory = wheeze, cough, pneumonia, infection, thick sticky mucus; frequent hospital - Endocrine = salty taste when kissed; pancreatic fat enzymes blocked DM in future - Digestive = decreased motility; constipation, steatorrhea, flatus, unable to pass meconium - Reproductive = blocked sperm duct, thick cervical mucus Treatment - Respiratory– chest physiotherapy, forced expiration, physical activity, bronchodilators - Nutrition – pancrelipase, fat vitamins, high calorie/fat diet, monitor BG - Vaccines to prevent infection, AB if it occurs - Lumacaftor/Imacaftor – corrects protein malfunction in specific mutations, NOT everyone - Opens chloride channels and decrease thickness of mucus Complications - Infection – highly colonized, NO sharing rooms with other CF patients - CF diabetes - End stage lung disease, respiratory failure, lung transplant – depends on access to tx

Neuro Alterations

# **Pediatric Variations**

- Complete but immature nervous system – until 4 years old

- Brain and spinal cord develop from neural tube

- Large head and poor developed neck muscles

- Thin cranial bones – skull expands until 2, sutures unfused

- Excess spinal mobility – immature muscles/ligaments, incomplete vertebral ossification

- Risk of cervical injury or vertebral compression fractures with falls

*Pediatric Assessment*

- CT – may need sedation; lesions, tumors, edema, structures

- EEG – r/o seizures, continuous brain activity, wear for different amounts of time

- LP – ICP/CSF, may need sedation; spinal infection, meningitis

- MRI – tissue and structure, requires longer sedation; lesions, tumors, edema, structures

- XRAY – skull fractures

- EVM – lower is worse, want score of 15, used for nonverbal and “A&O” assessments

**ADULT**

**PREVERBAL & INFANTS**

- Time & Place (5)

- Confused (4)

- Inappropriate words (3)

- Incomprehensible words (2)

- No response (1)

- Smiles, coos, cries

- Irritable

- Cries in pain

- Moans in pain

- No response

# **Intracranial Pressure (ICP)**

*General IPC & Posturing*

- Force exerted by tissue, CSF, blood – decreased perfusion with increase in ICP

- Low EMV, neuro, LOC

- Meningitis, seizure, trauma, substance, stroke, brain tumors, electrolyte imbalance

- Treat ASAP, assess head circumference 1x/shift

- Posturing – LATE SIGNS of serious brain injury

- Decorticate = towards the body, rigid flexion from trauma ABOVE brainstem

- Decerebrate = away from the body, extension from brainstem injury

Infants VS. Child SX

- Infant = bulging fontanel, separate sutures, irritable then lethargic, increased sleeping, high pitch scream, distended veins, setting sun (sunken eyes)

- Child = HA, N/forceful vomiting, diplopia, blurry vision, seizures, indifference, drowsy, decline in activity/school, cannot follow simple commands, lethargy

Late Signs of Increased ICP

- Posturing, low HR/high BP, fixed large pupil, decreased motor/sensory, Cheyne-Stokes breathing, GCS &lt;8, coma

- Cushing’s Triad = increased systolic with wide pulse pressure, low HR, irregular RR

Treatment of ICP

- Evacuate cranial, Mannitol, elevate HOB 30

- O2 with ventilation if needed – stabilize airway

- Antibiotics (meningitis), fluids or blood

- Norepinephrine – increase perfusion and CO, serious cases

- Ventricular catheter – accumulated CSF from tumor

# **Seizures**

*Types, Stages, Manifestations*

General

- Brief paroxysmal behaviors from excessive abnormal neuron firing

- Diagnosed around 2, MOST idiopathic unless family hx

- Primary = absence of abnormality; epilepsy

- Secondary/Symptomatic = structural or metabolic dx; hydrocephalus

- Subtle signs if &lt;1yr – eye opening, fluttering, smacking, drooling, swimming or pedal movements instead of shaking

Types of Seizures

- Focal/Partial – one hemisphere from tumor or lesion

- Generalized – entire brain, epilepsy

- Febrile – rapid temperature from acute, risk of epilepsy in future, brief or 15 mins at 6m

- Tonic – rigidity of muscles

- Clonic – jerking movements

- Tonic Clonic – tonic first; excess drool or foaming, random noises, incontinence; postictal

- Absence – NO sx, brief LOC change, NO postictal, cluster or multiple a day, looks like zoning out or daydreaming

Stages of Seizures

- Aura = sensation alerting to oncoming seizure, NOT everyone has this

- Tonic

- Clonic

- Postictal = sleepy, confused, slurred speech, arousal only to pain

*Status Epilepticus (EMERGENCY)*

- Seizure &gt;30 minutes or multiple with NO return to normal LOC between

- Maintain airway, assist if needed (O2 through Ambu), turn onto side, DON’T restrain

- Administer medications (midazolam), respiratory assessment, prevent injury and falls

*Management & Nursing Care*

Seizure Precautions

- Padded side rails up, Ambu/suction working

- Emergency medications if &gt;5 minutes

- Midazolam (IN, home), Lorazepam (secondary), Diazepam

- Outpatient – swim buddy, showers, driving regulations, medical bracelet, medication adherence/safety, NO fire

Medications

**Emergency**

Midazolam – IN, 1st line

Lorazepam – IV push 2-3mins, secondary

Diazepam – IV or rectal

Phenytoin/Fosphenytoin or Phenobarbital – IV 2nd round

**Maintenance**

Try to stay on only one, follow-ups with neuro, need routine dental for gum AEs (gingivitis)

Phenytoin – monitor levels (neurotoxic), IV dose in NS

Fosphenytoin – less AEs

Valproic – monitor levels, PO

Levetiracetam – psych impulsivity, monitor gross motor, IV/PO

Phenobarbital – monitor levels, withdrawal sx if abrupt, sedation or hyperactive if toxic, drug interactions

Nursing Care

- Maintain appointment for levels

- DON’T suddenly stop taking the medication

- Birth control less effective

- Decreased seizure threshold with alcohol, weed, and street drugs

- Try keto or high fat diet

- Check driving regulations for recent seizures

- IF medication and diet NOT working…

- Vagal nerve stimulation – implant that sends impulses to increase perfusion and decrease number of seizures

# **Hydrocephalus**

*General*

- Imbalance in production and absorption of CSF

- Common in spina bifida, acquired from trauma/abuse

- Production &gt; absorption = accumulates, increasing ICP, dilation of ventricles

- DX: CT/MRI

In Infants

- Head grows abnormally, fontanels bulging, dilated scalp veins, separated sutures

- IF SEVERE – frontal bossing or protrusion, setting sun, sluggish fixed pupils

*Ventriculo-Peritoneal Shunt*

- Shunt in the ventricle to direct and reabsorb excess CSF

- Internal and end in the abdomen or RA of the heart

- Can be for life if congenital

- Needs revisions with growth – breakdown or length

- Risk of malfunction, infection, or occlusion

- May need to remove and place externally until infection treated

- Monitor ICP, head circumference, elevate HOB, keep calm (less crying)

# **Meningitis**

*General*

- SX: poor feeding, crying, V/D, poor muscle tone, temperature changes, apnea in clusters, seizures

- Infant = fever (bacterial), bulging fontanels, lethargy, irritability

- Child = signs, severe HA, photophobia, drowsy, altered LOC

- Kernig – lift leg but cannot extend at knee, pain prevents flexion in supine

- Brudzinski – flex head causes involuntary knee/hip flexion

Management

- Private room if viral, droplet precautions – quiet rest periods to decrease ICP, cluster care

- VS/neuro/I&O – pupils, EMV, fontanels, head circumference, eating or drinking

- Antibiotics – broad until C/S

- Seizure precautions and medications – risk from high ICP and meningitis

- Alter for progressive sepsis – purpura, petechiae, low BP, mental status changes

- Vaccine – 12yrs to prevent severe, can lessen if given at diagnosis

*Bacterial Meningitis*

- Inflammation of meninges -&gt; cerebral edema -&gt; elevated ICP

- NEED antibiotics, more serious for newborns because immature immunity

- DX: lumbar puncture; high WBC/protein, low glucose, +gram stain

# **Acute Head Injury**

*General*

- Complication of head trauma – seen with shaken baby

- SX: changes in LOC, transient confusion, somnolence, listless, irritable, pallor, 1+ episodes of projectile vomiting

- Progress = altered mental/difficult arousal, mounting agitation (behavior), focal neurological (movement), high BP, apnea

- Severe = increased ICP, bulging fontanel, retinal hemorrhage (SBS), hemiparesis, quadriplegia, elevated temp, unsteady gait

Medications

- Mannitol/Hypertonic 3% - pull off fluid and decrease pressure

- Steroids (dexa or methyl) – decrease ICP/pressure

- Anticonvulsants (pheno/y) – decrease seizure risk

- Sedative – caution with children, hard to tell if med or progression

- Ventricular drain if needed

# **Infant Botulism**

*General*

- Soil, honey &lt;1yr, improperly canned foods

- Progressive so catch early

- SX: HA, V/C, neurological impairment, weak descending paralysis and tone in respiratory muscles, hypotonia

- Seen in 12-36 hours after contamination

- TX: IV antitoxin, supportive or respiratory/nutritional

- MOST recover, but can lead to death if untreated

Endocrine & Metabolic Dysfunction

# **Pediatric Variations**

- Immature but similar to adults – sex differentiation as fetus, growth/development, puberty

- Release of hormones controls cellular activity that regulates growth and metabolism

# **Disorders of the PITUITARY**

*Diabetes Insipidus – Dry Inside*

- LOW ADH – cannot HOLD water, concentrate urine, or sustain hydration

- Inadequate production = central; autoimmune, tumor, trauma

- Ineffective action = nephrogenic; medication AEs or medication toxicity

- SX: polydipsia, polyuria, enuresis in kids (dehydration)

- HIGH serum Na/osmolarity, dilute urine

- TX: DDAVP to decrease UOP and thirst

- Nursing – daily weight, I&O, cold fluids, assess dehydration

*SIADH – Soaked Inside*

- HIGH ADH from feedback failure – HOLDS water, water toxicity, cellular edema

- Brain tumors/trauma, CNS, pulmonary disorders, positive pressure ventilation

- SX: FVO, HTN, JVD, crackles, weight gain WITHOUT edema, concentrated urine

- LOW serum Na, HIGH urine Na, LOW BUN (cellular expansion)

- TX: diuretics, vasopressin

- Nursing – restrict fluids, monitor fluid balance, I&O, daily weights

*Precocious or Early Puberty*

- Sexual development before 9 (males) and 8 (females) – more in females

- HPA axis has premature activation

- Results in premature skeletal maturation and short stature

- TX: leuprolide IM or nafarelin acetate IN 2x/day to slow progress

# **Disorders of the THYROID**

*Congenital Hypothyroidism*

- MOST from organ abnormality or genetics, acquired is RARE, 3 months best prognosis

- C = few signs; thick tongue, hypotonia, umbilical hernia, hoarse cry

- A = like adult; cold, dry, constipated, thin hair, small height, delay bone/dental age

- Decreased hormones = delayed growth and developmental/intellectual delay

- Complications – retarded skull, delayed teeth eruption, ataxia, strabismus

- DX: newborn screening, LOW T3/T4, HIGH TSH

- TX: lifelong levothyroxine (10-15mcg/kg/day), T4/TSH checks

- Nursing – routine newborn screening before discharge, length/weight each visit (delays)

# **Disorders of the PANCREAS**

*Diabetes Mellitus*

- Disorder of hyperglycemia from insulin secretion or production deficiencies leading to metabolism problems

- MOST children have type 1 – only difference from adults is treatment

Types of DM

- Type 1 = autoimmune, abrupt, NO insulin production

- DX – fasting &gt;126, random &gt;200, A1C &gt;6.5

- SX – hyperglycemia, polyuria, polyphagia, polydipsia, weight loss, fatigue, enuresis

- Undiagnosed and leads to DKA

- TX – insulin; basal 1x/day, bolus with each meal or snack

**Carbohydrate Counting**

x grams/x units

**Glucose**

glucose - &gt;x, divided by ratio

**Total Insulin**

Carbs + Glucose (round at end)

Insulin Pump Therapy

- Glycemic control especially in kids – continuous basal, like normal pancreas

- Can get disconnected, change site 2-3 days, risk of infection and pump failure (DKA)

Blood Glucose Monitoring

- 4x/day and A1C every 3 months

- Before meals, bedtime, any hypoglycemia sx, before activity, illness (more)

Sick Days

- Monitor glucose q.1-4 hours – more frequently, increased DKA risk

- Test urine ketones if BG &gt;200 or q.2-4 hours

- Increase usual insulin dose but DON’T skip doses

- Maintain hydration

- Notify if cannot tolerate fluids, ketones, BG out of target, sx of dehydration

Developmental Considerations

- Toddler = funny feelings

- Preschool = reports lows and shaking

- School Age = supervise for mistakes with insulin, can inject and monitor carbs/sx self

- Adolescents – compliance; activity, substances

*Hyperglycemia*

- Causes – high carbs, too little insulin, incorrect administration, illness, injury, stress, decreased activity, eating too close together

- Gradual onset

- SX: lethargy, confusion, Kussmaul, thirst, hunger, dehydration, weak, fruity breath, fatigue

*Diabetic Ketoacidosis (DKA)*

- Relative or absolute insulin deficiency – new dx, noncompliance, stress, trauma, infection

- Glucose too low = breakdown of fats = ketones and metabolic acidosis/osmotic diuresis

- DX: &gt;200, positive ketones, pH &lt;7.3, HCO3 &lt;15, urine glucose, high BUN/Cr, electrolytes

- SX: abdominal pain, N/V, polydipsia, polyuria, fruity acetone breath, dehydration, Kussmaul respiration, mental status changes

Treatment

- Fluid restriction -&gt; NS bolus (10-20mL/kg) -&gt; dextrose (if drop or &lt;250 rapidly)

- Slowly replace electrolytes

- Insulin therapy for 12-24 hours then titrated and transition to SQ when stable

- Oral feedings when stable

- Monitor (q.1hr) – BG, neuro, VS, perfusion, RR

Prevention

- Monitor for abdominal pain, N/V, anorexia, 1-2 days with polyuria/polydipsia, illness without being able to eat

- Still need insulin when not able to eat

- Educate about the symptoms

- Check BG and ketones frequently, extra insulin or fluids

*Hypoglycemia*

- Low blood sugar between 70-80; MUST be symptomatic

- Kids at increased risk from growth, activity, insulin mistakes, eating patterns

- SX: irritable, nervous, shaky, difficulty concentrating, HA, dizzy, blurry vision, pallor, sweating, shallow respirations, high HR, palpitations

- Rule of 15 = test, 15 grams of carbs, retest and repeat until 70

- If unstable or unconscious glucagon kit, sugar gel, glucose paste

# **Inborn Errors of Metabolism**

- Inherited RARE, biochemical – urea, protein, metabolism

*Phenylketonuria (PKU)*

- Mutation disorder of amino acids that affects the body’s use of protein

- Results in CNS damage from toxic levels of phenylamine

- DX: newborn screening

- SX: restricted ht/wt, musty urine, hypopigmentation, vomiting, irritable, seizures, hypertonia, cognitive \`delays

- Irreversible brain injury if left undiagnosed

- NO CNS concerns if diet managed

- Dietary – formula low in phenylalanine, low protein diet that meets needs, NO aspartame

- Nursing – restricted throughout life, avoid in formula or in mom’s diet if breastfeeding

*Galactosemia*

- Disorder of carb metabolism – cannot convert glucose, galactose accumulates

- Leads to organ dysfunction, sepsis, brain and kidney damage

- DX: newborn screening

- S/S – poor sucking, no weight gain, V/D, hypoglycemia, hepatomegaly, ascites, jaundice, lethargy, seizures, coma

- TX: lactose or galactose free formula or diet, watch for added milk (antibiotics, etc.)

Cardiac Dysfunction

# **Pediatric Considerations**

*Fetal Circulation*

- Ductus Venosus/Arteriosus, Foramen Ovale

- Fetal shunts close shortly after birth

- Permanently in 10-21 days

*Pediatric Variations*

- Can have congenital or acquired cardiovascular concerns

- SVR increases and right atrial pressure falls

- RV &gt; LV – less use in utero from placenta, slowly grows

- Higher HR to maintain CO, metabolic rates, O2 demands

- Higher risk of HF – immature until 5, sensitive to volume and pressure overload

*Cardiovascular Disease in Children*

Manifestations

- Heart murmur is 1st sign

- Can be symptomatic after cord cutting or asymptomatic with a murmur

- If undiagnosed – exercise intolerance, CP, arrhythmias, syncope, sudden death

Diagnostics

- Chest X-Ray – anatomy, heart shape/size

- ECG – electrical activity, arrhythmias

- Echocardiogram – structure, flow, pressure

- MRI – anatomy, severity of defect

- Cardiac Cath – invasive to diagnose or treat; O2, CO, pressure, correct arrhythmias

- Bedrest for 4-6hrs with legs straight, minimal exercise for first 24hrs

- Monitor distal pulse (weak initially, loss of feeling/pulse), coolness or blanching (clot), HR/BP, bleeding, hematoma, F&E (IVF dextrose if low glucose, flush dye)

- Exercise Testing – stress test to monitor during exercise

- Labs – ABGs, SpO2, H&H

Assessment & Management

- Respiratory (more tired/WOB when eating), pulses (compare sides), BP between extremities, color of skin, murmurs, edema/distension (FVO and HF), cap refill, exercise tolerance, growth (higher O2 and metabolic demand, decreased with WOB)

- GOALS

- Improve resistance – vasodilators, ACEI, beta blockers, antihypertensives

- Remove excess fluid and Na – furosemide

- Decrease demands and SVR

- Improve oxygenation – CAREFUL supplementation of cyanotic defects

Digoxin Administration

- Used to improve strength, contractility, rate, rhythm, flexibility

- 2x/day, 1 hour before or 2 hours after eating, DON’T mix with food or fluids

- DON’T repeat dose if vomiting or double dose

- &lt;4hrs give dose, &gt;4hrs hold dose, miss 2 call provider

- Hold if HR &lt;100 – educate about counting pulses

- IF toxicity occurs – N/V, bradycardia, anorexia, yellow vision

# **NANDA Considerations for ALL Cardiovascular Disorders**

*Ineffective Tissue Perfusion*

- Administer Digoxin (monitor HR), diuretics, antihypertensives

- Monitor telemetry, I&O (fluid restrictions), daily weights, electrolytes

- Observe for circulation changes – pulses, edema, HR, skin, cap refill

- Rest periods – easily tired, heart cannot keep up, cluster care

*Activity Intolerance*

- Promote rest and utilize cluster care

- Prevent crying, encourage short play, prevent fevers – decrease O2 demands

- Supplemental O2 – CAREFUL administration with cyanotic disorders

*Altered Nutrition*

- Anticipate hunger to prevent crying

- Small frequent feedings - &lt;30-45mins, relaxed environment, semi-erect position

- Burp before, during, after or every ounce

- Increased calories in formula – burn more calories from O2 demands

- Soft preemie nipple with large opening – decreased WOB to suck

*Ineffective Breathing Patterns*

- Assess respiratory – WOB, O2 stats, RR, retractions, belly breathing, nasal flaring

- Position to encourage maximum expansion

- NO tight clothes or tight swaddling

- Supplemental O2 during crying or invasive UNLESS cyanotic duct dependent

# **Acyanotic Lesions**

*Summary*

- Left to right = increased pulmonary flow

- Higher lung resistance pressure creates right hypertrophy overtime

- NO cyanosis but murmurs with ALL

- SX: tachypnea, diaphoresis, eating exhaustion, pulmonary edema, rales, rhonchi

*Types of Acyanotic*

Patent Ductus Arteriosus (PDA)

- Left is open and patent

- Shunts from aorta to pulmonary arteries like in utero

- Can be NO sx or pulmonary

- TX: surgical ligation, Indomethacin (decrease prostaglandins to close)

Atrial Septal Defect (ASD)

- Opening between atria – blood to lungs

- Can close on own or patch surgically

- Can live with until sx, NOT immediate surgery

- Can involve tricuspid if large enough

Ventricular Septal Defect (VSD)

- Opening between the ventricles

- MOST common heart defect in children

- Can close on own or patch surgically

*Obstructive Defects*

Coarctation of Aorta (COA)

- Block in aorta – impaired flow to the body

- Increased WOB/pressure in left or abnormality in aortic valve leaflets

- Different BP in upper and lower extremities – low in lower with PDA close

- TX: prostaglandins, EMERGENCY heart cath or stent to stretch, anastomosis

Aortic Stenosis (AS)

- Narrowing of aortic valve – 2 leaflets instead of 3

- Increased WOB/CP from work on left – hypertrophy, injury

- Can have sudden death if only mild or asymptomatic

- TX: balloon, Ross, valve replacement

- Balloon – can renarrow, need valve replacement

- Ross – take own pulmonary valve to replace aortic

- Replacement – mechanical, will eventually need, lifelong anticoagulants

# **Cyanotic Lesions**

*Summary*

- Right to left = decreased pulmonary flow

- Deoxygenated blood through aorta to the body – CAREFUL with supplemental O2

- SX: clubbing, HF, cyanosis, TET/hypercyanotic spells (common when crying), polycythemia

- Risk of decreased end-organ perfusion and hypoxemia

*Types of Cyanotic*

Transposition of the Great Arteries

- Pulmonary artery (leaves left) and aorta (leave right) connected to wrong chambers

- Oxygenated blood goes to the lungs, NO O2 reaching body

- MUST have VSD/PDA open to gets O2, ductal-dependent

- SX: cyanosis (increased as ducts close)

- TX: arterial switch of vessels, prostaglandins or balloon if delayed surgical at birth

Tricuspid Atresia

- Tricuspid valve doesn’t work or exist – small RV from not working, hypoplastic

- ASD/VSD to get O2 – ductal-dependent

- Can lead to CHF, arrhythmias, stroke, clots – eventually need heart transplant

- Requires 3 surgeries in phases

- 1st = VT shunt to connect pulmonary artery and aorta, like PDA right flow, outgrows

- 2nd (Glenn) = superior vena cava to pulmonary artery to get pulmonary flow

- 3rd (Fontan) = connect superior and inferior vena cava to pulmonary artery

Tetralogy of Fallot

- 4 separate heart defects together

- Pulmonic stenosis – narrowing, hard to get blood to lungs, open or remove block

- RV hypertrophy – overworked from stenosis, remove tissue to decrease work

- Ventricular septal defect – large VSD, patched surgically to close

- Overriding aorta – enlarged about VSD, too much poor O2 blood, NO surgery

- Need VT shunt and then complete repair in few months with sx

- Tet spells – blue skin during crying or feeding

- Squat or knee to chest to increase pressure and send blood to pulmonary artery

- THEN O2 supplementation, surgery with increased frequency in episodes

# **Acquired Heart Conditions**

*Kawasaki’s Disease*

- Acute systemic vasculitis that affects coronary arteries – possible virus component

- Common in younger children, boys &lt;2 yrs

- MOST recovery, few progress to HF - can get arthritis and thrombocytopenia

Criteria (Crash & Burn)

- **C**onjunctivitis, **R**ash (chest/genitals), **A**denopathy, **S**trawberry tongue, **H**ands/feet swollen and peeling **+** 5 days of fever

Treatment

- High ASA and antiplatelets – fever and clots

- Immunoglobulin – prevents LT damage; consent, 2 nurses, hydrated, check renal before

- Nursing –cardiac, I&O, daily weight, fluids, monitor for MI (coronary involvement)

*Dysrhythmias*

- DX: 24hr Holter, ECG, Transesophageal (picture of heart)

- Brady – atropine or epi if symptomatic, check if HR normal for them first

- Tachy – can be normal in fever or shock

- SVT – MOST common; 200-300 bpm with narrow QRS

- Vagal/Valsalva first, adenosine (IV push fast), cardioversion, pacing (if reoccurring), ablation of source, digitalis, education (digoxin, maneuvers)

Respiratory Dysfunction

# **Eyes, Ears, Nose & Throat**

*Anatomical Differences*

Eyes

- Decreased visual acuity (8 inches) until 6-7 years

- Cannot distinguish eye color initially – can change

- Eyes smaller and more easily injured

Ears

- Tube smaller, narrower, horizonal

- Sucking, yawning, swallowing allows free air, more prone to ear infections

- Membrane close to surface

- Hearing begins at 20 weeks’ gestation, tested at newborn screening

Nose, Mouth & Throat

- Nose breathers – prone to mucus accumulation

- Large tonsils

- Teeth in first six months

*Nose & Throat Disorders*

Nasopharyngitis

- Viral common cold, contact/droplet precautions

- SX: fever, clear drainage, sore red throat, sneezing, V/D (draining secretions)

- Risk of hospitalization in young from inability to clear secretions – NEED to clear for airway

- TX: supportive; hydrate, antipyretics, rest, cool mist, saline/suction, smaller frequent meals

Acute Streptococcal Pharyngitis

- SX: fever, enlarged tonsils, sore throat, SOME have tonsil exudate

- IF strawberry tongue or sandpaper rash – progressed to Scarlet Fever (NOT always)

- TX: antibiotics; contagious until 24hrs post

- Nursing – oral intake (cold, non-acidic), pain management, full AB

- If difficulty breathing, excess drooling, sx of respiratory distress see provider, can lead to abscess of epiglottitis

Tonsillitis & Adenoiditis

- Inflammation or infection of tonsils and adenoids from virus or bacteria

- SX: red tonsils, enlarged nodes, sore throat, fever, exudate, nasal stuffiness/discharge

- IF swollen enough, can obstruct airway

- TX: antibiotics, tonsillectomy/adenoidectomy if 7+/year or sleep concerns

- Nursing – fluids, pain control, monitor for post-op hemorrhage

- Scabs falling off -&gt; excess swallowing or throwing up blood -&gt; ligate vessels

Otitis Media

- Inflammation and/or infection –allergies, smoke, daycare, URI

- Can be with effusions if sx of infection and fluid in middle ear

- SX: otalgia pulling at ears, fever, crying/fussy, loss of appetite, hearing loss, vertigo

- TX: high dose antibiotics then ear drops, supportive if NO infection

- Tubes if 3+/6 months or 4+/year to allow continuous drainage

# **Respiratory System Variations**

*Anatomical Differences*

- Grows and changes until 12 years old

- Shorter neck and narrower nostrils – higher risk of obstruction and congestion

- Less effective alveoli to ventilate

Upper Airway

- Shorter and narrower – size of pinkie finger

- Cartilage in trachea more flexible and easily compressed

- Increased airway resistances – narrow, increased effort with inflammation

Lower Airways

- &lt;36 weeks’ – immature lungs, bronchi/bronchioles highly sensitive to inflammation

- Children &lt;6 use diaphragm instead of intercostal muscles to breath

- Rib cartilage immature and flexible

- Higher metabolic rate – need more oxygen, little reserve, fatigue quickly

*Airway & Breathing*

- NEED to determine airway patency – clear secretions/objects, provide airway

- Adequate rise and fall – auscultate, retractions (sternal, subcostal/ribs, intercostal)

Interventions

- Patency – suction, sitting up HOB up, pillow or neck roller, tripod

- Oxygen supplementation if needed

- NC = colds, 10-15L/min

- Non-Rebreather = bag reservoir, high O2 quickly, emergency

- Venturi Mask = specific amount of O2

- High Flow NC = different machine, positive high pressure to open airway

- Medication – bronchodilators (asthma), hypertonic saline (secretions)

Worsening Conditions

- Distress – high RR, use of accessory, nasal flaring, grunting, tense face, irregular breathing patterns, bobbing of the head

- Worsening condition – increased O2 need &gt;50% FiO2/&gt;2L, periods of apnea, decreased breath sounds (any is BEST), decreased RR (high initially then fatigue), parental perception

# **Respiratory Distress & Upper Airway Disorders**

*Foreign Body Aspiration*

- Inhalation of object into the respiratory tract – severity based on size, composition, age

- Leading cause of unintentional death &lt;5 years old

- SX: choking, coughing, SOB, muffled or absent voice sounds, dyspnea, hypoxia, cyanosis

- TX: back blows (higher) or chest thrusts (lower, severe) 5x or until unresponsive

- Bronchoscopy in mouth or nose to remove if lower

*Sudden Infant Death Syndrome (SIDs)*

- Leading cause of infant mortality &lt;1 year (2-4 months)

- Prevention is key – sleep on back, NO bed sharing, limited objects in bed, 1 layer of clothes, decreased secondhand tobacco smoke exposure

- If roll on stomach during sleep, OKAY if rolling milestone met

- Often found morning later because NO symptoms of distress, blood-tinged frothy sputum

*Acute Respiratory Tract Infections*

- Swelling of the epiglottis and larynx – can extend to trachea and bronchi

- Contact and droplet precautions

- SX: 103-105 fever, poor feeding, vomiting from coughing, swollen abdominal lymph nodes, nasal blockage, cough, advantageous respiratory sounds, sore throat

- TX: supportive; hydration, antipyretics, saline/suction, cool mist, AB if bacterial (rare)

*Acute Epiglottis*

- Inflammation and obstruction of tissue in back of larynx

- Rapid progression, can be life-threatening if airway lost – MEDICAL EMERGENCY

- Prevention with HIB vaccine

- SX: drooling, sudden sore throat, absence of spontaneous cough, dystonia (thick muffled voice), dysphagia, stridor, high HR/RR, cherry red edematous epiglottis

- TX: intubation, constant VS in ICU, O2, cultures, suction, fluids, IV AB and steroids

- NOTHING in the back of the throat – tongue depressor, throat cultures or exam can cause sudden loss of airway

*Laryngotracheobronchitis (Croup)*

- Viral inflammation of the larynx, epiglottis, bronchi, and trachea

- Any virus can trigger

- SX: barky brassy seal-like cough, hoarseness, stridor, mild fever, runny nose, irritable

- Only inpatient if stridor present

- TX: racemic epinephrine 1-2x then monitor, steroids for LT

- Nursing – O2 if hypoxic, monitor respiratory and airway, cool mist, PO fluids or NPO/IVFs depending on distress

- NEED to maintain the airway

*Influenza*

- A/B most common, C is more mild

- Contact and droplet precautions

- SX: sore throat, dry cough, rhinitis, fever, chills, HA

- TX: supportive if uncomplicated, IV AB if pneumonia, oseltamivir within 48hrs for 5 days

# **Lower Airway Disorders**

*Bronchiolitis*

- Infection of bronchioles from RSV – NOT the same as bronchitis (URI)

- Common in winter and &lt;12 months, contact and droplet precautions

- 2nd/3rd days worse, recover in 5-7 days

- SX: runny nose, cough, wheeze, fever, high RR (&gt;70), retractions, cyanosis, dehydration, listless, apnea, respiratory failure, diminished breath sounds

Treatment & Nursing Care

- Symptomatic treatment

- Humidified oxygen (high flow NC), fluids, airway maintenance, saline drops or hypertonic saline, AB if bacterial

- NO inhalers or bronchodilators unless asthma dx or hx

- Synagis vaccine if increased RSV risk - $$$, NOT everyone

- Nursing – suction, saline/suction education, monitor WOB/O2/NC patency

*Pneumonia*

- Inflammation or infection of the bronchioles and alveolar spaces

- Community common, hospital acquired from vents

- SX: URI 1st, high RR, crackles, wheezes, increased WOB, CP, poor appetite, fever

- TX: IV AB and supportive, chest tube if pus/complicated

# **Chronic Lung Disorders**

*Asthma*

- Reversible constriction, inflammation, hyperresponsive airway resulting in bronchospasms

- DX: PFT

- Triggers – exercise, temperature, air pollutants, allergens, tobacco, emotions, GERD, aspirin/NSAIDS, viral infections, stress, chemicals, fragrance, pet dander, genetics

- NEED to determine and remove triggers

- SX: dry hacking cough at night, chest tightness, wheezing, SOB, dyspnea, restless, fatigue, anxiety, tripod position, retractions, nasal flaring

Medication Treatment

- Albuterol – bronchodilator, use spacer, hold breath for 10 seconds after use

- Beclomethasone – inflammation, 1x/day; inhaler first, wash components, rinse mouth after

- Montelukast – relax muscle, decrease edema/mucous, PO in evening (sedation)

Acute Episodes

- Access ABCs, monitor response

- Bronchodilator, O2, steroids (burst/maintenance), IV mag/terbutaline (inflammation)

Long-Term Management

- Inform school and provide medication access

- Peak flow meter – home management of respiratory function; push air out, used for 2 weeks to determine normal and progression (lower number)

- Asthma action plan

- Education – medication use/how to, nebulizers, cleaning, identifying/removing triggers

*Cystic Fibrosis*

- Multisystem recessive– defective protein causing mucus obstruction in pancreas, GI, lungs

- Low life expectancy from complications and lung transplant needs

- DX: sweat test; medication to induce sweating and test for chloride (GOLD)

- NO cure only prevention of progress

- GOALS = facilitate airway/exchange, prevent infection, provide nutrition, promote exercise for lung function, meet emotional needs

Manifestations

- Respiratory = wheeze, cough, pneumonia, infection, thick sticky mucus; frequent hospital

- Endocrine = salty taste when kissed; pancreatic fat enzymes blocked DM in future

- Digestive = decreased motility; constipation, steatorrhea, flatus, unable to pass meconium

- Reproductive = blocked sperm duct, thick cervical mucus

Treatment

- Respiratory– chest physiotherapy, forced expiration, physical activity, bronchodilators

- Nutrition – pancrelipase, fat vitamins, high calorie/fat diet, monitor BG

- Vaccines to prevent infection, AB if it occurs

- Lumacaftor/Imacaftor – corrects protein malfunction in specific mutations, NOT everyone

- Opens chloride channels and decrease thickness of mucus

Complications

- Infection – highly colonized, NO sharing rooms with other CF patients

- CF diabetes

- End stage lung disease, respiratory failure, lung transplant – depends on access to tx

Transcript for:peds mini 5

Transcript for:
peds mini 5