Transcript Infant and Toddler Growth and Development

Infant and Toddler
Growth and
Development
Elisa A. Mancuso RNC, MS, FNS
Professor of Nursing
Growth of Infant
• Cephalocaudal (head → toe)
• Proximodistal (trunk → periphery)
• General → Specific (Large → fine muscles)
• 1” a month during 1st 6 months
• Average Ht
6 months 25 ½ inches
12 months 29 inches
• Use recumbent length until 3 years
• than standing (vertical height)
Weight
• 5-7oz/wk until 5-6 months
• Birth weight doubles at 6 month
• Birth weight triples at one year
• Always refer to kilograms
2.2 lbs = 1 kg
•
All medications based on weight in kg!
Head Circumference = HC
Reflects brain growth
• Posterior fontanele closes @ 2 mos.
• Anterior fontanel closes @12-18
mos.
• Measure (Forehead → Occiput)
– For 1st 3 years
Chest (CC) and Abdomen
Chest = Head circumference @ 1 year
• Measure @ nipple line.
• Barrel chested as infant
• Chest > Head after 3 years
• After 1 year of age,
– A/P transverse diameter = 1:2
Abdominal Girth
• Measure above umbilicus
• √ Abdominal distention
•
R/O liver or intestinal diseases
Growth Charts
• Serial exams to assess growth progress
• Plotted as percentiles:
– 25th %, 50th %, 75th %, 95th %.
– @ 95th % = Pt > 95% of kids.
• Used to notice any ↓ or ↑ in weight,
height, or HC.
• Specific charts for premature infants
Denver Developmental
Screening Test (DDST)
Denver II
• Assesses from birth → 6 years
• Age divided monthly → 24 months,
– then q 3 mos. → 6 years
• Not an intelligence test
Four categories
• Personal/Social
• Fine motor/Adaptive
• Language
• Gross motor
Infant Reflexes
• Moro - Startle
– Loud sound = extension & abduction of
extremities
• Tonic neck – Fencing
– Turn head to one side ®
– arm & leg extend on ® side
• Babinski
– Dorsiflexion of big toe and toes fan out
• All of above disappear in about 3-4 months
Developmental Skills
Trust vs Mistrust (Birth to one year)
• Social responsiveness to others
• Trust develops with regular consistent,
loving care
• Self reliance and develops confidence
Early infancy 0 - 3 months
Smiles at significant other
Holds head & chest up when prone
Reaches for objects-grasp
Laughs
Developmental Skills
Early Infancy 4-6 months
• Pulls self to sitting position
• Sits with support
• Rolls over = “Safety issue”
– Tummy → back first at 2-3 months
– Back → tummy by 6 months
• stronger head and arm control
• Transfers objects from hand to hand
•
Makes vowel sounds oh-oh
Developmental Skills
Late Infancy 6-9 months
• Hold own bottle
• Develops preference for dominant hand
• Probes with index finger
• Feeds self finger foods
• Pincer grasp @ 9 months
– thumb and index finger used
• Sits erect-unsupported
• Crawls
• Separation Anxiety ↑cries with strangers
Object Permanance
Searches for items outside field of vision
Developmental Skills
9-12 months
• Triple birth weight and ↑ height by 50%
• Releases objects
• Pulls self to feet
• Sits from standing position
• Walks with help
– independent walking can be as late as 18
months!
• Responds to name
• Recognizes no
• Says 4 -5 words: mama, dada, no, bye
•
Teething (age – 6 = # of teeth)
12 mos – 6 = 6 teeth
Cool cold items to chew on
Tylenol 10-15 mg/kg q 4-6 hours
Developmental Tasks
• Achieve physiological equilibrium
– Rest, eat, play patterns
• Develop basic social interaction
– Desire for affection
• Manage a changing body
– ↑motor skills & eye-hand coordination
• Learn to understand and control world
• Develop a beginning symbol system
– Communication
Immunizations
• Regulated by CDC and American Academy of Pediatrics (AAP)
www.cdc.gov/nip/vacsafe
www.immunize.org
• ↓ Infectious diseases = ↓morbidity & mortality
• ↑ incidence of recent outbreaks:
– immigration from poorly compliant countries
– religious beliefs or cultural influences
– ↓ trust of medical care or poor education
• 2003 Nigeria stopped IPV
– Rumors that IPV could transmit AIDS
2006 20% of kids<5 no IPV and ↑ polio outbreak
•
2005 Amish Polio outbreak
2009 Immunizations
Hep B Hepatitis B Vaccine (IM)
• Birth, one month and six months
• Mom (+) HBsAg
– give baby HBIG (0.5mL) & Hep B within 12H
– @ 2 separate sites
– 90% infected infants → chronic Hep B carriers
• 25%-50% infected before age 5 RT HBV Carriers
• ↑ Transmission risk in adolescents
– All kids entering 7th grade must have Hep B
3 dose series
Immunizations
IPV - Inactivated Polio Vaccine (SC)
• 2, 4, (6-18) months and (4-6) years
• Formerly used OPV –Virus shed
• Contraindication; Allergy to neomycin
HIB - Hemophilus Influenza Type B (IM)
• 2, 4, 6 and (12-15) months
• Not associated with Flu
• Protects against many serious infections:
– Epiglottitis and Bacterial Meningitis
Immunizations
PCV7 - Polysaccaride Conjugate Vaccine(Prevnar) (IM)
• 2,4,6 and (12-15) months
PPV – Pneumococcal Polysaccharide (IM)
• One dose > 2 years
Protects against Strep pneumonia
• 6-12 months of age at high risk for S.
pneumoniae
↑ Risk patients
– Sickle cell disease, HIV/immune deficiency
– chronic cardiac or pulmonary etc
– Must receive PPV vaccine in addition to PCV
Immunizations
DTaP - Diptheria, Tetanus and acellular Pertussis (IM)
Diptheria
• Rare throat infection
– Gray/yellow film
• difficult to remove
– Air flow obstruction
– Sepsis
Tetanus
•
Clostridium produced in infected wounds
–
Severe muscle extension
Immunizations
Pertussis
• Gram negative bordetella pertussis
• “whooping cough”
– Post-tussive vomiting
– Cyanosis
– Subconjuctival hemorrhage
Three stages:
• catarrhal, paroxysmal (2 weeks) and decline
• ↑ outbreaks in Adolescents and Adults
RT ↓ titers
www.pertussis.com
Immunizations
DTaP Schedule
• 2,4,6,15 months and 4-6 years for DTaP
• √ Side Effect: Redness & swelling @ site
• New booster recommendations 2005:
– “Tdap” Adacel: one dose 11- 64 years or
– Boostrix: single dose 10 -18 years of age
– Adolescents 11-12 years of age should
receive single dose of Tdap instead of Td
(if up to date and have not yet received Td
booster)
• Need 5 year interval from Td to Tdap to ↓SE
Contraindication:
–
Encephalopathy in 7 days of DTaP
Immunizations
MMR - Measles, Mumps and Rubella (IM)
Measles
• Viral illness - macular/papular rash
• Kopliks spots oral mucosa
• Encephalitis/pneumonia
Mumps
• Inflammation salivary glands/parotid
• Boys develop orichitis/sterility
Rubella
• Viral illness- rash (face → body → extremities)
Pregnancy exposure:
– Fetal deafness, cataracts, cardiac defects, encephalitis
Immunizations
• MMR is live attenuated (weakened)
vaccine
• 12-15 months and 4 - 6years
• Contraindication:
Pregnancy
Immunocompromised
Allergy to neomycin
Immunizations
Varicella (SC)
• Varicella “chickenpox”
• Live attenuated virus healthy children only
• 12-18 months
• 2nd dose @ 4-6 years
• 2005 - All kids entering 6th grade
– ↑Risk > 13 years
• Give with MMR
– MMRV new vaccine
Contraindication
–
Pregnancy
–
Immunocompromised or
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Allergy to neomycin
Immunizations
MCV4 - Meningococcal Conjugate Vaccine 4 (IM)
MPSV4 - Meningococcal Polysacharide (SC)
• Protects against N.meningitids (not all
strains!)
• MCV4/ Menactra:
– One dose 11-12 years or @ high school entry or
college freshman in dormitories
– (↑risk smoking and crowds)
• MPSV4/Menomune:
Children> 2- 10 years ↑risk factors
Sickle cell disease.
Immunizations
TIV -Trivalent Inactivated Vaccine – Influenza (IM)
• Influenza virus → pneumonia and death
– 2004 -152 pediatric deaths
– ↑↑ # of cases in February
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6 mos - 5 years of age annually
> 5 years only high risk population.
0.25ml<3 years or 0.5ml>3 years
Contraindication – Egg Allergy
– √ Eat baked goods can have vaccine
LAIV - Live Attentuated Influenza Vaccine
> 5 years (2 doses 1st time)
New Vaccines Added
Rotavirus vaccine Rototeq
• Rotavirus is primary cause of acute
gastroenteritis in US
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–
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Three oral doses given at 2, 4 and 6 months
Dosing must be complete by 8 months of age
No catch-up for older infants
Do not re-administer if infant spits up
New Vaccines Added
Human Papillomavirus (HPV)
• Non-enveloped dbl stranded DNA virus
• >100 types with 15-20 oncogenic types
• 75% of sexually experienced men and women age 15-49 years
have had some type of HPV
Quadrivalent HPV vaccine (Gardasil)
• Protects against HPV 6,11, 16 & 18
• Type 16 and 18 account for approx 70% of cervical cancers
• ACIP recommended 6/29/06
• Routine vaccination of girls 11-12 years but may begin @ 9
• Catch-up vaccination for adolescents and young women who
have not been previously vaccinated
• Not indicated in pregnancy or hypersensitivity to substances
New Vaccines Added
HPV administration (3 separate doses 0.5ml IM )
• 1st dose on elective date
• 2nd 2 months from first
• 3rd 6 months after first dose
SE:
Very painful
Syncope & tonic –clonic movements
√ Pt remains seated or lies down x 15 minutes
Compliancy Issues:
– Moral issues can intervene
– Study with boys shows = a good immune response
– ↑ Vaccinate girls RT ↑↑ risk of Cervical CA
Only true contraindications
to vaccine administration
• Fever >102
• Immunocompromised:
(No MMR & Varicella)
– HIV, Leukemia, Lymphoma
– Alkylating agents or Antimetabolites
– Daily Corticosteroids Dose:
> 2 mg/kg or 20 mg/day
• Allergy to vaccine component
• Vaccine Adverse Event Reporting System
•
(VAERS)
Congenital defects
Cleft palate
• 1/750 births cleft lip
• 1/2500 births cleft palate
• Incomplete closure of the roof of the mouth
– 6th -10th week of gestation
• Opening from uvula→ soft palate → hard palate → lip
• Cleft palate 1st sign
– Formula coming out of nose
•
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Gloved finger to assess soft and hard palate in
newborn
Etiology
Multifactorial
– Genetic-familial tendency
• ↑ in Asians and lowest in African Americans
– ↑ Caffeine
– ↑ ETOH
– Dilantin or Valium
– ↓Folic Acid ↓ Vit A
Sequella
– Feeding difficulties
– Speech difficulties
– High risk for Otitis Media
Serous and Bacterial
Interventions
• Review defect
– Impact on infant
– Before and after photos
– Support Groups
• 3P Feeding technique
– Position - upright
– Pore - soft, premie nipples
• enlarged opening
– Patience - burp frequently
Surgery
• Lip repair usually 1-3 months
– Protect incision line after operation
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Palate repair @ 18 months
Supine with ↑ HOB
Elbow restraints
√I&O
Tracheoesophageal (TEF)
Fistula
• Fistula
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Opening between trachea and esophagus
Fluids enter lungs
↑ Aspiration PN
Large amounts of air into stomach
Esophageal Atresia EA
• Esophagus ends in a blind pouch
•
↑ in Pre-term and/or Polyhydramnois
30-50% multiple anomalies
TEF/ EA Clinical Signs
• Increased salivation
• Drooling
• “3 C’s”
– Choking
– Coughing
– Cyanotic episodes
• Laryngospasms
• Abdominal distension
• Unable to pass NGT with atresia
Interventions
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NPO
↑ HOB>30º
Maintain patent airway
NGT to low intermittent suction
Prophylactic antibiotics
– Aspiration PN
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Surgery correction of fistula
ASAP
Safety in Infants
Accidents leading cause of death btwn 6-12 mos
Suffocation/Aspiration
 # 1 cause of fatal injuries <1 year
 √ toys, mobiles

No H2O mattress or pillows
Falls
 Walkers 45%
Burns
 H2O temp @ 160 scalds skin in 10 seconds
 ↓ Temp to 120
Poisonings
 Plants, Cleaners, Grandma’s purse √ meds
Cars
 Car seat < 1 year back seat, facing rear
Nutrition
Vitamins for Infants
• Fluoride
– 0.25mg/day > 6 months - 3 years
– Poly-vi-flor 1cc QD
– >3 years ↑ 0.50mg/day
• FeSO4
– 0.5mg/kg/day > 6 months
– if BF mother not taking supplements
– after 6 months fetal stores are depleted)
Vit D
400 IU/day
if BF mother not taking supplements
Breast Milk
• Contains all nutrients and
– A,B, E
– Immunoglobulin IgA, T and B cells
• Lacks Vit C, D and Fe
• Twice sugar (lactose)= laxative
effect
– ↑ # of stools
• ↑↑ lactalbumun more complete protein
•
↓↓ caesin easier to digest
Formula
• No more than 32 oz/day
• No whole milk in infants!
– No iron in milk
– Infants unable to properly digest
– ↑ ↑ irritation of intestinal mucosa,
bleeding and anemia
Solids
• Begin at 4-6 months
• Too early introduction of solids
– ↑ incidence of allergies and celiac disease.
– No cereal in formula bottle!
• Assess physiological readiness
– ↓ Tongue extrusion reflex
– ↑ Coordinated suck & swallow
– Tooth eruption – ↑ biting & chewing
– ↑ Pancreatic enzymes for complex nutrients
• Introduce foods one at time
– New food after 3 days:
– Cereal → vegetables → fruits →meats → egg yolks
No egg whites <1 year
No honey/corn syrup <2 years
↑ Risk of botulism
No Nuts, Seeds or Popcorn
Kwashikor
• Severe protein deficiency
• Adequate caloric intake and ↑ ↑ carb diet
• Mycotoxin mold found in intestines
Signs and Symptoms
• Scaly, dry skin and ↓ pigmentation
• Hair thin/dry and coarse
• Ascites
– Edema RT ↓ protein
• Muscle atrophy
• Irritable, lethargic, withdrawn
• Permanent Blindness
Diarrhea→Infection →Death
Nursing Interventions
• Assess degree of malnutrition
• Neurological/muscular impairments
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– √ Developmental milestones
Hyperalimentation
↑ Protein diet
Antibiotics
Skin Care
Collaborate with OT and PT
Skin Disorders
Eczema (5-7% Infants)
• RT allergies (egg, soy and cow’s milk)
– ↑ Ig E levels RT ↑ Histamine,
Prostaglandins, Cytokines
• ↑ with stress
• 90% develop asthma
Signs and Symptoms
• ↑ in winter
• Skin Rash
– Erythematous, edematous,
– Pruritic, dry and cracked
– ↑ Lesions in skin creases,
Cheeks, forehead & scalp
• ↑ Risk of secondary infections
Treatment
• Hydrate
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– Brief bath with Dove soap
– Lubricants –Eucerin cream
Topical steroids
Antibiotics if secondary infections
Elidel and Protopic 0.03% non-steroidal
Pimercrolimus and Tacrolimus
– Only for children > 2 years
– Black box warning
– ?↑ risk of cancer
Impetigo
• Toddlers and Preschoolers
• ↑ incidence in Summer (hot/humid)
• 1st Skin is broken via bug bite
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infected - staph A or B strep
Very contagious
1st Macular & Pruritic
2nd Honey crusted, thick & bleed
Therapy
– Wash lesion c warm soapy H2O
– Soak and remove crusts
– Bactraban BID 7 days
PO Antibiotics
PCN, EES, Lorabid, Zithromax
Sebborrheic Dermatitis
Cradle Cap
• Chronic inflammatory
condition
• Dysfunction of
sebaceous glands
• Infants produce a lot of sebum
• Yellow scales from eyelids → Scalp
• Therapy
– Apply lotion, massage scalp
Fine comb remove scales
Toddler 12-36 months
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Growth slows – Physiological anorexia
Average weight gain 4-6 lbs/year
BW quadrupled by 2 ½ years
Height 3 inches/year
HC growth slows
A/P diameter 1:2
• Visual acuity 20/40
– Eyes can accommodate objects @ distance
↑ Neuromuscular control
Manipulates objects & people
Psychosocial Development
Autonomy vs. Shame and Doubt
• “Me do” stage
• Intense exploration of environment
• Fighting for autonomy
• Negativism “No”
• Ritualistic behavior to control their
environment
• Body Image develops
Psychosocial
• 2nd Separation Anxiety
– Cling and cry when left by parent
– Be honest regarding separation do not
disappear!!
• Body image develops
– knows certain body parts: eye, “pee pee”
• Begins to acquire socially accepted
behaviors
Toilet training
• Holding on and letting go is very important!
• Need to recognize the urge to “let go”
1st Bowel control after 18 months
2nd Bladder control @ 2½ - 3½ years
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Daytime bladder control before nighttime
Regular BM and patterns or child will alert you
Needs ↑ awareness and self discipline
Harder to train children with history of
constipation
Temper tantrums
• Common response to helplessness or
frustration
• Inadequate verbal skills
– Can’t communicate needs!
– Strike out physically
Monitor for speech delay children!
Interventions
• Set appropriate, clear and consistent
limits
• Safely isolate and ignore behavior
– Remove from situation
• Redirect or introduce another activity to
restore self-esteem
• Time out = minute per age
• Do not let toddler get too tired, hungry
or stimulated
• After tantrum subsides provide love and
attention
Developmental skills
• 300 words by 2 years.
– Understand more than they say
– 2 yr old 65% of speech should be
comprehendible
• Knows first and last name
• Dressing - takes off own clothes
• Walk, run, and jump with both feet
• Ride tricycle, build tower of blocks
• Parallel play
– Possession = ownership
• Ritualism
Comforting & ↓ Anxiety
Intellectual development
5th Stage of Sensorimotor @12-18 months
• Object permanence
– Exists when not visible “Where’d it go?”
– “Peek a Boo”
• Active experimentation
• Time perception
– Holidays, morning, noon, night
– 1 minute = 1 hour
• Space perception
– Nesting
– Stands on stool to get object
Magical thinking
Pre-operational Stage
Transitional Stage 18 - 24 mos
• ↓ Trial and error
– Memory and imitates actions.
– sweeping floor with broom is mom cleaning
• ↑ Problem solving
• Egocentric- “I” “me” “mine”
• Concrete thinking
– Literal translation
– “A little stick” for IV = tree branch
• Sense of Time
– Orientation RT activities
–
Mom will be back after nap instead of at 2 o’clock.
Toddler Developmental Tasks
• Differentiate self from others
• Toleration of separation of parents
• Slight delayed gratification
• Basic toilet training
• Socially acceptable behavior
– Biting and spitting bad!
•
Communicates effectively
Transitional objects
Favorite toy, blanket
↓ stress
Nutrition
• ↓ Growth period = ↓ protein and fluids
• Physiological Anorexia @ 18 mos
– ↓ nutritional need = ↓ ↓appetite
• Daily diet
– Milk 2-3 cups/day
– ↑ FE, CA, PO4
• Very fussy and food jags (1-2 items only!)
– Only peanut butter and bananas!
• Want to feed themselves = MESSY!
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May eat a lot one day
•
and not much following day
Nutrition
• Offer small, frequent nutritious
snacks
– Toddlers love to graze
• Not too much milk or juice (↑ sugar)
– Fills them up = won’t eat
• Do not force child to eat.
– Will eat when hungry.
– If child is not losing weight it is ok.
Dentition
• Twenty primary teeth by 30 months
• Brush teeth 2 x/day!
• No bottles of juice or milk at
bedtime.
• Dental carries can occur.
Safety
• Toddlers have no sense of danger
• ↑↑ Locomotion = DANGER!!
• Injuries cause > death in ages 1-4
Motor Vehicle Crash (MVC) = #1!
• ↑ Caused by lack or improper restraint
• SUV
– toddlers wander behind truck and get hit.
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DWI
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2500 kids/year
7/10 in car with impaired parent
Car Seat Safety Rules
• Universal Child Safety System (UCSS)
– 2 point attachment with tether system
– by 2002 all new cars must have entire UCSS
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<12 years of age = sit in back of car
Infant = rear facing (1 yr and 20 lbs)
Forward facing convertible seat till 40 lbs
>40 lbs belt positioning booster seat
New York State Seatbelt Laws
• March 2005 any child <7 years of age
– appropriate restraint system or booster seat
80 lbs or 4 ft 9 inches may use seatbelt
Seat belt must fit properly:
on hips not stomach
on shoulder not neck
Drowning
• # 2 cause of death for toddlers
– Totally Preventable!
• Only need 1” of H2O to drown
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Bucket to clean car
Ponds
Pools
Beach
• Always supervise near water!
Burns
• 3rd cause of death (boys)
– 2nd among girls
• 20,000 injuries/year and 1,000 deaths
– 16% RT child abuse
Types
• Thermal- flames, scalds (85%),hot objects
• Electrical- socket, chewing wires
• Chemical- Ingesting cleaning products
• Radiation- sunburn
First Degree/Superficial
(epidermis)
• Minor sunburn
• Red, dry and painful
• Heals spontaneously
– 3-7 days
•
No therapy needed
Second Degree
Partial Thickness
• Involves epidermis and upper layer of
dermis
• Moist, bulla
• Skin bright red
• Painful
Heals in 14 - 21 days with scarring
Third Degree/ Full Thickness
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Includes subcutaneous tissue
Dry, pale or brown/black
PAINLESS
Eschar– thick leather like
– dead skin
Healing requires skin grafting
»↑ painful
Fourth Degree/ Full thickness
• Extends all the way to bone
• Dry, whitish leathery appearance
• ↓Sensation to pain
•
Scarring and contractures
Total Body Surface Area
(TBSA)
• Varies with age
– ↓ age = ↑ TBSA
– ↑ surface area = ↑ Injury
“Rule of Nines”
– Determines % of burns
– Transfer to burn unit BSA>10%
Open palm of hand = 1 % of BSA
Thorax 18% Head 19%
Arm 8%
Leg 13%
Management
Respiratory
• Maintain patent airway
• R/O Inhalation injury
– Smoke, steam, toxic fumes
– Charred lips, singed nasal hairs,
– soot covered nares
• Humidified 100% O2
• Assess for:
– Respiratory Acidosis:
• ↑ RR, retractions, nasal flaring, ↑↑effort, ↓O2
Moist Breath sounds = Pulmonary edema
√ Carboxyhemoglobin (CoHb) levels
> 10% need hyperbaric chamber
Fluid Resuscitation
Hypovolemic “Burn” Shock
– ↑↑ capillary permeability
– Leakage of intravascular fluids
– ↓↓ Perfusion, ↓↓ BP, ↑↑ HR, ↓ Output
• Parkland Formula = 4mL LR x kg x %TBSA
1st 24 - 48 hours until capillary integrity is restored
• IV Maintenace Fluids: 4:2:1 Rule
4mL/kg for 1st 10 kg
2mL/kg for 10-20 kg
1mL/kg >20 kg
•
45 kg child: 4 x 10 = 40 mL
2 x 10 = 20 mL
1 x 25 = 25 mL
85 mL/H
Maintain urine output 1-2ml/kg/hour-(foley)
Strict I & O!
√ SG √ Wt.
√ VS and LOC
Monitor Lab values
Hyperglycemia
• ↑ NE/E, ↑stress, insulin resistance, glycogen released
Hyponatremia
– 3rd spacing 1st 24 hours = ↑NA excretion
Hyperkalemia
• 1st 24 hours = ↑ cell release of K+
Hypokalemia
• 2nd 24 -48 fluid shifts back to cell ↓ K+
Hypoalbuminia (<2)
• ↓ serum proteins 3rd spacing
• Albumin 1 gm/kg/day
Metabolic acidosis
• Renal failure, tissue damage RT sepsis
↑BUN ↑Creatine = ↑ SG
• Dehydration & renal failure
Pain Management
• Acute
– Burned skin and exposed nerves
– Moaning, grimacing, restlessness, guarding,
dilated pupils, clenched fists,↓↓ movement
• Procedures: PAIN
– Dressing changes ↑↑ anxiety & ↑↑ fear
• Medicate prior to all procedures.
– MSO4, Propofol, Fentanyl, Hydromorphone
• Imagery, relaxation, distraction
Therapeutic Touch
Wound Care
• Aseptic/sterile technique
– ↓↓risk of infection
– Invasive lines, compromised immune
• Protective Isolation
• Debridement
– Remove dead tissue
• Hydrotherapy
– Soaking wounds - remove old dsg
– 10 mins to prevent electrolyte and fluid loss
– Washing area
• Clean area & assess wound
• √ color, drainage, odor, sloughing,
granulation tissue
Antimicrobial creams
Mafenide Acetate (Sulfamylon cream)
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Painful but penetrates eschar
Gram (+)/(-) coverage
Apply & leave OTA or light dsg
√ Sulfa allergies
– Hypersensitivity reaction
• SE: Metabolic acidosis
Antimicrobial creams
Silver Sufadiazine (Silvadene)
• Painless
• Gram (-)/(+) coverage
• Not to use on face or electrical burns
• 1st Clean wound
• Apply & leave OTA or light dsg
• √ Sulfa allergy
• SE: Transient leukopenia
Antimicrobial creams
Silver nitrate 0.5%
• Most gram (+) & some gram (-)
• Painless soak
– Dampen dsg q 2H or TID
– Need large bulky dsgs
• Stains clothing and linens -black
• SE: ↓ K+ ↓ Na+ ↓Cl+
– √ lytes
Skin Grafts
• Autograft
– Patient’s own skin
– ↓ risk for Host Versus Graft (HVG) response
• Transcyte
– Newborn foreskin
– Bioactive skin substitute
– ↑ Re-epithelialization
• ↓ dsg changes ↓ hospitalization
• ↓scarring
Nutritional Support
• NPO x 24 hours
– √ Bowel sounds √ Abd girth √ N & V
• Curling’s Ulcer
– ↓ GI perfusion ↑ occult blood via NGT & stool
• 2-3 times daily calories for wound healing
– ↑ BMR RT ↓ Protein & N loss
• Protein 25% of calories– eggs, peanut butter and milk
↑↑ Vit A and C important for skin
oranges, grapefruit
strawberries, broccoli
Psychological Needs
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↑ Contractures & ↓ROM RT scars
Pressure Ace wrap cover to ↓↓ scars
Increase involvement in care
Play therapy & counseling
– Ease transition → community
• Prepare friends and school
– Wounds/scarring & emotional needs
• Support groups
Poisoning
• 150,000 kids < 5 years old = 120 deaths/year
• ↑ risk @ 2 years (improper storage)
• Poison Control # = 1-800-222-1222
• www.nyc.gov/html/doh/html/poison/poison.shtml
Aspirin Intoxication• # 1 most ingested drug
• ASA acetylsalicylic Acid
• ↑ Availability in home
– Combination OTC meds:
– Peptol bismal, cough and cold, wart preparations
Therapeutic Dose 40 -100 mg/kg
Toxic dose 200mg/kg
Severe toxicity 300 - 500mg/kg
Signs and symptoms
6 H delay before toxicity signs noted
– Hyperventilation
• ↑↑ RR
↓↓CO2
– ↑ Metabolism
• ↑↑BMR
↑↑ O2 use
↓↓ Glucose
– Metabolic acidosis
• ↑ ketones and organic acids
– Bleeding
• ↓↓ platelets
Interventions
• √ Serum salicylate levels
– Therapeutic 5-20mg/dl
– Toxic >25mg/dl
• Gastric lavage up to 4 hours post ingestion
• Activated Charcoal (1g/kg)
– ↓ absorption & ↑ elimination via GI tract
• Vit K for bleeding
• Correct lyte imbalances– ↑↑ Ca+ ↑↑ K+
• ↑↑ Hydration
– Flush kidneys
•
↑↑Calories
•
May need hemodialysis
Acetaminophen Overdose
• Most common acute drug poisoning
– ↑↑ Risk c combination drugs
• ↑↑ Risk for liver damage
– RT metabolites binding to hepatocytes
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½ life = 3 hours
Liver necrosis within 2-5 days if not treated
Therapeutic dose = 90 mg/kg
Toxic dose = 150mg/kg
Clinical signs
• Phase one (1st 24 hours)
– N/V, anorexia and malaise
• Phase two (24-36 hours)
– Hepatomegaly, RUQ pain, ↑↑LFT’s
– ↑INR, PT, hyperbillirubin and oliguria
• Phase three (2-5 days)
– Encephalopathy, cardiomyopathy, anorexia, emesis,
liver failure, hypoglycemia, coagulopathy, renal failure
and death
Phase four (7-8 days)
Recovery or fatal hepatic failure
Interventions
√ Serum acetaminophen levels
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↑ validity 4 hours post ingestion.
Therapeutic level = 2 -20 mg
Toxic level > 50 mg
If extended release √ level 8 hours after ingestion.
Must know actual ingestion time.
√ INR (1.0 WNL)
– Earliest and most sensitive for hepatotoxicity
√ LFTs (AST Aspartate Transaminase)
– Bilirubin, PT
– Released with hepatic injury
√ BMP/ Panel 7
√ Renal- BUN
Interventions cont
• Gastric lavage most effective with extended release
• Activated charcoal most effective 1-2 hours after
injestion.
• N-acetylcystein-”Mucomyst”- PO
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•
Loading dose = 140 mg/kg x 1 PO
then 70 mg/kg x 17 doses PO q 4H.
Most effective with-in 8 hours of ingestion
Must be initiated with-in 16 hours.
Mix with coke smells like rotten eggs
Charcoal may bind with mucomyst give 1 hour apart
May use IV mucomyst if pt not tolerating PO
Lead poisoning Plumbism
• Home built before 1960’s
– ↑ Risk for lead based paint (banned in 1978)
– Recent ongoing renovations
• Nearby industry
– Battery plants, gas stations
– Leaded gasoline in soil children place hands in mouth
• Old furniture, ceramic pottery and lead toys
• Folk Remedies
– Azarcon, Greta, Ligra & Surma (200x Pb!)
• ↑Risk
< 6 years
Urban areas
Medicaid recipients 3 x’s lead levels
Lead Screening
Screen at 9 months to 1 year and then 2 years
Earlier/ASAP with risk factors
Clinical signs
• Most kids are asymptomatic! √ Level
– Pb serum level > 10 is toxic
– Pb > 45 = RX
– Pb > 70 = Medical Emergency (RX & ICU)
90% Pb attaches to RBC
– Interferes binding of iron to heme molecules
– √ H and H , Fe
– ↓ HgB = Anemia
• Absorption of Pb > Excretion
• 24 H Urine (lead) >3 mg
– Damages cells of proximal tubules
• Lead deposits in tissues, bones, gums and abdomen
Lead lines (bones, nails)
X-rays; Femur and Tib/Fib for deposits
Abdominal pain (paint chips on X-Ray)
Vomiting
&
Constipation
CNS Symptoms
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Hyperactivity
Aggression-irritability
Impulsiveness
Learning disabilities
Developmental delays
Lead Encephalopathy = Irreversible!
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↑ ICP
Seizures
Cortical atrophy-
•
Permanent brain damage→ Mental retardation
Coma and death
Treatment
Chelation Therapy for level >45mg/dl
Binds Pb to H20 water soluble form → excretion via urine
• Must use two meds if levels >70mg/dl
1. CaNa EDTA (calcium disodium edetate) IM/IV (20 doses)
• √ adequate kidney function
• Painful injections
– Apply EMLA 2 H before and inject with procaine.
2.
•
•
•
•
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BAL (dimercaprol) IM (24 doses)
√ renal function
Contraindicated with peanut allergy or G6PD
Usually not single therapy use in conjunction with EDTA
3.Succimer (Chemet or DMSA) PO (43 doses)
Alternate treatment for EDTA
19 day therapy
Hydrocarbons
• Gasoline and kerosene
•
•
•
•
•
•
– ↑Risk for aspiration/pulmonary toxicity
Turpentine = systemic toxicity
Antifreeze
Carbon Tetrachloride
Baby Oil
Camphor (Moth Balls)
Inhaled or ingested
Signs and symptoms
• Gagging, Choking, Cyanosis
• N & V
• ↑↑ RR Retractions Dyspnea
Grunting
• Aspiration PN in RUL
• Seizures
• Renal failure
• Coma
Therapy
•
•
•
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No emesis RT ↑Risk of aspiration
Gastric lavage
Humidified ↑ O2 + PEEP
Hydration
Antibiotics
– Prophylactic for PN
Lye, Corrosives
• Strong alkali with ↑↑ PH
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–
–
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Dishwasher detergent (Electrosol tablets)
Batteries
Denture cleaners
Oven/ Drain cleaners
• Erodes esophagus can cause perforation
Signs and symptoms
• Severe Burning Pain
– Mouth, throat and stomach
• White swollen mucous membranes:
– lips, tongue, pharynx
• Inspiratory stridor & Dyspnea RT
– Esophageal and tracheal edema
• Drooling
• Violent vomiting - blood & tissue
↑↑ Anxiety
Treatment
•
•
•
•
Don’t induce Vomiting!
Maintain patent airway
Administer analgesics
NPO or Dilute corrosive with 120 ml H2O
only!
• Steroids Methylprednisolone 2mg/kg/day
• Humidified O2
• Surgery
– Batteries can cause esophageal and gastric burns
– Esophageal strictures