Download Recall from Week 10

Week 12 - - KIDS’ COMMUNITY HEALTH CLINIC DAY
Case Study Readings
(a) Scoliosis p. 1773, 1810
 abnormal lateral curvature of spine with spinal rotation -most common in adolescent
girls
 most cases are idiopathic, some associated with neuromuscular conditions
 screening:
 early detection prevents permanent scoliosis
 check for uneven shoulder & hip levels (p. 1810, fig. 39-35)
 signs & symptoms
 presence of spinal curve
 asymmetry of scapula
 unequal distance between arms and waist
 backache, fatigue
 late changes: impaired resp. function
 management
 Boston or Milwaukee brace
 surgery – insertion of rods, fusions
 interventions (Nursing Care Plan, p. 1815)
 teach management of brace, skin care
 pre-op & post-op care
 pain management
 neurovascular assessments
 skin care
 maintain alignment
 promote positive self-concept
Legg-Perthes p.1807
 aseptic necrosis of femoral head - self-limiting (18 mos. to several yrs.)
 stages:
 avascular - aseptic necrosis of epiphysis
 revascularization - bone absorption & revascularization
 reparative - new bone formation
 regenerative - reformation of head of femur
 signs & symptoms:
 pain in hip, referred to thigh, knee
 stiffness,  ROM to hip, limp on affected side
 management
 goal: keep head of femur in acetabulum until it reforms
 rest, traction, active motion (non wt. bearing)
 no weight bearing during early stages
 braces, casts - surgical reconstruction as needed
 interventions
 promote comfort - analgesics, anti-inflammatories
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promote mobility - active ROM activities
teaching - use of braces, allowable activities
provide diversionary activities
(b) Hip dysplasia, Clubfoot, Hypotonia, Hypothyroidism
Congenital dislocation of the hip [hip dysplasia]
 abnormal development of proximal femur or acetabulum – may be preluxed, subluxed
or complete dislocation – more common in females
 assessment – “classic” signs (p.449, Fig. 11-10)
 asymmetry of gluteal folds
 unequal leg lengths – affected leg is shorter; decreased abduction of hip
 Ortolani’s sign – click heard on affected side
 Barlow’s sign – feeling of hip slippage
 later childhood – limping, toe walking, Trendelenburg sign
 confirmed by x-ray or u/s
 management
 maintain hip in flexed, abducted position – hip will mold into shape
 Pavlik harness (p.450, Fig 11-11) or splint
 spica cast, traction (Bryant’s with spread of pulleys)
 surgery may be required in few cases
 nursing diagnoses
 impaired mobility r/t deformity & treatment techniques
 risk for injury r/t neurovascular impairment
 knowledge deficit (parent) r/t unfamiliar treatments
 interventions
 early recognition – newborn checks
 neurovascular checks
 maintain positioning, skin care, comfort, exercise
 teaching re: cast/splint care, managing immobility
Clubfoot [talipes] p.451-453
 types:
 common deformity - 1:1000 births
 true clubfoot – genetic defect – prevents manipulation into correct position
 positional deformity – occurs in utero – involves bones, muscles, tendons
 more common in boys
 unilateral or bilateral
 varus – inversion – foot turns inward
occur in combination –
 valgus – eversion – foot turns outward
 equinus – plantar flexion
equinovarus most common
 calcanus - dorsiflexion
 assessment
 management
 serial casting – gradually stretch muscles – change q1-2 wks
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 Denis-Brown splint – shoes connected to metal rod
 true clubfoot or late diagnosis may require surgery (age 4-9 mos)
nursing diagnoses
 impaired mobility r/t deformity & treatment techniques
 risk for injury r/t neurovascular impairment
 knowledge deficit (parent) r/t unfamiliar treatments
interventions
 neurovascular checks
 cast care, skin care, comfort
 teaching re: cast care, managing immobility
 exercises (stretching & ROM)
Hypotonia
 decreased muscle tone – floppy, like a "rag doll"
 often a sign of abnormality – CNS, genetic or muscle disorders.
Hypothyroidism
 deficiency in secretion of thyroid hormone – congenital or acquired
 s&s:
o delayed g&d
o dry skin, sparse hair
o mental sluggishness
 treatment: hormone replacement
(c) Tattoos and piercings
Handout: Selikman, J. (2003) A New Era of Body Decoration.
See “Tattooing and Body Piercing: Decision Making for Teens”
http://www.vh.org/pediatric/patient/dermatology/tattoo/
(d) Grieving in children p.968-972
Understanding of death at various ages: p. 970
o Infant & toddler – no comprehension of death
o Preschool – think death is reversible – terms like "sleep" are understood literally (may
become afraid to go to bed)
 feel their thoughts are powerful – may feel they have caused the death
 repeated questions about death
o School age – begin to understand permanence of death
 curious about physical details
 accept parents' religious beliefs re: life after death
 need tangible ways to show grief
o Adolescent – understand death, but tend to feel it won't happen to them
 fear of pain and process of dying
Additional information at http://www.synspectrum.com/childgrief.doc
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Zoonotic disorders http://www.zoonotic-diseases.com/html/summary.html
 disease of animals that may be transmitted to man under natural conditions
 people at risk
 infants and small children (immature immune systems, hands in mouth)
 pregnant women (susceptible immune systems, fetal hazards)
 many diseases - examples:
 insect-borne – Lyme disease, West Nile virus, malaria
 pets – scratches, allergies, Cat Scratch fever, rabies, toxoplasmosis
 farm animals – brucellosis, salmonella, Mad Cow (BSE)
 wild animals – tuberculosis
(e) Type 1 Diabetes (Juvenile diabetes) p. 1732-1752
Recall information from 63-273, Fall 02
o autoimmune disease - immune system destruction of insulin-producing beta cells in
the pancreas
o autoimmune, genetic, and environmental factors (possibly viruses)
o 5 to 10 percent of diagnosed diabetes
o children can also develop Type 2 diabetes and MODY
o develops most often in children and young adults
o signs & symptoms
 hyperglycemia
  increased thirst
  urination
 constant hunger
 weight loss, blurred vision, and extreme fatigue.
 may develop diabetic ketoacidosis (DKA) – dehydration, acidosis, ketosis
o management:
 balance of insulin, exercise, diet
 goal is to maintain near-normal blood sugars, but avoid frequent
hypoglycemia Recall DCCT research from last semester.
 frequent monitoring of blood glucose levels & regular check of HgA1c
 insulin
 multiple daily doses, combination of long-acting/short acting
 s/c injections, insulin pumps
 future – islet cell transplants
 exercise -  need for insulin
 nutrition – adequate calories for metabolic needs & growth
 time eating to coincide with peak levels of insulin
 use of “exchanges” or carb counting (becoming more common)
o complications: (p. 1740, Table 38.5)
 hypoglycemia/insulin reaction – BS<4.0 with symptoms such as shakiness,
hunger – can become confused, comatose seizure
 treat with 15 g carbohydrate (juice, sugar tabs) + long-acting carb &
protein to stabilize BS
 glucagon for severe reaction
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hyperglycemia – elevated BS >13 over sustained period
 can develop DKA - +ve ketones, acidosis, dehydration
 requires IV fluid therapy + insulin
o Somogyi effect – elevated morning glucose levels because of rebound from
hypoglycemia through the night – need less insulin at bedtime, not more.
o honeymoon period – interval soon after diagnosis when insulin needs are low because
there is still some pancreatic functioning
o nursing care: NCP p. 1753-55
 education is key –family (+child) will have to assume responsibility for all
day-to-day aspects
 development of collaborative relationship between child, family & health care
team
(f) Foreign bodies
Nasal
 children may insert small objects into their nose
 may include food, seeds, dried beans, small toys, crayon pieces, erasers, paper wads,
cotton and beads.
 A foreign body allowed to remain in the nose may lead to irritation, infection, and
obstruction to breathing.
 symptoms
 foul-smelling or bloody nasal discharge
 difficulty breathing through the affected nostril
 irritation
 sensation of something in the nostril
 Do not probe the nose with cotton swabs or other tools
 Have the child breathe through the mouth and avoid breathing in sharply (which may
force the object in further).
 Once it is determined which nostril is affected, gently press the other nostril closed
and have the victim blow gently through the affected nostril. Avoid blowing the nose
too hard or repeatedly. If this method fails, get medical help.
 DO NOT try to remove an object that is not visible and easy to grasp; doing so may
push the object farther in or cause damage to tissue.
 DO NOT use tweezers or other instruments to remove an object lodged deeply in the
nose.
Prevention
 Keep small objects out of the reach of infants and toddlers.
 Discourage child from putting foreign objects into body openings.
Ear
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less common than in nose
can be difficult to remove because the ear canal is basically a tube through solid
bone that is lined with thin and very sensitive skin.
DO NOT attempt to remove the foreign object by probing with a cotton swab, pin,
or any other tool. To do so will risk pushing the object farther into the ear and
damaging the middle ear.
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DO NOT reach inside the ear canal with tweezers.
(g) Skin rashes
Recall from Week 10 – Sally Agua
 skin redness or inflammation; lesion; erythema
 cause of a rash may be determined from its visible characteristics and other
symptoms.
Common Causes
 Contact dermatitis following exposure to:
o Dyes and other chemicals found in clothing
o Chemicals found in elastic and rubber products
o Cosmetics
o Feminine deodorants
o Poison ivy and poison oak
 Eczema
 Medications or insect bites that cause allergic reactions
 Various diseases cause rashes, including:
o Measles
o Lupus erythematosus
o Roseola
o Hand-foot-mouth disease
o Fifth disease
o Juvenile arthritis
o Kawasaki disease
Care
 gentle skin care and avoidance of irritating substances.
 avoid scrubbing the skin, minimize the use of soap (using gentle cleansers when
possible), and moisturize frequently.
 eliminate any newly added soaps or lotions.
 hydrocortisone cream (1%)
(h) Gastro-esophageal reflux (GER) p. 1429
 transfer of gastric contents into esophagus – dysfunction of lower esophageal
sphincter
 most common age 1-4 months; usually resolves by 1 yr.
 risk factors: prematurity, bronchopulmonary dysplasia, cerebral palsy
 s&s:
 passive regurgitation of feedings, vomiting
 poor weight gain, anemia
 risk of aspiration respiratory infections, distress
 long-term – esophagitis – bleeding, pain in esophagus
 diagnostic tests: barium swallow, endoscopy
 treatment:
 small frequent feedings; thickened feedings
 positioning – prone, elevated head; avoid sitting ( intra-abdominal pressure)
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medications – ranitidine (Zantac), metoclopramide (Reglan)
surgery for severe cases – fundoplication (p.1430, Fig 33.3)
(i) Epistaxis
 nosebleeds
 causes: trauma, nose picking, dry air, irritants, foreign body, anti-coagulants, cocaine
use, bleeding disorder (e.g. von Willebrand disease)
 p. 1567 – Emergency Treatment
(j) Obesity, Hyperlipidemia, Hypertension
Obesity p.870
 22-33% of children
 obesity: above 95th percentile for weight – excessive body fat
 risk for: hyperlipidemia (hypercholesterolemia), hypertension, respiratory disorders,
cholelithiasis, Type 2 diabetes
 related factors: genetics, endocrine problems, lifestyle – nutrition, exercise
 17% of children who watch >4 hrs TV a day are obese (Crespo, 2001)
Hyperlipidemia
 normal values: cholesterol - >4.4 mmoL/L –borderline 4.4-5.1 mmoL/L
 LDL-c – 2.84 mmoL/L – borderline 2.84-3.34 mmol/L
 risk factor for CAD
 reduced by  LDLs and  HDLs
 management: dietary, medication – e.g. Questran
Hypertension
Recall norms for children
 consistent elevation beyond upper limits of normal
 factors: primary: heredity, lifestyle – dietary, obesity
 secondary: most common cause is renal disease (p.1517, box 34.10)
 s&s: headaches, vision changes, dizziness
 management:
 treatment of underlying cause, if known
 lifestyle changes – weight loss, limit salt,  exercise, avoid smoking
 medications – ACE inhibitors (e.g. captopril), beta blockers (propanolol)
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