1. What are some approaches to promoting comfort for children who have ear pain
associated with otitis media.
Analgesics (acetaminophen & ibuprofen) reduce mild to moderate pain & fever. Codeine for
severe pain, application of heat or a cool compress, have child lie on affected side with
heating pad or covered ice place on affected ear.
2. Outline the Canadian Pediatric Society (CPS) guidelines for the treatment of otitis
media with antibiotics.
Age & Severity
<6months
6month – 2years
6months – 2years
6months – 2years
>2 years, severe
>2 years,
nonsevere
>2 years
Certainty of diagnosis
Certain or possible
Certain
Possible, severe otalgia & fever>39
Possible, mild otalgia & fever<39
Certain, sever otalgia and fever> 39
Possible, mild otalgia & fever<39
Treatment
TREAT antibiotics
TREAT, antibiotics
TREAT, antibiotics
Observe
TREAT, antibiotics
Observe
Possible
Observe
*Severe: moderate to severe otalgia or fever 39 degrees or higher. Nonsevere: mild
otalgia and fever<39
Certain diagnosis of AOM is based upon rapid onset of symptoms, signs of fluid in the middle
ear, and signs or symptoms of inflammation in the middle ear, including a bulging tympanic
membrane with marked discoloration (hemorrhagic, red, grey, or yellow), rapid onset of ear pain
(otalgia), unexplained irritability in a preverbal child, and visible erythemia or the tympanic
membrane, The choice of antibiotic will depend upon the timing, the child’s age, and whether the
episode is a first or subsequent infection. *Allow for a period of observation or “watchful
waiting” in certain children to allow for natural resolution of AOM related to viral causes and
decreases the overuse of antibiotics. In previously healthy children watchful waiting and
observation for 48 to 72 hours without antimicrobial agents if: the child is older than 6 months,
the child does not have immunodeficiency, chronic cardiac or pulmonary disease, anatomic
abnormabilites of the head or neck, hx of complicated ottits media(chronic perforations), or
Down’s syndrome. The illness is not severe (otalgia appears to be mild and fever<39 degrees
without antipyretics. Parents are capable of recognizing signs of worsening illness and can
readily access medical care if the child does not improve.
3. When and why are myringotomy tubes indicated? Discuss considerations for care of
children with myringotomy tubes.
The standard treatment for persistent or problematic OME is surgical insertion of pressureequalizing (PE) tubes into the tympantic membrane via myringotomy (small tube inserted
into tympanic membrane middle to prevent the accumulation of fluid in the middle ear).
Tubes stay in place for several months, procedure done in outpatients. Teach parents post-op
to administer ear drops, avoid water entry into ears, wear earplugs while bathing/swimming.
PE tubes allowing for adequate hearing & speech development but do not prevent middle ear
infection. If infection occurs allow infected fluid to drain from ear, and contract doctor.
4.
Differentiate b/w conductive, sensorineural, and mixed forms of hearing loss.
Conductive hearing loss: transmissions of sound through the middle ear is disrupted, as with
OME (otitis media with effusion), when fluid fills the middle ear, the tympanic membrane is
unable to move properly, and partial or complete hearing loss occurs.
Sensorineural hearing loss: cause by damage to the hair cells in the cochlea or along the
auditory pathway. This may result from
Mixed hearing loss: occur when the cause may be attributed to both conductive &
sensorineural.
5. Name some causes of hearing loss in children and corresponding ways of reducing risk
of hearing loss in children.
Congenital hearing loss (1-6 infants/1000, ½ of all hearing impairments). Preterm infants and
those with persistent pulmonary hypertension increased risk. Hearing loss common with
congenital or genetic syndromes, & head/face anomalies. Newborn universal hearing
screening laws allow for early identification of infants with congenital hearing loss. Delayed
onset hearing loss: infection/fluid in middle ear (conductive), kernicterus, ototoxic
medication, and intrauterine infection with CMA, or rubella, meningitis, neonatal respiratory
depression, or exposure to excess noise(sensorineural). Regardless of the cause, early
intervention influences child speech development. Earplugs or covers for prematures infants
in NICU, hearing aids, cochlear implants, communication devices, speech education.
6. What are cochlear implants? How do they work? For what types of hearing loss are
they indicated?
Cochlear implants are surgically inserted electronic prosthetic devices for sensorineural
hearing loss, a tiny receiver implanted in the body part behind the ear and connected to a
microphone, minimum age 12 months.
Respiratory disorders in children (Ateah text chapter 19)
1. Review anatomy and physiology of respiratory system.
Newborns to infants (4-6weeks) breath through nose, cannot automatically open mouth to
breathe if nose is obstructed, nares must be patent for successful feeding. Tongue is larger
making airway obstruction more likely in unconscious child, airway d smallest at the
cricoid in <8years, smaller, narrower airway make children more susceptible to airway
obstruction, smaller lung capacity & underdeveloped intercostal muscles, infants and
toddlers appear barrel-chested, children rely on diaphragm for breathing, lack of firm bony
structure makes child more prone to retractions in respiratory distress, higher RR, and
demand for O2 makes hypoxia easier to occur.
2. Review fetal development of lungs. Know physiology of “baby’s first breath” and
transition from fetal/placental oxygenation to pulmonary respiration.
3. Know normal findings in RR across childhood : neonate (newborn), infant, toddler,
preschooler, school-aged child, adolescent.
Newborn - 6months
30 – 60/min
6 – 12 months
24 – 30/min
1 – 5 years
20 – 30/min
6 – 12 years
12 – 20/min
4. What are the signs of respiratory distress in infants and young children?
tachypnea, inspiratory stridor, expiratory wheezes, barking, brassy coughing,
supra/substernal or intercostal indrawing, nasal flaring, grunting, anxiety, restlessness,
orthopnea(older child-can’t lie down), fatigue, exhaustion, CO2 retention, respiratory
acidosis, Cyanosis circumorally (around the mouth) to central(midline, sign of hypoxia).
For the following illnesses/disorders, understand the general incidence,
causes/prevention, signs & symptoms, pathophysiology, medical/pharmacologic
treatment options, and nursing considerations for:
5. Asthma: chronic inflammatory disorder of airways, primary case of school absenteeism,
leading cause of child hospitalization, incidences are increasing, caused by genetic
predisposition & environmental stimuli (smoke, smog, stress, mold/dust/dander allergens,
upper respiratory infection). Inflammatory response of mast cells, eosinophils, & Tlymphocytes to stimuli caused accumulation of mucous and edema of airway, while spasm
of bronchi/bronchioles decreases airflow. Symptoms: dyspnea, wheezing, coughing,
decreased respiratory effectiveness leads to fatigue. Untreated can lead to barrel chest and
elevated shoulders. Treatment involves chronic disease management, Peak expiratory flow
meter, ongoing primary care provider. Inhalation corticosteroids, beta-adrenergic agonists
(salbutamol/ventolin), MDIs. In emergency(severe respiratory distress, status
asthmaticus)=ventolin mask, systemic corticosteroids, IV MgSO4 (smooth muscle
relaxant)
6. Cystic Fibrosis: Inherited autosomal recessive trait (both parents carries=1:4 have CF, 2:4
carries), gene on long arm of chromosome 7. An exocrine gland dysfunction causing
increased mucus secretion, obstruction of bronchi (airflow), sm. intestine(thick, sticky
stool, pancreatic ducts(malabsorption), & bile ducts(biliary cirrhosis). Symptoms: large,
bulky foul, frothy stools, or intestinal obstruction (meconium ileus in an infant), failure to
pass stool, wt. loss, failure to grow, Vit. A, D, E, K deficiencies, respiratory wheezing,
coughing, emphysema, atelectasis, frequent pneumonia. Progresses to barrel chest,
clubbing & cyanosis. Chest PT several times a day, pancreatic digestive enzyme
supplements, calorie/nutrient dense foods. Frequent hospitalizations for pneumonia.
Defiance of treatments, sadness, & depression common with adolescents.