CHAPTER 18 peds

Allergen related respiratory diseases are more prevalent in the spring and fall. 

•	NOSE
o	Newborns are nose breathers until at least 4 weeks of age. 
o	Newborns breath through their mouths only while crying
o	The frontal sinuses and the sphenoid sinuses develop by age 6-8 years, so younger children are less apt to acquire sinus infections than adults

•	THROAT
o	Tong of the infant relative to the oropharync is larger than in adults. 
o	Large tonsillar and adenoidal tissue can contribute to an increase incidence of airway obstruction

•	TRACHEA
o	Airway lumen is smaller in infants and children than adults. 
o	When edema, mucus, or bronchospasm is present, the capacity for air passage is diminished. 
o	Infants and young children have laryngeal narrowing, 
o	Infants and children larynx is funnel shaped.
o	Infants and children the larynx and glottis are located higher in the neck, increasing the chance of aspiration of foreign material into the lower airway
o	Congential laryngomalacia- occurs in some infants and results in the laryngeal structure being wearker than normal, yielding a greater collapse on inspiration.

•	LOWER RESPIRATORY STRUCTURES
o	Thebronchi and bronchioles of infants and children are narrower in diamter than in adults, 
o	Alveoli deveop at about 24 weeks gestation. 
o	Term infants are born with about 50 million alveoli
o	Alveoli growth continues until about age 7-8 yoa. 
o	Smaller numbers of albeoili place the child at a higher risk for hypozemia and carbon dioxide retention

•	INSPECTION
o	Pallor- occurs as a result of peripheral vasoconstriction in an effort to conserve oxygen for vital functions
o	Cyanosis- occurs as a result of hypoxia. It might first present circumorally (just around the mouth) and progress to central cyanosis.
o	First sign of respiratory illness in infants and children is tachypnea. 
•	COUGH AND OTHER AIRWAY NOISES
o	Expiration
•	Grunting occurs on expiration. Peosucwd by premature glottis closure
•	It is an attempt to preserve or increase functional residual capacity
•	Might occur with alveolar collapse or loss of lung bolume, such as in atelectasis, pneumonia, and pulmonary edema
o	Stridor
•	A high pitched, readily audible inspiratory noise, 
•	Sign of upper airway obstruction
•	Sometimes wheezes can be heard with the naked air, called audible wheezes
•	RESPIRATORY EFFORT
o	Increases breathing, particularly if associated with restlessness and anxiety, usually indicates lower respiratory involvement. 
o	Retractions- 
•	The inward pulling of soft tissues with respiration
•	Can occur in the intercoastal, subcoastal, substernal, supraclavicular, or suprasternal regions. 
•	Document mild, moderate, or severe. 
•	Bobbing of the head with each breath is also a sign of increased respiratory effort
•	ANXIETY AND RESTLESSNESS
o	Clubbing
•	An enlargement of the terminal phalanx of the finger, resulting in a change in the angle of the nail to the fingertip 
•	Might occur in children with chronic respiratory illness. 
•	It is the result of increases capillary growth as the body attempts to supply more oxygen to distal body cells
o	Auscultation
•	Prolonged expiration is a sign of bronchial or bronchiolar obstruction. Bronchiolitis, asthma, pulmonary edema, and an intrathoracic foreign body can cause prolonged expiratory phases.
•	Rales- (crackling sounds) result when the alveoli become fluid-filled, such as in pneumonia. 
•	Tachycardia may be present
•	An increase in heart rate often initallly accompanies hypoxemia
•	COMMON COLD
o	Referred to as a viral upper respiratory infection or nasopharyngitis. 
o	Cause- usually the human meta-pneumovirus
o	Can be spread from person to person or by viral particles in the air
o	Occur more frequenty in winter
o	Don’t use antihistamines
o	Nasal discharge= thick, white, yellow, or green. 
•	SINITITUS
o	A bacterial infection of the paranasal sinuses
o	Could be acute or chronic
•	INFLLUENZA
o	Spread through the inhalation of droplets or contact with fine-particle aerosols
o	Infected kids shed the virus 1-2 days before symptoms begin and may continue increased amounts of viral shedding 
•	PHARYNGITIS
o	Inflammation of the throat mucosa (pharynx) 
o	Group A streptococcal pharyngitis requires antibiotic therapy  and penicillin is generally prescribed
o	Promote comfort and provide family education
•	INFECTIOUS MONONUCLEOSIS
o	Self limited illness caused by the Epstein-Barr virus 
o	Characterized by fever, malaise, sore throat, and lymphadenopathy.
o	“kissing disease”
o	most often diagnosed in adolescents and young adults
o	can last as long as 6 weeks
•	Laryngitis
o	Inflammation of the larynx
o	May occur alone or in conjunction with respiratory 
o	Hoarse voice or loss of voice
o	Oral fluids might offer relief 
o	Resting the voice with allow the inflammation subside
•	Croup
o	Children btwn 3 months and 3 years are affected
o	Occurs because of inflammation and edema of the larynx parainfluenza is responsible for the majority of cases
o	 The inflammation and edema obstruct the airway,resulting in symptoms
o	stridor can occur
o	edema of larynx causes hoarseness
o	symptoms occur most often at night
o	lasts about 3-5 days
o	corticosteroids are used to decrease inflammation
o	cough may sound like barking (or a seal)
•	EPIGLOTTIS
o	Inflammation and swelling of the epiglottis
o	Most often caused by the hemophilus influenzae type B
o	Use Hib vaccine
o	Occurs 2-7 years and can be life threatening
o	Manage airway
o	IV antibiotic therapy is necessary 
o	Child will be in ICU
o	Note high fever, overall toxic appearance, may refuse to speak or speak only a few words
o	Sit forward with neck extended
o	Cough is absent
o	Don’t place in a supine position as airway occlusion may occur
o	Provide 100% oxygen
o	An emergency trach may be necessary
•	BRONCHIOLITIS (RSV)
o	Acute inflammatory process of the bronchioles and small bronchi.
o	Caused by a viral pathogen 
o	Peak incidence is in the winter and spring  (sept-May)
o	Peak incidence is at 6 months of age
o	Highly contagious and can be contracted through direct contact with respiratory secretions or from particles on objects 
•	PNEUMONIA
o	An inflammation of the lung parenchyma
o	Can be caused by a virus, bacteria, mycoplasma, or fungus.
o	Occurs in winter and early spring
o	If you have recurrent pneumonia, get evaluated for chronic lung disease or cystic fibrosis
o	Antipyretics, adequate hydration, and close observation
o	Aspiration is the most common cause of recurrent pneumonia in children and often occurs as a result of gastroesophageal reflux disease
o	Child with pneumonia may have retractions
o	Wheezes or rales may be present
o	Infiltrates are the most common finding
•	TUBERCULOSIS
o	Causes by inhalation of droplets of mycobacterium tuberculosis or mycobacterium bovis. 
o	Usually contract the disease from an immediate household member
o	Nonwhite children and children with chronic illness or malnutrition are more susceptible to infection
o	Incubation period 2-10 weeks
•	6 month course of antibiotic therapy. 

•	ACUTE NON_INFECTIOUS DISORDERS
•	EPISTAXIS
o	Nosebleed
o	Idiopathic (no cause) and recurrent
o	Child should sit up and lean forward
o	Apply continuous pressure to the anterior portion of the nose by pinching it closed. 
o	Encourage hild to breathe through the mouth during this time of treatment
o	Ice or cold cloth to bridge of nose may be helpful. 
o	Bleeding usually stops within 10-15 minutes 
•	PNEUMOTHORAX
o	Collection of air in the pleural space
o	Needle aspiration and/or placement of a chest tube is used to evacuate the air from the chest 
o	Sudden or gradual onset of symptoms
o	Chest pain may be present as well as signs of respiratory distress such as tachypnea, retractions, nasal flaring, or grunting
o	Child needs frequent respiratory assessments
o	If tube becomes dislodged, apply Vaseline gauze and an occlusive dressing, immediately perform appropriate respiratory assessment, and notify the dr.

CHRONIC DISEASES
•	ALLERGIC RHINITIS
o	Common chronic condition in childhood 
o	Associated with atopic dermatitis and asthma
o	Perennial allergic rhinitis occurs year round and is associated with indoor environments. 
o	Intermittent or persistent inflammatory state that is mediated by immunoglobulin E 
•	ASTHMA
o	Chronic inflammatory airway disorder characterized by airway hyperresponsiveness, airway edema, and mucus production
o	Most common chronic illness of childhood
•	Intermittent
•	1 or 2 times a week
•	nighttime symptoms 1 or 2 times a month
•	no interference with normal activity
•	use inhaler 1-2 days per week
•	Mild Persistent
•	Symptoms more than twice a week but less than once a day
•	Nighttime symptoms 3 or 4 times a month
•	Minor limitation on normal activity
•	Use inhaler greater than twice per week but no more than once a day
•	Moderate Persistent
•	Daily symptoms
•	Nighttime symptoms >1 time a week, but not nightly
•	Some limitation on daily activities
•	Use inhaler daily
•	Severe Persistent
•	Throughout the day
•	Nighttime symptoms often 7 times per week
•	Extremely limited normal daily activities
•	Use inhaler several times a day
•	Wheezing is a big sign of airway obstruction
•	Coarseness and breath sounds may be diminished 
•	CHRONIC LUNG DISEASE
o	Often in infants who experienced RDS and continue to require oxygen at 28 days. 
o	Normal alveoli number decreases to half
o	Lower birth rates, white race, and male gender pose increased risk for development of chronic lung disease
o	Anti-inflammatory inhaled medications are used for maintenance, and short-acting bronchodilators are used as needed for wheezing episodes. 
o	Tachypnea and increased work of breathing are characteristic of chronic lung disease
•	CYSTIC FIBROSIS
o	Autosomal recessive disorder that occurs about once in every 3300 live births and about one in every 16000 live black births 
o	A deletion occurring on the long arm of chromosome 7 at the cystic fibrosis transmembrane regulator is the responsible gene mutation
o	Therapeutic management- minimizes pulmonary complication, maximize lung function, prevent infection, and facilitate growth.
o	Choice of medication is determined by sputum culture and sensitivity results. Pancreatic enzymes and supplemental fat-soluble vitamins are prescribed to promote adequate digestion and absorption of nutrients and optimize nutritional status.
o	The epithelial cells fail to conduct chloride and water transport abnormalities occur. 
o	Results in thickened, tenacious secretions in the sweat glands, gastrointestinal tract, pancreas, respiratory tract, and other exocrine tissues.  
o	Salty taste of the skin and alterations in electrolyte balance and dehydration
o	 May present with bulky, greasy stools, poor weight gain and growth despite good appetite, abdominal pain or difficulty passing stool, meconium ileus or late, difficult passage of meconium stool in the newborn period
o	child will often have a barrel chest, clubbing of the nail beds, protuberant abdomen and thin extremities, with decreased amounts of subcutaneous fat, edema, cardiac or liver failure
o	adventitious breath sounds, fine or coarse crackles and scattered or localized wheezing might be present, breath sound may be diminished, may have asymmetric chest excursion if atelectasis is present, tactile fremitus may be decreased over areas of atelectasis
o	do a sweat chloride test  considered suspicious if the level of chloride in collected sweat is above 50 mEq/L 
o	management: minimize pulmonary complications, promote growth and development, and facilitate coping and adjustment by the child and family
o	 
•	APNEA
o	Absence of breathing for longer than 20 seconds; it might be accompanied by bradycardia
o	Apnea in infants may be central (unrelated to any other cause) or may occur with other illnesses such as sepsis and respiratory infection. 
o	Apnea in newborns may be associated with hypothermia, hypoglycemia, infection, or hyperbilirubinemia. Bag valve mask ventilation or rescue breathing may be necessary. 
•	TRACHEOStOMY
o	Artificial opening in the airway; usually a plastic tracheostomy tube is in place to form a patent airway.
o	Performed to relive airway obstruction, such as with subglottic stenosis (narrowing of the airway sometimes resulting from long-term intubation.
o	

CHAPTER 20: NURSING CARE OF THE CHILD WITH A GASTROINTESTINAL DISORDER

Babies are born with GI tracts that are not fully developed until age 2

•	ESOPHAGUS
o	The lower esophageal shincter prevents regurgitation of stomach contents up into the esophagus and/or oral cavity
o	The muscle tone of the LES isn’t developed until age 1 month so infants less than one month regurgitate their food
•	Stomach
o	Newborns have stomach capacity of only 10-20 ml
o	At 2 months, they can hold up to 200 mL
o	Age 16 1500 mL
o	Adulthood 2000-3000
•	Findings
o	Protuberant abdomen suggests the presence of ascites, fluid retention, gaseous distention, or even a tumor, but many kids have a prominent “pot bellied” abdomen as a normal variation of their anatomy. 
o	A depressed or concave abdomen would indicate a high abdominal obstruction or dehydration. 
o	Dullness or flatness is normally found along the right costal margin and 1-4 cm below the costal margin of the liver
o	Percussion of the rest of the abdomen should reveal tympany
o	Rebound tenderness can be a warning sign of appendicitis and should be reported to a physician immediately.
•	OSTOMY CARE
o	Pouches need to be changed about every 1-4 days 
•	CLEFT LIP & PALATE
o	Cleft lip is repaired around 2-3 months
o	Cleft palate is repaired 9-18 months
o	Cleft lip can be diagnosed by prenatal ultrasound, but it is diagnosed most commonly at birth by the classic physical appearance
•	MECKLES DIVERTICULUM
o	Result of an incomplete fusion of the omphalomesenteric duct during embryonic development
o	This causes a bibrous band to connect the small intesting to the umbilicus, known as a meckels diverticulum.
o	Most common congenital anomaly of the GI tract
•	DIARRHEA
o	Hypoactive bowel sounds may indicate obstruction or peritonitis
o	Hyperactive bowel sounds may indicate diarrhea/gastroenteritis
o	Tenderness in the lower quadrants may be related to gastroenteritis
o	Rebound tenderness or pain should not be found on palpation, if found, it could indicate appendicitis or peritonitis
•	ORAL CANDIDIASIS (THRUSH)
o	A fungal infection of the oral mucosa.
o	Most common in newborns and infants
o	Kids at risk include those with immune disorders and those receiving therapy that suppresses the immune system or children that use corticosteroid inhalers
o	Treat with oral antifungal agents such as mycostatin or fluconazole
o	Appears as thick, white patches on the tongue, mucosa, pr palate, resembling curdled milk
o	Patches do not easily wipe off with a swab or washcloth
o	Mycostatin should be given four times per day following feeding to allow the medication to remain in contact with the lesions
o	Advantage of fluconazole is its once-daily dosing but infants and children receiving it should be monitored for hepatotoxicity 
o	With oral lesions, the management should focus on pain management and hydration status.
•	HYPERTROPHIC PYLORIC STENOSIS
o	Requires surgery in the first two months of life
o	The circular muscle of the pylorus becomes hypertrophied, causing thickness in the luminal side o the pyloric canal. 
o	This thickness creates a gastric outlet obstruction, causing nonbilious vomiting. 
o	Vomiting becomes worse over times and becomes projectile 
o	Signs and symptoms: forceful, projectile vomiting, unrelated to feeding position, hunger son after vomiting episode, weight los due to vomiting, progressive dehydration with subsequent lethargy
•	INTUSSUSCEPTION
o	Process that occurs when a proximal segment of bowel “telescopes” into a more distal segment, causing edema, vascular compromise, and ultimately partial or total bowel obstruction.
o	A barium enema is successful at reducing a large percentage of intussusception cases. 
•	APPENDICITIES
o	Acute inflammation of the appendix, most common cause of emergent abdominal surgery in children 
o	Occurs between 4-15 years of age
o	Due to a closed-loop obstruction of the appendix 
o	Early diagnosis and intervention are the key elements to avoid perforation
o	Symptoms remain persistent and intensify
o	Common signs and symptoms: vague abdominal pain in the initial stages, localizing to the right lower quadrant, nausea and vomiting, small-volume, frequent, soft stools, often confused with diarrhea, fever
o	Appear anorexic and ill. They often cant walk or climb up onto the exam table. There will be maximal tenderness upon palpation in the right lower quadrant 
•	GERD
o	Passage of gastric contents into the esophagus. 
o	This is normal within the first few months of life but kids outgrow this by about 6 months
o	Management: appropriate positioning keep child upright for 30 minutes after feeding, smaller more frequent feedings may be helpful. 
o	Wheezing or pneumonia may be present
•	PEPTIC ULCER DISEASE
o	A term used to describe a variety of disorders in the upper GI tract that result from the action of gastric secretions
o	Mucosal inflammation and subsequent ulceration occur as a result of either a primary or secondary factor. 
o	Severe stress, such as burns or another illness necessitating critical care, can contribute to the development of a peptic ulcer in children. 
o	May have abdominal pain, GI bleeding, vomiting
o	Abdominal pain is the most common complaint. Pain tends to be dull and vague, it worsens after meals, and the pain may wake them at night 
•	HIRSCHSPRUNGS DIEASES
o	Most common cause of neonatal intestingal obstruction
o	Characterized by constipation in newborns
o	This is due to a lack of ganglion cells in the bowel, which causes inadequate motility in part of the intestine.
o	Surgery is necessary to promote proper bowel function
o	Stools pattern is key in recognizing this this diagnosis. 
o	If the newborn hasn’t passed a meconium stool with in the first 24-48 hours, they also have this 
o	Abdomen is typicall distended and stool masses can be felt 
o	Use a barium enema or a rectal suction biopsy to demonstrate an absense of ganglion cells 
o	May appear with dever, abdominal distention, chronic diarrhea, explosive stools, rectal bleeding, straining
•	SHORT BOWEL SYNDROME
o	Clinical syndrome of nutrient malabsoprption and excessive intestinal fluid and electrolyte losses that occur following massive small intestinal loss or surgical resection
o	Goals: minimize bacterial overgrowth and to maximize the childs nutritional status
o	Vitamin and mineral supplements are necessary
o	Antidiarrheal agents are used 
o	TPN
o	Review labs especially hydration status and liver function 
•	IBS
o	Chron’s disease and ulcerative colitis are the two major idiopathic inflammatory bowel diseases of children
o	Symptoms: abdominal cramping, nighttime symptoms, including waking due to abdominal pain or urge to defecate, fever, weight loss, poor growth, delayed secual development 
o	

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