Nursing Care of the Child Review For Exam 1 Part 5

Tonsillitis     Tonsillitis – inflammation of the tonsils Cause: strep virus The palatine tonsils are those removed during tonsillectomy. The pharyngeal tonsils, also known as the adenoids, are located above the palatine tonsils on the posterior wall of the nasopharynx. The manifestations of tonsillitis are caused by inflammation.  As the palatine tonsils enlarge from edema, they may meet in the midline (kissing tonsils), obstructing the passage of air or food.  The child has difficulty swallowing and breathing.  When enlargement of the adenoids occurs, the space behind the posterior nares may become blocked, making it difficult or impossible for air to pass from the nose to the throat.  As a result, the child breathes through the mouth.  Bad breath  Impaired taste and sense of smell  Chronic enlargement of the tonsils and adenoids may result in obstruction of breathing during sleep.  Persistent cough  Because of the proximity of the adenoids to the eustachian tubes, this passageway is frequently blocked by swollen adenoids, interfering with normal drainage and frequently resulting in OM or difficulty hearing. Medical treatment  Antibiotics (penicillin)  If there is a penicillin allergy give erythromycin  DO NOT give cephalosporins  Augmentin is a penicillin Surgical treatment  Surgical treatment of chronic tonsillitis is controversial. Except in documented cases of recurrent, frequent streptococcal infection or a history of development of a peritonsillar abscess, tonsillectomy is not indicated in the child who has recurrent pharyngitis  Tonsillectomy (surgical removal of the palatine tonsils) may be indicated for massive hypertrophy that results in difficulty breathing or eating. Absolute indications are peritonsillar abscess, airway obstruction, tonsillitis resulting in febrile seizures, and tonsils requiring tissue pathology  Adenoidectomy (the surgical removal of the adenoids) is recommended for children who have hypertrophied adenoids that obstruct nasal breathing; additional indications for adenoidectomy include recurrent adenoiditis and sinusitis, OM with effusion, airway obstruction and subsequent sleep-disordered breathing, and recurrent rhinorrhea  Contraindications to either tonsillectomy or adenoidectomy  (1) cleft palate, since both tonsils help minimize escape of air during speech        (2) acute infections at the time of surgery because the locally inflamed tissues increase the risk of bleeding (3) uncontrolled systemic diseases or blood dyscrasias. Food and fluid are restricted until children are able to swallow them and are alert with no signs of hemorrhage. Cool water, crushed ice, flavored ice pops, or diluted fruit juice is given; fluids with a red or brown color are generally avoided to distinguish fresh or old blood in emesis from the ingested liquid. Straws should be avoided, since these may damage the surgical site and cause subsequent bleeding. Citrus juice may cause discomfort and is usually poorly tolerated. Milk, ice cream, or pudding is not usually offered until clear fluids are retained because milk products coat the mouth and throat, causing the child to clear the throat, which may initiate bleeding. NURSING ALERT The most obvious early sign of bleeding is the child’s continuous swallowing of the trickling blood. While the child is sleeping, note the frequency of swallowing. If continuous bleeding is suspected, notify the surgeon immediately. DRUG ALERT -- CODEINE Codeine is contraindicated in pediatric patients post tonsillectomy and adenoidectomy. In 2012, the U.S. Food and Drug Administration (FDA) issued a Drug Safety Communication that codeine use in certain children after tonsillectomy and/or adenoidectomy may lead to rare, but life-threatening adverse events or death (US Food and Drug Administration Drug Safety Communication, 2012). In 2013 a boxed warning (the FDA’s strongest) was added to codeine drug labels to warn about the risks associated with it and to contraindicate its use in this population. Some institutions have removed codeine from its formulary for pediatric patients, and others have issued restrictions on its use. Codeine is converted to morphine in the liver by the enzyme cytochrome P450 2D6 (CYP2D6). Some patients are very slow metabolizers and do not convert adequate amounts of codeine to morphine and do not experience any analgesia; others are ultra- rapid metabolizers and will produce approximately three to four times as much morphine from a given dose of codeine as expected. As reported by the FDA, this has led to hypopnea, apnea, and death in a number of pediatric patients. At least four cases of death or severe respiratory depression have occurred following tonsillectomy among toddlers and children given codeine who were either ultra-rapid or extensive metabolizers. The deaths may be the result of genetically based differences in clinical response to codeine that are not detected without specific testing or the occurrence of an adverse event. Parents should seek immediate help if sleepiness, confusion, or difficult or noisy breathing occurs  Nurse Management:  Promote Airway clearance  If the child is NOT FULLY AWAKE à Place child in SIDE-LYING OR PRONE POSITION to facilitate safe drainage of secretion  If the child is AWAKE AND ALERT à Assist them to SIT UP W/ HEAD OF THE BED ELEVATED  AVOID SUCTIONING à however, if you suction, suction carefully to avoid trauma to surgical site  Inspect the area for dried blood that may be present on teeth and nares with old blood on emesis  TEACH the parents about the presence of blood so they will not be frightened when they see it  Maintain fluid volume  Bleeding may occur at any time from immediately after surgery (post-op) and can last for 10 days  Inspect the throat for bleeding à You may see mucus-tinged blood à FRESH BLOOD INDICATES ACTIVE BLEEDING****  Early bleeding may be identified by continuous swallowing of   small amounts of blood while awake or sleep à ask patient is they have been frequently swallowing FREQUENT SWALLOWING BY CHILD WARRANTS ATTENTION Assess the patient for other signs of bleeding à S/S include: tachycardia, pallor, restlessness, frequent throat clearing and emesis with bright red blood    Discourage coughing, clearing throat, blowing nose, and using straws Upon discharge instructions à instruct parents to report any signs of bleeding to their doctor  Maintain fluid volume post-op (use IV if necessary)  Encourage the child to take in fluids as desired  AVOID CITRUS JUICE, BROWN or RED FLUIDS WHY: b/c acid in citrus may irritate the throat; brown or red juices can be mistaken for blood  Relieve pain  During the first 24 hrs after surgery à the child’s throat will be very sore  Ensure that you provide adequate pain relief and establish     adequate oral fluid intake Provide Ice collar and analgesics with or w/out narcotics Counsel parents to maintain pain control upon discharge from facility (be consistent w/ meds) Preoperative care  Assess bleeding tendencies (do PTT); Need baseline vital signs; Need bleeding and clotting time  Provide psychological preparation (how to prepare child an parent for surgery) à Post-operative care  Prevent bleeding  Position patient at 30 degrees, side-lying, or fowlers  Assess pain control Use numeric pain scale (0-10); Wong Baker FACES scale; Cries à used on neonate to 28 days; FLACC à use this pain scale on infants to assess their face, legs, activity, cry, and consolability à each is scores 0-2; Vital signs (high vital signs indicate they may be in pain) Fluid and diet à they can have gummy bears as CL à DIET includes: CL à soft foods à slow hard food Provide discharge instructions Teach about home care     otitis media      Otitis media is the accumulation of fluid in the middle ear Occurs when pathogens travel upward from nasopharyngeal area to invade the middle ear space and cause fever/pain It causes increased pressure behind the tympanic membrane, perforation, decrease pain, and drainage in ear canal Complications: hearing loss, excessive speech delay, tympanosclerosis (scarring of the tympanic membrane), tympanic membrane perforation, chronic suppurative otitis media (chronic drainage via perforation), acute mastoiditis, intracranial infection, and bacterial meningitis Clinical Manifestations             Fever (104) otalgia (ear pain) irritability inconsolable crying batting/pulling on ear forward (newborn may rub ear on blanket) poor feeding difficulty sleeping fluid drainage from ear bulging and redness of the tympanic membrane dull or opaque tympanic membrane appearance puss in eardrum Treatment:     Give Antipyretics for fever Use heat or cool compression Insertion PE tubes if the ear has fluids accumulated inside the ear The latest American Academy of Pediatrics recommendations also place emphasis on assessment and management of pain in children with AOM.  For fever or discomfort associated with OM, analgesic–antipyretic drugs such as acetaminophen or ibuprofen may be given.  The health care practitioner may prescribe topical pain relief drops such as benzocaine or lidocaine.  A narcotic analgesic with codeine may be required for children with severe pain, but side effects are common and the child should be      closely monitored for GI upset, constipation, respiratory depression, and altered mental status When antibiotics are necessary, oral amoxicillin in high doses (80 to 90 mg/kg/day, divided twice daily) is the treatment of choice for initial episodes of AOM in children who have not received antibiotics within the past month (Lieberthal, Carroll, Chonmaitree, et al, 2013). The recommendation for the duration of antibiotic therapy is 10 days for severe AOM; for children with mild to moderate disease and those who are 6 years and older, a 5- to 7-day course is adequate Second-line antibiotics used to treat OM include amoxicillin- clavulanate (Augmentin) (which is recommended if conjunctivitis is also present); azithromycin; and cephalosporins such as cefdinir, cefuroxime, and cefpodoxime.  AUGUMENTIN IS A PENICILLIN -- WATCH OUT FOR ALLERGY Myringotomy, a surgical incision of the eardrum, may be necessary to alleviate the severe pain of AOM.  A myringotomy is also performed to drain infected middle ear fluid in the pres- ence of complications (e.g., mastoiditis, labyrinthitis, or facial paralysis) or to allow purulent middle ear fluid to drain into the ear canal for culture.  Nurse management:  Make sure that the patient use all the medication regimen given  Provide Tylenol for their pain and fever  Provide heat for comfort and ice for edema (you can place one on the pillow)  Place them on the affected side with heating pad or covered ice pack in place to that ear  Protect them from water protection with tubes  Use numbing eardrops (benzocaine “Auralgan”) Prevention of otitis media  Breast feed baby; avoid people with URI, do not expose child to second hand smoke, encourage immunization with Prevnar and flu vaccine, use xylitol syrup (sucrose substitute) otitis media with effusion  OM w/ effusion occurs when fluid is within the middle ear space, w/ or w/out signs of infection after 3 months   age 5-14 yrs     Risk factors: passive smoking, absence of breastfeeding, frequent viral upper respiratory infection, allergy, young age, males, adenoid hypertrophy, Eustachian tube dysfunction Assessment:  Popping sensation or fullness behind eardrum  Dull, opaque tympanic membrane (white, gray, or blue)  Mobility absent or diminished upon otoscopy  Tympanometry confirm dx Nursing Management:  Antihistamines, decongestants, antibiotics, corticosteroids NOT RECOMMENDED!!*  OME usually resolves spontaneously  Do not feed infants in supine position, avoid propping bottle  Monitor child for hearing loss à because it could cause depress language deficit and learning problems  To communicate with child with OME: Turn off music/tv Position yourself within 3 ft in front of child before speaking     Face child Use visual cues Increase volume of speech slightly Speak clearly Provide postop care with pressure-equalizing tube (will be in place for several months, will fall out on its own) Administer eardrops post op Avoid getting water into ears  Wear ear plugs    Cystic fibrosis Error! 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Cystic fibrosis is an autosomal recessive disorder characterized by excessive mucus production  It occurs due to a deletion in chromosome 7 at the CFTR responsible for gene mutation  It can be detected prenatally through DNA testing  It is most common in European descent Pathophysiology and Etiology  In cystic fibrosis, the CFTR mutation causes alteration in epithelial ion transport on mucosal surfaces resulting in generalized dysfunction of exocrine glands; epithelial cells fail to conduct chloride and water transport abnormalities à this results in thickened, tenacious secretions in sweat glands, GI tract, pancreas, respiratory tract and other exocrine tissues  Diagnoses  To be diagnosed with CF, you must have: family history of CF, absence of pancreatic enzymes, and an elevated NaCI level and chromic pulmonary problems S/S: Bronchial obstruction (caused chronic bronchial), obstruction of small intestine (, pancreatic ducts (malabsorption syndrome) , and bile ducts (portal hypertension) Complications:  Hemoptysis, pneumothorax, bacterial colonization, cor pulmonale, intestinal obstruction, Gastroesophageal reflux disease, diabetes, portal hypertension, liver failure, gallstones, and decreased fertility     Therapeutic Management:  Aimed towards: minimizing pulmonary complications, maximizing lung fct, preventing infection, aiding growth  All children w/ CF who have pulmonary involvement require chest physiotherapy w/ postural drainage several times daily to mobilize secretions from lungs  Physical exercise encouraged**  Pulmozyme given daily using nebulizer to decreased sputum viscosity and help clear secretions  Antibiotics are also given as well (choice of antibiotics depends on sputum culture results and sensitivity)  Inhaled bronchodilators and anti-inflammatory agents are also given  Pancreatic enzymes and supplemental fat are also given to promote digestion and absorption of nutrients  High calorie, High protein diets are recommended (sometimes formulas can be given via oral or feeding tube) à some children may need TPN to gain weight  Lung transplantation Nursing Assessment: Common S/S:  Salty taste to child’s skin (excess chloride loss via perspiration)  Meconium ileus or late, difficult passage of meconium stool in newborn period  Abdominal pain or difficulty passing stool (infants or toddlers might present w/ intestinal obstruction or intussusception at time of dx)  Bulky, greasy stools  Poor weight gain and growth despite good appetite  Chronic or recurrent cough and/or upper or lower respiratory infections  Health History:  Respiratory status à cough, sputum production or work of breathing increased  Activity tolerance  Increased need for pulmonary or pancreatic medications  Presence of fever  Appetite and weight gain  Presence of bone pain  Any other changes in physical state or medication regimen  Physical Assessment  Inspection  General appearance and color  Nasal passages for polyps  Note respiratory rate, work of breathing, use of accessory muscles, position of comfort, frequency and severity of cough and quality and quantity of sputum produced  Barrel chest  Clubbing of nail beds  Rectal prolapse may be present  Child may appear small or thin for his/her age  Child may have a protuberant abdomen, thin extremities w/ decreased subcutaneous fat  There may be presence of edema (sign of cardiac/liver failure)  Note distended neck veins or presence of a heave (signs of cor pulmonale Auscultation  Reveal variety of adventitious breath sounds  Fine or coarse crackles and scattered or localized wheezing might be present  Progressive obstructive pulmonary involvement, breath sounds might be diminished  Tachycardia  Presence of a gallop (might occur w/ cor pulmonale)  Adequacy of bowel sounds  Percussion  You may hear hyperresonace due to air trapping  Diaphragmatic excursion might be decreased  Abdomen might reveal dullness over the enlarged liver or mass R/T intestinal obstruction  Palpation  Asymmetric chest excursion if atelectasis present  Tactile fremitus decreased over areas of atelectasis  Tenderness is present over liver (might be an early sign of cor pulmonale)  Laboratory and Diagnostic Test  Sweat chloride test (suspicious if level of chloride collected = 50 mEq/L; Diagnostic if > 60 mEq/L)  Pulse oximetry (oxygen saturation will be decreased with CF)  Chest x-ray (may reveal hyperinflation with CF)  Pulmonary function test Nursing management:        The goal of treatment: provide mucus clearance Provide hydration (increase fluid), use of pulmonary function test, ensure adequate nutrition, screen, provide home care, provide family support Maintaining patient airway  Chest physiotherapy à involves percussion, vibration, postural drainage or another bronchial hygiene therapy à it must be performed several times a day to assist w/ mobilization of secretions  Breathing exercises to promote mucus clearance  Encourage physical exercise promote mucus secretion providing cardiopulmonary conditioning  Pulmozyme administered, as well as inhaled bronchodilators and anti-inflammatory agents  Older children and adolescents à flutter-valve device, positive expiratory pressure therapy or high-frequency chest compression vest  Cycles of exhalation are repeated until coughing yields expectoration of secretions  Vest airway clearance system à provides high-frequency chest wall oscillation to increase airflow velocity to create repetitive cough-like shear forces and to decrease viscosity of secretions Preventing infection  Vigorous pulmonary hygiene for mobilization of secretions  Aerosolized antibiotics given at home/hospital  Frequent or severe respiratory exacerbations might require lengthy courses of IV antibiotics Maintaining growth  Pancreatic enzymes must be administered w/ all meals and snacks to promote adequate digestion and absorption of nutrients  Number of capsules required depends on extent of pancreatic insuffiency and amount of food being ingested  Need additional enzyme capsules when high-fat foods are being eaten  Infant or young child à enzyme capsule can be opened and sprinkled on cereal or applesauce Well-balanced, high-calorie, high-protein diet is necessary to ensure adequate growth Infants à breastfeeding should be continued w/ enzyme administration; some infants require fortification of breast milk or supplementation w/ high-calorie formulas  Supplementation w/ vitamins A, D, E and K is necessary  Administer gavage feedings or total Parenteral nutrition as prescribed to provide for adequate growth Promoting Family Coping  Family should be encourage to live a normal life à encourage child to participate in activities and school attendance during periods of wellness  Family should be involved in child’s care  Ongoing education about illness/treatments  Families welcome support and encouragement  Refer parents to local support group  Assist w/ anticipatory grieving and making decisions r/t end of life care are other important nursing interventions Preparing child and family for adulthood w/ cystic fibrosis  Lung transplant proven to be successful and length life expectancy  Goal: promote independent living as an adult; making transition from pediatric medical home to an adult medical home  Adults w/ CF are able to find rewarding work and pursue relationships  Men w/ CF à capable of sex, but unable to reproduce  Females w/ CF à difficulty conceiving, but cautioned if they are about respiratory strain and that ALL children of parents w/ CF will be carriers of the gene    