Chapter 23

Otitis externa

• Swimmer's ear
• Acute infection of external canal
• SS: pain and tenderness with manipulation of the tragus
• Tympanic membrane will look normal
• TX: 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
• Infants
• general irritability, frequent rubbing or pulling at the ear and rolling of the head from side to side
• If 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)
• Diagnosis
• Lack 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 objects
• 1-3 months tears can be seen
• 9 months for depth perception
• 6 wks should be able to focus on object
• 2.5-3 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 retina
• yellowish, 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, pain
• TX:standard tx is enucleation (removal of eye) is no hope of saving vision
• smaller 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

• Menigitis
• inflammation 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

Slide 10

• 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 hypoglycemia
• shaken baby syndrome, meningitis or encephalitis 15-60% of children with CP develop epilepsy
• Mainfestations
• 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 functioning
• LOC: attention short and long term memory perceptions
• Thought Processes: insight judgement affect mood
• Expressive language: Vocab, abstract thinking, intelligence
• Stanford-Binet most often given test

Slide 13

• Head Injury
• major cause of death and injury in children older than
• Concussion: 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