Pediatrics Midterm- Food Allergies, Glasgow Coma Scale, Respiratory

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Food Allergies, Diagnosis and Treatment

-- 15-30% of children have some form of allergy or involvement of the immune system.
--Early prevention can begin with encouraging women to breastfeed so that infants are not exposed to cow milk protein.
--Delaying introduction of solid food until six months may not be as beneficial as thought.
--Environmental control to reduce number of home allergens can drastically reduce allergy symptoms.
-- Avoid use of latex, common child allergy
-- Avoid spraying perfumes, air fresheners, smoking, eliminate wool blankets, choose toys carefully, keep room free of dust.
-- Allergies are type of disorder that typically causes chronic rather than acute symptoms.

Allergy

--Allergic disease occur as a result of abnormal antigen- antibody response.
-- Allergic symptoms can be chronic and minor such as seasonal rhinitis or acute and severe- anaphylatic reaction.

Hypersensitivity

Underlying cause of all allergic disorders appears to be an excessive antigen- antibody response when the invading organism is an allergen rather than a simple immunogen. Type I, II, III, IV response

Type 1 Response Anaphylaxis IgE

Immediate response- IgE.
IgE attached to surface of mast cell triggers release of intracelular granules from mast cells on contact with antigens
Effect: Allergies, asthma, atopic dermatitis, anaphylaxis

Type II Cytotoxic- IgG or IgM

Antigen antibody reaction leading to antigen destruction, complement is activated.
Effect: Hemolytic anemia, transfusion reaction, erythroblastosis fetalis

Type III Immune Complex Disease- IgG or IgE

Antigen- antibody complexes precipitate, complement is activated leading to inflammatory response.
Effect: Rheumatoid arthritis, systemic lupus erythematsus

Type IV- Delayed-
T Lymphocyte

T cells combine with antigen to induce inflammatory reactions by direct cell involvement or release of lymphokines
Effect: Contact dermatitis, transplant graft reaction, PPD test

Assessment of Allergy in Children

Check if family history- familial tendency with allergic disease.
Obtain exact symptoms to help identify allergen.
Time of year allergy occurs

Laboratory Testing for Allergies

Most children with allergies have increased eosinophil count
--Skin Testing: detects presence of IgE in skin or to isolate antigen (allergen) to which IgE is responding or to which child is sensitive.
When allergen introduced into child's skin and child sensitive to allergen a wheal or flare response appears at site of test. This is because of response of histamine which leads to vasodilation. Antihistamine should not be given 8 hrs before test will inhibit response. Corticosteriod theraphy does not affect skin reactivity and may be continued.

Skin Testing Types: Apply patch, Scratch Test or Intracutaneous Injection.

Scratch Test

Place drop of allergen solution on skin and scratch through drop of liquid with a sterile needle.

Intracutaneous Injection

Inject small amount of solution of allergen below epidermis of skin. Done on forearm so if sensitivity reaction occurs a tourniquet can be applied proximal to test site to prevent further absorption fo antigen.
- Given just below epidermal layer of skin- almost painless

Allergic Response

After all forms of skin testing if child allergic to test solution a wheal and erythema (redness) will occur at the test site.
Size of reaction is measured and graded as 1+ to 4+ or as slight, modrate or marked.
Have syringe filled with 1mL of Epinephrine (Adrenalin) to ocunteract unexpected anaphylactic reaction.

Food allergies

Skin testing ineffective
Remove suspected food from diet and see if improvement in symptoms.
After a time of improvement reintroduce food. If child is allergic to the food symptoms will reappear.

Anaphylactic Shock

immediate, life threatening type I hypersensitivity reaction that occurs after exposure to an allergen. Within minutes symptoms begin

Assessment:
- Initially child may become nauseated, vomiting, diarrhea because of sudden increase in GI secretions produced by stimulation of histamine. Followed by urticatia (hives) and angioedema (welts)
- Bronchospasm leads to hypoxia, as blood vessels dilate blood pressure and pulse rate falls.
Seizures and death may follow as soon as 10 minutes after allergen introduced to body.
- Therapeutic Management:
Ask parents if child reacted to any medication in past.
Child should wear bracelet or necklace identifying drug allergy

Food Allergies Symptoms

Wheezing, anaphylaxis, difficulty breathing, itchy skin, rashes, N/V/D, abdominal pain and swelling around mouth and throat.

-Manifest differently from one child to next but urticaria (hives), angioedema(welts), pruritus (itching), stomach pain, colic, cramps, diarrhea, resp symptoms, atopic dermatitis (dry skin/ itching and turns to red raised rash) common.
- Symptoms begin minutes after consumption.

Most common foods that cause immediate allergy symptoms are: egg white, fish/ seafood, berries and nuts.
Delayed food reactions: cereals (wheat and corn), milk, chocolate, pork, legumes, white potatoes, beef, food additives and coloring and oranges.
If child allergic to milk probably allergic to milk products as well.
Children allergic to eggs cannot eat foods containing eggs or certain vaccines (flu).

Food allergy Assessment

Encourage child or parents to keep food diary of foods eaten each day. Note presence of symptoms if any.

Elimination diet- feed child only foods that don't cause allergy for 7 days. Then add one by one at 2-3 day intervals suspected allergy food. If symptoms occur eliminate food on permanent basis.

Food Allergy Therapeutic Management

Treatment is to permenantly eliminate offending food from diet.
Parents must read labels carefully to be certain foods don't contain allergy product.

Food allergy Action Plan

Plan designed for protection of children diagnosed with food allergy.
Alerts and allows teachers and support staff permission to assist and treat child experiencing reaction.
Massachusetts law must abide by plan
According to plan give epinephrine for severe anaphylactic reactions: Shortness of breath, wheeze, repetitive cough, pale blue, faint, Trouble breathing/ swallowing, hives, itchy rash, swelling, vomiting, call 911, give antihistamine and inhaler (if asthma)
For mild symptoms: itchy mouth, few hives around mouth/face, mild nausea/ discomfort give antihistamine. If symptoms progress use epinephrine.

Food Allergies: Nursing Diagnosis

Alteration in Nutrition, Knowledge Deficit, Alterations in Family Coping

Glasgow Coma Scale

Scale to evaluate changes in level of consciousness.
Three part assessment: Eye opening, Verbal response and motor response
The lower the numer the more severe deeper coma.
Score of 3-8 suggests severe trauma.
Number less that 5 suggests very severe prognosis.
Score of 9-12 Moderate trauma.
Score of 13-15 slight trauma

Respiratory

Ethmoid and maxillary sinuses are present at birth whereas frontal ( involved in sinus infection) and sphenoidal sinuses do not develop until 6-8 years of age.
- Respiratory mucus functions as a cleansing agent by moving invading organisms or other particles out of lungs.
- Newborns produce little respiratory mucus which makes them more susceptible to resp infection. Excessive mucus production in child up to 2 yrs can lead to obstruction because bronchial lumens so small.
- After 2 yrs right bronchus is shorter, wider and more vertical than the left. Inhaled foreign objects lodge in right bronchus. Infants use abd muscles to assist in inhalation. Change to thoracic breathing begins at 2-3 years of age and is complete at 7 years.

Respiratory: Physical Assessment

Physical assessment includes observation of symptoms such as ocugh, syanosis, pallor, resp and breath sounds.

- Cough reflex initiated by stimulation of nerves of respiratory tract mucosa by presence of dust, chemicals, mucus or inflammation, clears excess mucus or foreign bodies from respiratory tract.

- Paroxysmal Cough: refers to series of expiratory coughs after deep inspiration. (whooping cough, aspirated foreign object or liquid)

Respirations: Tachypnea- increases respiratory rate- indication of airway obstruction
Assess depth and quality

Retractions: chest draws inward creating retractions. Retraction of upper chest muscles suggests upper airway obstruction and retraction of intercostal or subcostal muscles suggests lower airway obstruction

Restlessness: when child has decreased oxygen in body cells (hypoxia) they become restless and anxious.
Cyanosis: blue tinge to skin indicates hypoxia.
Clubbing of fingers occurs with children who have chronic respiratory illness.

Breath Sounds:
Adventitious sounds (extra or abonormal breathing sounds) caused by pathologic conditions and can be heard on lung assessment in children with respiratory disorders

Rhonci: If obstruction in nose or pharynx noise produced is snoring sound.

Stridor: Obstruction at base of tongue or larynx hear harsh, strident sound on inspiration.

Wheezing: Obstruction in lower trachea or bronchioles noticable on expiration- expiratory whistle sound.

Rales: alveoli become fluid filled fine crackling sounds.

Diminished or absent breath sounds occur when alveoli are so fluid filled that little or no air can enter.

Lab Tests to confirm or rule out respiratory disorder

ABG's, nasopharyngeal culture and sputum analysis, Chest X-Ray, Pulse O2, Respiratory Syncytial Virus Nasal Washings (used to diagnose RSV infection)

Therapy to Improve Oxygenation

Goal is to maintain or re-establish airway to help ensure adequate oxygen reaches blood.

- Expectorant Therapy: Liquefying agents (Robitussin (liquify mucus in trachea and bronchi), Saline nose drops- moistening dry mucus in nose)

- Humidification- provides moisture to airway (vaporizers/ nebulizers)
Encourage coughing to help raise mucus. Cough/ cold medicine not recommended children under 2. Incentive Spirometry

- Pharmacologic Therapy: Nasal sprays, Antihistamines, Decongestants, Expectorants, Bronchodilators, Antibiotics, Corticosteriods.

Nasopharyngitis (Acute- Common Cold)

Most frequent infectious disease in children- toddlers avg 10-12 colds year, School age children and adolescents 4-5 yr. Incubation period 2-3 days- most occur fall/ winter
- Caused by viruses: rhinovirus, coxsackievirus, RSV, adenovirus, parainfluenza and influenza viruses.

Assessment: Symptoms- nasal congestion, watery rhinitis, low grade fever, mucus membranes inflamed (cause diff breathing), sore throat, upper airway secretions that drain into trachea lead to cough. Cervical lymph nodes swollen. Last about 1 week and then symptoms fade.

Therapeutic Treatment: No specific treatment for commom cold because colds caused by virus not bacteria. Tylenol/ Motrin only if they have fever over 101, saline nose drops/ spray, removing mucus via bulb syringe, use Guaifenesin(loosens secretions does not suppress cough), cool mist vaporizer, increase fluids

Tonsililitis

Infection and Inflammation of the palatine tonsils.

Assessment: Drooling because throat too sore to swallow, fever, lethargic, tissue appears bright red and so enlarged two areas of palatine tonsilar tissue meet midline, nasal quality of speech, mouth breathing, difficulty hearing, sleep apnea, halitosis.
Occurs most commonly in school age children
Child younger than 3 cause often viral
School age causative organism group A betahemolytic streptococcus.

Tonsillitis: Therapeutic Management

Therapy for bacterial tonsillitis: Antipyretic, analgesic for pain, full 10 day of antibiotic (penicillin or amoxicillin)
No therapy for viral other than comfort or fever reduction.

Tonsillectomy

Removal of palatine tonsils. In past common procedure but not recommended today unless all other measure to prevent frequent infections prove ineffective.
Tonsillar tissue removed by litigating tonsil or by laser surgery. No sutures so risk of hemorrhage post op.
Chronic tonsillitis only reason for removal of palatine tonsils. Never done while organs infected because operation might spread organisms into bloodstream causing septicemia.

Tonsillectomy

Done as ambulatory or 1 day surgery. Observe for loose teeth on surgery day. After surgery observe vital signs carefully to assure child is not bleeding from surgical area. Place child on side or abdomen with pillow under chest so head is lower than chest. This allows blood adn unswallowed salive to drain from child's mouth rather than back to pharynx where could be aspirated.

If hemorrhage occurs after tonsillectomy it can be acute and intense. child will swallow blood so heavy bleeding will appear little blood. Assess for subtle signs of hemorrhage: increase pulse/ resp rate, frequent throat swallowing/ throat clearing or feeling of anxiety.

_ If surgical site bleeding elevate head, if heavy bleeding may need to return to surgery for sutures to halt bleeding.

- First 24 hours most dangerous when clots are forming and days 5-7 when clots dissolve. If new tissue hasn't formed hemorrhage with occur.

If no complications from surgery, able to swallow fluids, voided discharged later same day. Restrict childs activity and inform of danger signs. Return appt 2 weeks post op for follow up assessment.

Post op: Liquid analgesics, rectal administration, IV pain relief. Drinking helpful swallowing causes active pharyngeal movement increasing blood supply to area reducing edema and pain.
Child commonly promised ice cream- avoid this forms tenacious secretions that are difficult to swallow. Offer clear liquids, Popsicles or ice chips, avoid acidic juices will sting tissue, avoid carbonated beverages irritate- allow to flatten. AVOID RED fluid like Kool Aid if vomited may be mistaken for blood.

24-48 hours soft diet- gelatin, mashed potatoes, soup, cooked fruit. Eat only soft foods for first week. Some children may develop earache after tonsillectomy for first week- due to shifting pressure on eustachian tube.

Epiglottitis

Inflammation of epiglottins (flap that covers opening to larynx to keep out food and fluid during swallowing.
- Rare but an emergency because swollen dpiglottis cannot rise and allow airway to open
--Occurs frequently in child 2-7 yrs old.
- Either bacterial or viral in origin. H influenzae type B replace as most common bacterial cause by pnemococci, streptococci or staphylococci, echovirus and RSV.

Epiglottitis: Assessment

Symptoms very similiar to croup. Symptoms begins as those of mild upper respiratory infection. After 1-2 days inflammation spreads to epiglottis, cild suddenly develops severe inspiratory stridor, high fever, hoarseness and very sore throat. Difficulty swallowing and may drool, protrude tongue to increase free movement in pharynx. Cherry red inflammed epiglottis
Do Not use tongue blade to visualize epiglottis or obtain throat culture can completely obstruct glottis and child cannot inhale.

-- Lab studies show leukocytosis, neutrophils increased, blood culture to evaluate for septicemia and ABG'S to evaluate respiratory sufficiency. Use xray or ultrasound which will show enlarged epiglottis.
-- Don't allow child with possible epiglottitis to go for testing with just parent or aide- in case obstruction occurs.

Epiglottitis: Therapeutic Mangagement

Moist air to reduce epiglottal inflammation, oxygen is cyanosis present. Antibiotic (cephalosporin such as cefotaxime, IV therapy to maintain hydration. Prophylactic trach or endotrach intubation may be necessary to prevent total airway obstruction.
After antibiotic therapy begins epiglottal inflammation recedes rapidly, 12-24 hrs airway may be removed, full 7-10 days antibiotics. HIB vaccine helps prevent epiglottitis so not seen as often
Racemic epinephrine, rest, fluids

Cystic Fibrosis

Inherited disorder affecting exocrine glands
Mucus secretions become so tenaciuos difficulty flowing through gland ducts
- Marked electrolyte change in secretions of sweat glands (chloride concentration of sweat five times above normal)
- Occurs most commonly in Caucasian children
- Chorionic villi sampling or amniocentesis can be done early in pregnancy to detect fetuses who have disease.

- Boys with CF may be unable to reproduce be of persistent plugging and blocking of vas deferens from tenacious seminal fluid. Girls may have thick cervical secretions that sperm penetration in limited. Artificial insemination or in vitro can be accomplished.

Cystic FIbrosis: Pancreas Involvement

No pancreatic enzymes in duodenum child cannot digest fat, protein and some sugars. Stools become large, bulky, greasy (steatorrhea) and foul smelling.
--- Show signs of malnutrition, Fat soulble vitamins A, D, E cannot be absorbed because fat not absorbed. Protuberant abdomen.

- Thick meconium in newborn may obstruct intestine, develops distended abdomen with no passage of stools. Meconium ileus should be suspected in any infant who doesn't pass stool within 24 hours of life.

Cystic Fibrosis: Lung involvement

Thickened mucus pools in bronchioles, infection begins in these secretions. Secondary emphysema occurs because air cannot be pushed past thick mucus on expiration. Bronchiectasis and pnuemonia occur. Respiratory acidosis may develop, Atelectasis occurs as result of absorption of air from alveoli behind blocked bronchioles. Fingers become clubbed because of inadequate tissue perfusion. Anterior posterior diameter of chest becomes enlarged.

Cystic Fibrosis: Sweat Gland involvement

Level of chloride to sodium is increased 2-5 times above normal.
Kiss child taste strong salt in perspiration.

Cystic Fibrosis: Assessement

May be suspected in newborn when newborn loses normal amount of weight at birth does not gain back in usual time of 7-10 days not until 4-6 weeks of age because they cannot make use of fat in milk.
Respiratory infection develops at 4-6 months, wheezing and rhonci may be heard.
By preschool cough prominent, percussion chest is hyperresonant, rales and rhonchi are heard, clubbing of fingers.

Sweat test: Sweat collected by placing filter paper on skin and analyzed for sodium choloride content. Normal 20 mEq, CF > 60mEq.

Cystic Fibrosis: Therapeutic Management

Consists of measures to reduce involvement of pancreas, lungs and sweat glands.
- Placed on high calorie, high protein, modrate fat diet. Supplement ADE vitamins. Extra salt added to diet in hot months to replace perspiration loss.
Infants cannot be totally breastfed not enough protein in breastmilk, need supplementary formula.

-- Take pancreatic enzymes before each meal or snack. Open capsules for young child add powder to teaspoon of food. Don't add to hot food will destroy some of enzyme. Don't add to infants bottle all of enzyme may not be taken.

- If child overheated lose excessive sodium and chloride through perspiration and become dehydrated. Keep home temp at 72 or below and offer water frequently.

- Important to keep bronchial secretions moist and freely flowing as possible so they can drain from bronchial tree.

- Right side of heart tends to enlarge because congestion in lungs increases pressure in pulmonary artery and rigth ventricle.
Oxygen supplied by mask, priongs, ventilators or nebulizers.
3-4 times a day aerosol therapy by means of nebulizer to provide antibiotics or bronchodilators. Mucomyst can be addeed to liquify secretions.
-- NEVER give cough syrups to suppress cough, because getting secretions out is essential for air exchange and prevent infection. Question Codeine order because it will suppress cough.

- Maintain usual activities as much as possible, frequent postion changes in bed so all lobes of lungs will drain. Sit up part of each day.
--Provide periods of rest during day but don't group too many activities together all at once. Plan rest period before meals so child not too tired to eat. Plan for long rest period before chest pt so can be tolerated better.

- Important to get routine immunizations pertussis and measles vaccine- these cause severe respiratory complications. Should receive influenze, meningooccal, pneumococcal vaccines.
Reach adolescence candidates for lung transplant- life span greatly improved.

Asthma

Immediate hypersensitivity type 1 response- most common chronic illness in children. Tends to occur before 5 yrs old.

- Affects small airways and involves three seperate processes: bronchospasn, inflammation of bronchila mucosa and increased bronchila secretions (mucus)
- Reduces size of airway lumen leading to acute respiratory distress.

- After exposure to allergen or trigger episode begins with dry cough often at night. Wheezing heard on expiration, if heard on inspiration child is having extreme breathing difficulty. May cough up copious mucus with white casts bearing shape from bronchi which it was dislodged. Asthma affects all lobes of lungs, wheezing heard in all lung fields. If only wheezing heard in one lung lobe suggests foreign body present like a peanut.

Asthma Assessment:

The common symptoms are wheezing heard on expiration, coughing - which starts as a dry cough and progresses to a more wet cough, shortness of breath. The more the child tries to inhale, the worse it gets, making the child feel as though they are suffocating.

Physical assessments: check 02 sats, hear wheeze (without a stethescope), >eosinophil count, peak flow meter will be low. Eventually, without treatment, you may not be able to hear wheezing because the air is so trapped that they'll be minimal escape. If at that time you percussed the lungs, you would hear a hyperresonant sound.

Asthma: Peak Flow Monitoring

Use peak flow meter daily to measure gross changes in peak expieatory flow over time and help in planning appropriate therapeutic regimen

- To use peak flow meter child places indicator on apparatus at bottom of numbered scale and takes deep breath. Child places meter in mouth and blows as hard and fast as possible. Repeated 2 times and records highest number achieved. Done daily during a 2 week period. Highest number achieved during this period is personal best.

-- Green Zone: no asthma symptoms present- take routine meds

-- Yellow Zone: signals caution- asthma episode may be beginning.

-- Red Zone: asthma episode beginning. Immediately take prescribed meds such as inhaled beta 2 agonist then repeat peak flow assessment. If reading not in green zone parents should alert doctor of impending asthma attack.

Asthma Therapeutic Management

Therapy involves planning for three goals of allergic disorders: avoidance of allergen by environmental control, skin testing and hyposensitization to identified allergens and relief of symptoms by pharmacologic agents.

Cough suppressants not used because as long as child coughing up mucus not in danger. When they stop coughing mucus plugs form that may lead to pneumonia, atelectasis, acidosis.

Asthma Medications

Mild but persistent asthma prescribed inhaled anti imflammatory corticosteriod (Flovent)

Moderate persistent symptoms: ;long acting bronchodilator at bedtime in addition to inhaled antinflammatory daily corticosteriod.

Severe persistent asthma: high dose both oral corticosteriod adn inhaled corticosteriod daily as well as long acting bronchodilator at bedtime. May be prescribed short acting beta 2 agonist bronchodilator such as albuterol or terbutaline to use if attack begins.

Most common short acting inhaled beta-2 is albuterol or terbutaline and used when an attack begins.

Cromolyn (a mast cell inhibitor) is used to prevent an episode- not effective once symptoms begin.

- Singular to prevent asthma but taken orally- not effective acute attack.

Important teaching that should accompany medication therapy is: make sure that the child knows how to use an inhaler, that nebulizers are really medication, not to share the inhaler, keep in nearby especially if the child plays sports, increase fluids because increased respirations will dehydrate a child making the mucus thicker

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