The Chronically ILL Child

By: Rogei Taro RN, MAN

Common Health

problems of gas

exchange among

CHILDREN

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

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)

STIMULUS

Chemical mediator release

Bronchospasm Inflammatory cell

activation

Epithelial

damageEdema

mucus

production

Increased airway resistance, obstruction

And airflow obstruction

ACUTE ASTHMA ATTACK

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)

Collaborative care

-Diagnostic tests

Pulmonary function tests

Challenge of bronchial

provocation testing

ABGs

Skin testing

-Disease monitoring

Peak expiratory flow rate

Medications:

Expectorants(guaiafenesisin)/mucolytic

Antitussives

Dextrometrophan

Bronchodilators

Aminophylline

Salbutamol(ventolin)

Terbutaline(bricanyl)

Metaproterenol(Alupent

Antihistamine

Benadryl

Steroids (prednisone,dexamethasone)

Antimicrobials

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

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

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

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

“ 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.”

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

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

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)

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

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

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

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.

“ Bromelain, an enzyme derived

from pineapple, has been

proven effective to relieve

symptoms of sinusitis.”

Common

Cardiovascular

Disorder among

Children

Infective Endocarditis

Inflammatory process

of the endocardium,

especially the valves due to

infections.

• Etiology:

- leading causative agent: S. aureus

- Congenital Malformation

- cardiomyopathy

- Fungal organisms – after open heart

surgery

- S. viridans – after dental procedure

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 .

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.

Clinical Manifestations

Fever, chills, alternating with sweats , body malaise,

weakness, anorexia, weight loss, pallor, backache, and

splenomegaly.

“roth spots

-retinal hemorrhage)

osler’s nodes (painful, erythematous, pea-

sized nodules on tips of the fingers and toes.

Janeway’s lesions (flat, small, non-tender

red spots )

Diagnostic TestBlood cultures

Ultrasonography

Echocardiograpy

ECG

radiography

Medical Management

Pharmacotherapy

IV antibiotics for 2-6 weeks

(gentamycin,penicillin)

Anti-fungal agents(Amphotericin

B)

Surgery

-valvular replacement

“ MicroRNAs Add a New

Dimension to Cardiovascular

Disease such as In infective

Endocarditis “

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)

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

Work up

History taking & Physical Exam.

Oxygen saturation,CBC,Hemoglobin

concentrations,

electrolyte levels ,BUN & Creatinine

levels, hepatic and renal functions

12-lead ECG,Echocardiography

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

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

“ Cardiac Resynchronization

therapy(CRT)-emerged as

useful therapy in the

treatment of CHF ”

Common immune

disease among

Children….

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

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

Management:

*Rest, ROM exercises, prevent

infection, avoid exposure to sunlight,

calcium, protein diet, pharmacotherapy

(ASA, steroids, NSAID, anti-malarial,

cytotoxic agents)

“Flaxseed & Fish oil as a relief for Lupus

Symptoms”

-

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

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.

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

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.

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.

Aggressive combination drug

therapy in early polyarticular

juvenile idiopathic arthritis.

(infliximab plus methotrexate)

Common Hematologic

disorder in children

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

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

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.

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.

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

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.

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

Nursing Care

Monitor for signs/symptoms of

hypoxia

increase dietary intake

Provide emotional support

Promote rest & Safety

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).

Common

Gastro-

intestinal

disorder in

children

Chronic inflammatory

bowel disease

ULCERATIVE COLITIS

CROHN’S DISEASE

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

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

Distinguishing features from Crohn’s:

Absence of small bowel involvement

Limitation to the mucosa

Subsequent freedom from deep ulceration

and fistula formation

Endoscopic appearance

Diagnostic Procedure:

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

Complications

PerforationIntractable hemorrhageToxic megacolonSclerosing cholangitisColonic carcinoma

Duration of colitis Extent of colonic involvementTotal colitis: 15% at 20 years

Mucosal dysplasia : pre-malignant

Surgical

emergencies

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

Unpredictable course

Spontaneous remission and

relapses

Extraintestinal manifestations

aphtous oral ulceration;

erythema nodosum;

pyoderma gangrenosum

Iritis; arthopathy;

sacroilitis

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%

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

New Imaging Technology Improves

Diagnosis of Bowel Disease

(Capsule endoscopy )

THANK YOU!!!