Chapter 5- Immunizations

Diana Kovacic DNP, RN

Immunization Objectives
1. Describe the basic principles of immunization.
2. Identify the recommended immunizations of childhood, immunization
management concepts, and barriers to immunization.
3. Vaccinations at most 4ml in the glute of an adult

Methods of Obtaining Immune Protection

Naturally Acquired- Active Immunity
● Naturally Acquired (active immunity): Immune system produces antibodies
after a person is exposed to a disease:
○ You naturally acquired immunity from getting the disease itself
○ Ex: ​Chickenpox​!
■ I had chicken pox as a kid therefore I ​naturally​ acquired immunity
but my body ​actively ​worked to make Antibodies!
○ It’s considered an ​Active process​ because your ​Body makes antibodies
○ Protection lasts for a lifetime
○ Risk for developing adverse effects is high because disease is contracted
Naturally Acquired- Passive Immunity
○ Person doesn't have to acquire or be injected with the disease for
immunity, antibodies are passively received
○ Passive because the body doesn’t have to work to make the
antibodies/No active immune process is involved
○ Naturally acquired means ​NOT​ manufactured/artificial ! It’s passed from
mom to the baby Via….
■ Placental transfer by way of IgG*
■ Breastfeeding​ by way of colostrum
 Artificially Acquired- Active Immunity ​= ​Immunizations
○ Medically engineered substances that are inhaled or injected to stimulate
the immune response against a specific disease
○ The body works to produce the antibodies this why it’s active & NOT
passive!
○ Examples of artificially acquired-active immunity are…….... ​Any and
every Immunization!!!
■ Vaccinations are medically engineered (artificial) substances that
are injected into the body
■ Being Active means the body works to produce antibodies for
protection against re-exposure to the disease in the future
Artificially Acquired- Passive Immunity
● Receiving Straight Antibodies:
○ Antibodies are used either as antitoxins or as a prophylactic/pre treatment
○ Antibodies provide immediate protection that lasts for weeks or months
Instant protection against a condition or illness
○ Artificial=​ It's a manufactured medication that’s injected
○ Passive=​ Injected without stimulating the immune response
■ No work from your body is required to make antibodies
■ Ex​: ​Rabies IVIG (immunoglobulin) Shot ...Most​ of us don't get a
rabies shot unless, you’re bitten by a bat. Then you are given a
rabies shot.
● Instantly gives you antibodies protecting you from the virus
(Rabies) that's coursing itself through your body already.
■ HBIG​ in pregnancy is the same concept to protect baby from being
positive with Hep B incase mom is positive
Immunizations/Vaccinations
Are they Live/Attenuated or Are they Inactivated???
● Live Vaccinations…...
○ A live but weakened Organism:​ Grown under suboptimal conditions,
resulting in a live vaccine with reduced virulence
■ Confers 90%-95% protection for 20+ years with a single dose
■ With a second dose 100% protection for life!
○ Promotes full range of immunologic responses
○ Inactivated by heat: ​Must be kept cool & refrigerated
 ○ Refrigeration can be an issue for some developing countries d/t:
■ Refrigerator access in those countries is an issue etc...
○ http://vaccine-safety-training.org/live-attenuated-vaccines.html
○ If patient is immunocompromised:
● You may infect them with what their being vaccinated
● Their immune system may be unable to make antibodies
NO LIVE vaccinations for IMMUNOCOMPROMISED PATIENTS!
● Educate parents:​ On the risks of possible illnesses if the child doesn’t get
vaccines!
● Vaccinations are medications: ​The rare side effects are very slim…
○ Think about S/E of the many OTC meds we take without a second
thought!
○ Good explanation for parents whom are nervous about vaccinating their
child!

This is a chart of rare side effects on Live/Attenuated Vaccinations:

● Examples of live Vaccinations:

○ Oral polio virus (​OPV​) ​PO
○ Measles mumps rubella (​MMR​) ​Sub-q
○ Varicella/Chicken pox ​Sub-q
○ Intranasal flu mist ​Nasal
○ Rotavirus ​PO
Inactivated Vaccinations……completely killed organism
● Inactivated vaccines offer a weaker response than live vaccines
■ Necessitating frequent boosters in order to achieve the 90-100%
protection!
■ Provides 90%-100% protection (with the required boosters!)
○ Educate:
■ You cannot get sick from an inactive vaccination (flu)
■ May feel run down because the body is producing antibodies
○ Examples of Inactivated Vaccinations:
■ Inactive polio vaccine (IPV) ​IM
■ Intramuscular Flu vaccine ​IM
■ Dtap (diphtheria tetanus pertussis) ​IM
■ Hep A & B vaccinations (Hepatitis A&B) ​IM
■ HPV (human papillomavirus) ​IM
■ Meningococcal (for meningitis) ​IM
■ Pneumococcal (for pneumonia) ​IM
****Immunocompromised patient can still receive inactivated vaccines!

Immunization Management
The watchdog Agency here in the US: Is the CDC
(​center for disease control & prevention​)
● Advisory Committee on Immunization Practices (ACIP) of the Centers for
Disease Control and Prevention (CDC)
● Recommended age for beginning primary immunizations of infants is at birth
Immunization Schedules
By a branch of the CDC….
● A​dvisory ​C​ommittee on ​I​mmunization ​P​ractices (​ACIP​) of the Centers for
Disease Control and Prevention (​CDC​)
http://www.cdc.gov/vaccines/parents/downloads/parent-ver-sch-0-6yrs.pdf
http://www.cdc.gov/vaccines/who/teens/downloads/parent-version-schedule-7-18yrs.pdf
 Immunization management
● Vaccine storage & administration directly impact the efficacy
○ Administer vaccine by correct route very important:
■ Mouth (​Oral​)
■ Subcutaneous Injection (​Sub-Q​)
■ Intramuscular Injection (​IM​)
● Importance of manufacturer’s package insert:
○ Very good to read if first time giving the vaccination
○ Contains possible side effects research all the info out on the vaccine;
important need to know hand out inside box
● Vaccine Information Statements (VIS) should be given:
○ Published by the CDC
○ Go through/give it prior to administration, if needed get translator
○ Document you went through it & that you gave it
● Reactions to previous immunizations:
○ Very important and is always routine to ask if patient has ever had any
reactions to previous vaccinations!
○ Example of Anaphylactic/systemic whole body reactions:
■ Swelling of the throat/Stop breathing
■ Hives etc.
○ If answer is yes about previous anaphylactic reaction to vaccine
■ No further vaccinations ​are to be given period!
■ Even if reaction was to a different vaccination it’s a NO!

● Screen for precautions & contraindications: ​VIS is a good source**

○ Screen for cautions specific to the vaccination being given
○ Look at the Vaccination Information Statement for cautions
○ Ex: Inactivated Influenza Vaccine…​Tell your provider if the person
getting the influenza vaccine ​has ever had/has
■ Guillain-Barré Syndrome (GBS)
■ ​Allergic reaction after a previous influenza vaccine
■ Any severe, life-threatening allergies contraindicated to the vaccine.
● In the case of influenza vaccine an egg allergy is the
contraindication
● Vaccine Information Statement:
○ This must be printed out for the child & family
○ Go over it with the child & the family
○ Document that you went over this & gave it to them
http://www.cdc.gov/vaccines/hcp/vis/current-vis.html
What the VIS looks like (HepB VIS)

● Proper documentation is very important:

○ Must have accurate documentation when giving vaccines:
■ Incase of reactions, bad batches, etc.
■ So that the CDC & any parties involved can back track the origin of
vaccine with this information, ​Note the…..
● Date administered
● Name of the vaccine
● Lot number & expiration date
● Manufacturer’s name
● Site & route the vaccine was given
● Edition of Vaccination Information Statement
● Name & address of facility administering vaccine
● Name of person administering the vaccine
○ Give family record of the immunization:
■ Many kids are being over vaccinated for no reason
■ If Dr. doesn’t have a record of the Vaccination: he/she may
re-vaccinate for accuracy purposes
● Ex​: when I was growing up they gave a booklet for patients
to keep their own immunization records on hand….
● Now a days computers keep track but not all health systems
are linked/talk to each other
○ This is ideally a future goal!
 Key Facts About Immunizations
● Children who began primary immunizations at the recommended age but
fail to receive all of the doses:
○ Do Not Need to begin the series again
○ Only give the missed doses, a matter of catching them up
● If there is doubt the child will return for immunizations:
○ Any of the recommended vaccines can be administered simultaneously
(using different muscles or the same muscles)
○ Some come as ​premixed/combo​ in one syringe= ​one​ ​injection
● All routinely recommended pediatric vaccines contain no mercury
(thimerosal*)
○ Was a huge concern in falsely linking Autism to vaccinations/mercury
○ No Thimerosal* (mercury)​ ​in vaccines since 2001
■ Autism has increased since the removal of Mercury (not linked= false)
■ Another way to view this is Mercury is in fish so, if it’s a problem for the
patient/family be more concerned with seafood intake all year vs. one flu
shot a year!
■ http://www.cdc.gov/vaccinesafety/concerns/thimerosal/
○ Only Vaccine that still contains Thimerosal is the Flu vaccine but one may
request a Thimerosal free version, if is a concern to them
● Temporarily postponing vaccines recommended only if the child…
○ Has a severe illness with a high fever (>38 degrees Celsius)
○ Has Immunosuppression
○ Recently received blood products (within the past week or so)
■ The body is processing blood product & might not make antibodies
○ YES​ ​Postpone= Severe illness!
● Do Not Postpone vaccines if the child has.....
○ Minor respiratory illness (runny nose scratchy throat)
○ Low grade fever
● These would not be reason enough to postpone
● Severe illness makes sense to postpone not mild!
 Immunization Descriptions
● Diphtheria, Pertussis and Tetanus vaccine (​IM​):
○ DTaP for infants & children under 7 ​(​5 of these=Inactivated​)
■ 2 months of age
■ 4 months of age
■ 6 months of age
■ Between 15-18 months of age
■ Between 4-6 years of age booster before Kindergarten
○ Bigger ​“D”​ for infants & kids= Bigger dose to develop stronger immunity &
Antibodies
■ Infants will feel sick, cry, & spike a fever especially with progression
of series
■ The older & more progressive the series the worse the reaction
post injection (sick feeling & fever spikes)
● TdaP for older children >7, adolescents, & Adults (​IM​)
○ Little ​“d”​= smaller dose of diphtheria for adults/older kids:
■ Diphtheria in any dose when older makes people more sick &
miserable after vaccine
■ This is why smaller dose of Diphtheria with older ages
○ Rising pertussis cases since 1970s in uS
■ Tdap Booster: ​Recommended at least once in adult life d/t little
ones not being fully vaccinated until kindergarten (final booster)
■ Pregnant women are being given this each pregnancy!
● For each baby’s protection
○ Protect little ones around us from pertussis
■ If an Adult doesn't get pertussis it won't spread to little ones around
them whom are still not fully vaccinated!
● Td: ​Given every 10 years= Mostly for tetanus protection
● Haemophilus influenzaeType B vaccine (​IM​)
○ This vaccination is not the one you want to space out
○ Haemophilus Influenzae type B causes life-threatening illnesses to kids
under the age of 5 years so within the first year we want them fully
vaccinated/protected
○ If a child gets it they can be very sick leading to…..
■ Meningitis, epiglottitis, septic arthritis in joints
○ Given 4 times​ (​4 of these=Inactivated​)
■ 2 months of age
■ 4 months of age
 ■ 6 months of age
■ Between 12-15 months of age
● Inactivated Polio Vaccine/IPV (​Sub-q​)
○ Inactivated polio vaccine ​(IPV)​ currently recommended in US
○ Most of the world use​ OPV​(oral) but not here in the USA!
○ OPV is a live vaccine: ​only 1 or 2 doses needed to be fully vaccinated
■ It’s by mouth, easier than injecting (sterility, needles etc.)
■ Rural towns in poor countries an abundance of visits to keep up
with an inactive vaccine schedule is not realistic
○ Only 2 countries in the world where active polio still exist:
■ The USA is not one of them and doesn’t want to be!
○ In the USA we use the inactivated polio vaccine: Because….
● It’s a killed virus= poses no risk of infections/No chance of giving
kids polio!!!
○ IPV Given 4 Times ​ (​4 of these=Inactivated​)
● 2 months
● 4 months
● Between 6-18 months
● Between 4-6 years old before kindergarten
● Measles, mumps, and rubella (MMR): (​Sub-q​) (​2 shots= live/attenuated​)
○ MMR is a live attenuated virus combination
○ It’s given to children > 12 months old
○ Wait until 12 mos of age for MMR & most live vaccines because:
■ Babies under 1 year have weak immature immune systems we
need to wait for about a year for them to fully make antibodies
○ Given​ ​2 Times: (​2 shots= live/attenuated​)
■ At 12 months of age
■ Booster between 4 to 6 years old

● Hepatitis A vaccine (Hep A): (​IM​) ​(​inactivated​)

○ Inactivated whole virus vaccine
○ one of the ​most​ frequently ​reported​ diseases in the ​US​:
○ Passed via fecal to oral (mostly via food contamination)
■ Ex: Food service employee doesn’t wash after a bowel movement.
They transfer to your food they touched, you eat it & contract
Hepatitis A
■ Think about sexual acts (fecal to oral) this too can be a form of
transmission for Hep A
 ○ If traveling Internationally Hepatitis A vaccine is recommended:
■ d/t lack of sanitary practices in other countries…..
■ We have strict health boards and this still happens imagine outside
the US….
○ Any Hepatitis worrisome about liver (liver failure or liver cancer)
○ Given 2 times: (​2 of these inactivated​)
■ At about 12 months of age
■ 2cnd dose 6 months later

● Hepatitis B Vaccine (Hep B): (​IM​) (​inactivated​)

○ Hep B spread through blood & body fluids
○ Hep B can be transferred via sexual transmission
■ Hep B much easier to contract than HIV via sexual activity
● This is a huge concern
■ With any Hepatitis we worry about liver effects (liver failure/cancer)
○ Series usually started at birth before discharge from hospital
■ Given 3 times:
● 1st dose at birth before discharge from hospital
● 2cnd doseat 1-2 months of age
● 3rd dose at roughly 6 months of age
○ Hep A & B​ most places give together as a ​combined vaccine
■ Good for​ ​adults who’ve never had hep A or B vaccines:
■ Give this Combination in a 3 shot series over 6 months!
Note/Educate:​ Hep A & B vaccinations were not a school requirement until the 90s!
There are people out there who have never gotten the protection yet are still sexually
active…
● Varicella vaccine (chicken pox): (​Sub-q​) (​2 of these live/attenuated​)
○ Live attenuated virus
○ For children > 12 months
○ If you’ve had chicken pox you’re protected
■ Until shingles vaccine time
■ If you don’t get shingles first!
○ Given 2 times:(​2 of these live/attenuated​)
■ First dose at 12 months of age
■ Booster between 4-6 years of age
● Pneumococcal vaccine: (​IM​) (​4 of these inactivated​)
○ Streptococcus pneumoniae most common cause of serious infection in
children under age 2 years old:
■ We want them fully vaccinated by 1 year of age
○ In infancy given as:
■ Conjugate vaccine given (​13 strains​) started in infancy
■ Under two yrs old with weakened immature immune systems
○ Cannot space these out must have all 4 by about 1yr of age
○ When given to an adult:
■ Polysaccharide vaccine (​23 strains​)
■ Infants & kids under 2 have a weakened immature immune system
& doesn’t make antibodies to polysaccharide vaccine
■ Also given to high risk children > 2 years of age
○ Given 4 times: (​IM​) (​inactivated​)
■ 2 months
■ 4 months
■ 6 months
■ 12-15 months of age
● Influenza vaccine (​IM​) (​inactivated​)
○ Giving it intramuscularly= More accurate delivery
○ Universally recommended > 6months of age
○ Used to be more recommended to high risk groups
■ Healthcare providers (high risk) etc.
■ Now recommend everyone get it every flu season!
○ The first time a baby gets the flu shot @6 months of age they have to get
another a month after the first one
■ d/t the first dose not making antibodies in their immature bodies,
the second one is a reminder for the body to make antibodies
■ Then once a year like everyone else
■ You cannot get the flu from the flu vaccine and even if you get the
flu after vaccination symptoms are less severe, better odds
○ Many parents prefer the flu mist (in nostrils) version for the kids because
of pain & hate getting shots ​Reasons for IM over mist…...
■ Intranasal flu mist is a live/attenuated vaccine, ​it can spread
around & cause immunocompromised people to get sick from the
residual in the air!
■ With mist child may not intake the whole dose
■ Can cause illness to others around inhaling
■ Flumist was banned for a while, came back this season
 ● Rotavirus vaccine (​PO​) (​Live/attenuated​)
○ No injection needed
○ Rotavirus is the most common cause of severe gastroenteritis in young
children all over the world
■ Causes severe diarrhea (dehydration) & death
○ This is a live vaccine, given orally to infants
○ Given 3 times (not usual with live vaccines)
■ 3 doses because the weak immune systems of infants
■ To ensure protection as young as possible by 6 mos!
○ Given 3 times:​ (​PO​,​ Live/Attenuated Vaccine​)
■ 2 months
■ 4 months
■ 6 months

Older kids Vaccines/Vaccine Series:

● Human papillomavirus vaccine (HPV): (​IM​) (​Inactivated​)

○ Recommended at 11-26 years of age in both Girls & Boys!
■ Recently extended to 40 years of age (when it was first released
they capped it at 26)
■ Unfortunately 11-12 year olds are already sexually active!
■ Better protection when given before start of sexual activity: Some
physicians will give as early as 9 years old!
○ HPV is mostly contracted via sexually activity:
■ Adolescents & young adults @ higher risk for HPV!
○ Used to be given only to girls now given to boys as well
■ They too can contract warts & get cancer aside to spreading the
disease!
○ Even with the vaccination, One can still get HPV!!!
■ Vaccine protects from the most common strains of HPV
■ There are​ ​over 100 strains of it ...(genital warts or Cancer)
■ 50% leave warts on your skin (no cancer) & 50% cancer!
○ Gardasil 9​ ​is the most current HPV vaccine out right now:
■ Protects from ​7 most common cancer​ causing strains of HPV &
the ​2 most common wart ​causing strains of HPV
 ○ Depending of type of sex/contraction the cancer can be:
■ Oral
■ Throat
■ Penile
■ Anal
■ Cervical
○ Given 3 times:​ (​IM​) (​inactivated​)
○ 3 doses over 6 months
■ 1st dose as early as 9 years of age
■ 2cnd dose in about 1-2 months later
■ 3rd dose/final dose 6 months later

● Meningococcal vaccine (​Meningitis) (​IM​)​ (​2 doses=inactivated​)

○ Neisseria meningitidis​: Causes meningitis & sepsis (serious)
■ 10-12% of infected people die
■ 20% of survivors live with complications & suffer for life
■ Peak age is 18 for NM
■ Used to be marketed for students going off to college….
● Droplet/transmission in the air
● Small dorm room hazards/Easily spread
○ Given 2 times: (​2 times= inactivated​)
■ 1st dose at 11-12 years of age
■ Booster at 16 years of age
● Fully vaccinated way ahead of 18 to ensure protection!

Reactions from Immunizations (side effects)

● Inactivated Antigens Side effects...
○ Most likely to occur within a few hours or days of administration
○ Local reactions are less severe when in deltoid as opposed to vastus
lateralis (more severe)
■ Little ones we use vastus lateralis because deltoid is not big
enough
○ Common s/e are usually limited to the injection site
■ Tenderness
■ Erythema
■ Swelling
 ○ Side effects due to the work in making Antibodies can be:
■ Low grade fever
■ In kids Behavioral changes….
● Drowsiness
● Decreased appetite
● Prolonged or unusual crying
○ DTaP Reactions​:
■ Become more severe as we progress through the series…
● Definitely spike fevers!
● They’re miserable & Crying after the vaccine

● Live/Attenuated Virus Vaccines:

○ Reactions and “vaccine associated” disorders can occur up to 2 weeks
possibly even 30-60 days later
○ Usually mild reactions seen:
■ Low grade fever
■ Rash at the site of injection

The National Vaccine Injury Compensation Program

● Rare event​! If you or your child has a serious reaction to a vaccine:
○ A federal program has been created to help pay for the care of those who
have been harmed
○ Details about the program:
■ 1-800-338-2382 or visit website at
https://www.hrsa.gov/vaccinecompensation/

Q#1: ​Which action would be appropriate to minimize pain and local reactions when
administering immunizations to a 12-month-old client?
A)Select a 1 ½ inch needle to deposit the antigen deep into the muscle
B)Administer the injection into the deltoid muscle
C)Apply topical anesthetic to the injection site 1 hour before the injection
D)Give oral pain medicine on arrival to the clinic
Q#2: ​A 6-month-old infant is scheduled for a DTaP immunization. According to the
mother, after the previous DTaP injection, the infant had a temperature of 102.8 F. Prior
to administering the DTaP vaccine, what would be the most appropriate nursing action?
A)Notify The physician
B)Divide the dose in half and give one dose now, and the other dose tomorrow
C)Administer the dose and instruct the mother to give the child acetaminophen every
4-6 hours for the next 24 hours
D)Withhold the vaccine
Q#3: ​The nurse is discussing risks and benefits of vaccines with a family. The nurse
emphasizes that which of the following reactions to vaccines are extremely rare?

A)Encephalopathy
B)Itching around the injection site
C)Fever of 100 F
D)Maculopapular rash
Q#4: ​A 6-year-old child is to receive his regularly scheduled immunizations. The parent
states the child is not feeling well and asks the nurse if they can come back next week
for the vaccines. What is the nurse’s best response?

A)Ask if the child has missed school due to the illness

B)Check the child’s temperature
C)Ask If the child has ever had a reaction to immunizations
D)Make an appointment for the child next week
 Chapter 41-The Child with an Infectious Disease
Diana Kovacic DNP, RN
Infectious/Communicable Disease Objectives
1. Discuss anatomic and physiologic differences in children vs. adults in relation to
the infectious process.
2. Identify appropriate nursing assessments & interventions for the child with an
infectious or communicable disorder.
3. Distinguish various infectious illnesses occurring in childhood, such as pertussis,
viral exanthems, Lyme disease, & parasitic and helminthic infections.

Variations in Pediatric Immune Response

● Infants & young children are more susceptible to infection d/t immature
responses of the immune system:
○ Newborns:
■ Have a decreased inflammatory response
○ Young infants:
■ Limited exposure to disease
■ Are losing passive immunity from maternal antibodies
○ Young children:
■ Increased risk of infection due to incomplete immunization status

Child With an Infectious Disease

Preventing Infection: ​Most things are spread in the hospital by touch & poor hand
hygiene!

● Proper hand hygiene is essential:

○ Handwashing
○ Foaming in & out of the room
○ RN may end up with dry cracked hands d/t constant washing etc.
■ Take precautions: can easily contract infection with open skin!
● Gloves when in contact with blood & bodily fluids
● Any toys kids play with should be cleaned/wiped down
● Proper cleaning of equipment & disposal of soiled linens & dressings
● Encourage immunizations & answering questions & concerns about it
● All patients are considered infectious:
○ Blood & body fluid considered contaminated no question!
Standard Precautions & Isolation Precautions
Standard precautions used for all Pt’s based on care/contact with what
● Gloves
● If splashing a possibility:
○ Mask
○ Gown
○ Face shield
Transmission based precautions depend on the type of illness the pt has
● Contact Isolation Precautions:
○ Gown (fingers in loop, over neck ,& tied in the back)
○ Gloves over top of gown sleeve
○ Mask
○ Remove all items before exiting room:
■ Break through gown roll up and toss
■ Foam out & wash hands properly
○ Majority of infections spread through contact!!!
○ Contact Isolation Diseases:
■ MRSA
■ C-diff
■ Scabies
■ Lice
■ RSV (also droplet)
● Airborne Precautions:
■ N95 particulate respirator mask (disposable don’t reuse!!!)
■ Negative pressure room:
● Air is blowing outside of hospital not circulating in the room
or hospital halls
■ Airborne Diseases:
● TB
● Measles
● Chickenpox/Varicella

● Droplet Precautions:
○ Surgical Mask within 3-6 feet of patient (always)
○ Droplet diseases:
■ Influenza
■ Mumps
■ Pertussis
■ RSV (also contact)

Common Drugs for Communicable Diseases

● Antibiotics:
○ For bacterial infections
○ Must finish full course to avoid antibiotic resistance
○ Antibiotics won’t work for Viral infections…...
■ Most infections in kids are viral & Antibiotics won't cure it!
● Antivirals: they end in OVIR...
○ Good for shortening course of viruses
○ Ex: non vaccinated child gets chickenpox gets ​acyclovir​ to shorten the
course & severity of lesions.
● Antipyretics:
○ Help with fevers (comes up a lot w/ viral)
■ Acetaminophen
■ Ibuprofen​ ​>6 months of age
● Antipruritics: (usually antihistamines)
○ Diphenhydramine​ (Benadryl)
○ For allergies & itching (not to knock your kid out!!!)
○ Benadryl can cause an opposite reaction in kids instead of them being
sleepy they’re hyperactive!

Assessment of kids with infectious disease

● Health history:
○ Have you been around anyone with any infections?
○ Are your immunizations up to date?
● Physical examination:
○ Start with Inspection
○ Look thoroughly at lesions or rash & document what they look like
● Lab & diagnostic tests: For infectious disease
○ Wound culture:
■ Sample first
■ Start antibiotics
■ After result tweak antibiotics (if needed)
○ C-reactive protein (CRP)
■ Protein made by the liver in presence of infection or inflammation
■ Usually elevated with bacterial infections vs. viral
● Helps dr. Determine if antibiotics needed
● Not waste time thinking viral & no med given to treat
● If CRP elevated Dr. will prescribe antibiotics
 Managing Fever

Fever:
● Most common reason parents bring kids to Urgent Care & ED
● Fever is a natural, healthy response of the body to illness/infection
○ It’s a good thing we don’t want to suppress it too much!
● Infants ​>3​ mo with fever ​<39C​ manage it at home
○ Acetaminophen
○ Cool bath
○ Fan to bring down temp
● Sometimes child must be brought in:
○ Infant​ <3​ mo w/fever ​>38C
○ Immature immune system cannot fight off infection
○ Medical care d/t risk for sepsis
Viral Infections
● These four infections are ​vaccine preventable
○ Measle
○ Mumps
○ Rubella
○ Varicella

● Many vaccine preventable diseases can cause other diseases

○ Can cause death
○ Educate on the risks of not vaccinating

● Rubella (German measles): ​Droplet precautions

○ Spread through droplets, blood & body fluid
○ Start off cold like symptoms
○ Swollen lymph nodes
○ Progresses to a rash
● Measles (Rubeola): ​Airborne precautions (N95/neg pressure room)
○ Highly contagious
○ Spread through droplets in air
○ Cold symptoms then rash
○ Develop Koplik’s spots (unique to measles)

● Mumps (Parotitis): ​Droplet precautions

○ Swelling of parotid glands
○ Can be unilateral or bilateral
○ Start with fever then...
○ Swelling of one or both parotid glands
○ Can lead to meningitis (scary)
○ Can lead to deafness
○ In little boys infection can travel down to testes:
■ Can lead to sterility
● Chickenpox (Varicella): ​Airborne & Contact (itch-vesicles)
precautions
○ Start with flu like symptoms
○ Then break out with itchy vesicles all over
○ Highly contagious on= airborne precautions
○ When lesions come up= contact precautions
○ If not vaccinated can contract varicella
○ Can lead to meningitis or pneumonia
● Hand, foot and mouth (Coxsackie A virus): ​Standard Precautions

○ No vaccination for this but it’s a virus!

○ Develop extremely painful vesicles on hands, feet, & in mouth!
● Hand, foot and mouth
○ Often when seen in hospital vesicles so bad inside the mouth
■ They can’t eat or drink
■ They’ve become dehydrated
■ Placed on IV fluids to restore hydration
■ Highly contagious
● In daycare one child gets it bunch of kids get it too
● At home child gets it parents get it too
■ Use standard precautions
● The above Viral Infections are treated with supportive measures no antibiotics
are going to cure these, they need to run their course!
○ Fluids
○ Encourage rest
○ Fever spikes & do not feel well:
■ Acetaminophen
■ Ibuprofen

Bacterial Infections
● Pertussis- ​whooping cough (​bacterial infection​) ​Droplet precautions
○ Cough so severe can break ribs from coughing
○ http://www.pkids.org/diseases/pertussis.html
○ Copious secretions (frequent suctioning)
○ To prevent spread in not fully vaccinated kids
■ Adults to get tdap booster at least once in adulthood
■ Between ages 19 to 64 to protect little ones
■ Bacterial: Dr. prescribes Antibiotics (macrolides)
● Azithromycin
■ High humidity environment (humidifier): Help w/coughing
■ Frequent suctioning for copious secretions
 Borrelia Infections(zoonotic)

● Lyme Disease:
○ Most common zoonotic infection in the US
○ Spread by deer tick (NE Ohio has many deer)
■ This is an issue to keep it in mind when evaluating
■ High incidence/chance for Lyme disease
○ If the actual tick infecting/hanging out of you isn’t obvious:

■ Creates anular (round) bull’s eye rash w/central clearing

● Depending where tick borrowed, may not see rash
○ Back vs. Arm
○ Rash may go away before you see it
● Rely on other symptoms if you didn't see tick bite
○ Start to feel tired
○ Extreme fatigue & joint pain if been awhile
■ This could mean anything
■ In NE ohio be on alert tick possible
○ Can be detected on blood test if suspicious
● Treated with antibiotics:
○ If permanent teeth are in: ​Doxycycline ​given
○ Tetracycline affects teeth still growing
○ If still temporary teeth:​ Amoxicillin

Stages of Lyme disease/tick bites

Early Localized Early Disseminated Late Disseminated

Skin lesions are most Cardiac & neurologic findings are Arthritis is the main manifestation
prominent: 1-31 days prominent 1-4 months after the bite months to years after the initial
Local reactions to tick bite ● CNS symptoms : tick bite. Occur intermittently &
● Vague flu like ○ Severe headaches with include:
symptoms: myelitis ● Chronic arthritis
○ Headache ○ Nausea ● Profound fatigue
 ○ Chills ○ Vomiting ● Chronic neurologic
○ fatigue ○ Facial nerve paralysis manifestations
○ Muscle aches & (bp) ● The debilitating effects
pain ○ Forgetfulness frequently affect a child's
● Bull’s eye rash w/ ○ Decreased ability to participate in
central clearing lasts concentration normal activities d/t
3-4 weeks gradually ○ Cerebral ataxia extreme fatigue or cardiac
fading ○ General complication
Because ticks need be ● Infrequent carditis
embedded for >36 hours to ● lymphadenopathy
transmit the disease ● Joint muscle pain
inspecting & preventing is Affects large joints knee most often
key! involved

Early Localized Care Early Disseminated Care Late Disseminated Care

Oral Antibiotics: IV:​ Ceftriaxone for 2-3 weeks IV ceftriaxone for many weeks​,
Doxycycline if permanent If caught in the earlier stages the late Treat fevers & arthralgia with
teeth in if child still has disseminated stages won’t be an antipyretics and analgesics
temporary teeth amoxicillin issue prevention/inspection is key!

Helminthis
● Pinworms
○ Most common worm infection in the U.S.
○ Very common in School-age children have highest rates of infection
■ Bad hand hygiene
■ Occurs in more than one family member
■ Pinworms infective within a few hours after being deposited on the
skin
■ Can survive up to 2 weeks on clothing, bedding, or other objects
■ Become infected after ingesting infective pinworm eggs from
contaminated surfaces or fingers
○ Can become a vicious cycle
● Assessment of pinworms:
○ Itching around anus:
■ Especially at night
■ Female pinworm comes out anus to lay eggs around anus
■ Itching while asleep wake up & touch/spread everywhere
■ Disturbed sleep, wake up irritability
 ○ Pinworms If heavily infested: ​loss of appetite, restlessness, difficulty
sleeping
● Interventions:
○ To test/sample:
■ place a piece of scotch tape to anus peel back in the am
■ Will see larvae take to Dr. Office for testing/confirmation
○ Treatment with medication: ​mebendazole
■ Treating entire family for pinworm or risk of
○ Bathe in morning to remove large proportion of the eggs/larvae
○ Frequent change of clothes & bedding
■ Wash in high heat dry in high heat to avoid any leaving any!
○ Specific personal hygiene...
■ Hand hygiene thorough washing
■ Keep nails short
■ Avoid scratching anal area/biting nails/reduce spread

Parasitic Infections (Ch 49)

● Pediculosis Capitis (Head lice) ​Anyone susceptible educate pt/family:
○ Nothing to do with socioeconomic status
○ Unrelated to the hygiene of the child or family
○ Caused by blood-obligate parasite
■ Feed once a day (live close to scalp)
○ Common in school-age children who
■ Share clothing, combs, hats, & headphones etc.
■ Have close physical contact
○ Can live anywhere you have hair
■ Brows
■ Under arm
■ Pubic area
○ Diagnosis:
■ Gold standard for dx: finding a ​live/​moving​ ​lice in head
● Brown translucent mites not big at all
■ Lice can be seen easily or harder depending on hair type
■ Tiny white eggs
■ Nits​: are easier to spot at the nape of neck or behind ears within 1
cm of scalp
● Red rash like bites by hair shaft/back of neck
● Itchy at neck because lice feeding
 ■ Dandruff:
● Diagnosis with nits alone not accurate
● Could be dandruff/dry scalp
Head Lice

● Treatment
○ Nix ​Permethrin (1%, OTC) retreat in 7-10 days when super lice are
resistant
■ Recommended treatment of choice
■ Low mammalian toxicity
■ Treat the environment sheets, pillows, etc. hot wash/dry
● If ​Nix​ fails….
○ Malathion​ (0.5%) FDA approved ​>6 yrs of age
○ Treat environment:
■ Washing clothing/pillowcases/towels in hot washer/dryer

● Nursing considerations
○ Educate parents
○ Schools send children home if lice found in their hair they cannot come
back until treated and no lice if seen/found on inspection
○ Some schools have a “No nit” policy meaning...
■ If residual nits are still visible even if dead or not activated child
cannot come back to school yet!
■ Some schools have changed this policy also d/t stigma & bullying
■ CDC does not agree with no nit policy they agree after treatment
and lice gone child should attend school

● Scabies: ​Is a mite!

○ Characterized by ​intensely​ pruritic/itchy (esp. at night feeding off blood),
erythematous, papular rash
 ○ With Scabies...
■ Burrowing of adult female mites in epidermis @night
■ Patient may describe the rash being extra itchy @night
■ You can’t see the mite but it’s under the red scabie
○ Lesions are generally distributed/anywhere on the body
■ But often are concentrated on the hands and feet and in body folds.
○ In infants, young children & those immunocompromised
○ The rash may look awful & include….
■ Vesicles
■ Pustules
■ Nodules

○ Transmission usually through​:

■ Prolonged, close, personal contact (humans are the source)
■ Could be sexually transmitted from skin to skin contact!

● Treatment:
○ Includes application of ​5% Permethrin​ lotion or cream (drug of choice)
containing a scabicide
■ Rub a thin layer from neck down over entire body
■ Leave on overnight 8-10 hours
■ Shower first thing in the morning to wash it off
● This should kill any scabies mites
■ Treating environment hot wash dry etc.
Scabies Rash
 The Child with an Alteration in Tissue Integrity
Diana Kovacic DNP, RN

Child with an

Integumentary Disorder Objectives

1. Compare anatomical & physiological differences of the integumentary system in
children vs. adults.
2. Describe common medications & other treatments used for management of
pediatric integumentary disorders.
3. Identify appropriate nursing assessments & interventions related to pediatric
integumentary disorders.
4. Distinguish common pediatric integumentary disorders, including bacterial &
fungal infections, diaper dermatitis, & atopic dermatitis.

Nursing Care of a Child With an Integumentary Disorder

Variations in Pediatric Anatomy & Physiology
● Skin of a child vs. adult:
○ Infants have very thin skin….
■ More prone to skin breakdown & infection
○ Dark-skin children have more defined & pronounced skin reactions
■ More Pronounced chicken pox spots than lighter skin
○ More likely to have Keloid formation d/t any little trauma
■ Keloid is an overgrowth of scarred tissue
○ Sebaceous & sweat glands:
■ Immature in childhood
■ Hard for little kids to regulate temperature well
 Common Medical Treatments
Medical Treatments for skin disorders/wounds
● Wet dressing or Dry dressing: ​Depends on the type of wound the child has &
treatment required:
○ Wet to Dry:
■ Pack wound with wet dressing pull out dressing when dry, this is to
Debris the wound
○ Wet dressings:
■ We want to keep the wound bed moist so the wet dressing is to be
wet the entire time, in and out wet/moist
● Sunscreen:
○ Recommended for kids 6 months and older
○ <6 months not recommended= d/t thin skin systemic absorption
○ Babies under 6 months skin is sensitive don’t take out
under sun
● Drugs: ​Given systemically (Oral or IV), Topical as well
○ Antibiotics:
■ Oral, IV, or Topical administration
○ Corticosteroids:
■ Oral, IV, or Topical administration
○ Antifungals:
■ Oral, IV, or Topical administration

● Assessment for skin issues

○ Health history: ​History of the illness
■ When did it start?
■ What are the symptoms?
● Rash, lesions, etc.
■ Ask about external environment, new….
● Pets, detergent, down coat, food, or diapers

○ Physical examination:
■ Describe rash:
● What it looks like, location, any drainage?
 ○ Lab & diagnostic testing:
■ CBC (elevated WBC poss infection)
■ Wound cultures
■ Allergy testing (specifically for eczema)
● At Dr. office
○ TB syringe wheel of possible allergic things
○ May break out in hives (supervised)
○ They administer medication to help!
● Adults​: Arm is fine adults have better itch control
● Kids​: Back is best no itch control hard to reach back to itch

Contact Dermatitis
● Diaper Dermatitis: Aka “Contact Dermatitis”
○ Urine or feces contact with skin in the diaper area leading ​to…
■ Redness, irritation, & skin breakdown

○ Nursing assessment:
■ Ask how long has it been going on for?
■ What treatments have you tried at home?
○ Nursing management:
■ Main piece educate parents about prevention with Diaper cream
(balmex,desitin)
■ Diaper cream should be used ahead of time as a skin barrier no
need redness to appear for cream application
● Goes On with every diaper change period!
■ Changing diapers frequently is also good practice
■ Baby appropriate cleansers & Wipes
● Unscented/sensitive/gentle
● Baby skin very sensitive to scents etc.
■ Diaperless periods, airing out, tummy time etc.
■ Do not use baby powder won't protect & may cause other issues
such as aspiration pneumonia etc.
 Atopic Dermatitis
● Atopic= Allergic…..Atopic Dermatitis
● Eczema:
○ Is an allergic dermatitis known as “The itch that rashes”
■ You itch & scratch, & patch/rash appears
■ The more you scratch the more
it spreads!
● Nursing assessment
○ Health history:
■ You want to know if a child is
allergic to certain things
■ Ask about any asthma, any
allergies
● Many kids know their triggers & if they encountered them &
that their eczema has flared up as a result
■ Asthma & Chronic allergies (allergic rhinitis) go hand in hand with
eczema:
● This is called Atopic Triad
● In kids usually all 3 of these present
■ Child with Asthma has…
● Eczema & Chronic Allergies as well
● All allergic in nature with children

○ Physical examination:
■ Pay attention to skin folds (In kids eczema found here)
■ Listen to lung sounds if they have asthma as well you may hear
wheezes etc.
 ○ Lab & Diagnostic tests:
■ Allergy testing if hasn’t been done already to
● Figure out What they’re allergic to
● What their triggers are to avoid them
● Control aggregation/flare ups
The Red scaly appearance on this baby’s face is eczema

● Therapeutic management for child with eczema:

○ Skin hydration:
■ Mild cleansers with showers
■ Most companies make eczema friendly/version cleanser
● Mild/Hypoallergenic
■ Post showers: Skin slightly damp apply Moisturizer/lotion
● Pores open & absorb/lock in moisture better
● When skin is dry you itch & eczema flares up
■ Cotton breathable clothing (wool not good/itchy)
○ Topical corticosteroids:
■ For severe eczema not responding to lotions
■ Dr. may prescribe 2 week course for really bad flare up
● Steroids thin the skin
● Two weeks skin calms down & back to lotions/moisturizers
previously used
○ Oral antihistamines:
■ Benadryl needed for some kids d/t bad itching
○ Antibiotics:
■ given only if secondary skin infection involved
■ Eczema is not an infection its an allergic response
● Scratching can break skin
● Skin has bacteria Staph, Strep, Fungus etc.
■ If ends with infection will require antibiotics to cure
 Skin Infections-Bacterial
Impetigo

● Impetigo
○ Caused by bacteria
○ Highly contagious and easily spread (daycare)
● Nursing assessment:
○ Impetigo differentiated by honey colored crusts
○ Commonly on the face around the lips & mouth
● Nursing management:
○ Treat with topical or Oral Antibiotics

Cellulitis

● Cellulitis:
○ Caused by bacteria
○ In kids usually develops as a result of skin trauma
○ Child gets a cut or scrape the normal bacteria that lives on skin gets inside
causing infection that spreads

● Nursing assessment:
○ A child with cellulitis will present with:
■ Localized redness
■ Pain
■ Edema
■ Warm to touch/feel the heat radiating from site
● Nursing management:
○ IV​ ​antibiotics to treat usually via picc line for a couple of weeks
○ Home care RN come home 3xs a day to administer antibiotics
○ Once Antibiotic started: swelling/infection should subside
○ Draw a line of demarcation where healthy & Red skin meet
■ Don’t want it to spread but if so we want to know! Can also monitor
progression in state of health

Tinea Infection
● Tinea:
○ Tinea is the medical term for fungus:
■ Further identified by location/area of the body tinea is
■ Fungus thrives in warm, dark & moist places
■ Can be spread by pets (especially cats) some dogs too..

○ Tinea Corporis-peripheral:
■ Ringworm is another common term for tinea corporis
■ Peripherally on our body
■ Annular (round) type of rash with red & central clearing
■ If you touch will be/feel raised

○ Tinea Capitis-head (scalp):

■ On the scalp can lead to permanent scarring & hair loss
■ Traumatic experience for child

○ Tinea Versicolor-upper back & chest:

■ Overgrowth of normal fungus located on skin
■ Common in pregnancy d/t hormonal shift
■ Hypopigmented lesions on chest & back
■ Not contagious has to do with own fungus/hormones
■ Usually goes away after delivery of baby, body regulates

○ Tinea Pedis-feet (between toes):

■ Also​ ​known as athlete's foot
■ Fungus of the feet/in between the toes
■ From barefoot in locker rooms, public pool areas
● Easy to catch from another person who has it
 ○ Tinea Cruris-inguinal creases:
■ Commonly known as Jock Itch
■ In genital area/folds down by the thighs

○ Diaper candidiasis:
■ This is not diaper dermatitis! Know the difference
● More scabby, scaley, crusty, sort of yellow
● Satellite lesions present (past diaper down to thigh)
■ Desitin won’t cure this it is fungal and requires Antifungal

● Tinea Nursing assessment:

○ Ask about sports involvement: this is how many kids get it
○ Ex: ​If one has ringworm close contact can spread it…
■ Football players & Wrestlers from contact
○ Swimmers sitting/wet bathing suits prone to Tinea Cruris

● Tinea Nursing management:

○ Will get Antifungal:
■ Topical or Oral
○ Environmental modifications:
■ Flip flops in locker rooms & common spaces
■ Cotton breathable underwear & fabrics

Pedis-feet (between toes) Corporis-peripheral/ringworm

Versicolor-upper back & chest Cruris-inguinal creases

 Diaper candidiasis Tinea capitis

Q#1: ​Which statement concerning the transmission of tinea corporis would be the most
important teaching delivered by the nurse?
A)This viral infection rarely causes permanent hair loss
B)This fungal infection is spread by skin-to-skin contact
C)This bacterial infection is spread from animal to person
D​)This fungal infection disappears spontaneously

The Child with a Respiratory Alteration

Diana Kovacic DNP, RN

Child with a Respiratory Alteration Objectives:

1. Compare how the anatomy & physiology of the respiratory system in children differs from
adults.
2. Discuss common medications & other treatments used for management of pediatric
respiratory conditions.
3. Identify appropriate nursing assessments & interventions commonly used for respiratory
illnesses in children.
4. Distinguish various pediatric respiratory illnesses, including croup, bronchiolitis (RSV),
foreign body aspiration, asthma, and apnea/SIDS.
Upper Airway Structures: ​PEL

1. Pharynx= ​Is at the back of throat

​ lap that prevent food/liquid from going down into the trachea
2. Epiglottis= F
○ Choking & turning red when epiglottis fails and food goes down into the trachea
rather than the esophagus
3. Larynx= ​Is your voice box

Variations in Pediatric Anatomy & Physiology

Children are different from Adults in body systems

● Kids Lungs not fully developed or fully functional at birth:

○ Still need time to develop
● Young infants obligate nose breathers (until 1 month/4 weeks of age):
○ Do not tolerate nasal congestion
○ Any mucus or congestion in the first month it’s hard for them to breath
● Tongue of infant relative to oropharynx larger than adults:
○ Tongue is large compared to the size of mouth & can obstruct their airway
● Child respiratory tract has narrower lumen than adult until age 5:
○ Trachea is tiny diameter is much smaller than in an adult
○ Great skills needed to intubate a child, difficult to slide OET tube in
■ Physicians and Respiratory therapists do this (intubation)
○ Respiratory illness most common reason kids end up in the hospital!
● Larynx narrow- located higher in neck:
○ Can increase the risk of aspiration down into the trachea/lungs
● Bronchi and bronchioles narrow:
○ Mucus & congestion in lower airways can give distress & cause difficulty
breathing
● Alveoli continue to develop & increase in size through childhood:
○ Gas exchange compromised d/t less alveoli
○ Puts them at risk for hypoxia
● Respiratory distress results in retractions/use of accessory muscles:
○ Grunting, Flaring, Retractions: Prominent signs of difficulty breathing
● Normal for infants to have slightly irregular breathing:
○ Why we count respirations for one full minute in kids under 2!
○ They take 10 quick breaths stop breathing 15 sec. then 5 breaths etc.
■ Important to count for one full minute!
 Common Medical Treatments for Respiratory Problems
● Suctioning:
○ Must be very careful inserting catheter
○ Bifurcation into the left & right main stem of lungs is higher in kids
■ No need to suction too deep!
■ You may go into a lung & cause damage to lung tissue!
■ Just insert catheter enough to make them cough applying suction & take
the catheter out. Don’t keep advancing!
● Medications:
○ Racemic epinephrine:
■ Commonly used for croup
■ Via nebulizer by Respiratory therapist
■ It Bronco dilates/opens & reduces edema in the airways
○ ​Caffeine:
■ Medication caffeine stimulates them to breathe
■ Many preemies given caffeine d/t periods of apnea
■ Centers in the brain responsible for reminding them to breathe are not
fully developed as a result they experience this apnea

○ Synagis:
■ An injection for high risk infants <35 weeks gestation or <2 years old with
heart or lung problems
■ Given monthly during RSV season (September to May) to prevent RSV
(respiratory syncytial virus)
■ High risk kids/preemies <2 years old are really affected by RSV
● They get really sick end up in ICU intubated, and suctioned
constantly
○ Viagra:
■ For kids with pulmonary hypertension
■ This vasodilates, improves oxygenation, & blood flow specifically to the
lungs

Child with a Respiratory Disorder

● Assessment
○ Health history:
■ How long have they been sick?
■ What are their symptoms?
○ Physical examination: pay attention to
■ Color:
● Especially looking for cyanosis (sign of hypoxia)
■ Rate & depth of respirations:
● Looking for accessory muscles being overworked
● Work of breathing ​GFR​, signs of troubled breathing!
■ When breathing is difficult
● D/t lungs being congested/ filled with mucus you breathe harder
and faster & become tachypneic
● Little kids bop head when having difficulty breathing
■ Listen to lung sounds can tell us a lot about what’s wrong​:
● If ​wheezing​ heard this is ​narrowing or constriction​ (common
with asthma)
● If ​crackles​ heard this indicates ​fluid overload ​(a bad pneumonia,
heart failure)
● If ​Rhonchi​ heard it sounds coarse and you can till ​mucus filled &
congestion
● If ​Stridor​ a high pitched on inspiration possible ​croup
○ If heard intubation & emergency carts warranted
○ Indicator airway is closing off & need intubation

■ Lab & diagnostic tests:

● Rapid swabs:​ instant results, many available today
○ Flu
○ Strep
○ RSV
● RVP: ​Respiratory Viral Panel
○ Culture/nose swab up the nose
○ Very uncomfortable/kids don't like it
○ Takes 24 hrs to get results
○ Dx many common viruses pt may have
● Cultures/Sputum Culture:
○ Obtained prior to starting any antibiotics
 Respiratory Disorders: Acute Infectious
● Croup:
○ Is a set of symptoms not a specific disease in itself
○ Many things can cause croup like symptoms
○ Most cases of croup are viral in nature
○ Commonly affects kids 3 months of age to 3 years of age

● Nursing assessment:
○ Croup is an upper airway issue, swelling of larynx & trachea
○ The swelling of the larynx (voice box) leads to a barking cough:
■ High pitched inspiratory sound (gasping like)
■ Sound like baby seals
■ https://www.youtube.com/watch?v=rC4NlifTYbs
○ In worse case scenarios of croup stridor develops d/t swelling
○ Croup symptoms are especially bad at night time

● Nursing management:
○ Steroids:​ To help with inflammation
○ Racemic​ ​Epinephrine:​ Nebulized by Respiratory therapist to help with swelling
& inflammation
○ Humidified oxygen: ​to add humidity to the air to help with coughing & breathing
■ At home cool steam vaporizers (hot is good but dangerous for child)
■ If at home no vaporizer available they can turn on hot shower in the
bathroom steam up child breathes better
○ Encourage fluids: ​To avoid dehydration
■ They lack the desire to eat or drink while sick
○ Quite & Restful Environment: ​Breathing can be affected
■ Prevent crying because symptoms can be exacerbated this is hard with
little ones
■ Try to anticipate their needs if possible
 Bronchiolitis (RSV)

● Bronchiolitis (RSV):
○ Is a set of symptoms not a specific disease or condition
○ Many things can cause bronchiolitis
■ Most common causes of bronchiolitis & its symptoms is RSV
● Bronchiolitis​ ​is a lower airway issue:
○ Inflammation & congestion in the bronchiole & bronchi
○ More common in winter months (RSV season right now)
○ Causes extreme mucus & secretion production
● Therapeutic management:
○ They need frequent suctioning, the main nursing intervention
■ d/t copious amounts of congestion & secretion production
● Nursing assessment
○ Health history:
■ Ask if born as preemie (preemies at risk for severe illness with RSV)
■ Usually starts with cold like symptoms & fever then progresses to lots of
mucus/congestion & difficulty breathing
○ Physical exam:
■ May notice cyanosis d/t hypoxia
■ Listening to lung sounds may notice Wheezes (inflammation or
narrowing) or Rhonchi (congestion)
■ If no base/lung sounds this is a complete blockage or complete
consolidation (no air movement) BAD SIGN!
● Kids can only compensate for so long
● They can deteriorate quickly
○ Lab & diagnostic:
■ Rapid RSV​ ​swab
■ RVP: takes 24hrs & includes RSV
 ● Nursing management: ​Mostly supportive because it’s a Virus must take its course
○ Acetaminophen & Ibuprofen:
■ For fever and discomfort
○ Promote hydration:
■ Easily dehydrated d/t lack of drink/eating
■ May need IV fluids
○ Maintain patent airway:
■ Suction frequently
○ Promote adequate gas exchange:
■ Humidified oxygen
■ Nasal cannula
■ Elevate HOB (easier to breath)
○ Reduce risk for infection:
■ They are on droplet & contact precautions if it’s RSV
■ If it’s RSV contact can spread when they cough & sneeze
■ The secretions dripping inside pt’s room they touch everything you come
in and touch everything after them and can transmit to other patients
■ Need to frequently wash hands well
○ Provide family education:
■ Teach family good hand hygiene to cut down on spreading the infection
○ Prevent RSV disease:
■ Synagis Injection:
● Given throughout RSV season monthly for high risk kids

Be alert to signs that seem “good”.......

● When kids have respiratory related issues & can get tachypneic from working harder to
overcome the respiratory infection
● If resps counted at 40 bpm and in a couple of hours counts at 20 bpm, this doesn’t
indicate curing….
○ We expect fast breathing with respiratory illnesses
○ Slowing down suddenly means they’re deteriorating d/t their inability to
compensate for too long!
○ They may be pooping out & may stop breathing altogether they are retaining
CO2 & becoming acidotic
○ Be very worried if sudden decrease in RR or no breath sounds or sudden
decrease in respiratory rate
 Respiratory Disorders: Acute Non-Infectious

● Foreign Body Aspiration:

○ When liquids/solids enter into the airway (down trachea to lungs)
■ Coughing profusely
■ If doesn't come back out it can lead to aspiration pneumonia
■ This is a common worry in pediatric care
○ Foreign objects​: Enter trachea & can cause complete blockage
■ need to be surgically removed if lucky enough to get to surgery
○ Common things kids aspirate:
■ Nuts:
■ Grapes:​ Cut them up appropriately
■ Hot dogs​: Should be cut in tiny pieces
■ Small toys​: Teach parents this trick!
● If it fits through tissue roll its too small for young child!
■ Button batteries​: worse things to aspirate on
● Harmful can block airway
● If not blocking the Airways, battery acid comes in contact with
tissue & fluids and will eat away/erode at anything…
○ Stomach lining, intestines, trachea, lungs etc.
○ Nursing assessment:
■ Commonly you will notice the child is coughing
■ Listening to lungs if something lodged= absent lung sounds
○ Nursing management:
■ Main focus here is prevention! Teach the parents:
● No nuts
● No popcorn
● No raw carrots
● Cut their grapes & hotdogs in small pieces etc.
● No small toys (toilet/paper napkin roll trick)
■ Most of these kids will get an X-ray for confirmation
■ May need bronchoscopy to go in & remove object
● If child not breathing cannot take to surgery!
 ● APNEA:
○ Is Absence of breathing for more than 20 seconds and usually followed by
Bradycardia (why we worry about this) ​Can be central or result of
illness/infection
● Apnea central:​ In the brain related to prematurity, breathing center not fully mature
● Apnea result of illness/infection:​ A child can become septic and then become Apneic
from the overwhelming infection
○ Acute life-threatening event ​(ALTE)​..​aka BRUE...​Brief Resolved Unexplained
Event ​(BRUE)
■ Combination of apnea, color change, muscle tone alteration, coughing,
gagging..
■ Ex: Child found at home unresponsive, not breathing, & cyanotic
● Parents bring child to ED, child now breathing pink everything is
good & Dr. trying to figure out why they went apneic in the first
place

● SIDS (​sudden infant death syndrome​):

○ SIDS is defined as a period of prolonged apnea
○ Believed to be related to unsafe sleeping environment & CO2 build up, they
become acidotic & stop breathing all together
■ Occurs in otherwise healthy young infants < 1 year of age

SIDS and ALTE are unrelated, they are both examples of apnea...SIDS being prolonged apnea.

● Nursing assessment:
○ An Apneic episode that you did not witness ask for the details
■ What happened?
■ Was there a color change?
○ Self-stimulate or require stimulation:
■ Did infant wake up alone and start breathing, or had to stimulate the
infant?
○ Infant’s position & activity preceding episode:
■ What was the child’s activity before it happened?
● Lying prone on the couch cushion etc..
 ● Nursing management:
○ Education to parents:
■ Have to teach about apnea
■ They need to know how to do CPR at home especially rescue breathing
incase happens and baby doesn’t spontaneously start breathing Again
■ Try Stimulating infant first! May breathe independently
■ If they don’t self regulate and start breathing they start CPR/chest
compression (why they need to know CPR)
■ At home mouth to mouth from parents (rescue breathing)
○ Some kids need a home apnea monitor until their systems grow and develop &
grow out of apnea:
■ It will alarm when it doesn't detect movement for a certain amount of time
○ In hospital we get ambu bag child’s right size and fit should already be there.
■ Hook mask to bag to O2 crank up to 10-15 liters, put mask over nose &
mouth seal it
■ Squeeze one breath every 5 seconds don't hyperventilate child! You call
for help room gets filled & figuring out what to do with child

Chronic Respiratory Disorders

Asthma:

● Asthma is the most chronic condition seen in kids:

○ Asthma in younger kids often called reactive airway disease before getting fully
diagnosed with the actual diagnosis Asthma
○ Reactive Airway​: Meaning reactive or hyperreactive to allergens & stimulants in
the environment: Most asthma in kids is allergic in nature (part of atopic triad)
● With Asthma we see:
○ Airway hyperresponsiveness:
■ Hyperresponsive to allergens & triggers from the environment
○ Airway edema:
■ They end up with Edema & Swelling
○ Mucus production:
■ Increased mucus production
 ​Normal Bronchiole vs. Bronchiole w/ Asthma attack

● Nursing assessment:
○ Health history: ASK….
■ About any known allergies & triggers….
● Most kids know what their triggers are!
● Were they around their triggers despite the risk?
■ Do they have any eczema or allergies?
■ Was there exposure to cigarette smoke?
● A trigger for many kids they go into Asthma attack!
○ Physical examination:
■ Looking for signs of distress
■ Lung sounds usually hear inspiratory &/or expiratory wheezing
○ Lab & diagnostic tests:
■ If a child has not had allergy testing they need to now
● This will identify their triggers so they can avoid them
■ They need a Pulmonary function test
● This will test the capacity & strength of their lungs
○ Nursing management:
■ Educate child/family:
■ They need to understand & know the difference between….
● Rescue medications: ​When having an active attack
● Maintenance meds:​ Daily to prevent an attack
■ Teach family & child about medication compliance
● If a child hasn’t had an attack for a while they may think it’s ok to
stop…. As a result, they're in the hospital for an asthma attack!
● Daily maintenance meds taken daily don’t suddenly stop them
■ If maintenance meds grabbed for an active attack it wont work it’s meant
to build up in their system over time…..​Can die! Must grab rescue med!
 ● Child needs to learn how to use a peak flow meter to measure current peak flow
○ Do this when feeling well to determine overall regular peak flow
○ They are to ​breathe into the device​ color will indicate their PF status:
■ Green​= Good to go
■ Orange​= Look into rescue meds
■ Red​= Use rescue inhaler and go to the ED
Maintenance Meds for long term asthma Control:

● Inhaled Corticosteroids:
○ Deliver​ ​topical anti inflammatory action directly to the airway!
○ Inhaled Corticosteroid med names:
■ Beclomethasone
■ Budesonide
■ Fluticasone
■ Flunisolide
■ Triamcinolone acetonide

● LABAs (​long acting beta-adrenergic agonists​)

○ Salmeterol (serevent)
○ Formoterol (Foradil)

● Combination medications: Corticosteroid & LABAs

○ Symbicort (budesonide & formoterol)
○ Advair (fluticasone & salmeterol)

● Leukotriene Blockers: ​diminishes the mediator action of leukotrienes

○ Montelukast
■ Given as young as 1 year old)
■ Sprinkles and chewable tablets available

● Anti-immunoglobulin ​(Anti-IgE)
○ For allergic-type moderate/persistent asthma
○ Anti-IgE med names:
■ Omalizumab​ ​(Xolair)
● For kids >12 yrs old
● Administered subcutaneously q2-4weeks
Rescue Medications for Asthma Attacks:

● SABAs ​(Short acting beta-adrenergic agonists)

○ Kids with intermittent asthma use them PRN for relief
○ To relax bronchial smooth muscle & inhibit release of mediators from mast cells
○ Delivered by MDIs or nebulizer 3-4 times a daily if symptomatic/prior to exercise
○ SABA med names:
■ Albuterol (ventolin, proventil)
■ Levalbuterol (xopenex)
■ Terbutaline (brethren, brethaire)

● Anticholinergics:
○ Can be used in combination with SABAs kids >12 yrs old with severe asthma
○ Anticholinergic med names:
■ Ipratropium bromide (Atrovent)

● Mast Cell Inhibitors: Inhaled NSAIDS

○ prevents asthma symptoms by blocking the release of mast cell mediators
○ Can be given 30 min before exposure to triggers
○ MCI med names:
■ Cromolyn sodium (Intal)
■ Nedocromil sodium (Tilade)= For kids >12 yrs old

● Systemic Corticosteroids:
○ Decreases airway inflammation
○ Preferably given in short burst courses of 5-7 days
○ SC meds...
■ Prednisone
■ Prednisolone
● Teach kids
○ How to properly use their inhaler, even adults miss half of their medication
○ In Peds ​spacers ​are commonly used to avoid dose irregularities
■ Holds the entire dose, keeps a seal & child breathes it all in
○ To avoid their triggers & allergies this is a chronic/long term condition
■ With each attack lungs permanently scarred & damaged
■ Some parents ignore the triggers d/t denial or underestimation of severity
● They keep Dogs, cats, cigarette smoke etc. around kids
 ● Promote child’s self esteem:
○ Can be very embarrassing for a child if or when they have an attack in public
● Promote family coping:
○ d​/​t chronic nature its a family process
○ Make sure parents understand the Severity, how to treat, and manage it & not to
allow the stopping of maintenance medications

Q#1: ​A 4-year-old client admitted with respiratory distress is diagnosed with asthma. Upon
assessment, the child is sweating profusely with wheezing audible without a stethoscope and
diminished breath sounds in the bases upon auscultation. What is your first action?
A)Check the chart to determine the last nebulizer treatment

B)Notify the physician and encourage the child to lie down

C)Stay with the child, call for help, and administer oxygen

D)Administer albuterol and epinephrine while waiting for the physician

Q#2: ​While caring for a 33-week preemie, you note that he is having an apneic episode. What
should your first course of action be?
A)Notify the physician

B)Increase the amount of oxygen the infant is receiving through his nasal cannula

C)Begin giving rescue breaths

D)Use tactile stimulation

Chapter 52-The Child with a Neurologic Alteration

Diana Kovacic DNP, RN

Child with a Neurologic Disorder Objectives

 1. Compare how the anatomy & physiology of the neurologic system in children differs from
adults.
2. Discuss common medications and other treatments used for management of pediatric
neurologic conditions.
3. Identify appropriate nursing assessments & interventions for the child with a neurologic
illness.
4. Distinguish various neurological illnesses occurring in childhood, such as spina bifida,
cerebral palsy, epilepsy, hydrocephalus, and bacterial meningitis.

Nursing Care of the Child with a Neurologic Disorder

Variations in Pediatric Anatomy & Physiology
● Brain & spinal cord development:
○ Happens very early in gestation about 3-4 weeks in utero
○ One often finds out their pregnant after 4 weeks!
○ Nothing mom can do to affect a child's brain or spinal cord at that point
■ It’s Recommended that women of child bearing age take folic acid
supplementation daily to prevent neural tube defects
■ Prenatal vitamins daily even when not pregnant
● Nervous system:
○ Process of Myelination:​speeding up of nerve impulses along the nerve fibers
■ Allows kids to have more gross & fine motor movements
■ Process of myelination finishes at 2 years of age
■ Example of myelination effects:
● Infant at birth is unable to hold head up on its own but by 2 yrs old
they are running around!
■ Myelination occurs in a proximal distal & cephalocaudal pattern:
● Head to toe & inner to outer
● Head size:
○ Infants have large head compared to the rest of their body
○ They are more prone to injury if they fall or have any type of trauma
Common Medical Treatments
Medical Treatments:
● Shunt placement/Ventriculoperitoneal (VP) Shunt​:
○ A Catheter that is inserted into a damaged ventricle in the brain
○ Helps drain cerebrospinal fluid it’s a whole system inside the body
○ All that’s noticed externally is a raised area behind the ear (the valve here)
■ CSF drains from damaged ventricle through the body into the peritoneal
cavity then cerebrospinal fluid eventually absorbed & peed out
○ VP shunt is the most common shunt placed for kids with Hydrocephalus
○ System is internal & depending on how young the child is when placed
■ Will receive multiple shunt revisions throughout life with continued growth
Internal shunts can become infected or stop working: ​Need to allow healing or replacement
time However fluid needs draining continuously here, ​EV drainage comes into play….
● External Ventricular Drainage system:
○ Used​ ​In the event an internal (VP) shunt is infected or malfunctioning, while
allowing internal shunt to heal (on antibiotics)
○ Draining needs to Continue external ventricular drainage= VP shunt/draining
■ Difference is catheter is exposed & draining into a closed sterile system
● RN will monitor system & drainage…..
○ Amount of drainage has to be measured, should be Clear, & have no foul odor
○ Child stays in the hospital until internal shunt is healed/replaced
○ These kids are kept in ICU d/t the system needing kept at level of ear or clavicle
■ If a child is raised too high or low & isn’t adjusted appropriately the system
can pull too much fluid off the brain & cause major problems
■ Most floor nurses don't want this responsibility…...

Medications….
● Anticonvulsants: ​commonly used for kids with seizures
○ Many kids on a combination of seizure meds to control/stop seizures
○ Expect Many side effects with seizure meds
○ Non compliance can become an issue d/t undesired side effects & not having
had one in a while so they think its ok to stop…..
■ When/If they stop they start having seizures again!
○ Some kids have lesser medication combinations & will have a higher than normal
dose because it's the only medication that’s controlling their seizures
■ Remember higher dose= Higher chances of side effects
 ● Diazepam (diastat)
○ Rectal Valium (Diastat) for kids with epilepsy to keep at home
○ Inserted rectally cannot give anything po during seizures
○ Kids don't have IVs daily rectal only route available at home in emergency
○ Parents should know how to use this with prolonged seizure >5 min

Assessment:

● Health history:
○ Ask if patient has a history of seizures?
○ Were they born premature? (preemies at risk for many neuro issues)
● Physical examination:
○ Pay attention to the child's level of consciousness:
■ In the am if the child is happy & interacting with you & 4 hours later child
is lethargic and only responding to pain
■ This is a change in neurovascular status
■ Not a good sign condition may be worsening
○ Head circumference:
■ Kids under 3 we routinely measure head circumference
● make sure no macrocephaly (big) or microcephaly (small)
● Lab & diagnostic tests:
○ MRI
○ CAT-scan
○ EEG:
■ EEG for kids with seizures
■ Measures brain wave activity to see if they’re having more seizures
● ICP= Sunsetting of the eyes:
○ when the sclera is visible over the iris/pupil of the eye
○ All you see is the whites of their eyes
○ This indicates intracranial pressure
○ Distended scalp veins d/t pressure build up
○ With hydrocephalus we worry that vision is affected (poss blind)
○ Easily acquire pressure ulcers must be turned q1 to q2
■ This is an orphan in Haiti thought that she was blind and she had stage 2
& 3 pressure ulcer (bandages in place)
 Posturing

● 2 types of posturing: Decorticate & Decerebrate:

○ With ​Decorticate & Decerebrate ​you’re​ ​patient has significant brain injury
○ Of the 2 postures ​Decerebrate​ is particularly ​troublesome​:
● Decorticate:
○ Hypertonia= increased rigid muscle tone
○ Everything is turned inward/ towards core
○ Problems with ​C​ ​spine​ or cerebral cortex in the brain
● Decerebrate:
○ Hypotonia= increased rigid muscle tone
○ Extensor posturing away from the core turned outward
○ Problem with the brain stem (essential for life)
■ Decerebrate is more troublesome

Spina Bifida Occulta & Cystica

Multiple variations of Spina bifida not all have chronic long term issues
● Spina bifida common risk factors:
○ Lack of prenatal care
○ Lack of folic acid ingestion
○ Drug use during pregnancy

● Spina Bifida Occulta

○ Noticeable defect along spine:
○ Tuft of hair, extra dimple, or discolored area
○ No neurological impairment (benign)
○ Just a different variation at birth
● Nursing assessment SBO
○ Noticeable dimpling
○ Abnormal patches of hair
○ Discoloration of skin at site
● Nursing management SBO
○ Educate family it is a benign disorder
■ No neurological impairment
■ Children grow up to be fine

● Spina Bifida Cystica: 2 types of SBC

○ Born with external cyst or sac
○ Two different variations of the sac
○ Protrusion of spinal cord or meninges
#1 Meningocele SBC:
○ The Meninges herniate out through the sac
○ Spinal cord remains intact/in place
○ Child will need surgery shortly after birth
○ Won’t have neurological/long term complications

● Nursing management of SBC meningocele:

○ The #1 priority is to prevent rupture or trauma to external sac
■ Child is at risk for Infection
■ Located on the sacrum consider stool & urine contamination
○ Child will need surgery day 2 or 3 of life
■ No impairments post surgery
■ Child will learn to crawl & walk etc. when it's time
○ Child needs Pre-op & post-op support
■ Usually kept prone or side lying position
○ Provide nutrition/hydration:
■ Hard to feed them like this (IV fluids given until off to surgery)
■ Encourage breast/bottle feeding but hard to latch if prone/side
#2 Myelomeningocele SBC: ​Most severe form of SBC
○ Born with external cyst everything herniates out from that point
■ Spinal cord, Meninges, spinal fluid, all herniated into the sac
○ Depending where herniation occurs along the spinal column
■ The child will usually have paralysis from that point down!
■ Spinal cord ends at the defect/sac
○ Depending where sac happens child will…
■ Walk with a cane, or crutches
■ Be wheelchair bound
■ Pt will need catheterization, enemas etc. for entire life
○ Nursing management for SBC myelomeningocele:
■ Prevent rupture of sac/infection
■ Surgery after birth
● Pre-op, post-op support
● Provide nutrition/hydration

● Therapeutic management:
○ Will get Cat scan or MRI to assess spinal cord involvement
○ Prevent trauma to cyst/sac, helps prevent infection
■ Keeping child prone/side lying
■ Keep sterile saline soaked gauze on top of sac
● Prevents drying/cracking the opening of sac can lead to...
● Contamination from stool/urine bacteria etc.
● Nursing management:​ ​This is a lifelong chronic condition…..
○ Urination​: Child will have neurogenic bladder, doesn't fully empty
■ Needs intermittent catheterization for life
■ Parents need to know how to do it
■ Many kids when older catheterize themselves
○ Bowel Elimination:
■ Kids get on a routine especially when attending school they want to avoid
accidents
■ Using meds and diet control they can make it so they have bowel
movements at a specific time every day
● Enemas, Laxatives, & Diet control
● Ex​: 5 pm daily Bowels = after school at home
 ○ Provide adequate nutrition & hydration:
■ Hard to feed them like this (IV fluids given until off to surgery)
■ Encourage breast/bottle feeding but hard to latch if prone/side

● Kids with SB often have latex allergy:

○ At the hospital most things are latex free (catheters, gloves etc.)
○ Family at home & the child need to be aware of this!
● Maintain skin integrity:
○ Baby is kept prone so looking for areas of breakdown:
■ Elbows
■ Hips
■ Knees
■ Clavicles
■ Ears fold & baby turned to side
● Educate & support family/child
○ This is a lifelong condition
○ They need to understand all aspects of care
○ At home interventions done clean not sterile like hospital
○ They wash with soap & reuse catheters etc.

● https://www.cbsnews.com/news/2-year-old-who-overcame-the-odds-and-learned-to-walk
-inspires-millions/
Hydrocephalus

● Hydrocephalus: ​Is an issue with the ventricles Congenital or Acquired

○ Congenital​: Born with this damage to ventricles in the brain
○ Acquired:​ Result of an Infection leading to this damage in ventricle
■ Ex: ​Bacterial meningitis
○ Kids at risk for increased developmental delays & vision problems
■ Want to catch it early to cut down on these problems
● Therapeutic management:
○ Main way we treat it is to recognize it early:
■ Monitor head circumference measurements
■ Put in a shunt as soon is fluid build up is noticed
● Nursing assessment
○ Health history:
■ Ask about infections
■ Any symptoms child has/is complaining about
○ Physical examination
■ Catch early signs so they don’t progress to late signs
■ Monitor incision on head & abdomen
● Lab & diagnostic tests:
○ Cat-Scan & MRI
■ To assess fluid build up & damage to ventricle
● Nursing management
○ Preventing & recognizing shunt infection & malfunction:
■ Top priority in any patient with a shunt is thinking about infection &
malfunction.
○ VP shunt head and abdomen incisions also must monitor
○ With the internal shunt system when ​Identifying infection ​one would look for:
■ Spiked fever
■ Elevated vital signs
■ Elevated WBCs
■ Reddened Shunt Tract
● Raised area behind ear where valve is may be reddened &
inflamed if shunt is infected

○ If infection noted treat with antibiotics

■ Sometimes shunt needs to come out while the infection clears
■ They will replace a temporary external device until its cleared or if internal
is malfunctioning will replace with a new shunt

○ With VP shunt identifying malfunction one would notice:

■ Symptoms of increased intracranial pressure are back:
● Vomiting
● Increased head circumference
● Bulging fontanels
● Change in level of consciousness
● Pupil changes
 ○ Supporting & educating child/family:
■ Parents should also be thinking about/ looking out for infection and
malfunction in their child with a shunt
■ Is a lifelong condition the shunt is for life not temporary
● As they grow multiple revisions
● Looking out for infection & malfunction

Early Manifestations of Hydrocephalus Late Manifestations of Hydrocephalus

Infant​: Infant​:
● Rapid head growth= increase above ● Sun setting eyes, sclera above iris
normal growth curve visible
● Full, bulging anterior fontanel ● Frontal bone enlargement
● Irritability ● Vomiting; difficulty feeding/swallowing
● Poor feeding ● Increased BP Decreased HR
● Distended prominent scalp veins ● Altered respiratory pattern
● Widely separated cranial sutures ● Shrill, high pitched cry
● Sluggish or unequal pupillary
response to light

Child​: Child​:
● Strabismus ● Seizures
● Frontal headache in am relieved by ● Increased BP
vomiting or sitting upright ● Decreased HR
● Nausea & vomiting (poss. projectile) ● Alteration in respiratory pattern
● Diplopia ● Blindness from herniation of the optic
● Restlessness disc
● Changes in ability to do school work ● Decerebrate, extension posturing and
● Behavior or personality changes rigidity
● Ataxia
● Papilledema
● Irritability
● Sluggish & unequal pupillary response
to light
● Confusion
● Lethargy

Cerebral Palsy
● Cerebral Palsy (CP)
○ Abnormal development of, or damage to ​motor areas ​of the ​brain
○ Results in brain’s ability to control movement and posture
 ○ CP is a Chronic lifelong condition:
■ Considered nonprogressive since the brain injury does not progress
■ Can happen during birth issues with delivery etc.
■ Most cases of CP develop in utero & nothing to do with birth/trauma
● Nothing mom could’ve done to prevent CP
● CP happens on a spectrum:
○ Not every CP case equal
○ Depending on motor areas damaged in the brain
■ may encounter different impairments together or alone....
● Issue in left hand movement
● Nonverbal
● Wheelchair bound
● Feeding tube etc…
● Spastic Cerebral Palsy
○ The most common type of CP is spastic CP
○ Affects about 80% of people with CP
○ People with spastic CP have increased muscle tone:
■ Muscles are stiff and, as a result, their movements can be awkward.
Spastic CP usually is described by what parts of the body are affected:

● Spastic diplegia/diparesis
○ This type of CP:
■ Muscle stiffness is mainly in the legs
■ Arms less affected or not affected at all
■ Difficulty walking because tight hip & leg muscles cause legs to:
● Pull together
● Turn inward
● Cross at the knees (also known as scissoring)

● Spastic hemiplegia/hemiparesis:
○ This type of CP affects only one side of a person’s body
○ Usually the arm is more affected than the leg
● Spastic quadriplegia/quadriparesis​:
○ Spastic quadriplegia is the most severe form of spastic CP
○ Affects all four limbs, the trunk, and the face.
○ People usually cannot walk
○ Often have other developmental disabilities such as
■ Intellectual disability
■ Seizures
■ Problems with vision, hearing, or speech
■ http://www.cdc.gov/ncbddd/cp/facts.html
● Therapeutic management
○ Physical, occupational, & speech therapy
○ Orthotics & braces commonly used to prevent contractures
■ Once contracted almost impossible to realign them
● Pharmacological management:
○ Baclofen​:
■ Is a skeletal muscle relaxant helps with spacity/rigidity of the muscles
■ Can be taken by mouth, feeding tube, or pumps inserted underneath
stomach where catheter goes in spine & delivers low dose of baclofen to
continuously relax the muscles
○ Over dose of baclofen!
■ Any route can cause the muscles of the diaphragm to over relax
■ Diaphragm muscles are required for breathing!
■ They may stop breathing altogether with OD of baclofen
■ Usually kids end up in ICU if the pump malfunctions
● Nursing assessment
○ Health history:
■ Ask about prematurity (preemies at risk for CP)
■ If the Child not meeting/lack of milestones
○ Physical examination:
■ Hypertonia: increased rigid spastic muscle tone
■ Contractures of muscles
○ Lab & diagnostic tests:
■ MRI to assess damage to the major areas of the brain

● Nursing management
○ Promote mobility: ​Via...
■ PT or OT
■ Orthotics/braces
■ Hippotherapy (therapeutic horseback riding)
 ○ Promote nutrition:
■ Soft blended diet muscle work required for chewing & swallowing
■ A child may need adaptive silverware to eat independently
● Padded fork or spoon
■ Some kids require a feeding tube to maintain appropriate weight
○ Provide education & support parent/child
■ This is a lifelong condition doesn't get better over time
■ Kids under 3 benefit from help me grow/early intervention therapy to help
them catch up developmentally
■ Once school age on IEP (individualized education program) in place for
success in the school district
Seizure Disorders

Epilepsy:
Epilepsy is Defined as recurrent seizures (more than one) some kids grow out of seizures as
brain grows & develops
Two main types of Seizures….
#1 Partial- Focal
○ Most common form of epilepsy
○ Involves one area of the brain
○ Further broken down into Simple or Complex partial seizures
■ Meds don’t work we remove the part of the brain that’s leading to the seizure
activity and they can grow and & develop without the missing piece of the brain
seizure activity usually stops
#2 Generalized Seizures:​ 2 of the Main GS are ​Tonic Clonic & Absent

● Tonic-Clonic​:
○ Whole brain is involved with seizure activity
○ Major motor movement during seizure whole body jerking & shaking
○ They lose consciousness
○ Have postictal state:
■ Don’t remember they even had a seizure
■ Usually sleepy for a couple hours after seizure
 ● Absent seizures:
○ Opposite of tonic no movement just dazed cant get their attention
○ But still whole brain is involved
● Therapeutic management:
○ Anticonvulsants to reduce or control the seizures
○ Combination of Anticonvulsants & really high doses sometimes needed
● Nursing assessment:
○ Often you don't witness you need all the details must ask:
■ What happened at the time of the seizure?
■ How long did it last?
■ What was the child doing before the seizure happened?
■ What medications do they take at home?
Health history:
● Physical examination:
○ Must do thorough neuro exam:
■ Push pulls
■ PERRLA
■ Cranial (tongue mouth movement etc)
■ Hand grasps
■ Level of consciousness/Are they alert crying consolable crying etc..
● Lab & diagnostic tests:
○ If first seizure poss lumbar Puncture to r/o meningitis as cause
○ EEG (glue smell awful) will tell if having anymore seizure activity many have
video now monitor of multiple screens seeing activity at time of seizure what the
onset is
● Nursing management
○ Seizure precautions:
■ Padded beds & rails
■ Working Suction at bedside
■ Working O2 at bedside (when seizure actively d-Sat)
● Non rebreather face mask
● 100% oxygen flow
● Crank to 10 to 15 liters
■ Bed locked and low
■ All 4 side rails up!

Relieve anxiety:

■ Kids w/ seizures want to be treated like every other kid

■ Worry about seizure in school/public
 If patient seizes at home family needs to know

■ Clear environment
■ Pay attention to start time
■ If >5 min of seizure time give diastat (rectal diazepam)
● Call 911 prolonged seizures damage brain
■ Do not put anything in the mouth!

Manage treatment:

■ Teach about the anticonvulsants

■ Must stay on them until physician wants them off never stop on your own
● If dr wants this will be in Epilepsy unit to wean off or stop
medications & monitor activity
■ Keep them on their side for aspiration precautions

Meningitis
● Bacterial meningitis:
○ Group B strep:
■ Is the​ ​most common agent that leads to bacterial meningitis in newborns
■ We screen moms when pregnant: If positive they go on antibiotics so
baby doesn't get bacterial meningitis when passing through vagina!
With other kids the worry is:
■ HIB ​(haemophilus Influenza B)
■ Neisseria​ ​Meningitidis
■ Streptococcus Pneumoniae
All of these are Vaccine preventable!!!!

Nursing assessment

● Health history: ask about any...

○ High fever
○ Vomiting
○ Seizure activity
○ Older kids may complain of neck pain
● Physical exam:
○ Physician will check for Kernig & Burzynski signs
■ Positive Kernig sign​:
● Severe stiffness of the hamstrings causes an inability to straighten
the leg when the hip is flexed to 90 degrees
 ○ Positive​ ​Burzynski​ ​sign​:
■ Severe neck stiffness causes a patient's hips and knees to flex when the
neck is flexed
■ Movement in assessments cause pain in meninges= child will react
○ Positive Signs: ​Clue physician in that a child may have bacterial meningitis

● Lab & diagnostic tests:

○ Will get lumbar puncture (LP)
○ We help physicians with this make sure it gets done and sent off before the start
of any antibiotics!
■ Older kids popstions for LP: ​on their side tuck chin into chest back is
exposed to physician
■ Little babies position for LP: ​hold them upright support their neck,
arms, & legs at one time, spine available to physician to get sample

Nursing management:

○ It’s bacterial & we treat it with antibiotics

○ Child is on droplet precautions until 24 hours of antibiotic treatment have passed
○ Child is contagious this is spread through the air:
■ They are Isolated
■ We wear masks
■ Recommended to treat family with antibiotics as well because the child
may have gotten from them!
 ■ Reduce fever:
● Acetaminophen or
● If >6 months Ibuprofen can be given
● In some cases cooling blankets to rapidly bring down a really high
fever
■ Prevent bacterial meningitis:
● Group B strep in pregnant women to protect NB
● We give vaccinations:​ to prevent other kids from getting bacterial
meningitis:
○ HIB
○ Pneumococcal
○ Meningococcal

Chapter 50- The Child with a Musculoskeletal Alteration

Diana Kovacic DNP, RN

Child with a Musculoskeletal Disorder Objectives

1. Compare the anatomy & physiology of the neuromuscular system and musculoskeletal
system in children vs. adults.
2. Discuss common medications & other treatments used for management of pediatric
neuromuscular and musculoskeletal disorders.
3. Child With a Neuromuscular Disorder Objectives:
4. Identify appropriate nursing assessments & interventions commonly used for
neuromuscular and musculoskeletal disorders in children.
5. Distinguish common pediatric neuromuscular and muscular disorders including rickets,
scoliosis, and fractures.
 Child with a Musculoskeletal Disorder
● Variations in Pediatric Anatomy & Physiology
○ Myelination:
■ This finishes by 2 years of age
■ The speeding up of nerve impulses through nerve fibers
■ Occurs in a cephalocaudal, proximal distal fashion
■ Because myelination kids have many more gross & fine motor skills as
they age (more movement in a 2 year old than infant)
○ Muscle development:
■ Muscles, tendons, ligaments all present in utero
■ When poor we expect infants to have normal muscle tone
● No hypo or hypertonia
○ Skeletal development:
■ Kids more flexible than adults they usually bend not break
■ It would take a huge amount of force to break
■ When they do break they heal quickly d/t vascularity & blood supply

○ Growth plate:
■ Area where bone is growing & developing
■ Considered weak vulnerable structure
● Kids get fractures often along growth plate!

Common Medical Treatments

● Treatments for bone healing
○ Casts​: used when kids have fractures
■ Plaster or Fiberglass cast depending on which will dictate if they can wet
or not
 ■ Compartment syndrome will be something to look out for first 24-48 hrs
● Excessive swelling the 5 Ps
○ Pain (above & beyond fracture pain)
○ Pulselessness (weak/diminished pulse)
○ Palor (pale color)
○ Paresthesia (numbness & tingling)
○ Paralysis (cannot move it from swelling)
● When this happens it's considered an emergency
● Requires to cut through muscle (fasciotomy) to relieve pressure)
○ Traction: two different types
■ Skin traction:
● External device with weights to realign the fracture
■ Skeletal traction
● External device with pins & screws inside the fracture with heavier
weights
○ External fixation:
■ Pins going straight into bones infection at pin site huge concern with this

● Medications: mostly for pain

○ Acetaminophen
○ IBuprofen
○ Opioids: scoliosis
● Assessment
○ Health history:
■ What happened?
■ History of orthopedic problems in the family (hereditary;scoliosis)
○ Physical examination:
■ Assess for range of motion
■ Check neurovascular status (distal to any fracture)
● Can move everything
● Their pulses good etc.
■ looking for scoliosis (junior high/scoliosis screen)
● Bend over scapula more elevated on one side
○ Lab & diagnostic tests:
■ X-ray most common test if musculoskeletal problem
 Musculoskeletal Disorder
Acquired Disorders: Rickets
● Rickets: Is Softening or weakening of bones:
○ Rarely seen in the US more common in foreign born kids
○ Can affect bones; often the long bones (bowed legs)
○ Rickets d/t Nutritional deficiencies​:
■ Can occur in kids from US d/t GI issues
● Malabsorption
● Imbalance of calcium & phosphorus & vit D
○ Occurs mostly during rapid growth periods:
■ Infants & teens have rapid growth spurts
■ Most often diagnosed in infants 6 months-36 months
○ Calcium usually laid into bones in third trimester
■ Preemies would be affected/miss out on good amount of calcium)
■ Preemies would be on vitamin D & calcium supplementation
● Therapeutic management:
○ Correct imbalances is priority...
■ Calcium, Phosphorus, & vitamin D supplementation
■ Calciferol at hospital
● Nursing assessment...History:​ you may see
○ Prematurity
○ Diet with lack of dairy ingestion
■ large amount of calcium,phosphorus, & vitamin D in dairy
○ GI disorders
○ Kids who live in cities who’s don’t get vit. D from sun (Cleveland)
○ Hx of fractures/bone pain

● Nursing management: ​Supplements very important!

○ Ca & phosphorus supplements
■ Calcium and vit D is ok to take together
■ Calcium and phosphorus give separately or calcium won't be absorbed
○ Foods high in Vitamin D​:
■ Milk, Dairy, Fish, & Eggs
○ Sun exposure:
■ without sunscreen
■ Encourage 20 min or more
○ Bracing or surgery
■ Some kids need for severe curvature r/t rickets
○ Educate the family
Injuries: Fractures
● Fractures
○ Are frequently a result of accidental trauma:
■ Falls, sports injury etc
○ Growth plate
■ The most vulnerable portion of the child’s bone
■ Frequent site of injury (wrist & arm common d/t parachute reflex)
○ Spiral, pelvic, and hip fractures rare in children
■ Fractures in kid <2 suspicious (child abuse)
■ Kids under 2 bones require a lot of force to break/bend before they break
■ Consider the age and activity vs. the type of injury etc. (abuse signals)
● Therapeutic management
○ Casting​:
■ Provides further comfort
■ Allows decreased activity while fracture heals
● Heals pretty quickly
○ Worry about compartment first 24/48 hours/swelling
○ Elevate/ice for first 48 hours (20 minutes on & 1 hour off while awake)
■ Cuts down on swelling or risk for compartment syndrome
● Nursing assessment
○ Health history:
■ Sports involvement
■ Ask about recent trauma
■ Consider any inconsistency in stories (fell off tree, fell back stairs etc.)
○ Physical examination:
■ Obvious swelling & deformity
■ Child will complain of pain
■ Neurovascular status (distal to fracture/pulses)
○ Lab & diagnostic tests:
■ X-ray​: For any fracture
■ CAT-scan:​ For complicated fractures
■ MRI or Cat-scan:
● Looking for old fractures when child abuse suspected
● Multiple bones in various stages of healing= abuse over time
● Nursing management/Family education
■ Compartment syndrome!! The 5 Ps
● First 24-48 hours
● Parents need to look out for this
● Compartment syndrome is an emergency
○ Must be be brought right in if seen/suspected
 ○ Elevate/ice:
■ First 48 hours (20 minutes on & 1 hour off while awake)
○ Medications​:
■ Mostly for pain
● Acetaminophen
● Ibuprofen
○ Prevent fractures
■ Use protective equipment: especially with sports
● Shin guards
● Wrist guards
● Helmets

Musculoskeletal Disorder: Scoliosis

● Scoliosis- Lateral curvature of the spine that exceeds 10 degrees

○ Congenital or idiopathic (65%)
○ Occurs most during adolescence/rapid periods of growth
○ Affects teen females more than boys
● Therapeutic management
○ Prevent progression of curve
○ Decrease impact on pulmonary & cardiac function
○ Treatment based on the age of child, expected future growth; severity of curve
● Nursing Assessment
○ Health history:
■ Ask about scoliosis in family history
■ Recent growth spurt as it becomes evident here
○ Physical examination:
■ Look for scapula elevation
○ Lab & diagnostic tests
■ X-ray so we can measure the curvature
● Nursing management:
○ Require bracing if…
■ Curvature 25 degrees or more to the side with no effect on heart or lungs
■ This brace doesn't fix the curvature it just prevents further curvature
○ Encourage compliance with bracing...
■ 23 hours/day brace stays on (can take off to shower only)
■ Very difficult with teens/teen girls (concerned with body image)
● Need surgery/Spinal fusion if…
●
○ Curvature 40-50 degrees off to the side or any severity of curvature that affects
their breathing, or circulation (cardiac issues)

● Spinal fusion:
○ cannot be done if child continuing to grow this stops their growth
○ Young child will have multiple fixations that still allow for growth
● Provide pre-op care
○ Recovery rough for these kids & they need to be warned
○ Educate them about procedure, post care, etc.
■ Before they experience the pain & difficulties
● Provide post-op care
○ Main priority for first 24 hours: Neuro checks
■ Hands, feet, push pulls. cap refill. etc
■ Q4 hours (priority)
■ Had back surgery we should always worry
○ First 24 hours pain is controlled with a PCA pump:
■ At about day 2 anesthesia pulls epidural
■ Day two & beyond trying to get control of the pain
○ When pump gone pain becomes an issue
■ RN will continue to give opioids via IV push
■ Eventually will transition pt. to oral opioids
○ Will have a foley catheter placed
○ At about day 2 PT expecting them to get up & walk
○ Pt should be using an incentive spirometer to prevent pneumonia