Atopic dermatitis (eczema)
♦ Inflammation of epidermis
Care goals
- relieve itching
- lubricate skin
- reduce inflammation
- control secondary infections like impetigo (watch for honey-colored crusts).
S/S
- Redness,
- scales,
- itching,
- minute papules (<1cm diameter), and
- vesicles (fluid filled).
- May have weeping, oozing, crusting of lesions.
Interventions
- Avoid skin irritants, excessive bathing of affected areas.
- Bathe w/ lukewarm water, and lubricate immediately after.
- No scratching! Put cover on hands and keep nails short, clean.
- Corticosteroids : apply thin, sparingly to cleaned affected area (entire body application would cause systemic absorption)
- Intermittently apply cool, wet compresses to relieve itching but dry well in between tx.
- Use mild detergent on clothes and wash 2nd time w/o.
** A child with any integumentary disorders needs to be monitored for signs of superficial and systemic infection.**
Impetigo
♦ Contagious bacterial infection of the skin caused by beta-hemolytic strep or staph
- Occurs most commonly during hot, humid months
- Can be a primary or secondary infection
- Commonly found face - around nose and mouth
S/S:
- Lesions begin as vesicles or pustules surrounded by edema and redness
- Lesions progress to exudative and crusting stage
- Honey-colored crusts
Interventions
- Contact and standard precautions
- Infectious up to 48h after application of antibiotic
- Strict hygiene
- Allow lesions to air dry
- Remove crusts with warm saline or Burow sol’n compress 2-3x to soften and mild antibacterial soap/water to remove
- Use emollients to prevent skin from cracking
- Towels, linens, and clothes must be washed separately
Pediculosis Capitis (lice)
♦ The infestation of hair and scalp with lice
♦ Nits = eggs (white)
- Female lays eggs on hair shaft close to scalp; hatch in 7-10 days
- Lice can survive 48hrs away from host
- Heads lice can only live and reproduce on humans and are transmitted by direct contact
♦ Adult lice are harder to see – small tan or gray specs that move quickly
Interventions
- Wash linens/clothes daily in hot water and dryer for one week
- Things that cannot be washed must be sealed in plastic bags for at least two weeks
- A pediculicide product should be used per instructions
- Use a extra fine toothed metal comb to remove nits
- Boil hairbrushes and combs for 10 min or soak in a commercially prepared solution for 1hr
- Vacuum frequently and empty vacuum container/bag
- May need to treat all members of family
Scabies
♦ Parasite burrows in skin, spread by close contact.
♦ Infectious during entire course of infection.
♦ Host mite dies after 4-5 weeks in burrow but eggs hatch in 3-5d and mature to complete life cycle.
S/S
- Pruritic papular rash
- Fine grayish red lines, may be difficult to see
Interventions
- Permethrin (Elimite)
- Apply to cool, dry skin 30 min after bathing
- Head to toe avoiding eyes
- Massage in all of skin (not just affected area) and leave for 8-12h, then remove with shower.
- Lindane (do not use if < age 2 b/c of risk of neurotoxicity and seizures)
- All linen/clothes to be washed daily in hot water/dryer/iron for 1 week.
- Nonwashables sealed in plastic bag at least 4d.
- Handwashing!!!
Pediatric Burns
♦ Lower temps and shorter exposure can cause a more severe burn in a child b/c skin is thinner
♦ Severely burned children at risk of
- Fluid and heat loss
- Dehydration
- Metabolic acidosis
♦ Higher proportion of body fluid to mass puts kids at increased risk of CV complications
♦ Scarring is more severe in children; may delay growth
♦ Fluid replacement always needed in first 24-hr. (especially if more than 10% of TBSA burned)
- Monitor vitals (esp. HR), urine ouput, cap refill, and sensorium status (LOC)
- Crystalloid solutions used first
- Colloid solutions follow to maintain plasma volume (albumin, Plasma-lyte, FFP)
Interventions
- Stop burning process
- Assess ABCs
- Begin resuscitation if child not breathing
- Remove burned clothing and jewelry
- Cover wounds with clean cloths (prevents contamination and reduces pain by eliminating air contact)
- Keep child warm
7.
Sickle Cell Anemia
♦ Hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S
♦ Sickledex (sickle-turbidity test) can be done with finger stick and produces results in 3 min – positive result requires confirmation via hemoglobin electrophoresis to distinguish a carrier from someone with the disease
** Hemoglobin S is sensitive to changes in the O2 content of the RBC **
- Insufficient O2 causes the cells to sickle - the cells become rigid and clump, obstructing capillary blood flow
- Clinical manifestations usually due to obstruction caused by sickling
Situational precursors
- Fever
- Dehydration
- Emotional or physical stress (trauma)
- Conditions with increase need for O2 (hypoxia)
- Conditions that alter O2 transport
Interventions
- Multidisciplinary approach
- Focus on prevention
- Treatment – hydration, oxygen, pain management, bed rest
- Maintain adequate hydration to promote blood flow – w/o hydration, pain cannot be controlled
- O2 and blood transfusions to increase tissue perfusion
- Administer analgesics around the clock
- Raise HOB no more than 30, avoid strain on joints, promote venous return
- High calorie, high protein, with folic acid supplementation
- Prophylactic antibiotics
- Monitor for anemia, decreased perfusion, signs of shock
- Avoid Meperidine (Demerol) b/c with repeat dosing the CNS is stimulated to cause anxiety, tremors, seizure.
Sickle Cell Vaso-Occlusive Crisis
Caused by stasis of blood w/ clumping of cells in the microcirculation, ischemia and infarction Manifestations: -fever -painful swelling of hands, feet, and joints -abdominal pain
Sickle cell Splenic Sequestration
Caused by pooling and clumping of blood in the spleen (hypersplenism) Manifestations: profound anemia, hypovolemia, and shock
Sickle Cell Hyperhemolytic crisis
An accelerated rate of RBC destruction
Manifestations: anemia, jaundice, reticulocytosis
Sickle Cell Aplastic crisis
Caused by diminished production and increased destruction of RBCs, triggered by viral infection or depletion of folic acid Manifestations: profound anemia and pallor
Iron-deficiency anemia
Causes
- Blood loss
- Incr metabolic demands
- Syndromes of GI malabsorption
- Dietary inadequacy
S/S
- Pallor, weakness, fatigue, low H&H, microcytic and hypochromic RBCs
Interventions
- Dietary supplementation – dark green leafy veggies, egg yolks, fortified breads and creals, kidney beans and legumes, nuts, potatoes, prune juice, raisins, seeds, shellfish, tofu
- IM injection (need to use Z-track method)
- Liquid (use straw to avoid staining teeth)
- Take with Vit C for greater absorption
Iron-rich foods
- bread, cereals, whole grains
- dark green, leafy vegetables
- legumes, kidney beans, tofu
- Liver, meats, shellfish, egg yolk
- dried fruit, raisins
- Nuts, seeds
- potatoes, molasses, prune juice
- iron-enriched infant formula and cereal
Aplastic Anemia
♦ Deficiency of circulating erythrocytes and all other formed elements of blood, resulting in the arrested development of cells within the bone marrow
- Primary (present at birth) or secondary (acquired)
- Pancytopenia = deficiency of erythrocytes, leukocytes, and thrombocytes
S/S
- Petechiae, Purpura, Bleeding, Pallor, Weakness & Fatigue, Tachycardia
- Definitive diagnosis via bone marrow aspiration
Therapeutic management
- Focuses on restoring function to the bone marrow and involves immunosuppressive therapy and bone marrow transplantation
- Colony-stimulating factors
- Corticosteroids and cyclosporine (Sandimmune)
- Blood transfusion
Hemophilia
Clotting deficiency: VIII (A, Classic), IX (B, Christmas) Primary tx: clotting factor replacement ID w/ abnormal bleeding with trauma/surgery (sometimes first detected after circumcision), nosebleeds, joint bleeding that causes pain, tenderness, swelling, limited ROM, bruis easy. Tests show Platelet, Hgb, Hct is normal, clotting factor function abnormal (so prolonged PTT). Immobilize affected extremity if there is joint pain, elevate, apply ice. If active bleed apply pressure 15min. Assess neuro status (risk of intracranial hemorrhage), monitor urine for hematuria. Avoid contact sports. Wear protection gear while learning to walk or participating in sports (helmet, knees/elbows). MAKE THEM SWIMMERS! Should have medic-alert bracelet!!!
von Willebrand’s disease
Deficiency of protein by same name
Characterized by tendency to bleed from mucous membranes
The d/o causes platelets to adhere to dmg’d endothelium.
SEE: nosebleed, gum bleeding, easy bruising, excessive menstrual bleed
Tx: similar to hemophilia, factor replacement
Should have medic-alert bracelet!!!
Beta Thalassemia Major
Autosomal recessive disorder (both parents must be carriers)
Highest incidence in individuals of Mediterranean descent
Reduced production of 1 of the globin chains in the synthesis of Hgb
Tx is supportive – goal of therapy is to maintain normal hemoglobin levels by the administration of blood transfusions
Monitor for iron overload; chelation therapy may be necessary
Iron administration
-Best on empty stomach 1 hr before meals or 2 hr after. -Give with multivitamin or Vit C to help w/ absorption -Don’t give w/ milk or antacids (decr absorption) -Give liquid iron in straw and rinse mouth or brush teeth after -Tell parents that stools will be black, can cause constipation and has foul aftertaste
Normal child temperature vs Fever s/s
- 36.4 to 37 C (97.5F - 98.6F) normal temps
- 38C (100.4 F) is considered a temperature
- flushed skin, warm to touch diaphoresis, chills restlessness, lethargy
Tx: can give ibuprofen/Motrin
(not ASA (aspirin) b/c of Reye’s syndrome which seems to occur when given for flu or chicken pox as well)
~ Reye’s is a sudden acute brain damage and liver function problem
Moderate dehydration
increased pulse, RR, irritable/more thirsty, dry mucous membranes, decreased tears, sunken anterior fontanel, slowed cap refill
PKU (Phenylketonuria)
♦ Genetic disorder that results in central nervous system damage from toxic levels of phenylalanine (and essential amino acid) in the blood
♦ Test done w/in first 48 hrs of life after baby has started formula or breastmilk
♦ Required by all 50 states
♦ Tests for phenylalanine in the blood, toxic levels > 20 mg/dL
- Normal in NB (1.2 - 3.4) Normal thereafter (0.8 - 1.4)
♦ Causes dmg to CNS
TESTING: after NB has begun formula or breastfeeding
♦ Assessment in all children: -digestive issues and vomiting -seizures -musty odor of the urine -mental retardation
♦ Assessment in older children: -Eczema -Hypertonia -Hypopigmentation of the hair, skin, and irises -hyperactive behavior
♦ Foods to restrict (that have phenylalanine): -meats and diary -aspartame
Leukemia: General
♦ Malignant increase in # of leukocytes (usually at an immature stage) in the bone marrow
♦ Proliferating immature WBCs depress the bone marrow, causing anemia from decreased erythrocytes, infection from neutropenia, and bleeding from thrombocytopenia
♦ S/S: fever, pallor, fatigue, anorexia, hemorrhage (usually petechiae), bone and joint pain
♦ WBC count could be normal, elevated, or depressed depending on presence of infection or #s of immature vs mature cells
♦ Diagnostic test: bone marrow biopsy
Hodgkin’s Disease
♦ Malignancy of the lymph nodes that originates in a single lymph node or a single chain – metastasizes to nonnodal sites, esp. spleen, liver, bone marrow, lungs, medistinum
- clinical manifestations:
- painless, firm and moveable adenopathy in the cervial and supraclavicular area
- abdominal pain as a result of enlarged retroperitoneal nodes
- hepatosplenomegaly
♦ Characterized by presence of Reed-Sternberg cells in lymph node biopsy
♦ Generally good prognosis
Wilms’ Tumor (Nephroblastoma)
♦ Most common intraabdominal and kidney tumor of childhood
♦ S/S: swelling or mass in the abdomen (firm, nontender, deep); urinary retention; anemia (from hemorrhage in tumor); pallor, anorexia, fatigue (from anemia); hypertension (due to secretion of renin from tumor); weight loss; fever
♦ Avoid palpating the abdomen!!
♦ Measure abdominal girth daily
Brain Tumors
♦ Often characterized by a headache that is worst upon awakening and improves throughout the day
- vomiting unrelated to feeding or eating
