EXAM 2 N4

EXAM 2 Module 3 Cellulitis  Acute bacterial infection of the skin  Can be secondary complication from primary infection  Normal flora enters the dermis where organisms multiply and cause inflammation  Caused by skin surface streptococci or staphylococcus invading all layers of the skin  RF: (children) trauma, insect bites (adults) aging, tinea pedis  Rapid S/S: irregular shaped areas of the skin with redness and swelling, erythema, edema on affected area, warmth, or tenderness on area o Regional lymphadenopathy o Systemic involvement if fever, chills, and malaise occur o Lymphangitis: red line stemming from cellulitis to lymph node o Increase in WBC  Complications: facial, peri orbital or orbital involvement needing immediate action  Nursing Tx: CBD, WBC, blood and wound cultures to confirm causative agent, monitoring VS and infection  Tx: antibiotics o Streptococcus: Cefazolin, Nafcillin o H. Influenzae: Amoxicillin o Staphylococcus: Dicloxacillin o MRSA: Bactrim, Clindamycin, Bactroban ointment  Impaired Skin Integrity: warm compress, elevation, medication before dressing change  Infection: antibiotics, VS q 4h, short fingernails, avoid school for 24-48 hours unless contained  Acute Pain: reposition, assess CMS, medication PRN and reassess  Interrupted Family Process: educate caregivers on when to call caregivers such as if >101 F or trace of wound is changed Conjunctivitis  Inflammation or infection of the conjunctiva  Caused by chemical irritants or foreign body such as bacteria, adenovirus, allergens  RF: attending school or daycare, upper respiratory infection or otitis media, contacts  S/S: red eyes, foreign sensation, tearing, mild eye discomfort with burning or pain, photophobia, discharge o Viral: red, itchy eyes with severe photophobia, excessive tearing, watery mucoid drainage, pre auricular adenopathy  HSV: ophthalmologist referral, painful and itchy red eye

 Tx: topical and systemic antivirals o Allergens: itching, reddened eyes with watery or white stringy discharge with cobblestone appearance to upper conjunctiva  Tx: avoid allergen, cold compress, antihistamines o Bacterial: purulent, crusting with glued eyelids after sleeping  Tx: topical ophthalmic antibiotics such as tobramycin, erythromycin, sulfacetamide, polymyxin  Gonococcal Tx: Ceftriaxone  Chlamydia Tx: oral Erythromycin, Tetracycline  Dx: CS of exudates, fluorescein stain to rule out corneal involvement  Nursing Tx: warm cloth inner to outer cleaning, avoid reading, frequent eye irrigation, soak lids with cool compress, good handwashing  Risk for Infection: isolation, highly contagious  Education: 24 hours on antibiotics before returning to school, no sharing towels, wash hands before eye medications Influenza  Highly contagious viral respiratory disease  Airborne droplet and direct contact  S/S: coryza, fever, cough, systemic symptoms o Rapid profound malaise, nonproductive cough, chills, fever, sore throat, flush face  RF: young children, infants, >50, LTC residents, pregnant, immunocompromised, HCP  Complications: Reye’s Syndrome o Followed by viral infection due to administration of aspirin to children o Causes altered LOC, fatty deposits in liver and cerebral edema o S/S: vomiting, change in LOC, seizures  Tx: antiviral drugs such as Oseltamivir (Tamiflu), Ribavirin (Inhaled Virazole), Acetaminophen, antitussives  Ineffective Breathing Pattern: pace activities, elevate HOB, assess lungs q1h  Ineffective Airway Clearance: adequate hydration, increase humidity, cough techniques  Disturbed Sleep Pattern: increase rest, antipyretic and analgesic  Risk for Infection: standard precautions, handwashing, control secretions for visitors with tissues and distance of 3 feet, droplet precautions Acute Otitis Media  Ear infection that is most common in childhood illness o Occurs in middle ear such as in ossicles and eustachian tube o May occur due to tympanic membrane not able to drain fluids or secretions in ear due to angle difficulty  Most infants have at least 1 case by 1 year and peaks during first 2 years

Cleft Lip and Palate  Facial malformations that occur during embryonic development  May appear separately or together  A: notch in vermilion border o Small opening in left lip only  B: unilateral cleft lip and palate o Opening in left lip and palate  C: Bilateral cleft lip and palate o Openings in left and right lip and palate is separated open  D: Cleft Palate o Opening in palate only  Assessment: ability to suck, swallow, breathe, handle normal secretions  Tx: surgery to close lip defect precede correction of the palate, Z-plasty to minimize retraction of scar, protection of suture line with Logan bow o Occurs around 12-18 months o Soothe child after surgery to not cry due to possible opening incision  ESSR Feeding: Enlarge nipple to allow food to be delivered without sucking, Stimulate sucking by rubbing nipple on lower lip, Swallow, Rest o Hold child in upright position and direct formula to side and back of mouth to prevent aspiration o Feed small amounts gradually o Burp frequently  Increased Risk of Aspiration, Upper Respiratory Infection and Otitis Media Hernias  Protrusion of portion of an organ through abdominal opening  Danger of incarceration or strangulation  Diaphragmatic: protrusion of abdominal organs through opening in diaphragm commonly in the left side o S/S: tachypnea, cyanosis, dyspnea, absent breath sounds, shock o Dx: X-Ray o Tx: surgery  Hiatal: protrusion of abdominal structures usually the stomach through esophageal hiatus may slide o S/S: dysphagia, growth failure, vomiting, GER association o Tx: Manage GER symptoms, position, medication  Omphalocele: hematoma alike with umbilical cord with intraabdominal viscera protruding into base of umbilical cord o Needs surgical repair

 Gastroschisis: obvious at delivery, protrusion of intraabdominal contents through abdominal wall lateral to umbilical ring o Surgical repair  Umbilical: weakness in abdominal wall around umbilicus with incomplete closure of abdominal wall allowing intestinal contents to protrude o Small defects need no treatment o Repair 2 cm at 2 years Dehydration  Significant loss of water and electrolytes from decreased fluid intake or vomiting or diarrhea  Fluid output > Fluid intake o Expressed as % of body weight lost  Mild <3%  Moderate 5-10%  Severe >10%  Isotonic: deficiency of fluid and electrolytes in approximately equal proportions  S/S: change in LOC, altered response to stimuli, decreased skin elasticity, turgor, prolonged cap refill, increased HR, sunken eyes and sunken fontanels  Tx: oral fluid administration over 4-6 hours, 50 mL/kg of ORS o Pedialyte o No high sodium contents like milk or broth o IV fluids if hospitalized o 75-90 mEq of Na + per liter o Daily volume of maintenance hydration: <150 mL/kg/day  Assessment: urine output, weight, I/O Diarrhea  Leading cause of illness in <5 years  Can cause gastroenteritis, enteritis, colitis, enterocolitis  Acute: sudden increase in stools may be associated with URI or respiratory illness, self limiting  Caused by rotavirus (fecal oral, contaminated water), salmonella, shigella, campylobacter organisms, Giardia-parasitic in toddlers and elderly, Cryptosporidium- parasitic, C. Diff gram positive anerboic  Dx: stool culture  Tx: self-limiting, antibiotics, ORT  Prevention: personal hygiene, clean water supply, careful food preparation, handwashing, skin care for diaper area region Hypertrophic Pyloric Stenosis (HPS)

Peptic Ulcer Disease  Chronic Disease that affects the stomach or duodenum  Cause is unknown but may have relationship between H. Pylori, ulcers, and gram- negative bacilli  Gastric ulcer affects mucosa of stomach  Duodenal ulcer involves pylorus or duodenum  S/S: periumbilical pain, poor eating, vomiting, irritability, nighttime wakening, hematemesis  Dx: upper endoscopy with biopsy, blood test for antigen, stool sample  Tx: antacids, H2 Receptor antagonists, PPI, mucosal protective agents, triple drug therapy, prokinetics Hirschsprung Disease  Aka Congenital Aganglionic Megacolon  Mechanical obstruction from inadequate motility of intestine with absence of ganglion cells in the colon  S/S: accumulation of stool with distention, failure of internal anal sphincter to relax, enterocolitis  Tx: surgery, temporary ostomy with then pull through procedure Celiac Disease  Inability to tolerate foods containing gluten found in wheat, barley, rye and oats resulting in accumulation of the amino acid glutamine which is toxic to intestinal mucosal cells  Results from inborn error or metabolism or an abnormal immunologic response  Tx: gluten free diet, supplemental vitamin, calcium, iron, folate o Avoid Foods such as: milk, grains, like bread, cookies, cakes, crackers, cereals, spaghetti, beer, ale, soups Acute Hepatitis  Inflammation of the liver  Caused by: EBV, CMV, HIV, drug reaction, auto immune, neoplastic  Hep A: direct or indirect, fecal oral route, vaccine  Hep B: parenteral or percutaneous or trans mucosal route, vaccine  Hep C: parenteral through exposure to blood and blood products, drug use, injections, blood products before 1992, multiple sex partners Hospitalized Child

 Stressors: separation anxiety, loss of control, effects  Parental Reactions: may have guilt, anger, shock  Sibling Reactions: may be jealous, angry  May have child life specialist to assist family with reacting to hospitalization  Magic Thinkers have a different reaction due to believing they caused the child to be in the hospital  Shock and Denial, Adjustment, Reintegration and acknowledgement, support system Promotion of Normal Development  Early Childhood: basic trust, separation from parents, beginning independence  School Age: industry, activity  Adolescence: independence, autonomy End of Life  Fears: pain, dying alone, home vs hospital  No greater comfort than security and closeness of a parent  Normal Grief: somatic distress, preoccupation with image of deceased, guilt, hostility, loss of usual patterns of conduct Cognitive Impairment  Any type of mental difficulty or deficiency  Mental Retardation  Early Behavioral Signs: no response to contact/voice/movement, irritability, poor or slow feeding, poor eye contact during feeding, diminished spontaneous activity Intellectual Disability  Subaverage intellectual function of IQ <75  Onset begore 18 years  Functional Impairments must be at least 2 out of 10 o Communication o Home Living o Community Use o Leisure o Health and Safety o Self-Care o Social Skills o Functional Academics o Work o Self-Direction

 Social Situations Risk: chronic stress, divorce, separation, economic problems, inadequate housing, substance abuse/addiction, birth of additional sibling, working parents with multiple commitments, substitute caregivers  S/S: History and injuries do not match o Conflicting injuries of how injuries occurred o Accident described and injury inconsistent with developmental ability o Physical signs, burns, various stages of healing, under nutrition, poor hygiene  Tx: hospitalization, referral to CPS, team approach Burns  Risk Factors: younger than 5 years, older than 65 years, careless smoking, intoxication, physical and mental disabilities  Infants: thermal burns, flames, hot water  Toddlers: hot water, chemical cords, contact burns, chemical ingestion o Check water heater setting or grease  Preschool: hot appliance contact  School Age: playing with matches, fireworks, climbing high-voltage tower  Physical Assessment: thinner skin, epidermis loosely connected, less subq fat  Chemical: direct contact with alkaline, acids, or organic compounds o Flush for 10-20 minutes  Electrical: severe tissue damage, extent depends on duration of current and amount of voltage  Thermal: flames or dry heat exposure  Radiation: cutaneous burns local or systemic  Classification of Burns: depth, extent o Superficial Partial Thickness Sunburn  Bright red moist, glistening, blisters and pain  Burned skin remains intact  Heals in 3-6 days  Wear sunscreen and avoid times of lengthy sun o Deep Partial Thickness  Dermis to above subcutaneous  Pale, waxy, moist or dry, painful or decreased pain and sensation, blisters  Heals in 21 days with contractures or scaring possible o Full Thickness  All layers of skin  Extends to subcutaneous fat, connective tissue, muscle, bone  Area looks pale, waxy, leathery, yellow, brown, mottled, charred, red, black, firm  Caused by prolonged contact with source of burn  Requires skin grafting to heal o Extent expressed as percentage of TBSA

 Rule of 9s: total anterior and posterior of head and neck 9%, total anterior and posterior upper limbs 18%, total anterior and posterior trunk 36&, total perineum 1%, total anterior and posterior lower limbs 36%  ABA: burns caused by electrical and inhalation, concomitant trauma with burns, 3 rd degree burns, partial thickness covering >10% TBSA, major burns (hands, face, feet, major joints, eyes, ears, perineum)  Referral of burn patients to burn units  Wound Healing o Inflammation following injury: vasodilation, increased perfusion to injured area, neutrophils infiltrate o Proliferation: fibroblasts 2-3 days, granulation tissue forms, epithelial cells cover wound o Remodeling: lasts for years, collagen fibers reorganize, scars contract and fade, hypertrophic scar, keloid  Pathophysiologic Changes: respiratory function compromised, dysrhythmia, circulatory failure, massive infection, fluid and electrolyte imbalance, hypothermia o Hypovolemic Shock: loss in fluid and fluid shift  Burn Site: fluids shift to interstitial causing edema and burn site  Systemic: fluid shift due to inflammatory process stimulating an increase in capillary permeability; fluids move from intravascular to interstitial contributing to peripheral edema and hypovolemia o Decreased Cardiac Contractility- assess for hyperkalemia o Nutrition: albumin indicates nutrition level with low level indicating inflammation, shock and malnutrition o Stress Ulcers: increase in secretion of HCL o Immune System: compromise in cell-mediated and humoral systems  Emergency: eliminate heat source, stabilize patient, identify type of burn, prevent heat loss, reduce wound contamination, transport o 100% humidified oxygen o HOB 30 degrees elevated o Bronchodilators o NG tube for TBSA over 20% o Remove jewelry and contact lenses o Crystalloid through 2 large bore catheters o Hourly urine output: 30 mL/hr. or 1 mL/kg/hr. for peds  Acute Phase: standard precautions, no plants or fruits, antibiotics (sulfamylon, silver nitrate soaks, Silvadene, systemic) o ROM q 2hr o Uniform Pressure o Mechanical Debridement o Surgical Debridement: escharotomy, removal of dead tissue  Homograft: human cadavers