Transcript clinical manifestations

Organization of day hospitals.
Work home hospitals.
Prepared by MD, Ass. Prof. Kovalchuk T.A.
Department of Pediatrics # 2
PREPARING THE CHILD AND FAMILY
FOR HOSPITALIZATION
Foremost in the preparation of children for hospitalization on any
unit is preparing the family.
If the family is well informed about and understands the child’s
illness, confidence in their medical recommendations, and the
support of understanding nurses, then they are more likely to be
able to assist in preparing the child for the hospital experience.
Types of hospitalization
Hospitalization
Planned
Unexpected
Types of hospitalization
When the hospitalization is planned, the caregivers and child have
time to prepare for the event. Many hospitals and agencies
concerned with the care of the young child provide age-appropriate
materials to assist caregivers and children to prepare for the
experience of hospitalization.
When hospitalization is unexpected, it is of utmost importance that
children be given opportunities to explore their new surroundings
and encouraged to view hospitalization as an adventure that they
can handle. The nurse treats all children and their caregivers with
respect, listening attentively, with an open-mind, in a nonjudgmental
way.
Reception
The child directed to a hospital gets into a reception room where his
initial examination will be carried out.
The appointment card (= direction letter = referral note) may be
given by the polyclinic doctor, the specialist, or the family doctor;
the patient may be delivered by the ambulance. Only patients in
severe condition can be accepted without an appointment card.
City children's hospital # 3 Appointment card
Borody Oleg lv., 2 years old, the address is: Solnitchnaya str., 14/92, goes on
hospitalization.
The diagnosis: Acute Bronchitis.
Iron deficient anemia of 1st degree.
The general blood analysis on 14.12.2010: RBC — 3.4 T/L, Hb — 92 g/L, WBC —
10 G/L, ESR — 12 mm/hour.
No contact with infectious patients, infringements of stool are not present.
15.12.2010
Sign, and stamp of local doctor
Reception
If the child is delivered into the department without parents (in
cases of accident, trauma, sudden significant deterioration of the
health state), the information of hospitalization should urgently be
told to the parents of the patient or the local police station should
be informed for the search of the parents in case the child's
health is deteriorated.
In children's medical establishment, there is an independent
reception with separate medical personnels (doctors, nurses). In
small children's hospitals, the child is accepted by the doctors on
duty in the children's branch or the pediatricians occupying the
post of the doctor on duty in the hospital, sometimes local doctors
do it.
Reception of the patient should be carried out
according to the following standard obligatory
plan
I Registration
First the nurse fills in the data concerning the patient in the 'Admission register'
or 'hospitalization register’ (date, full name, age of the child, the address,
the diagnosis in the appointment card) and draws up a passport part in the
case history.
Simultaneously, the child's body temperature is measured and later examined
by the doctor on duty. The specified order is broken in case when a
condition of the patient is severe and demands urgent help.
II Doctor's examination
Collection of complaints, the anamnesis of diseases and life, the estimation of
the child's condition, etc.) is carried out in approximately 20-30 minutes
depending on the disease and seriousness of the condition of the child.
Then the doctor (in our country personally) writes down all received data in
the case history. At the end of this, the preliminary diagnosis, a plan of the
inspection of the patient and his treatment are indicated (the list of
medications and medical procedures).
Reception of the patient should be carried out
according to the following standard obligatory
plan
III The sanitary processing of the patient
 First of all, the hygienic condition of the child (by examination of the neck,
ears and all surface of the skin, nails on the fingers and toes, as well as the
hair) is checked.
 In case of long nails, they should be cut.
 At diagnosis of pediculosis, the appropriate processing should be carried
out.
 Then, if necessary, according to the prescription of the doctor, the child
takes a hygienic bath or shower.
Attention! In case of severe condition of the patient, sanitary processing
should be carried out only after rendering the urgent help and with the
permission of the doctor.
Reception of the patient should
be carried out according to the
following standard obligatory
plan
IV Transportation
The kind of transportation is defined by the doctor depending on the condition of the
patient:
• If the state of health of the child is satisfactory, then he/she can go to the
department independently under the nurse's supervision.
• Children of the first-second year of life are carried on hands.
• The medical staff transports heavy patients on stretcher, carriages, etc.
• In absence of carriages, lift escalator or elevator, the child of an advanced age
can be transferred on the bed sheets or blanket.
Transportation of the patient comes to an end with the case history and the
prescription form (the plan of treatment and inspection of the patient):
 To a nurse from the child's department (if a condition of the patient is not severe,
in evening-night shift).
 To the doctor on duty (in the afternoon; if the condition of the patient is very
serious at any time of the day).
If the child is under 1 year of age, feeding schedule is also prescribed. Besides, an
additional verbal communication with the department about the condition of the
hospitalised patient is necessary.
Pediculosis
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CLINICAL MANIFESTATIONS
Itching is the most common symptom of head lice infestation, but many children are
asymptomatic.
Adult lice or eggs (nits) are found in the hair, usually behind the ears and near the nape
of the neck.
Excoriations and crusting caused by secondary bacterial infection may occur and often
are associated with regional lymphadenopathy.
In temperate climates, head lice deposit their eggs on a hair shaft 3 to 4 mm from the
scalp. Because hair grows at a rate of approximately 1 cm per month, the duration of
infestation can be estimated by the distance of the nit from the scalp.
Pediculosis
The technique of eliminating process of the child at revealing head lice:
 It is possible to shear hair (it is usually done with boys — an ideal momentary
way!) or to process the head of the patient with one of solutions used for such a
purpose: Lotions 'Nittifor', 'Miloca', 'Lanchet', special shampoos, etc.
 After processing, the head is wrapped up with a polyethylene bag, then a scarf
is put on it; in such position, the child stays for 20-40 minutes (according to the
instruction).
 Then, the head is washed by hot water with laundry soap.
 The next moment is the most scrupulous one; it is gradual combing of the
patient's hair with a fine-tooth comb with a piece of cotton wool (moistened in 9%
vinegar solution).
 The head is swilled with a lot of water.
Cut off hair, and the hairs cut should be put on an oilcloth and burnt. At revealing only
nits, it is possible to apply more simple solution: the hair is processed with warm
(30°C) 9% solution of vinegar, then for 15-20 minutes, the head is wrapped up
with a scarf, after that, the hair is combed out and the head is washed.
The clothes on which body lice are revealed should be packed into a polyethylene
bag and sent into the chamber for disinfection.
Scabies
CLINICAL MANIFESTATIONS
Scabies is characterized by an intensely pruritic, erythematous,
papular eruption caused by burrowing of adult female mites in
upper layers of the epidermis, creating serpiginous burrows.
Itching is most intense at night.
In older children and adults, the sites of predilection are
interdigital folds, flexor aspects of wrists, extensor surfaces of
elbows, anterior axillary folds, waistline, thighs, navel, genitalia,
areolae, abdomen, intergluteal cleft, and buttocks. In children
younger than 2 years of age, the eruption generally is vesicular
and often occurs in areas usually spared in older children and
adults, such as the head, neck, palms, and soles . The eruption
is caused by a hypersensitivity reaction to the proteins of the
parasite.
The characteristic scabietic burrows appear as gray or white,
tortuous, thread-like lines. Excoriations are common, and most
burrows are obliterated by scratching before a patient is seen by
a physician. Occasionally, 2- to 5-mm red-brown nodules are
present, particularly on covered parts of the body, such as the
genitalia, groin, and axilla. These scabies nodules are a
granulomatous response to dead mite antigens and feces; the
nodules can persist for weeks and even months after effective
treatment.
Cutaneous secondary bacterial infection can occur and usually is
caused by Streptococcus pyogenes or Staphylococcus aureus
Scabies
TREATMENT
 Infested children and adults should apply lotion or cream containing a scabicide
over their entire body below the head. Because scabies can affect the head,
scalp, and neck in infants and young children, treatment of the entire head, neck,
and body in this age group is required.
 The drug of choice, particularly for infants, young children, and pregnant or
nursing women, is 5% permethrin cream (not approved for children younger than
2 months of age), a synthetic pyrethroid. Alternative drugs are 10% crotamiton,
ivermectin, or 1% lindane cream or lotion. Permethrin should be removed by
bathing after 8 to 14 hours.
 Crotamiton is applied once a day for 2 days followed by a cleansing bath 48
hours after the last application, but crotamiton is associated with frequent
treatment failures and has not been approved for use in children.
Pinworm Infection/Enterobius vermicularis
CLINICAL MANIFESTATIONS
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Although some people are asymptomatic, pinworm infection (enterobiasis) may
cause pruritus ani and, rarely, pruritus vulvae.
Pinworms have been found in the lumen of the appendix, but most evidence
indicates that they are not related causally to acute appendicitis.
Many clinical findings, such as grinding of the teeth at night, weight loss, and
enuresis, have been attributed to pinworm infections, but proof of a causal
relationship has not been established.
Urethritis, vaginitis, salpingitis, or pelvic peritonitis may occur from aberrant
migration of an adult worm from the perineum.
Pinworm Infection/Enterobius vermicularis
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TREATMENT
The drugs of choice are mebendazole, pyrantel pamoate, and albendazole, all of which
are given in a single dose and repeated in 2 weeks.
Pyrantel pamoate is available without prescription.
For children younger than 2 years of age, in whom experience with these drugs is
limited, risks and benefits should be considered before drug administration. Reinfection
with pinworms occurs easily; prevention should be discussed when treatment is given.
Infected people should bathe in the morning; bathing removes a large proportion of
eggs. Frequently changing the infected person’s underclothes, bedclothes, and
bedsheets may decrease the egg contamination of the local environment and decrease
risk of reinfection. Specific personal hygiene measures (egg, exercising hand hygiene
before eating or preparing food, keeping fingernails short, avoiding scratching of the
perianal region, and avoiding nail biting) may decrease risk of autoinfection and
continued transmission. Repeated infections should be treated by the same method as
the first infection.
All family members should be treated as a group in situations in which multiple or
repeated symptomatic infections occur. Vaginitis is self-limited and does not require
separate treatment.
Ascaris lumbricoides Infections
CLINICAL MANIFESTATIONS
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Most infections are asymptomatic.
Moderate to heavy infections may lead to malnutrition, and nonspecific
gastrointestinal tract symptoms may occur in some patients.
During the larval migratory phase, an acute transient pneumonitis associated with
fever and marked eosinophilia may occur.
Acute intestinal obstruction may develop in patients with heavy infections. Children
are prone to this complication because of the small diameter of the intestinal lumen
and heavy worm burden.
Worm migration can cause peritonitis, secondary to intestinal wall penetration, and
common bile duct obstruction resulting in biliary colic, cholangitis, or pancreatitis.
Adult worms can be stimulated to migrate by stressful conditions (eg, fever, illness,
or anesthesia) and by some anthelmintic drugs.
Ascaris lumbricoides has been found in the appendiceal lumen in patients with acute
appendicitis, but a causal relationship is uncertain.
Ascaris lumbricoides Infections
TREATMENT
Albendazole in a single dose, mebendazole for 3 days, or ivermectin in a single
dose is recommended for treatment of asymptomatic and symptomatic infections.
Although limited data suggest that these drugs are safe in children younger than
2 years of age, the risks and benefits of therapy should be considered before
administration.
Reexamination of stool specimens 3 weeks after therapy to determine whether
the worms have been eliminated is helpful for assessing therapy but is not
essential.
Surgical intervention occasionally is necessary to relieve intestinal or biliary tract
obstruction or for volvulus or peritonitis secondary to perforation. If surgery is
performed for intestinal obstruction, massaging the bowel to eliminate the
obstruction is preferable to incision into the intestine. Endoscopic retrograde
cholangiopancreatography has been used successfully for extraction of worms
from the biliary tree.
Medical department
During all the time of stay in a hospital, the child is treated in the medical
department. In total, the hospital may have from 1 -2 up to 10 and more
departments depending on its size. In one children's department, there may
be patients with different uncontageous diseases (rheumatic fever,
pyelonephritis, gastritis; in the same branch, only in a separate chamber,
patients with bronchitis, pneumonia, etc.). There are specialized hospitals in
which children with diseases of one system (cardiological,
gastroenterological, hematological, etc.) are treated.
The main objective of all medical personnel in the department is an
operative inspection of the patient, the timely statement of the correct
diagnosis and, at an opportunity, the full treatment of the child or (in case of
incurable disease) realization of the necessary complex of medical actions
for the patient
Structure of the Children Department
The department consists of isolated ward sections; for children of the 1st
year of life, there should be no more than 24 beds, over one year— not
more than 30 beds. The best for the children of breast-feeding age are box
wards, when every child has his own ward which prevents possible
infections to other patients. Till this time, in some hospitals, according to the
old rule there are wards which may not be very effective half-boxes with
wooden-glass partitions only between beds.
Hygienic requirements in wards are: The distance between beds should
not be less than 1.5 m. Every child should have a personal bedside table
and a case for clothes. In each ward, one quartz lamp should be hung. If
there is no separate toilet near the ward, then the presence of a washbasin
with cold and hot water is necessary.
Structure of the children's department
The department manager's room.
Duty room — a room for the doctors work.
A room of the senior nurse.
A post of the attendant nurse (on duty) for the convenience of constant
supervision, it is often located in corridors of the department; near the table of the
nurse, there are some hospital shelves in which the most necessary medicines
and medical tools are kept.
In the department, there is nurse's room for inter-muscular injections, eye
dropping and other medical procedures, in which, by obligatory rules, medical
products and tools for manipulations are kept in the safe, refrigerator or in usual
shelves.
A separate (!) manipulation room for intravenous injections.
In the branch, usually there is a special separate room for specific medical
procedures with the purpose of treatment and inspection (for example, for
intubation of the patient, examination by the ENT-doctor, the urologist, and the
gynecologist, etc.).
A physical procedure cabinet (inhalation, electrophoresis, etc.).
A dining room.
A rest room for the doctor on duty.
Bathroom.
A toilet (separate for medical staff and patients).
Sanitary-and-hygienic and anti
epidemical regime
Sanitary-and-hygienic and anti epidemic regime is the extensive
complex of actions which are carried out by all employees of the
medical personnel, and also by patients, the purpose of it is
maintaining cleanliness in the medical establishment and
anticipation of future epidemics of infectious diseases.
Sanitary procedures
Every week each patient takes a hygienic bath.
In the department, bed sheets and clothes should be changed in due time.
The frequency of the change depends on the pathology, age of the child
and his condition.
Furniture and the object of common use (couch and pillow on it) should
be covered with polyethylene film which is wiped up by 1% sol. of
chloramines or 0.5% sol. of chloride of lime 2 times after every patient, with
an interval of 15 minutes, and after that with water. Sterile disposable film
sheets can be used. Simultaneously after every patient, the bed sheet on a
couch are changed.
The medical staff should observe the rules of preparation and
distribution of food, and patients — rules of eating food. Usually, it is
prepared in a special room. After delivery to the department, it is possible to
keep food stuffs in a separate room not longer than 2 hours. Portions are
given into a dining room through a special window. The utensils are
exposed to special processing after use.
There should be drinking water for patients.
Special features of the medical
personnel hygiene
Tidy appearance.
A standard medical smock (coat).
A cap or a kerchief on a head.
Short nails.
Special hospital footwear which is easily disinfected (for example, leather).
Hands well washed up with soap.
To medical sisters engaged in surgical manipulations, watches, rings,
varnish on nails are forbidden.
According to indications (the maternity, infectious department, epidemic of
influenza, etc.) a mask is put on; it is necessary to change a gauze mask
every 4 hours; at an opportunity, it is better to use disposable sterile masks.
Rules of hygiene for
children of the first year
of life in the Children
Hospital
The care of the appropriate parts of the head and trunk: Cleaning during the 1st month
of life is carried out once a day (in the morning), on the 2nd-3rd month and further— two
times a day (in the morning and in the evening), warm boiled water is necessary; it is
better to wipe the face with cotton wool. Since the 5th month of life of the child, it is
advised to wash him/her with water from the tap (temperature 18-20°C).
Ears are wiped during face washing; external acoustical canals are cleaned with dry
cotton-buds only under indications.
Eyes, if necessary, are washed from the external corner towards the internal corner
with a piece of gauze moistened with tea.
For cleansing of nostrils to the depth of 1-1.5 cm, a sterile cotton strand moistened
with sterile Vaseline oil is used (a separate one for each nostril), then the canal is
cleaned by quick rounding movements outwards.
Nails of elderly children are cut once a week.
The younger the child is, the more often it is necessary to wash him/ her, as it is done
after every urination and defecation, it is necessary to use only water from the tap. The
girl's genitals are washed in the direction from front to back. After that it is necessary to
wipe and grease the skin with sterile oil.
Rules of hygiene for children of the first year
of life in the Children Hospital
Obligatory rules for the hygienic bath:
Frequency — the first bath is usually done on the 2nd week of life, when the remains of an umbilical cord
disappears and the umbilical wound has began to dry: during the 1st half-year — every day, during the
2nd half-year — every two days.
The bath is taken at specific times — not earlier than 1 hour after feeding or 40-50 minutes before it, and
also 1-1.5 hour before sleep. After bath, the child needs 30 minutes of rest (i.e. if the child bathe in the
evening and eats for the last time before sleep at 24.00, the best time to bathe him/her is 11 p.m.).
Tubs (plastic, enameled) should be washed well before each bathing, especially for a one month old child,
then rinsed with hot water.
during 1st month — 37.5-37°C
Temperature of water:
2-6 months — 37-36.5°C
after 6 months — 36.5-36°C
The duration of one bathe during the first year is gradually increased from 3-5 to 10 minutes.
The position of the child:
Under 6 months — the child should be placed in such a position, that the head is a little bit higher than the
trunk (water should not get into the external acoustical canals). For this purpose, it is possible to put
something under the head part of the tub (there are specially made tubs with the raised head part for
it) or to hold the head of the child in the hand. Water is poured up to the nipples of the child, leaving
the chest part open.
After 6 months — in sitting position.
Twice a week to wash with children's soap all the surface of skin, especially the folds (on the neck,
between buttocks, behind ears, axillary, inguinal area, etc). Raise the child above the water, to rinse
him/her with clean water from a separate basin. To wrap the child in to the sheet quickly to dry up all
him/her skin accurately. To grease folds with sterile oil. To dress him/her up.
Rules of hygiene for children older
than 1 year of life in the Children
Hospital
Washing— 2 times a day, in the morning and in the evening, according to indications (intake of
food in horizontal position, the child in a serious condition, etc.) the amount of washing
procedures should be increased.
Cleaning teeth with a brush — 2 times a day. The sick child should rinse his/her mouth after
each reception of food, especially during diseases of the mouth (stomatitis, quinsy, pharyngitis); it
is rational to rinse the mouth with 1.5%-2.5% of soda or 1% of salt solution.
It is necessary to wash ears every day. If there is some ear-wax in the ear canals, the nurse
cleans the patient's ears in the following way: 3-5 drops of the 3% solution of hydrogen peroxide
or sterile Vaseline oil are instilled into the ear, after which the wax plug is removed with the help of
cotton-buds.
Eyes are washed without special assignment 2 times a day. If the patient's eyes turn sour,
eyelashes stick together, it is necessary to wash the eyes with warm tea of strong concentration
(brown color), moving a piece of gauze moistened with tea, from an external corner up to the
nose bridge.
As for nostrils, the child of the advanced age usually clears them out himself/herself. With such a
purpose, the nurse at first puts cotton-buds, moistened with oil solution (Vaseline, Glycerin) into
nasal cavity, then for 2-3 minutes, the head of the child is pushed backwards, and then by
rounding movements, clears nostrils. The nostrils are processed one by one.
The nails are cut once a week.
External genital organs are washed with warm water; to girls with the purpose of prevention of
urogenital infections, the washing should be carried out from front to back.
Hygienic baths — once a week; duration of a bath for 2 year old child is 8-10 minutes, after 2
years of age — 10-20 minutes.
Usually the clothes and the bed-sheets are changed once a week
Preventive disinfection
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is a complex of actions for preventing the accumulation and distributions of
activators of diseases in the hospital.
Preventive disinfection should be carried out by the following ways:
Ventilation of wards — four times a day.
Quartz (UVR) wards 2 times a day for 15 minutes.
Vacuum cleaning or shaking out in the fresh air of soft things (e.g. mattresses,
blankets, curtains, etc.).
The complex of preventive disinfection includes the above mentioned rules of the
observance of hygiene by medical staff and patients, and also the rules of preparing
and distribution of food.
Wiping at least 2 times a day (in some departments — more often, for example, in the
infectious one — 4 times a day) the floor, windows, furniture. toys with specially
prepared solutions:
Chloramines В (in dry form, it is a powder of white color) — for usage,1% solution is
made by gradual stirring of the necessary quantity of the powder, first in a small volume
of hot water (50-60°C), and then adding more and more water up to the necessary full
volume (for example: 50 g of powder and 5 L of water). To store a solution is possible
no more than 5 days.
Dezaktin — dry powder mixed in water for 1-2 minutes, for the formation of 0.1-2.5%
solution which is used for the current and final disinfection. When water temperature is
60°C, there will be an accelerated dissolution of the medium (for concentrations over
0.5%). You can save 24 hours.
The basic duties of nurses
1. Participation during the process of admitting patients into hospital.
2. Performing all recommendations assigned by a doctor :
Distributing medicines to patients (in case the child is alone ,in a hospital, a nurse should
make sure that he/she takes the medicine on time and correctly).
Dropping medicine into eyes, nose and ears.
Carrying out different manipulations (e.g. intramuscular, intravenous injections, infusion
therapy, etc).
Measuring weight arid height of children.
Collecting samples for laboratory analysis from patients (blood, urine, stool, nasal and
oral swab, etc.), delivering them to the laboratory. When the analyses are completed, it
should be taken by the nurse from the laboratory and attached into the case history.
Taking general care of the patients and carrying out complicated methods of treatment
and examination of patient (feeding the child through a tube, catheterization of urinary
bladder, and gastrointestinal tract as well as indirect massage of heart, etc).
Transporting patients for radiography, spirography and other kinds of specific
examinations, physiotherapy, consultations with subject specialists, etc., and timely
submission of all the results after performed analyses and conclusions with subject
specialists to a doctor.
Calling specialists for consultation from other departments of hospital.
Carrying out hydrotherapy for patients and be present during the procedure, if it is
assigned by a doctor.
Calling ambulance for transportation of patients.
The basic duties of nurses
3. Permanent duties of a medical nurse that are carried out daily with no special
prescription made by doctor:
 Filling in medical documentation (except for case histories).
 Measuring patient's body temperature in the morning and in the evening, sometimes the
temperature should be taken every hour (if the patient is in severe condition or undergoes
infusion therapy) and sometimes even more often. The data are to be put down into a
Temperature sheet.
 In some cases, heart rate and blood pressure are measured (sometimes a medical nurse
puts down these data into the Temperature sheet of the case history) measurement of
respiration rate.
 Measuring weight and height of children once a week, according to a plan.
 Reporting every morning to the medical personnel of the department about conditions of
patients, especially those who are critically ill or newly hospitalized, and about those whose
condition unexpectedly got worse.
4. Be present at general doctor's rounds, where all necessary information about the
condition of patients is given.
5. Check if all necessities are delivered into department timely:
 Medicines
 Medical tools and bandage materials.
 Food for patients.
 Sets of clean bed linen and underwear for patients.
The basic duties of nurses
6. Stick to the following rules:
 Personal hygiene.
 Personal hygiene of patients.
 Order at the medical nurse's post.
 Storage of medical products which include 2 groups of medical products that are to be
stored in special metal boxes as safes with inscriptions 'A' and 'B' or cabinet. Safe 'A'
contains poisonous and narcotic products. Safe 'B' is used for strong active remedies.
7. Teach children and their parents the following rules, if necessary:
 Working hours of the hospital.
 Getting food products from friends and storing them.
 Taking medicines.
 Personal hygiene.
 Child care.
8. Supervising the work of a junior medical personnel:
 Controlling reception and distribution of food, and if necessary rendering assistance in
feeding patients who are in severe conditions.
 Supervising their main duty — i.e. keeping children's department of the hospital clean
and in order.
Thank you for attention!