Pediatric Case Study Charlie is a 5- year Indigenous boy and Cindy is a 4-month old Indigenous girl who are siblings and live in Northern Ontario on a remote Reserve. Charlie and Cindy have both been brought into the local community clinic by their mother. They are both exhibiting symptoms of cough, fever, runny nose, and sneezing. Tests have confirmed that they have both contracted Influenza A. Charlie - 5 years old Cindy – 4 months old BP= 95/52 (low) T= 38.3 (oral) (high) oral temp for 2 yrs and up P= 150, irregular (Apical) (high) *radial pulse is palpable R= 30 (high side of normal) 02 sats = 94% on R/A via pediatric finger pulse oximetry probe (low normal) Weight = 17.9 kg (39.5 pounds) (average 40.5) Height = 108 cm (42.5 inches) (average 43) BP= 94/50 (low normal) BP taken at birth and then usually not until age of 3 with healthy check ups unless indicated T= 37.9 (axilla) (high) (axilla is 1 degree lower than oral temp)**rectal too invasive P=168 (Apical) *radial pulse is hard to palpate (high normal) R= 40 (normal) 02 sats= 96% on R/A via infant foot pulse oximetry probe (normal) Weight = 7.0 (15.4 pounds) (average 15.8) Height = 64.0 cm (25.2 inches) (average 25.3) Lying on the stretcher quiet, anxious and scared Lying in the crib crying and restless Nasal flaring with suprasternal and intercostal retractions noted upon breathing (abnormal) Is abdominal breathing (normal – abdominal breathers up to 6 years) Chest has audible coarse wheezes throughout (abnormal) Chest has decreased air entry to the bases (abnormal) Skin is dry, flushed, and warm to the touch (flushed) Skin is dry, flushed, and warm to the touch (flushed) Unable to palpate anterior or posterior fontanelles Anterior fontanelle is palpable (normal – close 9 to 18 months, diamond shaped); Posterior fontanelle is not palpable (normal – close at 2 months, triangle shaped) Nasal mucosa and throat are both red (red) Abdomen soft, not distended, tender, with bowel sounds hyperactive in all 4 quadrants (hyperactive) Nasal mucosa and throat are both red (red) Abdomen is soft, distended (normal for infants), with bowel sounds in all 4 quadrants Has had 3 large loose brown stools in the last 24 hours Has had 3 small mushy yellow stools in the last 24 hours Appetite is poor, not drinking sufficient amounts due complaints of a sore throat Continues to be exclusively breastfed q.s amounts every 2 hours History of asthma No history of any prior illnesses The above physical assessment was conducted by the clinic’s nurse. The nurse has paged the Dr. who is currently out making house calls to come back to the clinic and write treatment orders for both Cindy and Charlie. Questions 1. Explain specific physical, psychological, social, cultural, and spiritual nursing implications to consider when caring for pediatric patients such as Charlie (5 year old) and Cindy (4 month old) as opposed to an adult patient. Infants: 1 to 12 months old -Support a young infant’s head an neck -Nose breathers exclusively first 4-6 months (therefore will experience resp. distress if the nares are blocked) -When assessing the ears, pinna is pulled down and back to straighten ear canal until 4 years old -Head and chest circumference is measured. If fontanelles are sunken, it means dehydration; if fontanelles are bulging means increased intracranial pressure. -Normally are alert, looking around, able to focus on faces -If lethargic, limp, not crying, decreased cap refill – abnormal and could be emergency (or if they let yo do an invasive procedure without resisting) -Can usually sit up by months and walk usually by 18 months -Count number of wet diapers per 24 hours and amount of nursing time or bottles when assessing intake/output -Check skin turgor on the abdomen (should not stay tended up – should return to normal within 2 seconds) Capillary refill (less than 2 seconds) – for babies press on sternum for 5 seconds then release to see if colour returns -Breastfed infants usually grow at a slower rate than formula-fed infants -Stranger anxiety starts at 6 months of age Infants heads are the largest body surface area of their body- head remains disproportionately larger in comparison to the rest of the body until age 5 years old -Teeth first erupt between age 4 to 6 months (and loose first primary tooth around 7 years old) Screen for lead poisoning if living in a home that may contain lead0based paints (before 1978) or lead in the water pipes (before 1986). Lead poisoning includes abdominal pain, headaches, vomiting, confusion, muscle weakness -Immunizations should be up-to-date, are strongly recommended but in most provinces are not legally required -Breastfed infants require vitamin D supplement to prevent a deficiency -Aboriginal infants from ages 6-12 months need to be screened for iron deficiency (they are at an increased risk for this if living in First Nation Communities) -Weigh dry diaper than compare with we ones (should have 4 to 8 wet/day) Resp. System: -Abdominal breathers until up to age 6 years old (then become thoracic breathers in school years) -Thin chest wall, more noticeable xyphoid process under age 6 -Young children have higher metabolic rates, therefore higher resp. rates (normal resp rates vary greatly) -Tachypnea is usually the first sign of distress in the infant, if bradypnea occurs with cardioresp distress, arrest may be immanent -ped’s usually experience resp. failure more often than primary cardiac failure -Lung development is complete in healthy full-term newborns but resp. system is diff. from adult’s resp system -there is a lack of surfactant in premature newborns which is the primary cause of atelectasis (collapse of part or all of the lung) -Red flag – intercostals retraction (seen with resp. distress, thorax appears to be sinking in, grunting and nasal flaring may occur) Cardiac System: -Heart rate changes with resp, insufficiency, tachycardia - early sign of shock or resp. distress, bradycardia (later sign of hypoxia) -Innocent murmurs are common sometime during childhood (approx 70% of children will experience a murmur – may be caused from fever, increased metabolic rate, anemia 2. Identify differences in how you would carry out physical head-to-toe assessments for Charlie and Cindy (be specific for both), as opposed to how you would assess an adult patient. For both Cindy and Charlie: -Pediatric Assessment Triangle is used to form an immediate general impression. It assesses appearance, work of breathing, circulation of skin). It foramalizes a rapid observational assessment and determines the urgency of interventions and the need for life-support interventions. -Approach in a calm, professional manner, talk softly, praise frequently -Use simple terminology -Use play therapy -Distract infant/child -Ask parent if they have given any medicine (including complementary and or herbal medicine) -Use the Wong Baker Scale (faces to rate feelings - for Charlie) -Building a rapport with parents is critical, allow parents to stay with the child throughout the Emerg. Visit but remember that your first priority is the child -Have age approp. equipment Cindy - 4 months old (this applies for Neonates (first month) to infants (first 12 months) -Keep child warm; like to be wrapped up -Support a young infant’s head and neck -Have parent hold baby if possible; like to be held -When assessing the ears, pinna is pulled down and back to straighten ear canal until 3 years old -Head circumference is measured until age 3 -Count number of diapers wet/24 hours and amount of nursing time or bottles when assessing intake/output -Loud noises, bright lights will startle infants -6 to 8 months can usually sit up -If lethargic, not crying, decreased cap refill – abnormal could be an emergency -Blood is drawn from heel, toes, or finger -IV is inserted in the scalp vein, foot or central line Charlie - 5 year old -Have parent assist when possible -Can sit on request, but may need to examine patient with parents help (child sits on parents lap if needed) -Become verbal and actgive -Respect modesty (keep them covered) -Let child participate (let them handle some tools safely to help them cooperate) -Set limits on behaviour if the child acts out -Explain what you are doing (just beforehand if it is something that is going to hurt) -Not “abdomen” instead say “tummy” -Distract the child with a story -Make a game of the assessment -Get down to child’s level -Head to Toe assessment is best (least invasive first to gain their trust) but be flexible with approach and order for the assessment (best to keep most painful until the end) -**Best to check resps 1st, and auscultate the chest when they are sleeping -By 3 years old child should have 20/20 vision 3. Identify all of the abnormal findings in the case study. Signs and symptoms of dehydration: Hypotension, tachycardia, tachypnea, sunken eyes, lethargic, prolonged skin turgor (more then 2 seconds to return to normal, dizzy, dry skin, drowsy, not appearing well, decreased urine output, (concentrated in colour). Both hemoglogin and hematrocrit would be both high if there is no blood loss (both would be concentrated in the blood), Hypotension, tachypnea, tachycardia and fever can cause resp. alkalosis. 4. Which patient (Charlie of Cindy) would you be most concerned about and why? What risk factors have caused one to be sicker than the other? Why do you think the other is not as sick? Charlie is sicker. He has more risk factors: -school age therefore is in more contact with other children -more active age (running around, exerting himself, playing on the ground, touching things, not remembering to wash his hands always) -history of asthma (higher rates of asthma in boys) Cindy is less sick -she is nursing -not at school therefore less exposure to the virus -no history of asthma or any other illness 5. Identify the risk factors for contracting Influenza A? Describe what Influenza A is. What are the tests used to diagnose Influenza A? What is the treatment for Influenza A? What is type A influenza? Also known as the flu — is a contagious viral infection that attacks your respiratory system. Influenza viruses that infect humans can be classified into 4 groups: A, B, C and D. Type A influenza is the most serious and known to cause widespread outbreaks and diseases. Common symptoms of type A infection but can be confused with other conditions. While in some milder cases the flu can resolve on its own, severe cases of type A influenza can be lifethreatening. Unlike a common cold, the flu occurs with a sudden onset of symptoms. Common signs of an influenza A include: Common Signs and Symptoms coughing runny or stuffy nose sneezing sore throat mild fever headache fatigue chills body aches If left untreated or there are complications fever over 100ºF ear infection diarrhea nausea vomiting dizziness abdominal pain chest pain asthma attack pneumonia bronchitis cardiac issues Sometimes, influenza A symptoms may resolve on their own. However, if symptoms persist for more than a week without improvement, schedule a visit with your doctor. In rare cases, the flu can be deadly. Influenza A vs. influenza B Types A and B influenza are the more common forms of this infection, routinely causing seasonal outbreaks. Type C influenza usually only causes mild respiratory infections. Type B influenza can be just as severe as type A influenza but is less common. Type B viruses mutate much slower than type A infections and are categorized by strain. The virus strain changes only every few years. Humans are the natural host for type B infection. This drastically reduces the risk of a widespread pandemic. Type A influenza is the most dangerous, known to cause outbreaks and increase your risk of disease. Unlike a type B infection, type A viruses are categorized by strain and subtype. These viruses are always changing, creating new strains from one flu season to the next. Past flu vaccinations will not prevent infection from a new strain. Wild birds are the natural hosts for a type A virus (also called avian flu or bird flu), but this infection can also spread to other animals and humans. This often causes pandemics. Diagnosing influenza A Before treating your condition, your doctor will need to check for the influenza virus. The most commonly used test is the rapid influenza diagnostics test. In this procedure, your doctor swabs your nose or throat. The test will detect virus antigens within 30 minutes or less. Results are not always accurate, and your doctor may have to diagnose you based on your symptoms or other flu tests. Treatment for Influenza A In some cases, influenza A symptoms can clear on their own with ample rest and fluid intake. In other cases, your doctor may prescribe you antiviral medication to fight the infection. Common antiviral prescriptions include (???unsure if safe for children – therefore it is not often given to pediatric patients): zanamivir (Relenza) ***oseltamivir (Tamiflu) peramivir (Rapivab) Though effective, these medications can cause side effects such as nausea and vomiting. If you begin to experience any of these symptoms or if your condition worsens, stop using the prescription and visit your doctor immediately. Over-the-counter medication can also ease flu symptoms. Be sure to stay hydrated to loosen mucus in your chest and strengthen your immune system. How long is it contagious? If you have the flu, you are contagious from at least a day before you begin to experience symptoms up through five days after your symptoms begin. In more severe cases, you could be contagious for up to 10 days after you begin experiencing symptoms. This number can fluctuate if your immune system is weak or undeveloped, specifically in cases of children. Prevention The best way to prevent the flu is through annual vaccinations. Each flu shot protects against three to four different influenza viruses within that year’s flu season. Other ways to prevent spreading this disease include: washing your hands regularly avoiding large crowds, specifically during a flu outbreak covering your mouth and nose when you cough or sneeze staying home if you develop a fever and for at least 24 hours after it goes away Outlook Type A influenza is a contagious viral infection that can cause life-threatening complications if left untreated. While some cases of this infection can improve without prescribed medication, a visit to your doctor is recommended. Do not self-diagnose your condition. The flu can resemble the common cold, but may trigger worsening symptoms. If you worry you have been infected with influenza, schedule a visit with your doctor to discuss treatment. 6. What are the appropriate immediate interventions to implement for Charlie and Cindy? -Ensure Charlie has an asthma action plan -Monitor closely for further resp distress -Monitor for intake/output closely (watch for signs of dehydration) -Cooling measures, monitor for seizures (due to fever) -Ask: Should they be given ASA or Acetaminophen? ASA is an NSAID (NSAIDS increases mucus secretion, and cause bronchial constriction = narrowing of the bronchioles) Also, ASA is NOT recommended to give to children under 18 due to the risk for developing Reyes Syndrome in children -Should they be given Acetaminophen? Yes (children’s acetaminophen/tylenol) is the safest choice. It does not cause increased mucus secretion and does not cause bronchial constriction and is not linked to Reyes Syndrome. 7. Discuss your top 5 concerns as Charlie and Cindy’s nurse? -respiratory distress (particularily with Charlie due to his asthma) -death -dehydration (Charlie- lack of appetite and loose stools) -anxiety (can further exacerbate Charlie’s asthma) -controlling fever to prevent a seizure -further spread of the virus to others Resources: use your Maternity/Child textbook; Medical Surgical Nursing textbook; Nursing Fundamentals textbook; and the WWW to answer the above questions (remember to choose credible websites when using the internet). Refer to vital sign chart on next page. ***students do not need to memorize vital sign ranges for the test Effect of Age on Vital Signs AGE Nrn Newborn TEMPERATURE P PULSE RATE ˚Celsius RESP. RATE BL BLOOD PRESSURE 37-37.7 120-160 30-80 Systolic: 50-52 Diastolic: 25-30 3 Y 3 Year 36.9-37.5 80-125 20-30 Systolic: 78-114 Diastolic: 46-78 10 10 Year 36.3-37.0 70-110 16-22 Systolic: 90-132 Diastolic: 56-86 16 1 16 Year 36.4-37.1 55-100 15-20 Systolic: 104-108 Diastolic: 60-92 Adult 36-37.5 60-100 15-20 Systolic: <120 Diastolic: <80 Older Adult 35.9-36.3 60-100 15-25 Systolic: <120 Diastolic: <80 Ad Source: Dillon, P. (2016). Nursing Health Assessment: The Foundation of Clinical Practice, 3rd edition, page 23. F.A Davis Company: Philadelphia, PA. **please note that vital sign ranges may vary slightly depending on the source that you are referring to.