اخبلر الكلية
زوار موقعنا الكرم : لاتبخلوا علينا باقتراحاتكم وانتقاداتكم من اجل الارتقاء بالموقع

محاضرة pediatrics nursing

Acute Respiratory Infections (ARI)

ARI are worldwide problem in addition to diarrhea and malnutrition and it form the main cause of morbidity and mortality in developing countries.

Viruses causes 80-90% of childhood respiratory infections, the most important are respiratory syncytial virus (RSV), rhinoviruses, parainfluenza, influenza and adenovirus.

The important bacterial pathogens are Streptococcus pneumonia, Haemophilus influenza, Bardetella pertusis and Mycoplasma pneumonia.

 

 

* RISK FACTORS :

1\ malnutrition.

2\ poor socioeconomic status & large family size .

3\ parental smoking.

4\ prematurity & low birth weight.

5\ lack of breast feeding.

6\ Congenital abnormalities of heart or lung.

 

* ANATOMICAL CLASSIFICATIONS :

ARI is classified based on the site of infection as Upper Respiratory Infections (80%)              and Lower Respiratory Infections(20%) .


URI includes common cold , sore throat( pharyngitis & tonsillitis ) ,sinusitis ,laryngitis                          and otitis media.


LRI includes tracheitis, Bronchitis, Bronchiolitis and pneumonia.

 

 

 

 

Case Management

The standard case management of ARI cases includes:

1\ Assessment

2\ Classification

3\ Management

 

1\ Assessment :

1 * assess for feeding.

2 * assess for malnutrition.

3 * assess if child is abnormally sleep or difficult to wake.

4 * does the patient have convulsions during the current illness.

5 * Listen for stridor (harsh sound heard during inspiratory face of respiration due to narrowing of upper respiratory tract (larynx , trachea or epiglottis ). These conditions are often called croup.

6 * Listen for wheeze ( musical sound heard during expiratory face of respiration due to narrowing of the lower air passages in the lunges )

7 * Look for chest indrawing.

8 * assess for cyanosis

9 * assess for fever ,(a temperature of {38“C} or above) or hypothermia, (a temp.{Below35.5“C}

10 * assess for cough & grunting .

11 *Count the respiratory rate (RR) in one minute:

AGE                                                                                     RR\min.

2 months                                                                                    6o  +      >

2 --- 12 months                                                                     50  +

12 months up to 5 years                                                        40  +

 

 

 

2\ Classification :  According to age group

 

A\ 2 months up to 5 years: after the assessment is completed one of the following                          4 classifications is reached:

 

1\ Very sever disease:

Is made when any of the following danger signs is detected:

1* not able to drink

2* severe  malnutrition

3* abnormal sleep or difficult to wake

4* convulsion

5* stridor in calm child

We should act urgently because the child is at high risk of dying.

2\ Sever pneumonia:

1*  cyanosis

2*  chest indrawing

3*  nasal flaring

4*  grunting

Also we should act urgently because the child is at high risk of dying.

 

3\ Pneumonia:

The child has fast breathing (according to his age) without chest indrawing.

 

4\ No pneumonia:(cough and cold )

No chest indrawing & No fast breathing.

B\ Less than2 months: after the assessment is completed one of the following       3 classifications is reached:

 

1\ Very sever disease :

Is made when any of the following danger signs is detected:

1* decreased feeding

2* abnormal sleep or difficult to wake

3* convulsion

4* stridor in calm child

5*  wheeze

6*  fever or hypothermia

7*  cyanosis

8*  grunting

 

2\ Sever pneumonia:

Fast breathing (60+\ min.)

 

3\ No pneumonia ( cough & cold ):

No fast breathing & no chest indrawing.

 

3\ Management:

A\ Very sever disease  OR  Sever pneumonia :

1\  give the 1st pre-referral dose of paranteral antibiotics.

2\  refer urgently to hospital.

3\ treat fever if present.

 

 

B\ Pneumonia :

 

1\ Give the 1st dose in health center.

2\ The child is treated with antibiotics at home.

3\ One of the following drugs is given for 5 days( cotrimaxazol , amoxicillin  or procain pencillin ).

4\ Teach the mother how to give the dose, how much and for how many days.

5\ Advice home care.

6\ Reassess in 2 days or sooner if child become worse so return him to hospital.

If child improve so finish 5 days of antibiotics.



 

C \ NO pneumonia ( cough & cold ):

 

1\ no antibiotics

2\ Look for other problems such as cough ( so refer to hospital for further assessment for TB. , asthma , whooping cough) , ear problem or sore throat.

3\ advice for home care:  clear the nose, encourage feeding and fluid intake.

4\ treat fever if present.

5\ treat wheeze if present by bronchodilator.

 

Return child immediately to hospital if child develop :

Breathing becomes difficult or fast

Difficult feeding

Fever

* RISK FACTORS for ARI :

1\ malnutrition.

2\ poor socioeconomic status & large family size .

3\ parental smoking.

4\ prematurity & low birth weight.

5\ lack of breast feeding.

6\ Congenital abnormalities of heart or lung.

 

Control of Diarrhoeal Disease ( CDD )

 

DIARRHOEA:  passage of liquid or watery stool for at least 3 times\day.

Consistency is more important than frequency.

 

Diarrhea may be  - acute ……..  Less than 14 days

- persistant …. More than 14 days caused by infections

- dysentery …… mucous with or without blood

- chronic ….. recurrent due to non infectious cause , for more than one month

- paranteral ….. due to infections elsewhere in the body

Acute watery diarrhea

diarrhea that starts acutely and last less than 7 days  without visible blood , might have nausea  and vomiting and fever .

Causes :

Rota virus (50%) , Shigella , Entero invasive E. coli , salmonella , Vibrio cholera , campylobacter jejune , Enteropathogenic E. coli .

Complications and consequence

1-Dehydration                                                                                                                 2-Potassuim depletion                                                                                                  3-Acidosis                                                                                                                       4-Convulsion                                                                                                                   5-Renal failure                                                                                                                6-Cerebral damage

 

 

Dysentery (bloody diarrhea )

diarrhea that is accompanied by mucus with or without blood

Thedanger of this type(complications):

1-Septicemia

2-Hemolytic uremic syndrome

3-Malnutrition

Causes :

Shigella , Entameba Histolytica , EIEC  ,  C . jejuni , Salmonella , EHEC .

 

 

Persistent diarrhea (post-infectious diarrhea )

diarrhea that begins as acute watery or bloody diarrhea , last for at least  14 days ,it caused by infection or the damage that result from an infection.

The danger (complication):

Dehydration , septicemia , secondary disaccharidase deficiency , Cow's milk protein allergy , and malnutrition .

Causes :

any organism , especially  Shigella , enteroadherant  E coli

 

 

Chronic diarrhea :

It is the recurrent or long standing diarrhea due to noninfectious etiology as celiac disease , cystic fibrosis , autoimmune villus atrophy . It can cause malnutrition.

Parenteral diarrhea

It occurs due to infection elsewhere in the body as otitis media , meningitis , pneumonia , or UTI  . treatment of the original cause will stop the diarrhea .

 

*Causes of diarrhea :

1\ infectios …..  viral , bacterial or parasitic.

2\ non infectious……. Feeding problem , anatomical , surgical, malabsoption ,endocrine ……

 

 

*Diarrhea can lead to dehydration or malnutrition.

 

DEHYDRATION :    loss of water & electrolytes.

Q\ Why infant more affected by dehydration than adult ?

1\ higher total body fluid

2\ increased metabolic rates

3\ large body surface area

4\decreased fluid intake due to anorexia

5\ increased fluid loss due to fever

6\ frequency of gastroenteritis in infant more than adult.

 

 

Causes of dehydration :*

1\ G.E. ( VOMITTIG & DIARRHEA )

2\ MOUTH DISORDER

3\ D.M.

4\ BURN

5\ INTESTINAL OBSTRUCTION

6\ THYROTOXOCOSIS

 

 

 

Hypokalemia :

-hypotonia

- muscle weakness

- abdominal distention

- paralytic ileus

- arrhythmia

Potassium is given with i.v. fluid after patient pass urine.

 

 

Assessment of Dehydration

 

 

 

Mild (no dehydration)

 

 

Moderate   (some )

 

Severe   dehydration

 

General appearance

 

Alert

Thirst

Restless

Alert

Thirst

Drowsy

Drowsy

Sweaty

Coma

 

Anterior fontanel

 

 

 

Normal

 

Depressed

 

Deeply              depressed

 

Eyes

 

 

Normal

 

Sunken

 

Very sunken

 

Tears

 

 

Present

 

Decreased

 

Absent

 

Tongue

 

 

Moist

 

Dry

 

Very dry

 

Respiratory rate

 

 

Normal

 

Rapid

 

Rapid + Deep

 

Skin retraction

(Turger)

 

 

Rapid

 

Over  2  seconds

 

More than 2 seconds

 

Urine out put

 

 

Normal

 

Decreased

 

An urea

 

* Treatment:

According to WHO method, Dehydration is treated as :

1) No dehydration ….. give plenty of fluid and discharge the baby , if develop bloody diarrhea or become thirsty readmitted again .

2)Some dehydration ….. use ORS  75 CC / kg .  after 4 hrs recheck : No dehydration ,Some dehydration , Severe dehydration .

3)Severe dehydration ….. use IV  fluid

Less than 1 year  give 100CC / kg as follow

30 CC /kg / 1 hr  , 70 CC / 5 hrs

More than 1 year give 100CC / kg as follow

30 CC /kg / 1/2 hr  , 70 CC / 2.5 hrs . after 6 hrs recheck : No dehydration ,Some dehydration , Severe dehydration .

Fluid choices here are : N S  OR Ringer lactate

 

The ongoing loss calculated as :

Number of passed vomiting * 100CC + number of passed diarrhea * 100 CC

 

* Drugs not to be used in diarrhea :

1\ antibacterials…….. used only when there is lab evidence of bacterial infections.

2\ anti-protozoal …… used only when there is lab evidence of amoebic dysentery or giardiasis.

3\ mycostatin….. given when there is evidence of oral thrush .(monilia is normal inhabitant of G.I.T)

4\ anti-spasmodic & antimotililty…..  can caused paralytic ileus

5\ pectocaolin….. will coat the G.I.T. ,allow colonization of bacteria & lead to persistent diarrh.

6\ anti-emetic…… may cause CNS side effects.