TUBERCULOSIS

Tuberculosis is a contagious disease caused by an acid-fast bacillus, Mycobacterium tuberculosis. The transmission of tuberculosis is through inhalation of droplets from a person with active tuberculosis.

Children are more common infected than adult in family. They can be infected from family member or by another individual with whom they have frequent contact such as babysitter.

Sign and Symptoms:

• May be asymptomatic
• Malaise
• Fever
• Cough
• Weigh loss
• Anorexia
• Lymphadenopathy

Diagnose:

1. Mantoux Test
2. Sputum Culture

Medical Interventions:

1. Isoniazid (INH), rifampin (rifadin), and pyrazinamide
2. A 9 month course of INH is prescribed to prevent a latent infection from progressing to clinically active tuberculosis and to prevent initial infection in children in high risk situations
3. A 12 month course is prescribed to the HIV infected child
4. For child with active tuberculosis: INH, rifampin, and pyrazinamide daily for 2 months and then INH and rifampin twice weekly for 4 months

Nursing Interventions:

1. Wear a mask if the child is coughing and does not cover his or her mouth
2. Place children on airborne precautions until medications have been initiated, sputum cultures demonstrate a diminished number of organisms, and cough is improving
3. Maintain airborne precaution with family members
4. Adequate rest and diet
5. Advice the child and family to prevent transmission of tuberculosis

Mantoux Test:

• Positive reaction to the mantoux test will appear 2-10 weeks after the initial infections
• The test is done to determine whether the child has been infected and has developed a sensitivity to the protein of the tubercle bacillus
• A positive reaction does not confirm the presence of active disease
• Once the child reacts a positively, the child will always react positively
• A positive reaction in a previously negative test indicates that the child has been infected since the last test
• The test should not be done at the same time as measles immunization since it may cause false-negative reaction

Measuring of Mantoux Test:

• The result of the test is measured by indurations:
• 15 cm or more = positive in child 4 years or older who do not have any risk factor
• 10 cm or more = positive in children younger than 4 years and in those with chronic illness or at high risk for exposure to tuberculosis
• 5 cm or more = positive for the highest risk groups such as children with immunusuppressive conditions or human immunodeficiency virus

Sputum Culture:

• The test is positive if it demonstrates the presence of mycobacteria in a culture
• Gastric washing (aspiration of lavaged contents from the fasting stomach) is done to obtain specimen from an infant or young child since they often swallow sputum rather than expectorate it
• The specimen is obtained in the early morning before breakfast

Pneumonia

Pneumonia is an inflammation of the alveoli. It can be cause by a virus, mycoplasmal agents, bacteria, or the foreign substances aspiration. The causative agents are usually come to the lung through inhalation or from the bloodstream.

There are types of pneumonia:

1. Viral pneumonia
2. Primary atypical pneumonia (Mycoplasma pneumonia)
3. Bacterial pneumonia
4. Aspiration pneumonia

Aspiration Pneumonia

Aspiration pneumonia may occur when food, secretions, liquids, or other materials enter the lung and cause inflammation and a chemical pneumonitis.

Signs and Symptoms of Aspiration Pneumonia:

• Cough or fever with foul-smelling sputum
• Deteriorating results on chest x-rays

Bacterial Pneumonia

Bacterial pneumonia is a serious infection that sometimes need for hospitalization when pleural effusion or empyema accompanies the disease and is mandatory for children with staphylococcal pneumonia.

Signs and Symptoms of Bacterial Pneumonia:

• Acute onset, fever, toxic appearance
• In infant: irritability, poor feeding, lethargy, abrupt fever, respiratory distress
• In older child: chills, headache, abdominal pain, chest pain, and meningeal symptoms
• Diminished breath sound or scattered crackles
• Hacking, nonproductive cough
• Coarse crackles and wheezing are heard as the infections resolves

Nursing Interventions for Bacterial Pneumonia:

• Administer oxygen as prescribed
• Place the child in a mist tent as prescribed
• Administer antimicrobial, antipyretic, antitussives as prescribed
• Suction mucus if the infant is unable to handle secretions
• Chest physiotherapy and postural drainage every 4 hours as prescribed
• Encourage child to lie on the affected side to splint the chest and reduce the discomfort caused by pleural rubbing
• Provide fluid intake and take caution to prevent aspiration
• Institute isolation precautions according to the agency policy
• Continuous closed chest drainage may be instituted if purulent fluid is present
• Thoracentesis may be done to remove fluid accumulation in the pleural cavity

Primary Atypical Pneumonia

Primary atypical pneumonia is the most common cause of pneumonia in children between 5-12 years of age. Primarily it occurs in the fall and winter season and in crowded living conditions.

Signs and Symptoms of Primary Atypical

• Anorexia, headache, fever, chills, muscle pain, and malaise
• Rhinitis, sore throat, and dry-hacking cough
• Initially non productive cough, then production of seromucoid sputum that becomes mucopurulent or blood streaked

Nursing Intervention:

• Nursing interventions for patient with primary atypical pneumonia are symptomatic.

Viral Pneumonia

Viral pneumonia occurs more frequently than bacterial pneumonia. It is also associated with upper respiratory infection caused by viruses.

Signs and Symptoms of Viral Pneumonia:

• Slight cough, malaise, and mild fever, to severe cough, prostration, and high fever
• Non productive or productive cough with small amounts of whitish sputum
• Wheezing or fine crackles

Nursing Interventions for Patient with Viral Pneumonia:

1. Oxygenation with cool mist as prescribed
2. Encourage to increase fluid intake
3. Administer antipyretics and antimicrobials as prescribed
4. Chest physiotherapy and postural drainage as prescribed

Bronchiolitis / Respiratory Syncytial Virus (RSV)

Bronchiolitis is defined as an inflammation of the bronchioles. It causes production of tick mucus that occludes bronchiole tubes and small bronchi. The common cause of bronchiolitis is respiratory syncytial virus that is higly communicable and usually transferred by the hands.

Signs and Symptoms:

• Upper respiratory infection symptoms: rhinorrhea and low-grad fever
• Tachypnea
• Lethargy, poor feeding and irritability
• Increased difficulty in breathing
• Expiratory wheeze and grunt
• Nasal flaring and retractions
• Diminished breath sounds

Nursing Interventions:

1. Maintain patent airway
2. Place child at a 30-50 degree angle with the neck is slightly extended to maintain an open airway as well as decrease pressure on diaphragm
3. Provide cool and humidified oxygen
4. Assess for any signs of dehydration
5. Encourage fluid intakes

Special Consideration in Giving Care Child with RSV:

• Isolate the child in a single room or in a room with another child with RSV
• Good hand washing procedures
• The nurses who care for these children do not care for other high-risk children
• Wear gowns when soiling of clothing may occur during care
• Administer ribavirin (Virazole) as prescribed
• Prepare for the administration of respiratory syncitial virus immune globulin ((RSV-IGIV or RespiGam or palivizumav)

Key Concept in Administration of Ribavirin (Virazole)

• Administer Ribavirin via aerosol by hood, tent, mask, or through ventilator tubing
• Pregnant health care providers should not care for a child receiving ribavirin
• The nurse who wear contact lenses should wear goggles when coming in contact with ribavirin since the mist may dissolve soft lenses

Respiratory Syncytial Virus Immune Globulin

• The immune globulin is used prophylactically to prevent respiratory syncytial virus infection in high-risk child
• The immune globulin is not administered to infants or children with congenital heart disease or with cyanotic congenital heart disease

Bronchitis

Bronchitis is an infection of the major bronchi that may be referred to as tracheobronchitis.

Signs and Symptoms:

• Fever
• Dry, hacking, and nonproductive cough that is worse at night and becomes productive in 2-3 days

Nursing Interventions:

1. Monitor for respiratory distress
2. Provide cool and humidified air
3. Monitor for any signs of dehydration
4. Increased fluid intake
5. Administer acetaminophen (Tylenol) for fever as prescribed

Laryngotracheobronchitis

Laryngotracheobronchitis is gradual inflammation of the larynx, trachea and bronchi. It is a most common type of croup and may be caused by virus or bacteria.

Sign and Symptoms:

• Irritability and restlessness
• Fever at low to high grade
• Hoarse voice
• Inspiratory striddor and suprasternal retraction
• Seal bark and brassy cough
• Crackles and wheezing
• Use of accessory muscles for breathing
• Anorexia, nausea, and vomiting
• Signs of anoxia and carbon dioxide retention
• Cyanosis

Nursing Interventions:

1. Keep a paten airway
2. Assess respiratory status (nasal flaring, inspiratory stridor, sternal retraction)
3. Monitor for pallor or cyanosis
4. Elevate the head of the bed and provide bed rest
5. Provide humidified oxygen
6. Encourage fluid intake
7. Administer medication as prescribed (antibiotics, analgetics, bronchodilators, corticosteroids)
8. Epinephrine nebulizer may be given for children with severe disease, stridor at rest, retractions, or difficulty breathing
9. Have resuscitation equipment available

Epiglottitis

Epiglottitis is an inflammation on the epiglottitis. It mah be caused by Haemophilus influenzae type B or Streptococcus pneumoniae.

Epiglottitis most frequently occurs in winter in child between age 2 and 5 years. If it is happened, it is consideres as an emergency situation.

Signs and Symptoms:

• High fever
• Sore, red, and inflamed throat
• Drooling
• Absence of spontaneous cough
• Muffled voice
• Difficulty swallowing
• Inspiratory stridor
• Agitation
• Tripod positioning

Nursing Interventions:

1. Maintain a patent airway
2. Assess respiratory status and breath sounds (nasal flaring, stridor, using accessory muscles)
3. Avoid assess body temperature by oral route
4. To prevent spasm of the epiglottis and airway occlusion, no attempts should be made to visualize the posterior pharynx or to obtain a throat culture
5. Prepare for lateral neck films to confirm the diagnosis
6. Keep NPO
7. Do not restrain the child
8. Do not leave the child unattended
9. Do not force the child to lie down
10. Administer fluids and antibiotic intravenously as prescribed
11. Administer analgesics and antipyretics as prescribed
12. Provide high humidification to cool the airway and decrease swelling
13. Provide cool-mist oxygen therapy as prescribed
14. Have resuscitation equipment available
15. Prepare for endotracheal intubation or tracheotomy if there is severe respiratory distress
16. Ensure that the child has up-to-date immunization schedule

Tonsilitis and Adenoiditis

Tonsillitis is an inflammation and infection of the tonsils, while adenoiditis is inflammation and infection of the adenoids. Both of them are usually manage by tonsillectomy and adenoidectomy.

Signs and Symptoms:

• Enlarged, bright red tonsils (may be covered by white exudates)
• Persistent or recurrent sore throat
• Swallowing difficulties
• Fever
• Cough
• Mouth breathing and unpleasant mouth odor
• Enlarge adenoids lead to nasal quality of speech, mouth breathing, hearing difficulties, snoring, or obstructive sleep apnea

Pre-operative Interventions:

• Observe for sign of active infection
• Assess bleeding and clotting studies
• Assess for any loose teeth to decrease the risk of aspiration during surgery

Post-operative Interventions:

• Place patient in prone or side-lying position to facilitate drainage
• Keep suction equipment in reach, however do not suction unless if there is any airway obstruction


• Discourage coughing or clearing the throat
• Avoid milk products initially
• Provide clear, cool, noncitrus and noncarbonated fluid
• Avoid red liquids since will stimulate the appearance of blood if the child vomits
• Do not give child any straws, forks, or sharp objects that can be put in the mouth
• Administer acetaminophen (Tylenol) for sore throat as prescribed
• Notify physician if bleeding, persistent earache, or fever occur
• Instruct parent to keep child away from crowds until heal

Otitis Media

Otitis media is an infection in the middle ear as a result of a blocked Eustachian tube which prevent normal drainage. It is more prone to infants and children because their Eustachian tubes are shorter, wider and straighter. Otitis media also is common complication from an acute respiratory infections.

Signs and Symptoms of Otitis Media:

• Fever
• Irritability and restlessness
• Loss of appetite
• Rolling of head from side to side
• Earache or pain
• Puling on or rubbing the ear
• Signs of hearing loss
• Red, opaque, bulging, or retracting tympanic membrane
• Purulent ear drainage

Nursing Interventions:

1. Encourage fluid intake
2. Teach parent to feed infants in upright position
3. Teach parent about administering ear medication. In a child younger than age 3, pull the pinna down and back, while in a child older than 3 years, pull the pinna up and back
4. Instruct child not to chew during acute episode since it increases pain
5. Provide local heat and have the child lie with the affected ear down
6. Instruct and teach the parent how to clean drainage from the ear with sterile cotton swabs
7. Instruct the parents that screening for hearing loss may be necessary

Myringotomy:
Myringotomy is in insertion of tympanoplasty tubes into the middle ear to equalize pressure and keep the ear aerated.

Post-operative Nursing Intervention for Child with Myringotomy:

• Keep the ear dry
• Instruct patient to wear earplugs when bathing, shampooing, and swimming
• Avoid diving and submerging under water

Conjunctivitis

Conjunctivitis is an inflammation of the conjunctiva and it is usually caused by allergy, infection, or trauma. Conjunctivitis that is caused by bacteria or virus is extremely contagious.

Signs and Symptoms of Conjunctivitis:

• Redness
• Itching, burning, or scratchy eyelids
• Edema
• Discharge

Nursing Interventions:

1. Instruct patient in infection control: good hand washing, not sharing towels, and washcloth
2. Administer antibiotic, antiviral eye drops or ointments or antihistamines as prescribed
3. The child should be kept home from school or day care until antibiotic eye drops have been given for 24 hours
4. Cool compresses can be used to lessen irritation and dark glasses can be worn for photophobia
5. Discontinue wearing contact lenses (if any) and obtain new lenses to eliminate the reinfection
6. Discharge eye makeup (if any)

Strabismus

Strabismus is defined as a condition when the eyes are not aligned because of lack of coordination of the extraocular muscles. It is sometimes called as "squint" or "lazy eyes". Strabismus is normal in the young infant but should disappear after around age 4 months.

The most cause of strabismus come from the muscle imbalance or paralysis of extraocular muscles, however it also may result from brain tumor, myasthenia gravis, or infection.

Signs and Symptoms of Strabismus:
Amblyopia (it comes if not treated early)
Loss of binocular vision
Permanent loss of vision if not treated early
Impairment of depth perception
Squinting or tilting of the head to see
Frequent headaches

Nursing Interventions:
Instruct the parents regarding occlusion therapy (patching) of the good eye to strengthen the weak eye
Corrective lenses may be indicated
Inform the parent that the injection of botulinum toxin wears off in about 2 months, and if successful, the correction will occur
Prepare for surgery. The surgery is performed to realign the weak muscles if non-surgical interventions are unsuccessful. It is performed usually before 2 years
Instruct and encourage parents in regarding the need of follow-up visits

Child Abuse

The term of child abuse is involved emotional or physical abuse or neglect, sexual exploitation or molestation by caretakers or other individuals.

Signs and Symptoms of Physical Abuse:

• Bald spots on the scalp
• Unexplained bruises, burns, or fracture
• Apprehensive child
• Fear of parent
• Extreme aggressiveness or withdrawal
• Lack of crying when approached by a stranger

Signs and Symptoms of Physical Neglect:

• Poor hygiene
• Consistent hunger
• Inadequate weight gain
• Constant fatigue
• Inconsistent school attendance
• Delinquency
• Reports of lack of child supervision

Signs and Symptoms of Emotional Abuse:

• Speech disorders
• Psychoneurotic reactions
• Learning disorder
• Suicide attempts
• Habit disorders: sucking, biting, and rocking

Signs and Symptoms of Sexual Abuse:

• Difficulty walking or sitting
• Torn, stained or bloody under-clothing
• Pain swelling or itching of the genitalia
• Poor peer relations
• Bruises, bleeding, or lacerations in the genital or anal area
• Unwillingness to change clothes

Shaken Baby Syndrome:

• Intracranial hemorrhage
• Full bulging fontanelles and head circumference greater than expected

Nursing Interventions:

1. Assess any possible injuries
2. Support the child during a physical assessment
3. Report case of suspected abuse
4. Place the child in an environment that is safe
5. Document the objective manner information
6. Assess parent's strength and weakness in dealing with stress
7. Assist the family in identifying stressor, support systems, and resources
8. Refer the family to appropriate support groups

Tourette's Disorder

Tourette's Disorder is a disorder that is characterized by recurrent involuntary and rapid movement affecting various parts of the body, accompanied by vocal noises such as barks, grunts, or profanities. It appears between ages 2 and 5.

Nursing Interventions:

• One-to-one relationship
• Protect the child from harm
• Allow the child to have a favorite toy or other object
• Maintain eye contact
• Provide positive reinforcement for appropriate behaviors
• Assess suicide potential
• Remove dangerous objects from the environment
• Limit on socially inappropriate or manipulative behaviors
• Provide non-competitive group situations.

Attention-Deficit Hyperactivity Disorder

Attention-Deficit Hyperactivity Disorder (ADHD) is a disorder in child that is characterized by developmentally inappropriate degrees of inattention, overactivity, and impulsivity. The diagnosis is established base on self-reports, parent, and teacher report, and psychological assessments.

The child with Attention-Deficit Hyperactivity Disorder may probably has childhood problems such as lowered intellectual development, some minor physical abnormalities, sleeping disturbances, behavioral or emotional disorders, and difficulty in social relationships.

Signs and Symptoms:

• Easily distracted with external or internal stimuli
• Difficulty with following the instructions
• Poor attention span
• Talking excessively
• Shifting from one uncompleted activity to another
• Interrupting or intruding on others
• Engaging in physically dangerous activities

Nursing Interventions:

1. Encourage support group for parent
2. Provide environmental and physical safety measures
3. Enhance capabilities and self-esteem
4. Administer medications as prescribed such as methylphenidate hydrochloride (Ritalin), pemoline (Cylert), and dextroamphetamine sulfate (Dexedrine)
5. Inform the child and parent that the effects medication may come with in 1-2 weeks if taken as prescribed

Autism

Autism is a severe mental disorder begins in infancy or toddler-hood. It is characterized by impairment of reciprocal social interaction and in verbal and non-verbal communication. The cause of autism is unknown and the prognosis is poor, however, the diagnosis can be established through the symptoms and specialized autism assessment tools

Signs and Symptoms of Autism:

• Abnormal responses of body sensations
• Disturbance in the rate ad appearance of physical, social, and language skills
• Abnormal ways in relating to persons, objects, and events
• Self-absorbed and unable to relate to others
• The child may play happily alone for hours but have temper tantrums if interrupted
• Repetition of previously heard speech meaninglessly and reversal of the pronouns "I" and "you"
• Unusual attachment to a significant object and display frequent rocking, spinning, twirling, or other bizarre behaviors

Nursing Interventions:

1. Identify the child routines, habits, and preferences, and maintain consistency as much as possible
2. Observe the specific ways in which the child communicates
3. Encourage communication through the use of picture boards
4. Provide safety environment and safety precautions
5. Observe for stress and anxiety
6. Avoid placing demands on child
7. Initiate referrals to special programs as required
8. Provide support for child's parents

Mental Retardation

Mental retardation is a condition that is characterized by a below-average score on a test of mental ability or intelligence and limitations in the ability to function in daily life, such as communication, self-care, and getting along in social situations and school activities.


Signs and Symptoms of Mental Retardation:

• Cognitive skills and level of adaptive functioning are in under level of normal
• Speech delays
• Fine-motor and gross-motor are delayed
• Decreased spontaneous activity
• Irritability
• Non-responsiveness
• Poor eye contact during feeding

Nursing Interventions:

1. Promote care skills as much as possible
2. Facilitate appropriate playtime
3. Assist the child in communication and socialization skills
4. Provide safety precaution as necessary
5. Assist the family with decisions in relation to care
6. Provide information about support services and community agencies

Cerebral Palsy

Cerebral palsy is a condition that is characterized by impaired movement and posture due to an abnormality in the extra-pyramidal or pyramidal motor system.

Signs and Symptoms of Cerebral Palsy:

• Feeding difficulties
• Extreme irritability and crying
• Stiff and rigid arms or legs
• Abnormal motor performance
• Delayed gross development
• Muscles tones alterations
• Abnormal posturing (such as episthotonic)
• Persistent of primitive infantile reflexes

Nursing Interventions:

1. Assess the child's developmental level and intelligence
2. Encourage the child in early intervention and participation in school programs
3. Communicate and interact with the child on his/her developmental level
4. Prepare for using mobilizing devices
5. Provide a safe environmental
6. Provide safe and appropriate toys for age and developmental levels
7. Place the child upright after meals
8. Administer medication as prescribed