Chapter 23

Otitis externa

Swimmer's earAcute infection of external canal

SS: pain and tenderness with manipulation of the tragusTympanic membrane will look normalTX: Irrigation and topical antibiotics or antivirals 

Acute otitis Media

Inflammation of the middle ear middle ear opens into sinuses and connected to throat by eustachian tube (Lined by mucous membranes) Considered chronic if persists >3months Causes: after URI, strep, H-influenzae Infants more prone due to shorter eustachian tubes TX throat culture broad antibiotics, pain control 

SS pain irritability and diminished hearing Fever as high as 104, HA diarrhea and febrile seizures tympanic membrane reddened and bulging Infantsgeneral irritability, frequent rubbing or pulling at the ear and rolling of the head from side to sideIf an abcess forms a rupture of the eardrum may result and drainage of the ear 

Hearing Impairment

Types Congenital Deafness: child born with impairment Acquired: from measles, mumps, chickenpox, or meningitis-the common cold, some meds, exposure to loud noises, allergies, ear infections TEMPORARY: earwax(size of pea can cause hearing loss) DiagnosisLack of response to sounds or music, lack of startle reflex <4 months

Can be defects in sound transmission, damage to auditory nerve or ear structures, or from a mixed hearing loss that involves both nerve pathways and sound transmission Nursing Care: Get to eye lvl and face to face, eye contact, short sentences Visual aids, writing or drawing watch body language

Barotrauma

Change in atmospheric pressure causing pain chew gum, yawn Infants: bottle fed juice or water to promote swallowing  decongestants: taken when peak time is during airplane descent 

Underwater diving slow descent SS: hearing loss and vertigo with nausea and vomiting early signs Do Not Dive with URI or tympanic membrane perforation::vertigo n/v and disorientation can occur with dangerous results

Eyes

Developing at 4 weeks, less spherical 3-6 months infants can move eyes to follow people or objects1-3 months tears can be seen 9 months for depth perception 6 wks should be able to focus on object2.5-3 acuity tests using pictures if alphabet not known

Dyslexia defect in the cortex of the brain the processes graphic symbols  TX: remedial instruction Amblyopia Reduction or loss in vision for children who strongly favor one eye TX: patching off good eye, eyeglasses  At risk to age of 9

Eyes

Strabismus cross-eye: cannot direct both eyes toward same object--lack in muscle coordination--if not corrected can result in permanent damage  squinting or frowning, miss objects they reach for, tilt the head or cover one eye TX: patch good eye, can improve through use, eye exercises and glasses--surgery for when this is ineffective(3-4 years old) EyeStrain SS: inflammations, burning or aching of the eyes, squinting, short attention span, HA, difficultly with school work Teach, observe and refer to prevent complications

Conjunctivitis  inflammation of the conjunctiva, mucous membrane that lines the eyelids can be bacterial, viral, allergens, irritants, toxins and systemic diseases or blocked lacrimal duct TX: warm compresses and topical antibiotic eyedrops/ointment SS: edema, itching, crusting, pinkeye Hyphema presence of blood in anterior chamber of the eye (most common ocular injury) Forceful coughing or sneezing can cause this TX: topical meds, head of bed to 30-45 degrees to decrease intraocular pressure

Retinoblastoma

Malignant tumor of the retinayellowish, white reflex is seen in the pupil because of tumor behind the lens (cat-eye reflex)SS: loss of vision strabismus, hyphema and in advanced tumors, painTX:standard tx is enucleation (removal of eye) is no hope of saving visionsmaller tx w/ laser to destroy blood vessels supplying tumor or chemo/radiation

Nervous system neurological disabilities: congenital malformation, brain injure, infection ALOC: PaO2 below 60, PaCO2 above 45, decreased BP cause hypoxia, fever ( 1 degree increase, increases o2 needs by 10%) medications, seizures or increased cranial pressure

Conditions

Reye's Syndrome acute noninflammatory encephalopathy and hepatopathy that follows viral infection in children may be relationship b/w aspirin (acetylsalicylic acid) during viral flu or chickenpox SS: toxic lvls of ammonia in blood (cerebral edema, increased ICP) which causes altered behavior, ALOC, seizures and coma Sudden onset of effortless vomiting, lethargy (children) diarrhea, hypoglycemia, tachypnea, seizures 1 wk after RR illness TX:Early as possible, reducing ICP and airways, cerebral O2 and fluid electrolyte balance

Sepsis systemic response to infection from bacteria/viral/fungal systemic inflammatory response syndrome (SIRS) Untreated: septic shock Multiorgan dysfunction syndrome (MODS) SS fever, chills, tachypnea, tachycardia and lethargy septic shock is not diagnosed by decrease in BP b/c infant compensates by ^HR hypotension is ominous sign that body is unable to compensate  Blood work and spinal tap

Brain

Menigitisinflammation of the meninges: measles, mumps, herpes, H influenza, sepsis SS purulent(bacterial) mainly from intracranial irritation: poor feeding, HA, restlessness, fever, vomiting, stiffness of the neck (nuchal rigidity), delirium HIGH PITCHED CRY( infants) seizures are common, severe (involuntary arching of the back) petechiae rash TX Spinal Tap (cloudy) isolation(droplet) for 24hr after antibiotics 10-14 days Nursing: frequent neuro checks, vitals, I&O's, dim room decrease noise Report: slow pulse, irregular RR and ^BP (indicates ^ICP)

Encephalitis inflammation of the brain, encephalomyelitis is when spinal cord is also infected Toga-viruses and herpes 1 and 2 can cause this, can also follow URI, rubella or measles, rare from DTaP, or bacteria, fungi SS CNS response to irritation: HA followed by drowsy that may proceed to coma (sleeping sickness) Seizures (infants) fever, cramps, ab pain, vomiting, nuchal rigid, delirium, muscle twitching and ab eye movements TX sedatives and antipyretics, seizure precautions, adequate fluids and nutrition, neuro checks Speech, mental processes and motor abilities may be slowed and permanent brain damage can result

Brain Tumors 2nd most common neoplasm in children, occur mainly in lower part of brain (cerebellum or brainstem) school-aged children SS: related to location and size of the tumor, most ^ICP and have HA, vomiting, drowsy and seizures Nystagmus, strabismus and decreased vision may be evident, ataxia, head tilt, behavior changes, and cerebral enlargement  TX CT, MRI, EEG chemo/radiation removal if possible 

Seizures most common dysfunction in children, sudden, intermittent episodes that last secs-minutes  Causes: INTRACRANIAL--epilepsy, injury, trauma  EXTRACRANIAL--fever, heart disease hypocalcemia, hypoglycemia, dehydration and malnutrition TOXIC--drugs, poisons Types Febrile: 6months-5years rise above 102----control temp, rarely develop into epilepsy Epilepsy two types generalized and partial G: grand mal(tonic clonic) aura postictal lethargy (tired afterwards) P: Petit mal or absence 40% are these TX CT, MRI scans look for tumors hematomas, EEG to monitor absence or partial seizures Meds must be taken same time q day Ketogenic Diet : ^fats low in carbs

Cerebral Palsy (CP)

Motor disorder  caused by dysfunction of motor centers in the brain causes: existing prenatal brain abnormalities, exposure to maternal chorioamnionitis in utero, preme, severe hypoglycemiashaken baby syndrome, meningitis or encephalitis 15-60% of children with CP develop epilepsyMainfestations vary with severity suspected during infancy with::feeding problems non-febrile seizure and developmental delays Steps establish communication establish locomotion use and optimize existing motor functions provide intellectual stimulation promote socialization encourage self-care abd promote growth and development multidisciplinary approach  

Types Spastic: damage to the cortex of brain, spasms with movement, r/t cerebral asphyxia Athetoid: damage to basal nuclei ganglion, continuous involuntary writhing movements, often associated w/ hyperbillrubinemia Ataxic: uncoordinated movements and ataxia from lesion in cerebellum Mixed: combo of spastic and athetoid TX Botulinum Toxin to reduce spasticity and Levodopa help control athetoid symptoms Anti-seizure drugs (tegretol, depakote) encourage self-care and self feeding (decrease in ability to feed decreases nutrition)

Cognitive Impairment

Intellectual functioning below IQ 75 (AAMR)Limitations in at least 2 areas or adaptive behaviors communication self-care home living social skills community use delf-direction health and safety functional academics leisure work

Mental functioningLOC: attention short and long term memory perceptionsThought Processes: insight judgement affect moodExpressive language: Vocab, abstract thinking, intelligenceStanford-Binet most often given test

Head Injurymajor cause of death and injury in children older thanConcussion: temp disturbance of brain that usually followed by period of unconsciousness (jars brainstem) children more susceptible to concussion  can be from hypoxia with causes the brain to need ^ energy which ^blood flow which ^cerebral edema, if ICP raises too high cerebral perfusion decreases and brain damage or death occurs infants with fontanelles have ^tolerance to this Near-Drowning 4th leading cause death for children <19 defined as survival beyond 24 hours after submersion Immediate TX of hypoxia, aspiration and hypothermia submersion 10 minutes of longer and failure to regain consciousness at the scene or within 24 hours is ominous sign for severe neurological deficits is child survives

Shaken Baby tearing of the nerve fibers within the brain which can result in retinal, subarachnoid and subdural hemorrhages as well as high-level cervical spine injuries and permanent disability or death HA(fussy in toddler) drowsy, blurred vision, vomiting, dyspnea, severe completely unconscious Neuro Monitoring Pain stimuli LOC arousal awareness CN response Motor Response Posturing Eyes (PERRLA) Fontanelle (bulging means ^ICP) Scalp Vein distention Ataxia: damage to corticospinal pathways Moro/Tonic neck withdrawal reflexes