Exam 3 Flashcards
1
Q
Risk factors for Cancer (8)
A
- Genetic alterations (germline
- Certain meds (chemo, immunosuppressive therapies)
- Radiation exposure (incl. sunlight and tanning)
- Heredity (Wilms and retinoblastoma)
- Exposure to carcinogens (esp prenatally- smoking)
- Epstein Barr virus (EBV) (HL, NHL,
- advanced parental age
- birth weight > 4000 g (ALL)
2
Q
General Symptoms of Cancer (9)
A
- Unusual mass or swelling
- Anemia (Pallor and fatigue)
- thrombocytopenia (Petechiae, Sudden easy tendency to bruise)
- Persistent, localized pain or limping
- Prolonged, unexplained fever or illness
- Frequent headaches, often with vomiting
- Sudden eye or vision changes (leukocoria in retinoblastoma; squinting, strabismus, swelling if solid eye tumor)
- Excessive, rapid weight loss
- enlarged firm lymph nodes
3
Q
Leukemia
Patho
Most affected extramedullary areas (2)
A
Patho: unrestricted proliferation of immature white blood cells (blasts) in the blood-forming tissues of the body
Most affected extramedullary areas: spleen and liver b-c highly vascular
4
Q
Leukemia
Symptoms (5)
A
- Bone marrow (anemia, thrombocytopenia, leukopenia; bone and joint pain)
- Physiologic fractures r/t increased pressure in bone
- Enlarged spleen, liver, lymph nodes r/t infiltration -> can become fibrotic
- Leukemic meningitis r/t CNS infiltration
- Cellular Starvation r/t hypermetabolism
5
Q
Leukemia: Diagnostics
- CBC (2)
- Biopsy (3)
- Lumbar puncture
A
CBC
- immature leukocytes (blasts) present
- Low blood counts (WBC, RBC, platelets)
Bone marrow biopsy and/or aspiration
- Definitive diagnosis to differentiate b/w ALL and ALM
- Shows infiltration of blast cells
- Often sedation for pediatrics b-c must remain still
Lumbar Puncture (LP)
- Determination of CNS involvement (metastasis, brain tumors)
6
Q
Leukemia
Treatment (5)
A
- Surgery (palliative or curative)
- Chemotherapy (primary)
- Targeted therapy (tyrosine kinase inhibitors (TKIs), monoclonal antibodies, proteasome inhibitors)
- Radiotherapy
- Hematopoietic Stem Cell Transplant (HSCT) or Bone Marrow Transplant (BMT)
7
Q
Chemotherapy drugs
Nursing Care (6)
A
- Requires a double check from a second RN
- PPE (gloves, gowns, masks/face shield if splashes possible)- including gauze when in contact w/ drug
- Often need central line or infusion port
- DO NOT crush or alter chemotherapy drugs
- Stop infusion immediately if s/s of infiltration (pain, stinging, swelling, redness)
- Observe child for 1 hr after infusion for signs of anaphylaxis (rash, urticaria, hypotension, wheezing, NV)
8
Q
Chemotherapy Drugs
Notes (2)
A
- combo drug regimen used b-c optimal cell destruction with minimum toxic effects
- Not selectively cytotoxic for malignant cells (kills fast growing healthy cells i.e. bone marrow, hair, skin, and GI tract)
9
Q
Monoclonal Antibody drugs
Pros (2)
Cons
A
Pros
- fewer reactions vs chemo (no hair loss or mucositis)
- alters immune system to recognize cancer cells by attaching to proteins
Cons
- anaphylaxis common so premedicate w/ steroids or benadryl
10
Q
Granulocyte Colony stimulating factor (G-CSF)- filgrastim, pegfilgrastim)
Purpose (2)
Care (2)
A
Purpose
- Regulate reproduction, maturation and function of blood cells.
- Decreases duration of neutropenia
Care
- Discontinued when ANC > 10,000
- watch for bone pain, fever, rash, malaise, headache
11
Q
Biologic Response modifiers
- Action
- Examples (5)
A
Action: Alters relationship b/w tumor and host by changing the host’s biologic response to tumor cells.
Examples
- Monoclonal antibodies
- Chimeric Antigen Receptor T-cell Inhibitors (CAR-T)
- Angiogenesis inhibitors
- Colony-stimulating factors (CSFs)- G-CSF (filgrastim, pegfilgrastim)
- checkpoint inhibitors (block pathways that allow cancer cells to escape immune system)
12
Q
Radiation
Side effects (9)
A
Side effects (based on area)
- neck (hypothyroidism )
- chest (reduced lung function, heart damage)
- obesity and metabolic syndrome ( hormone-producing organs)
- ovaries and testes (infertility)
- GI (anorexia, mucosal ulceration, NVD)
- Skin (alopecia, dry or moist desquamation, hyperpigmentation)
- Head (NV(stimulation of vomiting center), alopecia, mucositis, parotitis, sore throat, loss of taste, xerostomia, GH deficiency, cognitive deficits, hearing loss)
- bladder (cystitis)
- Bone marrow (myelosuppression)
13
Q
Radiation
Nursing Care (3)
Patient education (5)
A
Nursing Care
- Encourage fluids & nutritional intake (Light, small, frequent meals)
- get I&O and Daily weights
- Do not refer to skin changes as burns b-c implies too much radiation use
Patient Education
- Use mild soap
- Do not remove skin markings
- Avoid creams or lotions
- Loose-fitting clothing over irradiated area to minimize skin irritation
- Protect area from sunlight and sudden temp changes (ice or heating packs)
14
Q
Hematopoietic Stem Cell Transplant (HSCT)
Indication (2)
Risks (3)
Pre-op
A
Indication
- malignancies unable to be cured by other means
- replacement of dysfunctional bone marrow
Risks: infection, relapse, Graft vs Host disease(due to HLA mismatch)
Pre-op: High dose chemo and radiation – to reduce ANC to nadir (0) (irreversible)
15
Q
Hematopoietic Stem Cell Transplant (HSCT)
Procedure (2)
Post-op (4)
A
Procedure
- Transfuse PRBCs, and platelets as indicated
- Autologous (self-donation) vs Allogeneic (family or volunteer, umbilical cord blood) stem cells
Post transplant
- Give G-CSF if ANC still low
- give calcineurin inhbitor w/ chemo to prevent graft versus host disease
- Minimize pressure in dependent areas (frequent movement, pressure-relieving)
- Promote healing (frequent sitz baths to perianal area and protective skin barriers i.e hydrocolloid dressing or occlusive ointments)
16
Q
Effects of Cancer Treatment: Infection
Related to? (2)
Patient education (4)
A
Related to: neutropenia (ANC < 500), altered nutrition (prolongs neutropenia)
Education:
- Avoid crowds and sick individuals
- wear a mask in public
- Low bacterial diet ( no fresh fruits, no soft serve; fully cooked foods, no deli meats)
- Avoid fresh flowers, live plants
17
Q
Effects of Cancer Treatment: Infection
Nursing Care (6)
A
- Handwashing
- Monitor s/s of infection or sepsis (fever)
- G-CSF Injections if ANC < 500
- Cultures and antibiotics as soon as possible for 7-10 days
- Protective isolation
- Prophylaxis against Pneumocystis pneumonia (trimethoprim-sulfamethoxazole)
18
Q
Effects of Cancer Treatment: Anaphylaxis( tachycardia, tachypnea, flushing, urticaria, hypotension)
Related to?
Nursing Care (6)
A
Related to: chemo, BRMs
Nursing Care
- pre-medicate if ordered
- Monitor patient closely (vital signs, and assessment)
- Assess for hx of anaphylaxis with certain meds
- discontinue drug if happens and maintain patency of IV line w/ NS
- Obtain crash cart give emergency drugs (epinephrine, dopamine)
- administer supplemental O2 (call RRT)
19
Q
Effects of Cancer Treatment: Hemorrhage
(epistaxis, gingival bleeding)
Related to?
Nursing Care (7)
A
Related to: thrombocytopenia (<20K)
Nursing Care
- Administer platelets as ordered (no need for cross matching; peak: 1 hr, Duration:1-3 days)
- Avoid invasive procedures and skin punctures
- Gentle mouth and perineal care (wipes front to back)
- AVOID rectal temperatures and suppositories
- Educate patient to avoid contact sports, bike or skateboard riding if < 100,000
- avoid aspirin products
- Frequent turns and pressure-reducing mattress under bony prominences to prevent pressure sores and decubital ulcers
20
Q
Effects of Cancer Treatment: Anemia
Nursing Care (4)
A
- Monitor for s/sx of anemia (pallor, fatigue, tachycardia, increased cap refill)
- Allow for frequent periods of rest (regulated by child
- Transfuse PRBCs if ordered (to increase Hgb > 10 g/dL)
- Administer G-CSF (filgrastim, pegfilgrastim)
21
Q
Effects of Cancer Treatment: Pain
Related to?
Nursing Care (3)
A
Related to: bone marrow involvement (acute, chronic, neuropathic)
Nursing Care
- Assess pain frequently w/ age-appropriate pain scale
- Administer pain meds PRN (IV (morphine or hydromorphone PCA), PO, transdermal patches (Fentanyl, lidocaine), nerve blocks/epidurals_
- Involve interdisciplinary teams (quality of life team; pain team)
22
Q
Effects of Cancer Treatment: Altered Nutrition
(Anorexia, NV)
Nursing Care (5)
A
Nursing Care (prevention is key)
- administer meds (ondansetron, lorazepam, diphenhydramine, dronabinol, granisetron, hydrocortisone) 30-60 min prior to admin of chemo and for 24 hrs after
- give metoclopramide w/ diphenhydramine if severe b-c metoclopramid has extrapyramidal effects
- Monitor I&O, daily weight, albumin/prealbumin (increased risk of dehydration and electrolyte disturbances)
- Fortify foods with nutritious supplements (High protein, high calorie)
- use NGT and TPN as needed
23
Q
Effects of Cancer Treatment: Altered Nutrition
(Anorexia, NV)
Related to? (3)
Patient Education (4)
A
Related to: chemo, radiation, steroids (increased appetite)
Parental education
- avoid strong smells
- relax pressure placed on eating.
- Allow child to be involved in preparation and selection to make food appealing
- give chemo at night
24
Q
Effects of Cancer Treatment: Mucositis/ Stomatitis (eroded, red, painful areas in mouth, pharynx, rectum)
Nursing Care
- mouth lesions (5)
- rectal lesions (3)
A
Nursing Care for mouth lesions
- Encourage frequent oral care (q2-4 hrs w/ soft sponge toothbrush) and Lubricate lips PRN
- Alkaline saline mouth rinses, viscous lidocaine, chlorhexidine mouth rinse (No lidocaine for under 2 yrs b-c diminishes gag reflex)
- Avoid alcohol rinse, lemon glycerin swabs and hydrogen peroxide b-c drying effects and acidity of lemon is irritating
- Administer nystatin for thrush as indicated
- Encourage a bland, moist, soft diet
Nursing Care for rectal lesions
- AVOID suppositories and rectal temps
- Daily CHG wipes/baths, Sitz bath as needed
- Occlusive ointments
25
Effects of Cancer Treatment: Neurologic problems
Examples w/ nursing care (6)
- Foot drop (Encourage use of foot board or high-top tennis shoes when in bed)
- severe constipation (use stool softeners, activity, laxatives)
- Peripheral neuropathy (Give antidepressants (TCAs), AEDs
- Jaw pain (use repetitive gum chewing or suck hard candy)
- Developmental delays
- Post irradiation syndrome (somnolence, anorexia, N/V, fever; 5-8 wks after CNS radiation lasting 4-15 days) (indicator of neurologic sequelae)
26
Effects of Cancer Treatment: Hemorrhagic cystitis (irritation of bladder lining)
Related to?
Nursing Care (5)
Related to: urinary stasis r/t radiation and chemo
Nursing Care
- Monitor for hematuria and blood clots in urine
- Ensure adequate oral or parenteral fluid intake (1.5x daily fluid requirement (2L/m2/day))
- Monitor strict I&O and ensure frequent voiding around the clock every 2 hrs until 24 hrs after last dose
- Administer bladder protectant (mesna) after certain chemo
- give chemo early in day to allow adequate flushing and fluids throughout day
27
Effects of Cancer Treatment: Body Image Concerns
Related to? (4)
Nursing Care (2)
Patient education (2)
Related to:
- alopecia (all body hair)
- weight changes, steroids (cushingoid)
- body additions (CVAD, IV lines)
- body changes (scars, amputations)
Nursing Care
- Encourage shorter haircuts prior to hair falling out b-c falls out in clumps
- Provide emotional support
Patient education
- Educate on options such as wigs, scarves, and bandanas
- Educate that hair grows back in 3-6 months
28
Effects of Cancer Treatment: Tumor Lysis Syndrome
What is it?
S/s (4)
Related to: rapid release of intracellular contents seen in lysis of cells in ALL or burkitt lymphoma
S/s
- hyperkalemia (NV)
- hyperuricemia (flank pain, lethargy, renal failure)
- hyperphosphatemia (muscle cramps, pruritus)
- hypocalcemia (tetany, seizures)
29
Effects of Cancer Treatment: Tumor Lysis Syndrome
Nursing Care (5)
Nursing Care
- monitor frequent serum chemistries and urine pH
- strict I&O
- aggressive IV fluids
- For hyperkalemia, furosemide
- For hyperuricemia, allopurinol (decrease formation) or rasburicase (convert to soluble allantoin)
30
Cancer: Immunizations (4)
- Avoid admin of live, attenuated vaccines (polio, MMR) due to immunosuppression
- Avoid exposure to childhood diseases such as chickenpox then give antivirals (acyclovir, valgancyclovir) if child develops varicella or is exposed
- If vaccinated 2 weeks prior to starting chemotherapy or during treatment, consider child unimmunized b-c immune system not strong enough for developing active immunity.
- Revaccinate or administer live virus vaccines 6 months after treatment is stopped.
31
Non-Hodgkin Lymphoma (NHL)
What is it?
Key s/s
Classifications (3)
Treatment (3)
Tumors of the peripheral lymph nodes, thymus, or abdominal organs such as the bowel.
Key s/s: tumors compressing organs (intestinal or airway obstruction, CN palsies, spinal paralysis)
Classifications: Lymphoblastic, Burkitt/Non-Burkitt (mature B-cell), Large Cell/anaplastic
Treatment: chemo, radiation (emergencies), surgery (Burkitt or anaplastic)
32
Hodgkin Lymphoma (HL)
What is it?
Key s/s (5)
Diagnostic
Treatment
progressive enlargement of affected lymph nodes and sometimes spread to the spleen, liver, bone marrow, bones, mediastinum, or lungs
Key s/s
- Enlarged, firm, nontender, movable lymph nodes in supraclavicular or cervical areas
- Mediastinal lymphadenopathy – persistent nonproductive cough
- Enlarged retroperitoneal nodes – unexplained abdominal pain
- splenomegaly/hepatomegaly
- Systemic symptoms: low or intermittent fever, anorexia, nausea, weight loss, night sweats, pruritus
Diagnostic: Lymph node biopsy shows Reed Sternberg cells (seen in mono as well)
Treatment: radiation and chemo
33
Neuroblastoma
What is it?
Diagnosis (3)
Treatment (3)
originate from embryonic neural crest cells (neuroblasts) which form adrenal medulla and SNS and cause abdomen (arising from adrenal gland) OR head, neck, chest, or pelvis tumor
Diagnosis
- usually after metastasis (silent tumor)- lymph node, bone, liver (lymphadenopathy, bone pain, hepatomegaly)
- Metaiodobenzylguanidine (MIBG) scan – biopsy and aspirate of bone marrow to evaluate metastasis
- CT or MRI to locate primary tumor
Treatment: chemo, radiation, surgery (primary)
34
Wilm's Tumor
What is it?
Key s/s (3)
Diagnosis (2)
Treatment (4)
Solid tumor of the kidneys from immature kidney cells
Key s/s
- UNILATERAL firm, nontender swelling or abdominal mass (does not move w/ respiration)
- hematuria
- HTN (due to excess renin secretion by tumor)
Diagnosis
- Metastasis is rare (Pulmonary metastasis (dyspnea, cough, SOB, pain in chest)
- CBC may show polycythemia if tumor secretes excess erythropoietin
Treatment
- DO NOT PALPATE (appropriate signage in room)
- surgical resection of tumor, adrenal gland, kidney (transplant if stage 5)
- radiation (maybe post-op depending on stage)
- chemo
35
Osteosarcoma
What is it?
Key s/s (4)
Arises from bone-forming mesenchyme in osseous tissue of metaphyseal region of long bones
Key S/s
- Pain, swelling, and sometimes decreased joint motion and limp (relieved pain w/ flexion)
- inability to hold heavy items
- occasional fracture at the tumor site if tumor presses on bone
- palpable mass
36
Osteosarcoma
Diagnosis (4)
Treatment (3)
Diagnostic Testing
- MRI of affected bone
- Plain radiograph - Radial ossification in soft tissue gives sunburst appearance of tumor
- chest CT b-c metastasis to lung usually
- increased alkaline phosphatase.
Treatment:
- Surgery – limb salvage or amputation then Post-op care: continuous passive motion; TCA (amitriptyline) for phantom pain
- Chemotherapy
- Thoracotomy if pulmonary metastasis
37
Ewing Sarcoma
What is it?
Key s/s (3)
Diagnosis (3)
Treatment (3)
- small, round cell tumors that arise in marrow spaces of bone or in soft tissues (extraosseous-pelvis, femur, tibia, fibula, humerus, ulna, vertebra, scapula, ribs, and skull
Key s/s
- Localized pain w/ limp
- spinal cord compression (back pain, sensation change, extremity weakness, loss of bowel or bladder function, respiratory insufficiency)
- respiratory distress (metastasis to lungs)
Diagnostic Testing
- X-ray (involvement of diaphysis w/ detachment of periosteum from bone (Codman triangle))
- CT/MRI of primary site and CT chest
- bone marrow aspiration and biopsy
Treatment: Chemotherapy, *high dose radiation*, surgery (limb salvage more likely)
38
Retinoblastoma
What is it?
Key s/s (4)
Intraocular malignancy usually unilateral and nonhereditary
Key s/s
- Leukocoria (whitish pupil glow) esp in flash photo
- Strabismus (due to poor fixation of visually impaired eye esp if tumor in macular (area of sharpest visual acuity)
- Late: blindness, pain, orbital cellulitis, glaucoma
- High risk for secondary malignancy (osteosarcoma)
39
Retinoblastoma
Diagnosis (2)
Treatment (5)
Diagnostic Testing
- ophthalmoscopy
- Blood and tumor samples – test for RB1 gene mutations
Treatment
- eye enucleation (if unilateral)
- chemotherapy
- brachytherapy, radiation
- photocoagulation (laser beam to destroy retinal BVs i.e. nutrition of tumor)
- cryotherapy (freeze tumor and destroys microcirculation of tumor and cells through microcrystal formation
40
End-of-life care: Nursing Care (5)
- Provide palliative care and support at the time of diagnosis of life-threatening illness or injury
- Advocate for parental empowerment (let them make decisions)
- include input of child after 14 yrs of age
- If parent does not want child to know truth, do not lie but do not disobey parents
- attend funeral services if helpful
41
Discomfort specific care at end of life
- Dyspnea (3)
- oral secretions
- fatigue
For dyspnea
- Allow position of comfort
- encourage use of fan
- use Morphine to calm patient and decrease work of breathing
For oral secretions
- Scopolamine patch
For fatigue
- minimize activities
42
Developmental Views of Death
- infant
- toddler/preschooler
- school age (2)
- adolescent
Infant
- Fear of separation so let parents hold
Toddler/Preschooler
- Death = sleep and reversible (so stay close)
School age
- most understanding and accepting of diagnoses
- think more factual vs emotional so may not understand completely what they are missing
Adolescent
- Understands what they are missing (heartbreaking grief)
43
How to emotionally support dying child? (4)
- Do not compare
- Do not tell how they should feel but interpret what they say
- Listen
- Be there (presence)
44
Kubler's general stages of Grief(5)
- Denial
- Anger
- Bargain
- Depression
- Acceptance
45
Fluid Requirements
Daily fluid requirements
Measuring Output (4)
- Based on child weight i.e. 100 (first 10 kg)+ 50 (2nd 10kg) + 20 (remaining kg)
Output
- q2h
- subtract weight of dry diaper from wet diaper (unable to distinguish stool from urine)
- minimum 1 mL/kg/hr (30 mL/hr if > 30 kg)
- Bladder capacity (oz) = Age (years) + 2
46
Conditions that increase fluid needs (6)
- Sweating losses (fever (12% per 1 C), radiant warmer, phototherapy)
- Tachypnea
- High output (Diarrhea, vomiting, blood loss)
- Low intake (malabsorption)
- Conditions (burns, shock, DI, DKA, high output kidney failure)
- Post-op bowel surgery (gastroschisis, omphalocele r/t GI suctioning)
47
Conditions that decrease fluid needs (6)
- Congestive heart failure
- SIADH
- Mechanical ventilation
- After surgery
- Oliguric renal failure
- Increased ICP
48
Dehydration: Isotonic
What is it?
Treatment
- balanced loss of electrolytes and water from ECF
Treatment: isotonic fluids (NS, LRs)
49
Dehydration: hypotonic
What is it?
Treatment
- electrolyte deficit (low Na) > water deficit so water goes into ICF
Treatment: hypertonic fluids (D5NS, 3NS)
50
Dehydration: hypertonic
What is it?
Treatment
- water deficit > electrolyte deficit (Na> 150) due to water loss or increased electrolytes; fluid goes from ICF to ECF
Treatment: D5W, 1/2 NS (DO NOT GIVE RAPID b-c risk for water intoxication
51
Dehydration: Mild (3-5% infant, 3-4% child)
Manifestations (4)
- Normal pulse, respiration, blood pressure, behavior, mucus membranes, fontanel
- Slight thirst
- Cap refill 2 sec
- Urine SG ›1.020
52
Dehydration: Moderate (6-9% infant, 6-8% child)
Manifestations (8)
- Slight increased HR, RR, normal to orthostatic BP
- Irritable
- Dry mucous membranes
- Moderate thirst
- Decreased tears
- Normal or sunken fontanel
- Cap refill 2-4 seconds, decreased turgor
- Oliguria
53
Dehydration: Severe (≥ 9-10%)
Manifestations (8)
- Very tachycardia and hyperpnea
- decreased BP/shock
- Lethargic to hyperirritable
- Parched mucus membranes and intense thirst
- Absent tears w/ sunken eyes
- Sunken fontanel
- Cap refill › 4 seconds, cool skin, mottled, acrocyanotic, tenting
- Oliguria, anuria
54
Oral Rehydration Therapy (ORT)
Purpose
Choices (6)
- Enhance the reabsorption of Na and water via reducing vomiting, diarrhea, and duration of illness (stomatitis, emesis)
Choices
- Use Centralyte, Pedialyte, Rehydrate w/ 50 mEq/L
- Add unsweetened Kool-Aid to ORS
- Low sugar popsicles
- do not give fruit juice, soft drinks, gelatin (high carb, low electrolyte, high osmolarity)
- do not give chicken or beef broth or gatorade (excess sodium, low carb)
- Avoid BRAT diet (contraindicated b-c little value (low protein, low energy, high carb, low electrolytes)
55
Degrees of Dehydration: Treatment w/ ORT or IV
Mild
Moderate
Severe
Amount Variations (2)
Mild dehydration- 50 mL/kg within 4 hours
Moderate dehydration- 100 mL/kg within 4 hours
Severe dehydration- IV fluids 40 mL/kg/hr until HR and LOC normal, then IV or oral rehydration solution
Amount Variations
- Add 10 ml/kg of ORT fluid for every loose stool or episode of vomiting
- If vomiting, ORT frequently in small amounts (5- 10 ml syringe q1-5 min)
56
TPN
Risk
Nursing Care (5)
Risk: infection due to hyperglycemia risk or hypoglycemia
Nursing Care
- Administer in central venous catheter
- Filtered tubing to remove particulate matter
- “Ramp up” and “Ramp down” rate of infusion slowly to prevent dysregulation of glucose
- Monitor glucose, electrolytes, liver function tests, triglycerides, albumin, renal function
- Daily weights
57
Diarrhea: Stool characteristics and potential problem
- Watery explosive stools
- Foul-smelling greasy bulky stools
- Diarrhea after cow’s milk, fruits, cereal intro (2)
- Neutrophils or RBCs in stool (2)
- Eosinophils (2)
- Gross blood or occult blood (3)
- Watery explosive stools = glucose intolerance
- Foul-smelling greasy bulky stools = fat malabsorption
- Diarrhea after cow’s milk, fruits, cereal intro = enzyme deficiency or protein intolerance
- Neutrophils or RBCs in stool = bacterial gastroenteritis or IBD
- Eosinophils = protein intolerance or parasitic infection
- Gross blood or occult blood = shigella, campylobacter, E-coli
58
Chronic nonspecific diarrhea (CNSD)
What is it?
Effects (3)
irritable colon of childhood and toddlers’ diarrhea which may be r/t sorbitol (artificial sweeteners) or excessive juice for > 14 days
Effects: no blood in stools, no enteric infection, no malnutrition
59
Diarrhea: Acute vs Chronic
Timing
Cause
Acute
- Timing: self-limited under 14 days usually in under 5 yrs old
- Cause: infectious agent (C.diff (antibiotic use), rotavirus (immunization), Giardia lamblia (day cares)) esp. URI, UTI, antibiotics, or laxatives
Chronic
- Timing: over 14 days
- Cause: malabsorption syndromes, IBD, immunodeficiency, food allergy, lactose intolerance, CNSD
60
Spitting up/Regurgitation
Cause
Treatment (5)
Cause: due to weakened Sphincter at entry of stomach until 6-12 months of age esp in bottle-fed
Treatment
- Frequent burping before/after feedings
- Minimum handling during/after feedings
- Position child on right side with head slightly elevated after feeding (stomach drains better)
- NEVER overfeed ~ more frequent smaller feedings
- meds (rare but Ondansetron (few side effects) is okay; Avoid promethazine and metoclopramide b-c somnolence, nervousness, irritability, and dystonic reactions)
61
Gastroesophageal Reflux Disease
Diagnostics (7)
- Modified Barium Swallow (MBS) Study
- Upper GI series for anatomic abnormalities
- 24-hr intraesophageal pH monitoring – not helpful for weak acid (4-7 pH seen in kids)
- Endoscopy w/ biopsy for esophagitis, strictures, Barrett esophagus; excludes Crohn’s
- Scintigraphy for radioactive substances in esophagus to assess gastric emptying (determine if aspiration from reflux OR poor oropharyngeal muscle coordination)
- CBC (anemia)
- hypoproteinemia
62
Gastroesophageal Reflux Disease
Cause
Complications (3)
Cause: inappropriate relaxation of lower esophageal sphincter causes damage due to variety of conditions (hermia, G-tube, neurological disorders, respiratory disorders, gastric distention)
Complications
- FTT
- respiratory difficulties (dysphagia, pneumonia, laryngitis)
- Barrett's esophagus (premalignant; esophageal strictures)
63
Gastroesophageal Reflux Disease
S/s in infant (6)
- Passive regurgitation/emesis & vomiting
- Anorexia/ feeding refusal
- respiratory problems (e.g., cough, wheeze, stridor, gagging, choking with feedings)
- Odynophagia (painful swallowing)- Arching of the back
- Irritability, excessive crying
- Hematemesis -> anemia
64
Gastroesophageal Reflux Disease
S/s in child (5)
- Intermittent vomiting (preschool)
- Heartburn
- Regurgitation and Re-swallowing
- Hematemesis and melena - > anemia
- Respiratory problems (Chronic cough, hoarse voice, Dysphagia, Asthma)
65
Gastroesophageal Reflux Disease
Treatment
- Surgery
- Meds (3)
- Feeds (4)
- Surgery (nissan fundoplication) - severe/last resort (post-op: NGT decompression, vent G-tube)
Medications
- PPIs (omeprazole (Prilosec), lansoprazole (Prevacid))
- Histamine antagonists (Famotidine (Pepcid)
- Erythromycin (low dose to help w/ gastric emptying)
Feeds
- Thickened formulas- w/ rice cereal
- Positioning (upright or prone post-feeding unless sleeping)
- Small, frequent feedings
- Avoid caffeine, citrus, tomatoes, alcohol, tobacco, peppermint, spicy or fried foods
66
Pyloric Stenosis
Cause
Labs (4)
Cause: hypertrophy of pylorus leads to gastric outlet obstruction and compensatory dilation, hypertrophy, and hyperperistalsis of stomach usually at 3-6 weeks of life
Labs
- Hyperbilirubinemia r/t decreased glucuronyl transferase
- Decreased Na, K, Cl but hemoconcentration may mask
- metabolic alkalosis (elevated HCO3)
- Increased BUN r/t dehydration
67
Pyloric Stenosis
S/s (6)
- Post-prandial emesis (projectile and nonbilious)
- Hunger
- weight loss (malnourished or dehydrated)
- jaundice
- palpable olive-shaped mass
- gastric wave
68
Pyloric Stenosis: Pyloromyotomy
- Pre-op (4)
- Post-op (2)
Pre-op: correct f/e balance
- IV fluids (NS bolus, D51/2 NS at 1.5x maintenance over 24-48 hrs)
- NPO and NGT decompression
- labs: BMP, CBC
- Watch for apnea b-c risk for aspiration w/ vomiting
Post-op
- Feeding (Pedialyte, formula) 4-5 hrs post op (full feeds at 48 hrs)
- Some emesis or spitting up expected- Not projectile
69
Failure to Thrive
Clinical Presentation (8)
- Developmental delay (Non-vocal, Infantile posturing – stiffens and arches back, no stranger anxiety)
- Poor Hygiene
- GI and respiratory infections
- Withdrawn (Dislikes physical contact, No eye contact, unresponsive facial expressions)
- Self-stimulating behavior: rocking, excessive sucking, head-banging
- Fussy, irritable
- Abdominal distention-Constipation
- Generalized weakness-Decreased muscle mass
70
Failure to Thrive: Treatment (7)
- Increase calories – formula with 24 cal/ounce and lipids
- Limit juices, water – offer milk and formula
- Do not force feed (offer for 35 minutes q2-3 hrs)
- Consistent meal times
- Feed in quiet environment
- Establish eye contact
- If severe, NG tube
71
Cleft Lip
What is it?
Repair
Purpose of repair
- congenital anomaly Involves 1 or more clefts in upper lip w/ varying degrees of nasal distortion
Repair: Surgical by 3-6 months of age; Cosmetic procedures modified later -4-5 years
Early repair promotes bonding and eases feeding
72
Cleft Palate
What is it?
Repair
Purpose of repair
- congenital anomaly from soft palate defect which may include hard palate & portions of maxillary sinus
Repair: multistage surgery at 6-8 months depending on severity (tonsils not removed)
Early repair enables more normal speech pattern development
73
Cleft Lip/Palate: Feeding tips (6)
- Monitor respiratory status while feeding
- Feed in upright position
- Feed slowly and burp every 1-2 ounces
- Rest after each swallow of formula to allow for complete swallowing
- Remove oral secretions carefully (Milk may come out nose)
- Encourage bonding: touch-cuddle-hold
74
Cleft lip/palate: Post-op care (7)
- Monitor for respiratory distress
- Keep objects out of mouth for 7-10 days including tooth brush
- Arm restraints to prevent touching face
- Feed child to reduce injury (liquids from a cup, soft foods from side of spoon)
- Cleanse lip and suture line after feedings and PRN
- Antimicrobial ointment (Neosporin) to suture line
- Speech therapy referral
75
Esophageal Atresia/Tracheoesophageal Fistula
Cause
3 C's of symptoms
Cause: failure of esophagus to fully develop leading to abnormal communication b/w trachea and esophagus
3 C's
- coughing (frothy cough, excessive drooling)
- choking (aspiration pneumonia, inability to pass NG tube)
- cyanosis w/ feeding (Respiratory distress (pneumothorax, atelectasis, laryngeal edema, tracheomalacia(weakness r.t compression by blind pouch)
76
Esophageal Atresia/Tracheoesophageal Fistula: Surgery
Pre-op (4)
Post-op (4)
Preoperative care
- Suction: continuous to blind pouch to reduce stomach distention
- Elevate HOB into anti-reflux position (30 degrees)
- O2
- NPO immediately w/ IV I & O
Postoperative (depends on stage of repair)
- G-tube care and feedings (do not clamp or flush; elevate to air)
- Contrast study or esophagram done before oral feedings to determine integrity of esophageal anastomosis
- Monitor: aspiration, respiratory distress, infection
- 4 pre-op care items continue
77
Celiac Disease
Cause
S/s (4)
Cause: autoimmune gluten sensitive enteropathy e.g. wheat, oats, rye, barley
S/s
- Bulky, malodorous, fatty, and frothy stools
- General malnutrition (FTT, muscle wasting, fatigue, anemia, anorexia, growth retardation)
- Behavioral changes (irritable, uncooperative, apathy)
- Abdominal distention and pain (aphthous ulcers)
78
Celiac Disease
- Diagnostics (2)
- Treatment (3)
Diagnostic:
- Tissue Transglutaminase IgG or IgA Antibody
- Endoscopy (flattened villi)
Management
- Gluten free diet (No wheat, rye, barley, and oats; cereal, baked goods; READ LABELS)
- Substitute rice, corn, millets for grains
- Avoid high fiber (nuts, raisins, raw veggies, and fruits) while bowel inflamed
79
Appendicitis
Cause
Diagnostics (5)
Cause: inflammation and obstruction of appendiceal lumen due to harden fecal material; swollen lymphoid tissue; or pinworms
Diagnostics
- CBC (> 10000 WBC, elevated % of bands (left shift))
- C-Reactive Protein (elevated > 10)
- CT
- KUB (Kidney, Ureters, Bladder) x-ray
- Ultrasound (enlarged appendiceal diameter, wall thickening, inflammatory changes (fat streaks, phlegmon, fluid collection, and extraluminal gas)
80
Appendicitis
S/s (7)
- Periumbilical pain that migrates to the RLQ
- pain is colicky constant, not intermittent (child may jump up and down)
- Fever (typically low-grade)-- no sore throat, no headache
- abdominal distention and palpable mass
- rebound tenderness at McBurney's point (b/w anterosuperior iliac spine and umbilicus)
- No appetite (anorexia, NV)
- stooped posture
81
Appendicitis
- Complications (3)
- Treatment (2)
Complications
- sepsis and hypovolemic shock (tachycardia, fever, tachypnea,
- necrosis (perforation or rupture w/ contamination of peritoneal cavity) - s/s: sudden relief then diffuse pain, pallor)-> abscess formation
- peritonitis (rigid abdomen and guarding)
Treatment
- Appendectomy: recommended (Laparoscopic vs Open Appendectomy); delayed 6-8 wks if unable to safely remove or difficulty expected
- Conservative management: antibiotics and IV fluids; avoid palpation unless necessary
82
Intussusception
Cause
S/s (6)
Cause: Telescoping or invagination of the distal intestine which leads to obstructive symptoms in the proximal portion (may be r/t viral illness)
S/s
- Colicky abdominal pain
- NV
- Currant jelly stools or sausage-shaped mass
- Lethargy and hypersomnia
- Dance signs (empty RLQ)
- Knees to chest positioning
83
Intussusception: Treatment (3)
- IV Fluids and NGT decompression for stabilization
- Air contrast enema
- Surgical reduction with possible bowel resection if failed air reduction enema, Bowel perforation, or Shock/hemodynamic instability
84
GI Red Flags (4)
- Bilious Emesis = pyloric stenosis
- Twisted Bowel- If it is twisted, you have 6 hours to save it
- Rigid abdomen = peritonitis
- Free air visible on x-ray in abdominal cavity = perforation
85
GU labs ranges
- Creatinine
- BUN
- Uric Acid
- Creatinine: 0.3-0.7
- BUN: 5-18 Child, 4-18 Infant
- Uric Acid: 2-5.5
86
Urinalysis
pH
Specific gravity
What's not in it normally?
pH: 5-7.8
specific gravity (1.001-1.020-infant, 1.001-1.030 child)- high w/ dehydration
Negative-Protein, glucose, ketone, nitrites, leukocyte esterase, bacteria, WBC, RBC, Casts
87
Enuresis
Diagnosis (4)
Family Guidance (2)
Diagnosis
- Developmental age of more than 5 years
- 2x/week or more for 3 months
- urgency, frequency at night
- rule out Organic causes (sickle cell, diabetes, UTIs, spina bilfida)
Family Guidance
- Support- avoid blame and punishment
- positive communication
88
Enuresis: Treatment (4)
- Retention control training
- TCAs- Imipramine hydrochloride (Tofranil) (inhibits urination, give with food, monitor for suicidality)
- Antidiuretic desmopressin acetate (DDAVP) (decreases amount of urine, 2 puffs nasally; Side effects- headache and nausea)
- Antispasmotics -Anticholinergics- oxybutynin (Ditropan) (decreases uninhibited bladder contractions for day time control)
89
UTI
S/s (4)
Complication
S/s
- Odiferous and cloudy urine
- Blood or blood-tinged urine
- Lower UTI: irritation of bladder, hesitancy, dysuria, frequency, incontinence, enuresis,
- Upper UTI or pyelonephritis: high fever, renal scarring, flank pain, NV, chills, fatigue
Complication: hydronephrosis (urine in renal pelvis due to obstructed outflow)
90
UTI
Diagnosis (4)
- Clean-catch is preferred
- U-bag for collection from child
- catheterization or suprapubic needle aspiration(<2 yrs) = more accurate
- urinalysis (+ protein, nitrites, leukocytes; high specific gravity; weak acid, bacteria
91
UTI: Treatment (5)
- Penicillins
- Cephalosporins (Keflex)
- Sulfonamide (Trimethoprim/sulfamethoxazole (Septra))
- Nitrofurantoin (Macrobid)- not used if pyelonephritis
- Hydration (8-oz(240 mL)/yr of age till age 8; or cranberry juice)
92
Vesicoureteral Reflux
What is it?
Treatment (3)
Retrograde flow of urine from bladder to upper urinary tract which increases risk of pyelonephritis from lower UTI but does not cause UTI
Treatment: antibiotics or Deflux or ureteral reimplantation
93
Hydronephrosis
Interventions (3)
Post-op notes (4)
- Antibiotics
- Deflux Gel (gel that protects ureter wall from urine back-flow aka vesicoureteral reflux)
- Surgery (Ureteral reimplantation)- goal stop reflux, prevent kidney damage
Post-op notes
- analgesia (Ditropan-oxybutiny) for surgical site and bladder spasm- belladonna and opiate suppository not recommended
- UOP: monitor retention and ensure hydration
- Maintenance of urinary diversion (do not clamp; no need for irrigation)
- Stent or Foley (keep sterile, gravity drainage, do not clamp)
94
Hypospadias
What is it?
Repair
Repair notes (4)
- Urinary hole on ventral shaft of penis (more severe if chordee)
Repair: Surgery enables child to stand voiding, improve physical assessment, preserve sexually adequate organ.
Repair notes
- Circumcision is avoided before surgery because the excess skin may be needed for the procedure.
- repair done b/w 6-12 months before body image forms
- urinary catheter for 5-10 days
- post-op use Bacitracin ointment at end of penis and diaper to prevent sticking
95
Acute Glomerulonephritis
Cause
Result
Cause: Antigen-antibody complexes become trapped in membrane of glomeruli and cause inflammation and decreased filtration 10-21 days after streptococcal infection of pharynx or skin
Result: excessive retention of water and sodium leading to circulatory congestion and edema.
96
Acute Glomerulonephritis
S/s (4)
Severe complications (3)
S/s
- Mild to moderate facial edema esp periorbital in morning
- Ill appearance (vomiting, pallor, Irritable, lethargic, anorexia)
- Dark colored, smoky brown and cloudy urine: Tea or cola
- HTN and circulatory congestion
Severe complications: CHF, kidney failure, hypertensive encephalopathy (seizures)
97
Acute Glomerulonephritis
When hospitalized? (3)
Labs (4)
- significant HTN and edema
- oliguria
- gross hematuria
Labs
- Urinalysisis( slight to moderate Proteinuria and hematuria, casts, glucose,
- Azotemia (Elevated BUN, creatinine)
- Antisteptolysin O (ASO) titer – detects streptococci circulating antibodies
- Reduced serum complements 3 (C3) activity (Useful to guide therapy; normal in 8 weeks after disease onset)
98
Acute Glomerulonephritis
Management
- fluid volume excess (3)
- Risk for injury (4)
Fluid volume excess:
- Strict I & O and daily weights
- Low sodium diet with NO added salt
- If oliguric, then low K+ diet
Risk for injury
- Bed rest during acute phase usually 4-10 days
- Limit activity until gross hematuria is resolved
- Antihypertensives and seizure precautions for elevated B/P
- Antibiotics are given for a persistent infection (take full course of antibiotic therapy for streptococcal infections to prevent)
99
Nephrotic Syndrome
Cause
When hospitalized? (3)
Labs (4)
Cause: congenital-autosomal recessive due to basement membrane of the glomeruli becoming permeable to plasma proteins
When hospitalized: severe edema or proteinuria OR infection
Labs
- Massive proteinuria (50mg /kg/ day primary indicator; > 2+ dipstick)
- hypoproteinemia
- hyperlipidemia w/o hematuria and HTN
- elevated platelets
100
Nephrotic Syndrome
S/s (9)
- more susceptible to infection (peritonitis, cellulitis, pneumonia)
- Hypovolemia -> circulatory insufficiency
- Edema (b-c fluid flows into interstitial space from loss of colloid pressure)
- Periorbital edema in morning-resolves as fluid shifts to abdomen (ascites), legs, genitals
- Lethargy
- Skin shiny, prominent veins, brittle hair - DVT
- Anorexia, malabsorption, diarrhea r/t edema of intestinal mucosa
- Vomiting r/t albumin lost and Na+ intake
- Foamy oliguric urine
101
Nephrotic Syndrome: Corticosteroid treatment (Prednisone)
Action
Notes (3)
Action: Decreases proteinuria: levels return to normal 2-3 weeks to trace or negative;
Notes
- Monitor for infection and glucose
- No added salt when taking steroids
- Prednisone titrated based on proteinuria for 6 weeks
102
Nephrotic Syndrome
Treatments (3)
- Decrease edema (IV albumin. diuretics, fluid restriction)
- decrease proteinuria (Prednisone (preferred), ACE inhibitors)
- manage infection (broad spectrum antibiotics)
103
Neuroblastoma
Key s/s (6)
- firm, nontender abdominal or chest mass that crosses midline
- Compression of kidney, ureter, bladder (urinary frequency or retention)
- urine catecholamines (secreted by tumor on adrenal gland)
- supraorbital ecchymosis
- periorbital edema (raccoon eyes) or Proptosis (bulging eyes)
- chest tumor (Dyspnea, stridor, dysphagia, Horner syndrome (ptosis, miosis, anhidrosis))
104
General Skin Alterations
Causes (6)
Prevention (3)
Causes
- Stress
- Weather
- Self (autoimmune, hormones)
- hypersensitivity reaction
- wound
- infection (vermin, bacterial, fungal, viral)
Prevention
- use DEET, sunscreen, long sleeves
105
General Skin Alterations
Treatment (7)
Treatment
- hygiene (hand hygiene, clean wounds, chlorine bath)
- avoid (scratching, squeezing, sun, and other irritants)
- cool compress (or warm)
-treat causative organism- antibiotics, antifungal, antiviral, anti (organism)
- stay hydrated
- Treat Fever (antipyretics, avoid heat)
- Treat pruritus (antihistamine-topical OR oral (do not overdose)- Diphenhydramine, Hydroxyzine); oatmeal baths; steroids)
106
General medications for Skin disorders (5)
- Antihistamines- diphenhydramine, hydroxyzine
- Anti Inflammatory- hydrocortisone creams (topical for allergic dermatitis and pruritus)
- Antibiotics (topical or parenteral after empiric therapy; or shampoo or lotion)- same for antivirals, antifungals
- Emollients (lotion, cream, ointment)- retain moisture in skin (gel or powder if too much moisture already); mupirocin (nares)
- Silver sulfadiazine - antimicrobial to increase healing of burns
107
Contact Dermatitis (Diaper Rash & Candida)
Risk factors (3)
S/s
Treatment (4)
Risk factors
- antibiotic use (r/t diarrhea side effect and altering of stool microbials)
- moist areas (urine promote fecal enzyme activity; increased friction, abrasion damage, microbial counts)
- exposure to irritants (urine, feces, soap, wipes, ointments)
S/s: red and bumpy rash (maculopapular) on convex surfaces due to candida
Treatment/Prevention
- observe closely for liquid stools
- Protective ointment (zinc oxide, cornstarch) - no talcum powder; no need to remove completely w/ diaper change
- Keep area dry (superabsorbent diapers
- Apply clotrimazole (Med for Candida Albicans- Yeast)
108
Seborrheic Dermatitis
Cause
Locations (5)
Diagnosis
Treatment (2)
Cause: Malassezia yeast due to increased sebum production in early infancy or during puberty
Locations
- Scalp (cradle cap- most common)
- Eyelids (blepharitis)
- External ear canal (otitis externa)
- Nasolabial folds
- Inguinal region
Diagnosis: based on appearance and location or crust or scales (thick, adherent, yellowish, scaly, oily patches w/ or w/o pruritus)
Treatment
- Mild or baby shampoo daily w/ mild soap and brush
- If severe, medicated shampoo (sulfa and salicylic acid)
109
Contact Dermatitis (Poison Ivy)
Cause
S/s
Treatment (6)
Cause: sumac from poison oak or poison ivy after two exposures (not spread person-to-person)
S/s: red, raised pinkish-reddish pruritic papules
Treatment
- Cool compress
- Treat pruritus (Antihistamines OR Topical or oral steroids)
- Rinse immediately with cold water to remove irritant b-c penetrates more the longer it stays
- lesions heal w/o treatment in 10-14 days
- DO NOT harshly scrub exposed skin b-c will remove protective skin oil and dilute urushiol and allow spreading
- Do not allow child to scratch lesion b-c can cause secondary infection
110
Atopic Dermatitis: Eczema
Treatment (5)
Prevention (3)
Treatment
- Hydrate skin ~cool or warm tepid baths, mild soap, emollient (Eucerin), humidifier
- Relieve pruritus ~oral antihistamine; avoid scratching
- Reduce flare-ups ~ topical corticosteroids, systemic antibiotics, coal tar
- Cool wet compresses ( soothing and antiseptic protection)
- Avoid heat
Prevent/control infection
- reduced exposure to allergens (i.e wool, rough fabrics, latex)
- topical immunomodulators (i.e., tacrolimus)- give prior to flare up
- avoid scratching
111
Atopic Dermatitis: Eczema
Cause (4)
S/s (3)
Cause (not contagious)
- stress
- weather (better in humidity; worse in fall and winter)
- autoimmune (esp. IgE elevation)
- fam hx of AD, asthma, allergies (food, rhinitis)
S/s:
- inflammation (red, swelling, pain)
- pruritus
- dry/rough/thick skin
112
Atopic Dermatitis: Eczema
Infantile (2)
Childhood (2)
Adolescent (3)
Infantile
- begins at 2-6 months; resolves at any age usually 3 yrs
- Generalized, esp. cheeks, scalp, trunk, and extensor surfaces of extremities
Childhood
-begins around 2-3 yrs., usually seen by 5 years
- Flexural areas (antecubital & popliteal fossa, neck) plus wrists, ankles, & feet
Preadolescent/ Adolescent
- Begins at 12 years and may continue indefinitely
- Mainly face, sides of neck, hands, feet,
- on antecubital and popliteal fossae to lesser extent
113
Impetigo
Cause
S/s (3)
Transmission
Treatment (3)
Cause: bacterial (strep or staph) infection of skin r/t scratching
S/s:
- honey-crusted vesicle
- pruritus
- inflammation (red, swelling)
Transmission: contact (from place to place & person to person)
Treatment
- antibiotics (PO penicillin, IV, and occasionally topical mupirocin)
- Avoid scratching b-c can cause spread and is contagious
- For pruritus, use hydroxyzine (Atarax) or diphenhydramine.
114
Dermatophytoses
Treatment (6)
Treatment (may take months)
- Topical meds–Monistat, Lotrimin
- Oral – Griseofulvin (take w/ high fat food; watch for leukopenia, liver, photosensitivity, insomnia))
- Itraconazole- (Sporanox- watch liver)
- return to school after treatment has begun
- avoid sharing hygiene products
- Selenium sulfide shampoos, ( decrease infection and fungal shedding)
115
Dermatophytoses
Locations (4)
Transmission
Locations (round w/ central clearing)
- Tinea corporis = RINGWORM OF SKIN
- Tinea capitis = SCALP
- Tinea cruris = JOCK ITCH
- Tinea pedis = ATHLETE’S FOOT (maceration and fissuring b/w toes)
Transmission: person-to-person OR animal-to-person
116
Candidiasis (candida albicans)
S/s (4)
Treatment (2)
S/s:
- inflammation (Erythema, edema, and heat)
- pruritus
- White patches in mouth (thrush)
- red, discrete diaper rash (diaper dermatitis)
Treatment
- Nystatin (Mycostatin)-liquid or oral, do not feed after giving)
- Amphotericin B for advanced cases
117
Lyme Disease
Cause
Treatment (5)
Prevention (2)
Cause: tick infected with Borrelia burgdorferi bites for 1-2 hrs
Treatment
- antibiotic (2‑ to 3‑week course) for clients who have confirmed disease
- doxycycline (may use erythromycin too) for children older than 8 years
- amoxicillin or cefuroxime for children under 8 years. (cefuroxime for children who have an allergy to penicillin)
- observe for at least 30 days
- remove tick w/ forceps or tissue
Prevention
- use repellents (diethyltoluamide (Deet) and permethrin)
- Vaccine approved for 15-70-year-olds
118
Lyme Disease
Stage 1 (3)
Stage 2 (3)
Stage 3 (3)
Stage 1
- 3 to 30 days following bite
- erythema migrans(bulls eye rash) at site
- chills, fever, itching, headache, fainting, stiff neck, muscle weakness
Stage 2
- occurs 3 to 10 weeks following bite
- Systemic involvement begins (neurologic, cardiac and musculoskeletal)
- paralysis or weakness in the face, muscle pain, swelling in large joints (knees), fever, fatigue, splenomegaly
Stage 3
- 2 to 12 months following bite
- Systemic involvement is advanced (musculoskeletal pain that includes the muscles, tendons, bursae and synovial); possible arthritis, abnormal muscle movement and weakness, numbness and tingling
- late neurological problems and cardiac complications (cerebral ataxia, encephalopathy, deafness, speech problems)
119
Rocky Mountain Spotted Fever
Cause
S/s (4)
Major complications (2)
Treatment (2)
Cause: tick bite leads to infestation caused by Rickettsia rickettsii
Symptoms
- fever
- Headache
- anorexia
- rash (incubation 2-14 days)
Major complication
- hemorrhagic lesion (if untreated rash)
- risk for thrombus, necrosis, edema, death
Treatment: Chloramphenicol (drug of choice) or tetracycline
120
Prevention of Tick Bites (6)
- Wear long-sleeved shirts, long pants tucked into long socks, and hat when walking in tick-infested areas
- Wear light-colored clothing to make ticks more visible if they get onto child
- Check children for the presence of ticks after being in high-risk or tick-infested areas (save tick for later ID)
- Follow paths vs walking in tall grass and shrub areas
- Apply insect repellents w/ diethyltoluamide (DEET) and permethrin before possible exposure to areas where ticks are found; also use on pets (use with caution in infants and small children)
- Keeping yards at home trimmed and free of accumulating leaves and other brush
121
Anaphylaxis Management
S/s of Anaphylaxis (7)
* Itching sensation or tightness in throat; difficulty swallowing
* “Barky” cough; hoarseness
* Dyspnea and wheezing
* Cyanosis and Respiratory arrest
* mild dysrhythmia to severe bradycardia and cardiac arrest
* mild to severe hypotension
* loss of consciousness
122
Scabies
Cause
S/s (2)
Treatment (4)
Cause: Scabies mites that burrows into the stratum corneum of epidermis and deposits eggs and excrement.
S/s: itching; black dot at end of burrow in intertriginous areas (b/w digits, antecubital, popliteal, inguinal)
Treatment
- anti-scabies med (Elimite (permethrin cream) or Lindane (Kwell))) - lindane is neurotoxic and contraindicated
- Apply over body, head and neck multiple times and overnight
- for pruritus, oral antihistamines or topical corticosteroid creams
- Treat family members and environment b-c spread by contact
123
Anaphylaxis: Epinephrine
Dose (2)
Side effects (4)
Note
Dose
- EpiPen Jr (0.15 mg) IM for child 8 to 25 kg (17.5-55 lbs.)
- EpiPen (0.3 mg) IM for child > 25 kg (55 lbs.)
Side effects
- tachycardia
- hypertension and headache
- irritability and tremors
- nausea
Notes
- give ASAP then send to hospital
124
Pediculosis Capitis (lice)
Cause
S/s (3)
Transmission
Patho: Infestation on lice and eggs usually in scalp.
S/s
- Scratching (may be only symptom)
- Nits- ¼ - ½ inch from scalp (grayish or whitish)
- red lesions on scalp
Transmission: direct contact (can jump but not fly) via sharing personal items
125
Pediculosis Capitis (lice)
Treatment (4)
- wash hair w/ Permethrin (NIX) or Pyrethrum (RID) OTCand leave for a while then comb nits out (malathion Rx for severe)
- Wash everything in hot water
- spray down everything except child in insecticide
- put stuffed animals and non washable items in bags then in heat for 14 days
126
Varicella Zoster (Chicken Pox)
S/s (2)
Transmission (3)
S/s
- lesions (macular, papular, vesicles, pustules, crust (MPVPC)) which are red and itchy in clusters
- flu-like symptoms
Transmission
- contact, airborne, droplet
- contagious 1-2 days before onset until lesions are crusted (5-7 days)
- Incubation: 2-3 weeks; 14-21 days
127
Varicella Zoster (Chicken Pox)
Complications (3)
Treatment (3)
Complications: encephalitis, internal chicken pox, shingles
Treatment:
- avoid scratching to prevent superinfections
- For pruritus, Antihistamine (diphenhydramine or hydroxyzine)
- For Immunocompromised or severe cases, use Acyclovir or immune globulin (VZIG) within first 96 hours
128
Rubeola (Measles)
Complications (4)
Treatment (2)
Complications
- Pneumonia,
- Encephalitis,
- Diarrhea
- Obstructive laryngitis (croup)
Treatment
- Stay home and isolate
- supportive w/ vitamin A therapy
129
Rubeola (Measles)
Cause
S/s (3)
Transmission (3)
Cause: RNA virus
S/s
- 3 C’s: coryza (runny nose), bad cough, conjunctivitis (red eyes)
- white Koplik spots in mouth
- rash at hairline spreads cephalocaudally over 3 days
Transmission
- contact and droplet isolation
- Incubation: 8-12 days incubation
- infectious 3-5 days before and 4 days after rash
130
Rubella (German Measles)
S/s (6)
- Rash (on face spreads cephalocaudally) for 2-3 days
- lymphadenopathy)
- forchheimer spots on soft palate
- coryza (Nasopharyngeal secretions and body fluids)
- headache and eye pain
- Other: fever, nausea, anorexia, sore throat
131
Rubella (German Measles)
Transmission (2)
Complications (2)
Treatment
Transmission
- Incubation 14-21
- Isolation- contact and Droplet (Nasopharyngeal secretions and body fluids)
Complications (less severe than rubeola unless pregnant):
- arthritis or arthralgia
- Congenital Rubella- growth delays, blindness, cardiac problems, deafness, intellectual disabilities (TERATOGENIC)
Treatment: supportive
132
Roseola Infantum (Exanthem Subitum)
Cause
S/s (3)
Transmission (2)
Treatment
Cause: Human Herpesvirus 6 in 3-36 month olds
S/s
- abrupt high fever (risk for febrile seizures) for 3-5 days
- maculopapular rash (after fever starting at neck and spreading up and down) disappears after 1-2 days
- Other: lymphadenopathy, cough, coryza
Transmission
- contact and droplet
- Incubation 5-15 days
Treatment: Antipyretics (avoid aspirin b-c viral infection and risk for reyes)
133
Scarlet Fever
Cause
S/s (2)
Treatment
Complications (6)
Cause- GABHS carried by direct contact
S/s
- Rash- red, fine located in groin, neck and axillary
- Strawberry tongue
Treatment: complete antibiotics & supportive therapy
Complications (spread of infection)
- Sinusitis
- Abscess
- Meningitis
- Osteomyelitis
- Rheumatic fever
- AGN
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Erythema Infectiosum (Fifth Disease)
Cause
S/S (3)
Incubation
Complications
Cause: parvovirus
S/s:
- slapped cheek appearance
- fever
- runny nose
Incubation: 14-21 days
Complication: aplastic crisis esp in pregnant, sickle cell, or immunocompromised
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Conjunctivitis
Cause
Transmission
Treatment (5)
Cause: bacterial, viral, or allergic
Transmission: direct contact if viral or bacterial
Treatment
- avoid scratching or touching eye
- If viral, clears on its own in 7 to 14 days.
- If bacterial, Starts in one eye, spreads to the other so clear with antibiotics
- If Allergic, clears with allergy medications.
- use warm moist cloth to remove crusted secretions (inner to outer canthus)
136
Otitis Media (acute, chronic, OME)
Cause
Risk Factors (5)
Cause: obstruction or partial obstruction of eustachian tube and nose leads to accumulation of secretions in middle ear which impairs ciliary transport in tube and inhibits drainage
Risk factors
- smoking
- bottle propping during feeding (breastfeeding is protective)
- Conditions (down syndrome, cleft palate)
- viral infection esp EBV and influenza
- enlarged adenoids or tonsil tumors
137
Otitis Media (acute, chronic, OME)
Complications (6)
- Cholesteatoma (epithelial lining forms scales and erodes middle ear)
- Tympanosclerosis (eardrum scarring)
- Adhesive OM (thickening of mucous membranes)
- Meningitis
- Mastoiditis
- hearing loss
138
Otitis Media (acute, chronic, OME)
Treatment (5)
Prevention (3)
Treatment
- Amoxicillin Clavulanate 80-90 mg/kg/day OR Azithromycin
- Cephalosporins (2nd line)
- Myringotomy, Tympanoplasty, pressure equalizing tube (PET)- if chronic (tubes fall out on therir own)
- keep ears dry (sterile alcohol cotton swab)
- For symptoms, corticosteroid or benzocaine drops, pain relievers
Prevention
- avoid lakes and shampoos
- Pneumococcal Vaccine- Prevnar, HIB, strep
- influenza vaccine for > 6 m
139
Otitis Media (acute, chronic, OME)
S/s (4)
- Fever (risk for febrile seizures)
- otalgia (ear pain)- pulling at ear, turning head side to side
- Purulent discharge (otorrhea)
- bulging tympanic membrane seen w/ otoscope (feeling of fullness)
140
Sunburns
UVA vs UVB
Prevention (4)
UVA: shorter, high frequency cause aging
UVB: r/t tanning and burning
Prevention
- Avoid midday exposure (10am-2pm)
- Use a high SPF
- Wear protective clothing (Wide brimmed hat, cotton with a tight weave clothing)
- avoid sunscreens <6 months (just keep them out of sun)
141
Prevention of burns
- Infants & toddlers (3)
- School age & adolescents (2)
Infants and toddlers (scald injuries most common)
- Adequate kitchen supervision
- Hot water heater at 120 degrees
- Cover electrical outlets/cords
School age children/adolescents
- Educate about risk taking behaviors (playing w/ matches)
- Fire safety (Stop, drop, and roll AND escape routes)
142
Prognosis of Burn Injury
Factors (8)
- Extent of injury (Life threatening if 10% TBSA; If >30% TBSA, systemic response w/ capillary permeability)
- Depth of injury
- Location of wounds
- Age (poor in tiny baby b-c thin skin esp under 6 months)
- General health (chronic illness complicate healing)
- Causative agent
- Respiratory involvement
- Concomitant injuries
143
Partial thickness burn: 1st degree
Wound appearance (3)
Wound Sensation
Course of Healing (2)
Wound appearance
- epidermis intact w/o blisters
- erythema
- blanches w/ pressure
Wound Sensation: painful w/o systemic effects
Course of Healing
- discomfort for 48-72 hrs
- desquamation in 3-7 days w/o scaring
144
Partial thickness burn: 2nd degree
Wound appearance (3)
Wound Sensation (2)
Course of Healing (2)
Wound appearance
- wet, shiny, weeping surface
- blisters
- blanches w/ pressure
Wound Sensation
- very painful and sensitive to touch and air currents
- systemic effects (capillary damage and edema, anemia, SNS activation)
Course of Healing
- superficial heals < 21 days (> 21 for deep)
- various amounts of scarring
145
Full-thickness burn: 3rd degree
Wound appearance (3)
Wound Sensation
Course of Healing
Wound appearance
- variable color (deep red, white, black, brown)
- thrombosed vessels visible (nerves, sweat glands, hair follicles destroyed)
- no blanching
Wound Sensation: insensate (decreased pinprick sensation)
Course of Healing: needs autograting
146
Full-thickness burn: 4th degree
Wound appearance (3)
Wound Sensation
Course of Healing (2)
Wound appearance
- color variable w/ dull and dry wound
- extremity movement limited
- charring visible in deepest areas (involves bone, muscle, fascia)
Wound Sensation: insensate
Course of Healing
- amputation likely
- autograft for healing
147
Burn Classifcations: Minor, Moderate, Major
Location of Care
Extent of injury
Major
- Burn Center
- › 20% total body surface area (TBSA)
Moderate
- Hospital with burn care expertise
- 10-20% TBSA
Minor
- Outpatient
- <10% of TBSA
148
Care for Major Burns (6)
- Stop burning (smother flames, place horizontally, roll; remove clothes and jewelry)
- Airway management (NPO, O2 therapy)
- Fluid Replacement (lots of diuresis w/ burns; IV fluids of crystalloid then colloid)
- Prevent infection (Cover wound; high cal/protein diet w/ zinc, vit A and C; topical antimicrobials; tetanus toxoid; debride)
- Cover the burn with a clean and dry cloth to prevent hypothermia, decrease pain from air contact, and prevent contamination (do not let two burned surfaces touch)
- Pain management (after other stuff; use IV vs subQ/IM b-c circulatory collapse and edema)
149
Care for Minor Burns (9)
- Stop the burning process AND Remove clothing or jewelry
- Apply cool water soaks or cool water (no ice b-c can cause burns AND circulatory collapse
- Flush chemical burns with large amounts of water
- Clean with mild soap/tepid water (keep wound bed clean and moist and cover w/ clean cloth)
- Use antimicrobial ointment (silver sulfadiazine, neosporin)
- No greasy lotions or butter
- Provide warmth
- Provide analgesia!!!
- Immunize for tetanus if > than 5 years since last shot
150
Major complications of burns (4)
- respiratory tract injury (erythema, pulmonary edema, hoarseness, bacterial pneumonia
- burn shock (fluid loss, reduced cardiac output, hypotension, tachycardia, decreased LOC, hyperthermia to hypothermia)
- local or systemic sepsis r/t fertile field for bacterial growth
- increased intra-abdominal pressure r/t larger than calculated number of fluids in resuscitation
