TEST 1 NOTES
TEST 1 NOTES NUR 349
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Date Created: 08/12/16
Chapter 54 Autism Spectrum Disorders Pervasive Developmental Disorders Autism Spectrum Disorders (ASD) Includes autism, Asperger Syndrome, PDDNOS Apparent in early childhood usually occurs before 3 years of age TQ Impairs age appropriate social interactions Impairs language & communication Restricted interests, activities, behaviors o Abnormal response to normal body sensations o Difficulty regulating emotions CoMorbidities o Seizures o Sleep Disturbances o GI Disorders o Psychiatric Disorders Signs & Symptoms o Impaired social interaction Dealing with social/emotional cues, relationships (peers) o Communication Delayed/no language use o Child may exhibit monotone speech & echolalia (repetition of words) –TQ (inappropriate volume, pitch, rate, rhythm, intonation) Inappropriate responses; echolalia o Restricted interests, social activities, behaviors Preoccupation Difficulty adapting to new situations o Change may cause the child to become withdrawn, self abusive, violent Rigid, social behavior o Apparent by age 3 o Characteristics: child clicks the light in the exam room on and off repetitiously, has a flat affect, mother reports the child has no interest in playing with other children. Select all that apply TQ o Selfstimulation is common and generally involves repetition of a sensory stimulus. Autistic children generally show a fixed, unchanging response to a particular stimulus. Autistic children generally play alone or involve others only as mere objects. Nursing Interventions o Work closely with parents o Help parents cope – explain that some children have extremely developed skill in a particular area such as music/math TQ o Add screening questions o Recognize that treatment may be perceived differently by child o Modifying the physical environment for safety o Assessment Determine the patient's developmental level/current level of functioning Assess for selfharm Determine patient's level of somatosensory disturbances Determine emotional disturbances Determine interventions that have worked in the past Identify effective communication techniques o Management o Stabilize environment stimuli o Provide supportive care o Enhance communication o Maintain routines – continue prescribed treatments and medications if possible if hospitalized with asthma – keep child’s routine habits and preferred preferences maintained. Children with autism are often unable to tolerate slight changes in routine TQ o Maintain safe environment – ensure that dangerous objects are out of reach, and child is directly supervised o Provide anticipatory guidance Acute & Infectious Respiratory Illnesses Tonsillitis ◦ Tonsils are masses of lymphtype tissue found in the pharyngeal area ◦ Tonsils filter pathogenic organisms which helps to protect the respiratory and gastrointestinal tracts ◦ Palatine tonsils are located on both sides of the oropharynx ▪ Removed during a tonsillectomy ◦ Pharyngeal tonsils (adenoids) ▪ Removed during an adenoidectomy ◦ Enlarged tonsils can block the nose & throat which can interfere with normal breathing, nasal & sinus drainage, sleeping, swallowing, and speaking ◦ Acute tonsillitis occurs when tonsils become inflamed and reddened ▪ Small patches of yellowish puss may also become visible ◦ Risk Factors ▪ Exposed to a viral or bacterial agent ▪ Immature immune systems ◦ Signs & Symptoms ▪ Sore throat with difficulty swallowing ▪ History of otitis media & hearing difficulties ▪ Mouth odor, mouth breathing ▪ Snoring ▪ Nasal qualities in the voice ▪ Fever, tonsil inflammation (with redness and edema) ▪ Positive throat culture ◦ Nursing Interventions ▪ Comfort care: rest, cool fluids, warm salt water gargles ▪ Administer medications (antibiotics [bacterial], acetaminophen) ◦ Surgical Interventions ▪ Tonsillectomy Nursing Interventions ◦ PreOperation ▪ Encourage the use of warm saltwater gargles and throat lozenges ▪ Encourage fluid intake and monitor hydration status ◦ PostOperation ▪ Positioning Position the child on side to facilitate drainage Elevate the head of bed when fully awake ▪ Assessment Assess the child for signs of bleeding ◦ Frequent swallowing, clearing of throat, restlessness, bright red emesis, tachycardia, pallor Assess child's airway & vital signs Monitor for difficulty of breathing R/T secretions, edema, bleeding ▪ Comfort Measures Ice collar & analgesics Keep the child's throat moist Administer pain medication on a regular schedule ▪ Diet Encourage clear liquids & fluids after a return of the gag reflex ◦ Avoid redcolored liquids and milk Advance the child's diet with soft, bland foods ▪ Education Discourage coughing, throat clearing, nose blowing (protection of the surgical site) Refrain from placing pointed objects in the back of the mouth (straws) Alert parents that there may be clots or bloodtinged mucous in vomit Encourage rest ▪ Discharge Education Notify provider if difficulty breathing, bright red bleeding, lack of oral intake, increase in pain, signs of infection Avoid straws, pointed objects in the mouth Administer pain medications for discomfort Encourage fluid intake and diet advancement to a soft diet with no spicy foods, hard foods, sharp foods Limit strenuous activity, physical play, swimming for 2 weeks Instruct that full recovery usually occurs within 10 days to 2 weeks ▪ Complications Hemorrhage Chronic Infection ◦ Chronically infected tonsils may pose a potential threat to other parts of the body ◦ May also develop other diseases such as rheumatic fever, kidney infection Common Respiratory Illnesses ◦ Upper Respiratory Tract ▪ Nasopharynx, pharynx, larynx, and upper part of trachea ◦ Lower Respiratory Tract ▪ Lower trachea, bronchi, segmental bronchi, subsegmental bronchioles, terminal bronchioles, and alevoli ◦ Risk Factors ▪ Age Infants between 3 and 6 months are at an increased risk due to decreased maternal antibodies acquired at birth and the lack of antibody protection Toddles & preschoolers are susceptible to viral infections ▪ Anatomy A short, narrow airway can become easily obstructed with mucous or edema A short respiratory tract allows infections to travel quickly Infants and young children have small surface areas for gas exchange Infectious agents have easy access to the middle ear through the short and open eustachian tubes of infants and young children ◦ Signs & Symptoms ▪ Recent infection ▪ Sore throat ▪ Decreased activity level ▪ Chest pain ▪ Fatigue ▪ Difficulty breathing ▪ Shortness of breath ▪ Decreased appetite Respiratory Illness Signs & Symptoms Nasopharyngitis (Common Cold) Nasal inflammation, rhinorrhea, cough, ◦ Virus that persists for 7 to 10 days dry throat, sneezing, nasal qualities heard in voice Fever, decreased appetite, irritability Pharyngitis (Strep Throat) Inflamed throat with exudate, pain with ◦ Caused by bacteria swallowing Headache, fever, abdominal pain Cervical lymphadenopathy Truncal, axillary, perineal rash Bacterial Tracheitis Thick, purulent drainage from the trachea ◦ Infection of the lining of the trachea that can obstruct the airway and cause respiratory distress Bronchitis Persistent cough (as a result of ◦ Associated with URI and inflammation inflammation of large airways ◦ Requires symptomatic relief Bronchiolitis Rhinorrhea, pharyngitis, intermittent fever, ◦ Mostly caused by RSV cough, wheezing Coughing that progresses towards wheezing Increased respiratory rate Nasal flaring, retractions Cyanosis Allergic Rhinitis Watery rhinorrhea, nasal congestion, ◦ Caused by seasonal reaction to itchiness (nose, eyes, pharynx), watery allergens (most often in fall and eyes, nasal quality of the voice spring) Dry, scratchy throat Snoring, poor sleep, fatigue Pneumonia High fever Cough that may be unproductive or productive of white sputum Retractions & nasal flaring Rapid, shallow respirations Chest pain Adventitious breath sounds (crackles, rhonchi) Pale color that may progress to cyanosis Irritability, anxiety, agitation, fatigue Abdominal pain, diarrhea, lack of appetite, vomiting Sudden onset Bacterial Epiglottis ◦ MEDICAL EMERGENCY Sitting with chin pointing out, mouth opened, tongue protruding Drooling Anxiety with respiratory distress Absence of spontaneous coughing Dysphonia (hoarseness, difficulty speaking) Dysphagia (difficulty swallowing) Inspiratory stridor Sore throat, high fever, restlessness Acute Laryngitis Hoarseness ◦ Viral infection Acute Laryngotracheobronchitis Lowgrade fever, restlessness, hoarseness, ◦ Caused by bacteria or virus barky cough, inspiratory stridor, retractions Acute Spasmodic Laryngitis Barky cough, restlessness, difficulty ◦ May result from allergens breathing, hoarseness, nighttime episodes of laryngeal obstruction ◦ Diagnostics ▪ Throat culture ▪ Blood samples ▪ CBC ▪ Sputum culture ▪ Chest XRay To rule out pneumonia ◦ Nursing Interventions ▪ Closely monitor progression of illness and respiratory distress Observe for increased heart rate, respiratory rate, retractions, nasal flaring, restlessness ▪ Make emergency equipment and intubation readily accessible ▪ Do not use a tongue depressor or take a throat culture if epiglottis is suspected ▪ Use oxygen and high humidity for infants and young children with hoods or tents ▪ Use postural drainage or chest PT to help mobilize and remove fluid from lungs ▪ Maintain adequate hydration ▪ Allow for the child to be held in a upright position ◦ Medications ▪ Epinephrine Decreases edema ▪ Corticosteroids (Decadron, Rhinocort) Decreases inflammation Can be given orally or IV ▪ Antipyretics (Acetaminophen) Decreases fever ▪ Mild analgesic Decreases pain ▪ Antibiotics Treats bacterial infection ◦ Discharge Instructions ▪ Use a coolair vaporize to provide humidity ▪ Rest during febrile illnesses ▪ Maintain adequate fluid intake ▪ Limit use of nose drops or sprays to 3 days to prevent rebound congestion ▪ Apply an ice bag or heating pad to the neck to decrease pain from enlarged cervical nodes ▪ Administer medications at appropriate time intervals ▪ Decrease spread of infection ▪ Seek medical attention if symptoms worsen or respiratory distress occurs ◦ Complications ▪ Airway obstruction May result from progression of respiratory infectious process or foreign body aspiration Nursing Interventions ◦ Position the child prone to promote lung expansion, prevent gas exchange, and prevent aspiration ◦ Perform suctioning of airways if indicated, limiting each attempt to 5 seconds ◦ Do not examine the child's throat with a tongue blade or take a throat culture if epiglottis is suspected ◦ Administer medications ◦ Chest PT ◦ Assist the child to deep breath with the use of a splint ◦ Assist the child to expectorate sputum ◦ Ensure availability of emergency equipment Chapter 35: Nursing Considerations for the Hospitalized Child Emergency Hospitalization – poses the greatest challenge to the nurse working with a child and family TQ Involves – limited time for preparation both for the child and family Situations that cause fear for the family that the child may die or be permanently disabled High level of activity, which can foster further anxiety Observation for 24 hours in an acutecare setting is often appropriate for children because children become ill quickly and recover quickly TQ Stress of Hospitalization Change in health and routine Children limited in methods of coping Stressors include (not just for kids, for parents as well) o Fear of the unknown o Child may – cry, kick, and cling to parent – this is a normal response to the stress of hospitalization TQ o Separation anxiety o Fear of pain or injury/disfigurement o Loss of control (can’t maintain normal schedules and routines) Common responses o Anger, Guilt, Regression Infants By 6 months – realize they are separate beings Can identify primary caregivers (mom, dad and family members) o May feel anxious with strangers separation anxiety o If left alone, hospitalization more traumatic – encourage parents to stay with infant (Encourage someone to stay, because it helps ease the child’s anxiety when someone is there with them**) Can sense parent’s anxiety Hospitalized neonate – offer a pacifier in between feedings TQ Stages of Separation Anxiety Protest – (child has to be taken from parent for a procedure etc.) o Child is agitated, resists caregivers, cries, and is inconsolable. o Child may appear angry and upset Despair o Child feels hopeless and becomes quiet, withdrawn, and apathetic. TQ* Detachment (if parent is gone long enough – long term absence) o Child becomes interested in environment; o Nurse may misinterpret this phase as a positive sign that the child has adjusted to hospitalization – in reality child has given up o may ignore parents' return o parents may think that the child does not want to see them – this reaction is a coping mechanism to protect the child from further emotional pain related to the separation o Parents may misunderstand their child’s reaction as a behavior problem Nurses need to reassure parents that this reaction is a normal response to separation and that most children will not have any permanent effects from the event Children’s Understanding of Health and Illness Different than adults Based primarily on o Cognitive ability at different developmental stages o Previous experiences with healthcare professionals Stressors with Hospitalization Infants Separation anxiety – protest, despair, detachment (encourage someone to stay with them) Fear of injury and pain previous experiences, separation from parents, restraint and preparation affect the reaction of infants and toddlers to pain and bodily injury o Views injury and pain concretely Loss of control often exhibited in behaviors related to feeding, toileting, playing and bedtime o Nurse should remember that each of these activities may have associated rituals and routines and that the child may also show some regression in these areas Infants’ Needs: o Trust o Consistent loving caregivers (helpful if someone is there) o If older then familiar people o Daily routines (try to keep them on their usual schedule) Toddlers (6 months – 30 months/ 13 years old) Begin to understand illness but not its cause (they don’t understand why) Object permanence – know if parent leaves that they still exist Age group most at risk for stressful experience Separation from parent is major stressor – TQ Toddlers’ Needs: o Deep breathing exercises – blowing bubbles – TQ o Autonomy – encouraging toddlers to do things for themselves assists with this developmental task (ex. Feeding self, putting on own socks) TQ ** o Daily routines and rituals following the child’s usual routines for feeding and bedtime helps a hospitalized toddler feel as sense of control TQ o Loss of control may contribute to: Regression of behavior – ex. If they are potty trained and then start wetting themselves again Negativity They are very negative – say “no” often Temper tantrums The Preschooler (36 y/o) Separation anxiety less obvious and less serious than in the toddler. Fear of injury and pain—specifically the fear of mutilation o Procedures that may be painful should be performed in the treatment room so children see their hospital rooms as safe places Loss of control – likes familiar routines and rituals and may show some regression if not allowed to maintain some areas of control o Allow child to decide which color arm board to use with IV if crying, screaming and resisting having an IV restarted – giving choices and control, while maintaining boundaries of treatment, supports the child’s coping skills – TQ o If child’s normal routine and rituals are maintained, cooperation will increase and anxiety will decrease (child who is toilet trained but has many accidents during hospitalization) TQ Guilt and shame – b/c of egocentric thinking Regression – if child used to sleep through the night and now awakens at intervals after a short hospitalization – reassure the parent that regressive behavior after a hospitalization is normal and usually short term TQ Preschoolers Needs: o Egocentric (they can only see the world from their point of view; can not see the world from someone else’s point of view) and magical thinking typical of age – TQ b/c of egocentric thinking – preschoolers may believe that their illness is somehow related to a thought or deed – TQ o Siblings of the hospitalized child that may have magical thinking o Look at whole family – child that may not survive and is taken off of life support o Can make connections (if this happens, then this happens – but is not always right) Nurse should assess child – use therapeutic communication and assist the child in identifying unfounded fears and beliefs o May view illness or hospitalization as punishment for misdeeds, need reassurance o Preoperational thought o Simple explanations of treatment and encourage child to visit hospitalized sibling TQ SchoolAge Children (612 years old) More realistic understanding of illness Like models, drawings as part of explanation Understands more about body parts – heart, lungs, bones Know parent will return, but separation from family and friends still stressful o Start to have a sense of time; know things that they are missing (in school, birthday parties, sports etc.) Fears: pain, stitches, disfigurement Reaction to Illness and Hospitalization The schoolage child Becomes distressed over separation from family and peers Fear of body disability and death** recognize that death is permanent (younger school children do not know how to cope with this well) Asks relevant questions Wants to know the reason for tests and procedures – TQ Allow child to participate in injection play – for child who has to undergo frequent blood work, injections, IV therapy, or any other therapy involving syringes and needles TQ School Age Children’s Needs o Striving for independence and productivity o Fears of death, abandonment, injury o Wants to know the reason for tests and procedures, asks relevant questions o Boredom – as they get better, they start to get bored (is stressful) – laying there and seems bored try interesting them in something else Adolescents Good understanding of illness and body Worry about body image, privacy o Surgery – worry about scarring o Weight gain from corticosteroids o How they look to someone else really becomes an issue Establishing selfidentity – allow choices and control when possible (autonomy) Major stressors of hospitalization – separation from peers* (instead of parents), home, and school o Prolonged hospitalization: TQ select all that apply Encourage parents to bring in homework and schedule study times Allow the adolescent to wear street clothes Encourage parents to bring in favorite foods Adolescents’ Needs o Struggle for independence and liberation o Peer group very important – encourage peers to call and visit when the adolescent’s condition allows TQ o May respond with anger, frustration o Need for information about their condition Maintaining a Safe Place A designated safe area can enhance a child's sense of security. Intrusive procedures should take place in a treatment room, not the child's room. The playroom should not be used for treatments and/or administering medications. Factors Affecting the Child's Response to Hospitalization Perception of events Age and developmental level Cognitive ability Preparation Previous experience Coping skills Parent and family responses (is family there or not) Diagnosis Individual Risk Factors That Increase Vulnerability to Stresses of Hospitalization “Difficult” temperament Lack of fit between child and parent Age (especially between 6 mos and 5 yrs) – 15 month old toddler – separation is the major stressor for children hospitalized between ages 6 and 30 months TQ Male gender Cognitive/Social Impairment Multiple and continuing stresses (e.g., frequent hospitalizations) Changes in the Pediatric Population More serious and complex problems Fragile newborns Children with severe injuries Children with disabilities who have survived because of increased technologic advances More frequent and lengthy stays in hospital Effects of Hospitalization on the Child Effects may be seen before admission, during hospitalization, or after discharge Child’s concept of illness is more important than intellectual maturity in predicting anxiety o Family may have to deal with the aftermath when the child goes home Beneficial Effects of Hospitalization Recovery from illness Increase coping skills Master stress and feel competent in coping (children are proud of themselves after being hospitalized because they got through it – helps them with their confidence) New socialization experiences Effect of Hospitalization on Family Disrupts usual routines o Changes in who is at home with siblings o Changes in who is working May be anxious or fearful o Severity of illness o Watching child suffer pain Stressors and Reaction of the Family Parental reactions o Disbelief, anger, guilt—especially if sudden illness Fear, anxiety—related to child’s pain, seriousness of illness Frustration—especially related to need for information Depression Assessment of family – ask, “ How has your child’s hospitalization affected your family?” TQ Effects on Siblings Less attention from parents May fantasize about illness or injury May fear ill child will die Guilt, insecurity, anxiety, jealousy Behavioral or school problems Nursing strategies Effects of Siblings Sibling reactions o Being younger and experiencing many changes o Being cared for by nonrelatives or outside of the home o Receiving little information about their ill brother or sister o They going to fill in the information for themselves – can be much worse then what is actually going on o Perceiving that parents will treat them differently Altered Family Roles Anger and jealousy between siblings and ill child Ill child obligated to play sick role Parents continue pattern of overprotection and indulgent attention What Can Nurses Do? Tailor care to family’s needs and preferences Honest and open communication View parent as the expert about the child Respect cultural practices Interventions: Planned Admissions Tours familiarity, handle equipment Therapeutic play Health fairs Books Interventions: Unplanned Admissions Orient to unit Explain procedures Discuss expectations o Let them know we are not going to keep them longer then we need to Recognize uncertainty of situation Isolation Added stressor of hospitalization (scary for the child) Child may have limited understanding Dealing with child’s fears Potential for sensory deprivation Play for the Ill Child Play rooms Therapeutic play Teaching through play Play as an emotional outlet Enhancing cooperation Unstructured play Child Life Programs Ageappropriate play o Diversional activities o Toys o Expressive activities o Therapeutic/Dramatic play Preparation for procedures Focus on emotional needs of child Support family in providing child’s care (Parties, games, movies, etc.) Purposes of Play Facilitates normal development Helps child o Learn about health care o Express anxieties o Work through feelings Achieve control o Helps assess knowledge of illness or injury o Therapeutic, dramatic play Toddlers Helps them release tension Playing peekaboo, hideandseek Read books and stories Dolls Building blocks Safe hospital equipment (stethoscopes, syringes without needles) *Be careful with anyone under the age of 3 – small pieces can be ingested *Cap of syringe near child Preschoolers Outline of body Playing with safe hospital equipment Crayons and coloring Puppets, play dough Pet therapy SchoolAge Children Child may regress with hospitalization Collecting objects Games, books, schoolwork, crafts, computers Adolescents Therapeutic recreation Focus on peers Telephone/electronic contact Examples o Pizza parties o Video games o Movie night Rooming In Parent’s stay in child’s room Accommodations made for parents (beds, cots_ Communication between parent and nurse is important Promoting Development and Usual Routines Be aware of developmental tasks based on child’s age Allow for usual routines when possible Parental Presence During Procedures Most parents want to be present Determine extent to which parents want to be involved (parents should never have to hold their child down) o Bear hugs Respect their wishes o If the parent does not want to be in the room during a procedure – must respect that Assessment of Family’s Ability to Care for Child at Home Begins upon admission Financial concerns Equipment needed Medication administration Learning styles Nurse as Teacher/Coordinator Coordinates services Teaches family special skills Equipment Medications Signs and symptoms of distress Emergency actions (CPR) Respite care Follow up appointments with providers Nursing Care of the Family Supporting family members o Child, family, and all professionals involved Providing information Encouraging parent participation Preparing for discharge and home care o Family must be able to demonstrate all aspects of care for the child Pediatric Altered Fluid & Electrolyte Balance Normal Values Review: Acid Base System is regulated by chemical buffering, respiratory control of carbon dioxide and renal regulation of bicarbonate and secretion of hydrogen ions TQ Sensible (measureable loss) – urine Insensible (can’t measure loss) – perspiration, etc Risk Factors: Neonates & Infants o Vulnerable to dehydration Larger extracellular fluid volume TQ Higher daily fluid requirement – higher metabolic rate Small fluid volume reserve Assessment most relevant – heart rate, sensorium, and skin color (early indicators of impending hypovolemic shock) TQ o GI tract is vulnerable to infection Infants to 2 Years of Age o Increased fluid requirements They lose more fluid via GI and GU o Greater body surface area Increases insensible losses o Higher basal metabolic rate Increases insensible losses o Kidney function is immature Kidney function matures at 2 years old When the kidneys are immature, they cannot conserve water or concentrate electrolytes o They can absorb the extra fluid when they need it, like an adult would o GI Tract is vulnerable to infection Older Children o High metabolic and respiratory rates Increases insensible losses o Dehydration can occur easily during physical exercise Especially in hot weather Threats to Balance o High Metabolic Rate + Less interstitial fluid reserve = increased risk for imbalance o Stressors cause imbalances to occur Disease, illness, exercise in hot weather Decreased fluid intake Fluid and electrolyte loss or retention Conditions that Effect Balance o Increased respiratory rate during illness o Fever o Vomiting, Diarrhea o Inadequate intake *Management depends on cause Interventions: o NPO Orders o IV fluids (deficit or overload) o Drainage o Blood sampling, bleeding, burns (pain and fluid/electrolyte problem) o Medications (diuretics, phototherapy newborns) Dehydration *Infants are at greater risk for dehydration because they have an increased extracellular fluid volume Occurs when the total output of fluid exceeds intake o Isotonic is most common in pediatrics o Fluid replacement over 24 hours o Hypotonic – electrolyte deficit exceeds water deficit o Fluid replacement over 24 hours o Hypertonic – water loos exceeds water deficit o Slower replacement rate to prevent a sudden decrease in the sodium level Initial dehydration – (first 3 days) Most fluid loss (80%) from extracellular fluid compartment 20% is from intracellular After 3 days – 6040% Assessment: o Urine, stools, vomitus, tears, sweat o Body weight % o Vital signs (increased HR, increased Respirations, decreased BP) o Behavior o Skin turgor, eyes, mucous membranes o Sunken in fontanel if dehydrated (infants < 18 months – palpable)/ bulging if over hydrated o Skin, capillary refill (normal is less than 2 seconds)*** much more sensitive in pediatrics * know for test – important in recognizing the difference between the three different types Signs & Symptoms o Decreased wet diapers o No tears when crying o Dry & sticky mouth o Lethargy o Poor skin turgor o Increased respiratory rate o Sunken fontanel, sunken eyes with dark circles o Abnormal skin color & temperature Treatment o Rate of fluid replacement depends on the type of dehydration – TQ o Young children may not cooperate with oral rehydration o Oral rehydration (Pedialyte) Rehydration solution with a balance of Na+, glucose and electrolytes, not high in sugar Minimal: ↓ 10kg – give 60 to 120 mL per episode o ↑ 10kg – give 120 to 240 mL per episode slowly then ↑ Moderate: Give 50100 mL/kg in 34 hours Teaspoon, dropper whatever you need to get them to drink it o IV Fluids (Normal saline, D5W w/ normal saline and Potassium*) *Potassium is only added when urine output is established – TQ Nursing Interventions o Monitor weight, lab values (↑ BUN, ↓ bicarbonate level) o Frequent monitoring and reassessment o Assess capillary refill o PRIORITY nursing intervention for a 6 month old infant with diarrhea and dehydration is measuring the infants weight TQ Fluid Volume Excess – weight gain, moist breath sounds, rapid bounding pulse – TQ select all that apply Diarrhea – gastroenteritis, enteritits, colitis, enteroclotitis Types: o Acute Infectious (E. coli, Salmonella, Campylobacter, Staphylococcus, Shigella, cholera, Giardia, Cryptosporidium, Clostridium difficile) o Chronic Underlying condition Causes: o Intestinal infection (bacterial, viral, parasitic, fungal) o Food intolerance o Malabsorption o Medications o Colon disease, IBS o Intestinal obstruction o Emotional stress Prevention o Mostly spread through fecaloral route o Education on personal hygiene o Clean water supply o Careful food preparation o Hand washing Teaching o Increased motility results in impaired absorption of fluid and nutrients rapid emptying of the intestines results in impaired absorption of nutrients and water. Electrolytes are drawn from the extracellular space into stool, and dehydration results – TQ o Antidiarrheal medications – may actually prolong diarrhea because the body will retain the organism causing the diarrhea, further increasing fluid and electrolyte losses. The use of these medications is not recommended for children younger than 2 years old because of their binding nature and potential for toxicity – TQ o Call the physician if the infant has not had a wet diaper for 6 hours – indicates dehydration TQ o Mild diarrhea – rice, potatoes, yogurt, cereal, and cooked carrots – Bland nutritious foods including complex carbs are recommended to prevent dehydration and hasten recovery – TQ o stay away from diary temporarily for a couple of days after an episode of gastroenteritis Vomiting Nursing Interventions o Observe & report vomiting o Assess for dehydration o Implement measures to reduce vomiting Small amounts of fluid at a time Ginger ale o Intake & output o Prevent aspiration Fluid Balance Excess o Weight, pulse, lung sounds, blood pressure, behavior, mucous membranes, neck veins, anterior fontanel (bulging), abdominal girth, skin, urine specific gravity o Parameters to monitor: vital signs and I&O Assessment o Crackles in lungs*** o Detect the cause of vomiting – then treat the cause TQ Treatment o Treat underlying disease o Administer diuretics o Monitor intake & output o Use small IV fluid bags and pumps to regulate IV rate flow for children o Skin care for edematous areas Daily Maintenance Fluid Calculate the child’s wt in Kg Divide pounds by 2.2 to get wt in kg and round to one decimal place!!! (10.18=10.2) Allow 100 mL/kg for the first 10kg body wt (up to 10kg) Allow 50 mL/kg for the second 10kg body wt (1020kg) Allow 20m mL/kg for the remaining body wt (greater than 20kg) Divide by 24 to get the rate to be given per hour 9 lb. 4 oz (4/16) = 0.25 9.25 lb 9.25/ 2.2 = 4.2 kg Example Daily Fluid Calculation for a child weighing 32kg, 8.5kg 32kg 10 x100 =1000 8.5kg 8.5x100=850mL 10x50 = 500 12x20 = 240 1740mL Practice with 7.2kg, 10.6kg, 25.3 kg and 15, 33 and 50 pounds Modifications If the child is 15% dehydrated r take 15% of the daily maintenance fluid and add that amount to the daily amount. If the child is taking fluid by mouth, the amount has to be subtracted HighRisk Infants Neonates are considered to be highrisk infants from birth to 28 days of life Adequate prenatal care is vital in identifying possible problems to premature birth – TQ Neonate pain is expressed: cry face, eye squeeze, increase in blood pressure TQ Classification Birth weight: o Low Birth Weight (LBW) < 2500 grams (5.5 lbs) o Very Low Birth Weight (VLBW) < 1500 grams (3.3 lbs) o Extremely Low Birth Weight (ELBW) < 1000 grams (2.2 lbs) Term o Preterm infants have a greater surface area in proportion to their weight TQ o Late preterm – at increased risk for: problems with thermoregulation, hyperbilirubinemia, and sepsis TQ o Term o Postterm – the nurse recognizes that the fetus may have passed meconium prior to birth as a result of hypoxia in utero (when labor begins, poor oxygen reserves may cause fetal compromise; the fetus may passed meconium as a result of hypoxia before or during labor increasing the risk of meconium aspiration) – TQ Gestational Age: (what’s their weeks gestation and what’s their weight) o Estimation of Gestational Age is based on: Neuromuscular maturity Physical characteristics o AG A (appropriate for gestational age) th o SGA (small for gestational age) infants are defined as below the 10 percentile in growth when compared with other infants of the same gestational age. – TQ Asymmetric intrauterine growth restriction – the head seems large compared with the rest of the body because the infants body is long and thin due to lack of subcutaneous fat TQ o LGA (large for gestational age) – prone to hypoglycemia, polycythemia, and birth injuries TQ Preterm Infants Less than 37 weeks gestation by dates/assessment o Late Preterm Infants: 34 to 37 weeks Etiology: not known o Factors: Multiple gestation, maternal illness/drug use, low income Extent of problems relate to degree of immaturity o Affects organ function, storage Appearance o Scrawny o Bright pink o Extremities are extended, not flexed Thermoregulation Neonates are at risk for thermal instability o They lose heat quickly Consequences of cold stress o Hypoxia o Metabolic acidosis o Hypoglycemia What can be done to regulate their temperature? o Overhead warmer o Doublewall incubators o Humidity o Manual vs. skin temp controlled (auto) Prevention of Heat Loss o Cover the head and feet o Set warming devices appropriately o Avoid drafts and cold surfaces Intervention: to maintain optimal thermoregulation of the premature infant, the nurse should put an undershirt on the infant in the incubator – air currents around an unclothed infant will result in heat loss TQ Hydration These infants are at risk for fluid and electrolyte imbalances o Lose fluid readily o Unable to handle excess due to low body weight and immature kidneys Accurate calculation of fluid needs Parenteral fluids required for long periods, but difficult to maintain o Peripheral IV catheters o PICC lines, Central Venous Catheters (umbilical) o Enteral feedings should be increased Nutrition At risk for nutrition problems due to immature suck and swallow and digestion/absorption but nutrient and calorie needs are high o Preterm infant who should receive gavage feedings instead of a bottle is the who one is unable to coordinate sucking and swallowing – TQ o Infants less than 34 weeks of gestation who weigh less than 1500 g generally have difficulty with bottlefeeding These infants need a ready source of glucose (D10%+) and electrolytes (calcium, phosphorus) These infants may also need TPN until feeding is well established o Infiltrated IV catheters can result in hypoglycemia – (because the high glucose is not going into their vein but going into their skin) Enteral Feedings o Initiated early (small amounts) o Timing adjusted (continuous with 1 hr or 2 off/ bolus feedings – depending on which one they tolerate best) o Type of fluid: breast milk o Method of feeding (tube, nipple) o Colostrum has an increased amount of antibodies o Should be advanced slowly Skin Care At risk for skin breakdown o Skin of preterm infant is immature until 2 to 4 weeks after birth o Gelatinous (looks shinny) Prevent drying, excoriation o No soaps o Few baths (first two weeks use sterile water and very sparingly) o Special adhesives o No solvents – because it is absorbed very easily through their skin Developmental Care At risk for altered development Exposed to inappropriate stimulation – noise, lights o Interrupted sleep (wakes up and cries; inconsolable until held) – ineffective coping related to environmental stress TQ Minimize stimulation and watch for behavioral cues o Try to cluster and allow periods of rest o When they’ve had enough allow them to rest Containment position o The infant will feel as if they are in the womb o Bringing there shoulders forwards and flexing their arms inward Pain management – preemptive analgesia assessment tools methods medications o Sucking on a pacifier distracts them Kangaroo care o Skin to skin contact with parents o Wearing a diaper only Parent psychological tasks Work through events of labor/delivery Anticipatory grieving – prepare for the baby to die to withdraw Deal with feelings of inadequacy and guilt Adapt to the NICU environment Develop parental relationship and care giving roll o Nurse must observe for signs that bonding is not occurring as expected – showing interest in other infants equal to that of their own, decreasing the number and length of visits, refusing offers to hold and care for the infant – TQ select all that apply Prepare for discharge o Parents of high risk infants need special support and detailed contact information – can have profound parental stress and emotional turmoil – parents need support, special teaching, and quick access to various resources available to help them care for their baby TQ Parental Response Birth of a highrisk infant is usually and unexpected and unplanned event o Physical separationencourage visiting, involvement o Encourage the parents to establish early bonding through physical contact (when infant is preterm, on a respiratory with IV lines and a lot of equipment) TQ o Participation in support groups Neonatal loss end of life issues Respiratory Distress Syndrome Diagnosed by ground glass appearance on xray This results due to lung immaturity (preterm) o There is an inadequate production of surfactant (surfactant prevents the alveoli from collapsing each time the infant exhales, thus reducing the work of breathing TQ) o This causes alveolar collapse/atelectasis o Results in impaired gas exchange o Results in increased work of breathing o With hypoxemia/hypercapnea (low O2, high CO2) pulmonary vessels constrict thus the lung is not well perfused Signs & Symptoms o Tachypnea o Retractions o SeeSaw respirations o Crackles o Grunting – TQ help retain some volume on exhalation o Indicates compensatory closing of the glottis o Nasal flaring o Pallor/cyanosis o Apnea o Bradycardia o Poor muscle tone o Unresponsiveness Treatment Goal o Provide airway and ventilator support (because they can’t not move a lot of air on their own) o Maintain adequate tissue perfusion/oxygenation o Maintain neutral thermal environment, fluid/electrolyte balance, nutrition Treatment o Administer exogenous surfactant via endotracheal (ET) tube (directly into the lungs) o Assisted ventilation Types of Assisted Ventilation: o Continuous Positive Airway Pressure (CPAP) o Given by nasal prongs or ET tube in a spontaneously breathing infant Must have adequate spontaneous breaths (30 breaths per minute) o The pressure prevents the complete closure of alveoli o Air, oxygen and pressure o Problem when baby opens their mouth – pressure is lost sometimes intubated if can not manage with nasal canual o Conventional o Intermittent Mandatory Ventilation: (Synchronized)IMV o Positive End Expiratory Pressure (PEEP) – given by ET tube – must be a sealed system These may be synchronized to the infant's breathing pattern and pressure limited (don’t want to rupture the lungs) o Advanced o High Frequency Ventilation o Inhaled Nitric Oxide (vasodilator to get blood flow to the lungs) o ECMO o These pulse small amounts of oxygen to decrease the amount of damage o Mechanical Ventilation o Nursing Care of MV Preterm Infant o Focused Assessments: VS, Respiratory, perfusion, ABG*, placement of the tube (listen to breath sounds – lung collapse and adventitious sounds), make sure they are not struggling to breathe o Nursing Diagnosis: gas exchange, obstruction, etc. o Nursing Interventions o Sudden deterioration: DOPE ET Tube can become Dislodged ET Tube can become Obstructed Developing Pneumothorax Failure of Equipment Always check breath sounds first unless the ET Tube is obviously dislodged Pneumothorax There is air in the pleural space that occurs when alveoli rupture (↑ ventilation pressure) Signs & Symptoms: o Desaturation o Hypotension (cardiac output drops because heart is being compressed) o Unequal or no chest rise* o Decreased breath sounds o ***Urgent care needed Treatment decompression of the pleural cavity is needed o Placement of chest tube (higher up in the chest to drain the air) o Needle aspiration o Place the baby in an upright position o Put the tip of the catheter (stainless steel needle) into 2 /3 intercostal space and remove air until chest tube is placed o Early recognition is vital *** Bronchopulmonary Dysplasia (BPD) Chronic lung disease that results from lung injury from high pressures and oxygen Signs & Symptoms: o Unable to wean from ventilator or oxygen* o Dyspnea o Bronchospasm o Wheezing o Air trapping o Barrel chest/flat diaphragm *good thing is that babies usually out grow this disease because they generate new lung tissue Treatment: o Positioning (upright position, not laying them flat) o Supplemental oxygen/ventilation (via a tracheostomy) o Medications: o Bronchodilators o Diuretics o Steroids o Patient education – care needed at home Apnea Cessation of breathing for more than 20 seconds o Accompanied with cyanosis, pallor, low tone, bradycardia (most common in newborn) o Not uncommon for preterm babies to do this o Treated with caffeine Apparent Life Threatening Event (ALTE) o Apnea accompanied by color change, low muscle tone, choking, gagging in near term/term infant o This can occur during sleep, wake times, feeding o Causes: o Reflux o Seizures o Breath holding o Neuromuscular disorders o Cardiac anomalies, arrhythmias o Respiratory disorders o Small mandibles o Obstructive sleep apnea o Metabolic/endocrine disorders o Child abuse Retinopathy of Prematurity (ROP) Vascular changes in the retina of a preterm infant that may result in blindness o This happens because vascular tissue is not mature in a preterm infant Results from wide swings in PaO2 levels (high arterial blood oxygen level) TQ o Causes the vessels to proliferate o If oxygen levels on O2 sat is 100% all of the time, notify doctor and have the oxygen levels lowere