Download - Chronically ill child
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The Chronically ILL Child
By: Rogei Taro RN, MAN
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Common Health
problems of gas
exchange among
CHILDREN
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Asthma
*Chronic inflammatory disorder of the airways
*Characterized by recurrent episodes of wheezing, breathlessness, chest tightness and coughing(+) increased responsiveness of the airways to multiple stimuliTriad: cough, dyspnea and wheezing
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Allergies; heredity; environmental factors; respiratory viruses; exercise and emotional stress.
CAUSES:
Asthma triggersViral infections; exercise; irritants; foods; indoor inhalants; pollens; and emotionsAmong Filipinos (dust, smoke, strong odors, temperature changes, exertion, URTI and food)
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STIMULUS
Chemical mediator release
Bronchospasm Inflammatory cell
activation
Epithelial
damageEdema
mucus
production
Increased airway resistance, obstruction
And airflow obstruction
ACUTE ASTHMA ATTACK
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Chest tightness, dyspnea, wheezing, cough,
tachypnea and tachycardia, anxiety and
apprehension
Manifestations:
STATUS ASTHMATICUS
Severe prolonged asthma that does
not respond to routine treatment
(hypoxemia, hypercarpnia and
acidosis)
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Collaborative care
-Diagnostic tests
Pulmonary function tests
Challenge of bronchial
provocation testing
ABGs
Skin testing
-Disease monitoring
Peak expiratory flow rate
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Medications:
Expectorants(guaiafenesisin)/mucolytic
Antitussives
Dextrometrophan
Bronchodilators
Aminophylline
Salbutamol(ventolin)
Terbutaline(bricanyl)
Metaproterenol(Alupent
Antihistamine
Benadryl
Steroids (prednisone,dexamethasone)
Antimicrobials
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Nursing Care
Health promotion
Assessment
Nursing Diagnoses and Interventions
Ineffective airway clearance
(bronchospasm,
bronchoconstriction, increased
mucus production and airway
edema)
Frequently assess respiratory
status; RR and depth, chest
movement or excursion, breath
sounds and PEFR
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Monitor skin color and temperature and LOC
(cyanosis, cool clammy skin, and changes in
LOC
Assess ABG results and pulse oximetry
readings; notify the physician of abnormal
values or changes in status
Place in Fowler’s, high – Fowler’s, or
orthopneic position to facilitate breathing
and lung expansion
Administer oxygen as ordered. If a mask is
used, monitor closely for feelings of
claustrophobia or suffocation
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Administer nebulizer treatments and
provide humidification as ordered
Initiate or assist with chest
physiotherapy, including percussion
and postural drainage
Increase fluid intake
Provide ET suctioning as needed
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Ineffective breathing patternMonitor VS and laboratory results
Assist with ADLs as needed
Provide rest periods between scheduled activities
and treatments
Teach and assist to use techniques to control breathing pattern
Pursed – lip breathing, helps keep airway open by maintaining positive pressureAbdominal breathing, improves lung expansionRelaxation techniques including visualization, medication, reduce anxiety and its effect on RRAdminister medications as ordered
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“ natural asthma remedies -
specific bioflavonoids & enzymes
that genuinely work to safely
eliminate asthma and allergy
symptoms by addressing the cause
not simply masking the
symptoms.”
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SINUSITIS
Inflammation of the mucous membranes of one or
more of the sinuses
Follows URI such as viral upper respiratory
infection or influenza
Etiologic agent:
Streptococci, S. pneumoniae, H. Influenzae and
Staphylococci
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Pathology
Mucus secretions collect in the sinus cavity spread to the opening of the nasal turbinates (draws serum and leukocytes to the area to combat the infection swelling and pressure
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Precipitating factors:Nasal polyps, deviated septum, rhinitis, tooth abscess or swimming or diving trauma; after prolonged intubation
May be acute (pain constant and severe) or chronic (dull and may be constant or intermittent)
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Complications:LOCAL COMPLICATIONS
Orbital cellulitis, subperiostealabscess; orbital abscess, cavernous sinus thrombosis; mucocele, OM
INTRACRANIAL COMPLICATIONS
Meningitis, epidural abscess, subdural abscess, brain abscess and venous sinus thrombosis
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Manifestations
-Often looks sick
-Pain ( with leaning forward)
and tenderness across the
infected sinuses; headache; fever
and malaise
Maxillary pain and pressure
over the cheek; referred to the
teeth
Frontal pain and tenderness
across the lower forehead
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Collaborative Care-Diagnostic Tests
Sinus x-rays; CT scan and MRI
-Medications
Antibiotic therapy (full 2 week
course)
Oral or topical decongestants
(reduce mucosal edema and
promote sinus drainage.
Anti – histamines ( nasal congestion and
facilitate sinus drainage)
Saline nose drops or sprays
Systemic mucolytic agents
-Aerobic exercise
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Nursing Care
Assessment
Nursing diagnoses and interventions
Pain
Assess pain using a standardized pain scale.
Administer analgesics as ordered
Apply ice packs to the nose
Elevate the head of the bed to fowler’s or high
fowler’s position for 24 - 48 hours after surgery
Imbalanced nutrition: less than body requirements
Provide clear liquid diet progressing to soft foods
as tolerated. High calorie dietary supplements
may be used.
MIO and weight.
Elevate head of the bed during meals.
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“ Bromelain, an enzyme derived
from pineapple, has been
proven effective to relieve
symptoms of sinusitis.”
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Common
Cardiovascular
Disorder among
Children
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Infective Endocarditis
Inflammatory process
of the endocardium,
especially the valves due to
infections.
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• Etiology:
- leading causative agent: S. aureus
- Congenital Malformation
- cardiomyopathy
- Fungal organisms – after open heart
surgery
- S. viridans – after dental procedure
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CAUSATIVE AGENTSStaphylococci; streptococci; E. coli; gram (–)
organisms; and fungi
After dental procedures, mouth or tooth
abscesses; oral irrigations or oral irritations
from dental floss or bridgework
Upper respiratory tract infection;
Hematogenous route .
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PATHOPHYSIOLOGYHEMATOGENOUS colonization at the
endothelium bacterial replication and
colony formation + fibrins and platelets
humoral immune system (antibody reaction)
vegetations clot formation abscess
formation untreated heart failure due to
structural valvular damage.
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Clinical Manifestations
Fever, chills, alternating with sweats , body malaise,
weakness, anorexia, weight loss, pallor, backache, and
splenomegaly.
“roth spots
-retinal hemorrhage)
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osler’s nodes (painful, erythematous, pea-
sized nodules on tips of the fingers and toes.
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Janeway’s lesions (flat, small, non-tender
red spots )
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Diagnostic TestBlood cultures
Ultrasonography
Echocardiograpy
ECG
radiography
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Medical Management
Pharmacotherapy
IV antibiotics for 2-6 weeks
(gentamycin,penicillin)
Anti-fungal agents(Amphotericin
B)
Surgery
-valvular replacement
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“ MicroRNAs Add a New
Dimension to Cardiovascular
Disease such as In infective
Endocarditis “
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Congested Heart Disease
in Children
Syndrome congestion of both
pulmonary and systemic
circulation due to inadequate
cardiac function.
CauseStructural heart Dis. (eg, aortic stenosis,septal defect))
Pulmonary venous obstructions
Cardiomyopathy
Pericardial Effusion
Arrhythmias (tachycardia or bradycardia)
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Signs and symptoms of congestive heart disease include the
following:
Tachycardia
Venous congestion
Right-sided
Hepatomegaly
Ascites
Pleural effusion
Edema
Jugular venous distension
Left-sided
Tachypnea
Retractions
Nasal flaring or grunting
Rales
Pulmonary edema
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Work up
History taking & Physical Exam.
Oxygen saturation,CBC,Hemoglobin
concentrations,
electrolyte levels ,BUN & Creatinine
levels, hepatic and renal functions
12-lead ECG,Echocardiography
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Treatment Medications
-digitalis(digoxin)
-diuretics (diuril,furosemide,aldactone)
-
vasodilators(hydralazine,nifedipine,captopril)
-Inotropic agents(dopamine,dobutamine)
Diet (Na restricted diet )
Activity-balanced program of activity and
rest
Oxygen therapy
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Nursing Management
facilitate oxygenation(semi-fowler’s position)
Promote rest & activity
facilitate fluid balance(control Na
intake,monitor I & O)
Provide skin care (change position
frequently,assess pressure areas)
Promote nutrition(bland,low calorie diet)
Provide emotional support
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“ Cardiac Resynchronization
therapy(CRT)-emerged as
useful therapy in the
treatment of CHF ”
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Common immune
disease among
Children….
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Systemic Lupus Erythematous
-Chronic multisystem, collagen disorder-it is a lot more common in young people
than is generally believed.
Causes:
Unknown
Autoimmune
Drugs
Viral
Genetic
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Malar Rash in females; 15-40 years of
age
Precipitated by:Pronestyl, Phenergan,
Apresoline, Dilantin, INH,
Quinidine
Diagnostic testsCBC (pancytopenia), ESR, ANA,
Anti – DNA, LE factor
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Management:
*Rest, ROM exercises, prevent
infection, avoid exposure to sunlight,
calcium, protein diet, pharmacotherapy
(ASA, steroids, NSAID, anti-malarial,
cytotoxic agents)
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“Flaxseed & Fish oil as a relief for Lupus
Symptoms”
-
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Juvenile idiopathic Arthritis
(Juvenile Rheumatoid Arthritis)
- It is an autoimmune disease affecting
children causing inflammation of
different joints.
Cause: Unknown-Research indicates that it is an autoimmune disease.
where, white blood cells lose the ability to tell the
difference between the body's own healthy cells and
harmful invaders like bacteria and viruses
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Manifestations:
limping or a sore wrist, finger, or knee.
Joints may suddenly swell and remain
enlarged.
Stiffness in the neck, hips, or other joints
can also occur.
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How to Diagnose JIA?
Detailed Medical History
Physical Examination
Blood Test(CBC,ESR,RF test, ANA)
Blood culture
Bone scan
removal of joint fluid in synovium -
(arthrocentesis)cloudy,milky white,increase
WBC;normal: clear synovial fluid
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Collaborative Management
Physical therapy
Regular exercise
Injection of corticosteroids into the joints or
surgery(in some situation)
Provide Emotional comfort
Medications:
oNSAID’s like ibuprofen (such as Advil or Motrin)
oCorticosteroids
omethotrexate.
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The goals of treatment are to
relieve pain and inflammation,
slow down or prevent the
destruction of joints, and restore
use and function of the joints.
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Aggressive combination drug
therapy in early polyarticular
juvenile idiopathic arthritis.
(infliximab plus methotrexate)
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Common Hematologic
disorder in children
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Iron-deficiency anemia
-Is a decrease of Hgb and RBC’s in bloodstream
often caused by insufficient iron intake,
-it is the major cause of anemia in childhood.
Causes of IDAinsufficient iron in the diet
poor absorption of iron by the body
ongoing blood loss, most commonly from
menstruation or from gradual blood loss in the
intestinal tract
periods of rapid growth
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Signs & Symptoms
fatigue and weakness
pale skin and mucous membranes
rapid heartbeat or a new heart murmur
(detected in an exam by your child's
doctor)
irritability
decreased appetite
dizziness or a feeling of being
lightheaded
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Diagnostic Test
Routine Physical Exam.
CBC
Reticulocyte count
Serum ferritin
ManagementIron Supplements
DIET: foods rich in iron
Foods rich in Vitamin C(citrus fruits)
-Promote rest, provide good oral & skin
care.
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Research Says:
Kids under 2 years old should have no more than
24 ounces of cow's milk a day. Milk can inhibit
absorption of iron, and drinking too much milk
can dampen a child's appetite for other iron-rich
foods. In addition, too much cow's milk has been
shown to irritate the gastrointestinal tract, which
may cause intestinal bleeding — a cause of iron
loss.
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Pernicious Anemia-(macrocytic,hyperchromic anemia)
decrease serum vit.B-12 due to decrease
absorption bound by intrinsic factor secreted at
parietal cells of the stomach.
Cause:
*Familial incidence
* autoimmune disorder associated
with gastric mucosal atrophy.
*Parasites that competes for
nutrient (tapeworm)
*inadequate dietary intake of vit.B12
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Clinical manifestations:
“Beefy” red,inflammed tongue
Tingling & numbness of extremities
fatigue,pallor,SOB
confusion
depression, psychosis
jaundice(faulty erythropoiesis)
Dizziness & headaches
reduced sense of taste.
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Diagnostic test
Gastric analysis(-)hcl
Schilling test
Full blood count ,
Management:-vitamin B12 oral & injectable (lifetime)
-Hydrochloric acid p.o. for 1 week
-blood transfusion as needed
-physical exam. Every 6 mos.
*at risk of gastric cancer
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Nursing Care
Monitor for signs/symptoms of
hypoxia
increase dietary intake
Provide emotional support
Promote rest & Safety
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Pernicious Anemia Test
*A new test for PA that doesn't test
your blood's Haemoglobin levels.
*This test checks for antibodies that
bind with a glycoprotein called
Intrinsic Factor (IF).
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Common
Gastro-
intestinal
disorder in
children
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Chronic inflammatory
bowel disease
ULCERATIVE COLITIS
CROHN’S DISEASE
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Recurrent ulcerative and inflammatory disease of the mucosal layer of the colon and rectumExacerbation and remissions
Ulcerative Colitis
Cause: Unknown
Familial
Emotional stress
Age: 15-40 years
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Predominant symptoms: diarrhea, abdominal pain, intermittent tenesmus and rectal bleedingAnorexia, weight loss, fever, vomiting, DHN; cramping, feeling of urgent need to defecate, passage of 10-20 liquid stools a day
(+) extraintestinal manifestations :
erythema nodosum; pyoderma
gangrenosum; perianal disease is less than
in Crohn’s
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Distinguishing features from Crohn’s:
Absence of small bowel involvement
Limitation to the mucosa
Subsequent freedom from deep ulceration
and fistula formation
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Endoscopic appearance
Diagnostic Procedure:
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Management Diet: initiate low fiber diet Sulfasalazine: reduce the synthesis of
prostaglandin and leukotrienesAminosalicylates: less side-effects than
sulfasalazineCorticosteroidsImmunosuppressive agents: cyclosporin and
azathioprineAntibiotics: metronidazole, aminoglycosidesAntidiarrheal agents: for patients who are not
severely illIleostomy/proctocolectomy
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Complications
PerforationIntractable hemorrhageToxic megacolonSclerosing cholangitisColonic carcinoma
Duration of colitis Extent of colonic involvementTotal colitis: 15% at 20 years
Mucosal dysplasia : pre-malignant
Surgical
emergencies
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Also called: Regional enteritis
Occur anywhere along the GI tract, but the
most common areas are the distal ileum and
colon
(+) fistula, fissure, abscesses
(+) prominent abdominal pain and diarrhea
unrelieved by defecation
(+) weight loss, malnutrition and secondary
anemia
Crohn’s Disease
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Unpredictable course
Spontaneous remission and
relapses
Extraintestinal manifestations
aphtous oral ulceration;
erythema nodosum;
pyoderma gangrenosum
Iritis; arthopathy;
sacroilitis
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Symptoms of Crohn’s Disease
•Diarrhea 70 - 90%
•Rectal bleeding 45%
•Abdominal pain 45 - 66%
•Anal lesions 50 - 80%
•Weight loss 65 - 75%
•Fever 30 - 40 %
•Fistula 8 - 10%
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Therapeutic mgt.Steroids, sulfonamides;
antibiotic; TPN
CONTROL DIARRHEA; CONTROL INFLAMMATION
RELIEVE PAIN; RESTORE FLUIDANTI-CHOLINERGICS; ANTIMICROBIALSMEALS – CORRECT NUTRITIONAL
DEFICIENCIESPSYCHOLOGICAL COUNSELLINGSUPPORT EMOTIONALLY/COPING
Diagnostic Procedure:
Endoscopy
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New Imaging Technology Improves
Diagnosis of Bowel Disease
(Capsule endoscopy )
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THANK YOU!!!