Peds Exam #2 PDF

Chapter 35- the child with a Sensory / Neurologic disorder Growth & Development Birth – Immature nervous system- EX: Legs movements Central & Peripheral Be able to communicate Improves as child grows = Development of gross and fine motor skills...

Chapter 35- the child with a Sensory / Neurologic disorder Growth & Development Birth – Immature nervous system- EX: Legs movements Central & Peripheral Be able to communicate Improves as child grows = Development of gross and fine motor skills Vision Newborn vision – Terrible!- blurry 20/200 Vision acuity 20/400 Vision acuity 2 Months they can follow objects with their eyes – track mom 7 months – Develop depth perception- Move objects from hand to hand Before 5-6 yrs vision screenings can back abnormal 20/20 vision – Around 5-6 years old Impairments – Myopia- Can see near but not far (Eye glass or contacts used) Hyperopia- I can see far but near (Eye glass or contacts used) Astigmatism- An eye condition that causes blurred or distorted vision at any distance (Eye glass or contacts used) Strabismus- Crossed eye / Muscles round the eye ball are week Treatment 1 - Patch the good eye first to strength muscle Treatment 2 – Surgically correct it Esotropia- Eye ball points towards the nose Exotropia- Eye ball points out towards the ear Partial sight- Blindness- Corrected vision given eye glasses or contacts still legally blind. Relay on their other senses Use plate to around the clock to know where food is at  Vision (Continued) Conjunctivitis (Pink Eye) Inflammation of the Conjunctival Sac – Bacterial- Drainage yellow & green goopy and comes back discharge & itchy. Starts in one eye and moves to second eye with kids Treatment- Antibiotic or Eye drops or Ointment Polytrim (Eye drops) 3-6 times a day Erythromycin (Ointment) Viral- Discharge white or clear Itchy and red Goes away on it and contiguous Allergic Both eyes are affected * Eye are red, watery, itchy and clear discharge Foreign body I got something in my eye (1 or 2 eyes) Red, watery, and irritated Hordeolum – Caused by staphylococcus aureus- Stye Bacteria Upper or lower eyelid Treatment Antibiotic Warm compresses 3 times a day  Hearing Hearing usually intact at birth Can hear at womb Hearing test is done after birth before they go home Failed- Physician will have to figure that out Hard of hearing vs. deaf Conductive hearing loss Reversible Blockage - Ear wax, Impacted cerumen, and fluid Remove Cause- It should come back Sensorineural hearing loss Worse nerves are damaged / Not reversible Permeant hearing damage Cause / Medications/-Lasix’s/ Meningitis Acute Otitis Media- Ear infection AKA ear infection Caused by bacteria: Strep, Haemophilus influenzae S/S – Restlessness, head shaking, tugging at ears, fevers, irritability, decreased appetite, hearing impairment. Older child- ear hurts Elderly- hurts worse when laying down or fluids backs up hurts even more Maybe fever or not Younger child Cant speak – restless, fever, rubbing at ear, head shaking, not eating well, and overall feel sick Starts W/ Cold or flu – can cause ear infection DX: Looks at the Tympanic membrane Normal- pearly gray translucent Abnormal- Red and inflamed looking Tx – Antibiotics or myringotomy Amoxicillin – Twice a day 10 days / come back in 4 weeks we will do a ear check Ear pain- no longer pain/ear ruptured / drainage or blood/hole in ear/ will heal on it own No ototoxic hearing medications Rule of thumb- 3 ear infections 6 months or 4 infections have to see an ENT Myringotomy Place tubes inside the eardrum Not permanent Help drain extra fluid 6 mos or 1 yr / falls out on its own  Reye Syndrome Commonly seen after viral infection; ASA use Damages many areas of the body, especially liver and brain.- Brain damage S/S – 1st symptom- Severe vomiting, irritability, lethargy, confusion Dx = Elevated liver enzymes, elevated ammonia, coagulation times extended, liver biopsy, lumbar puncture Liver biopsy will tell you if its true Reye Syndrome Can progress rapidly. Tx – Supportive measures in NICU/PICU- Intercranial pressure Avoid extreme flexion, extension, or rotation Keep HOV elevated at least 30 degrees Monitor for s/s of hemorrhage Comfort measures ABCs Patient education – No ASA/salicylates for kids under age 19. Pepto Bismol 13 in older given Aspirin – given when vomiting and diarrhea Peptide What is a seizure? Definition: Abnormal electrical activity in the brain can cause neurons to fire off inconsistently, leading to a seizure. Imbalance in the brain Causes: Infection, meningitis, medications, or illness Seizures Acute seizures Seizure Disorders Febrile seizures – Accompanies a Epilepsy- series of seizures fever Primary vs. secondary seizures Commonly seen from 6 months to 3 Focal onset seizures vs. generalized years old. seizures vs. unknown onset awareness seizures seizures (complex partial seizures) Focal seizures = Focal onset aware seizures (simple partial seizures) or focal onset impaired  Acute Febrile seizures Febrile seizures – Accompanies a fever Not temp # but how quickly it rose Fever related Commonly seen from 6 months to 3 years old. Some children may have one febrile seizure, while others may have multiple. Can lead to epilepsy in the future not guaranteed Adults- have Febrile seizures and are completely fine. Seizure questions Did they have a fever? Duration Symptoms Medical history Any previous history of seizures? Sick? What happened during the seizure, to better understand the situation? This helps differentiate to someone who has a true seizure disorder. Partial & General Seizures Partial seizure – one side the brain is Generalize- Complex affected Do not lose consciousness Both sides of the brain are affected Motor response arm jerking, Lose consciousness eye twitching, or lip- smacking One side of the body being affected  Generalized onset seizures Tonic-Clonic – Stages Status epilepticus Absence Atonic Myoclonic Infantile (aka West syndrome) Tonic-colonic stage 1st stage prodromal - Can occur 24 hours or 15 2nd stage Tonic stage – Stiff minutes before the seizure, where the person 3rd stage Colonic- Jerking movement feels "not themselves" and experiences 4th stage Postictal - seizure is over, don’t symptoms like lightheadedness, headache, know they had a seizure, very confused, and dizziness. reorientate them, incontinent, and very tired. Aura – see, hear, smell, feel or taste – Subjective Ex: metallic taste or see a flash of red light Aura during the prodromal stage / before it happens Prodromal can last 24 right before the seizure occurs Status Epilepticus Some people don’t go into the postictal stage Can have Tonic-Colonic- 30 min Have back-to-back seizures Postictal stage 5min then go into Tonic- Colonic seizure Dangerous to the brain and nerve damage – does not come back TX: IV benzodiazepines are commonly ordered to treat seizures. Lorazepam or Diazepam may be administered intravenously (IV) to help manage seizures.  Absence Seizures Common in the Pediatric population Missed diagnosis or not obvious “Daydreaming”- stares off into space TX: Unless it interferes with schoolwork Resolve before they become adolescents Atonic & Myoclonic Infantile spams (aka West syndrome) seizures Atonic- Lack of muscle tone / causing the Infantile Spams- Worse one – person to fall (drop attacks) Lots of complication Common in infants 4-8 months Prognosis very poor Myoclonic: (MYO-muscle) / Colonic- Symptoms: Muscle Jerking Muscle contractions Eyes roll back Cries before or after seizure One single event Cluster seizures 150 –seizures – back to back  Seizures 1-1 Diagnosis History Family history Pre-natal history – Mother exposure & complications during delivery Lab tests: Lead level 6-up months check, glucose, WBC infection, toxicology screen- chemical Normal lead level- under 3.5 / brain damage EEG- GOLD STANDARD /checks electrical activity within the brain The child must be hooked up to the EEG to capture the seizure Lumbar puncture- Check for meningitis CT scan- check for tumors or masses in the brain that may trigger seizures Febrile seizures: presence of fever that spiked quickly Seizures 1-2 Nursing Care Seizure precautions: Seizure precautions During a seizure: Inspected patient’s environment for Protect the airway, potential safety hazards if seizure protect the pt from injury, occurred; administer oxygen, note Keep bed low and side rails up, pad the time and rails, have oral suction and oxygen characteristics equipment ready for use. Post seizure: Place patient in a room close to Maintain ABCs, check for nurses’ station. injuries, perform neuro Turn patient to the side checks, note the time of Time seizure the postictal period Educate patient as to why you are Febrile seizures: doing this Control fever, typically only occurs once and the child will have no chronic issues.  Seizures / Epilepsy Medications Based on the child’s age and type of seizures. Starts at a low dose and increases over time until effective Ideally on 1 medication / some have 2-3 meds to control seizures Medications need to be taken at the same time every day. – In order for the threshold to be at level Keto diets have been prescribed – Leads to high ketone levels – Decreases seizure activity High fat – Low carb diet Status Epilepticus Prolonged seizure, more than 30 minutes. The child does not enter the postictal phase Maintain ABCs, IV access, likely will require intubation Haemophilus Influenzae Meningitis Bacteria Haemophilus influenzae Cause Meningitis - Inflammation of the membranes surrounding the brain and spinal cord. Meningitis can be caused by both viruses and bacteria. Spread through droplets S/S – High, pitched cry, fever, bulging fontanel, headache, stiff neck (nuchal rigidity) opisthotonos (a current position they take on), photophobia Dx – Brudzinski sign, Kernig sign, lumbar puncture Lumbar puncture- GOLD STANDARD TEST / Diagnosing Complications – Hydrocephalus, nerve deafness, intellectual disability, paralysis Prevention – HIB vaccine/ 2, 4, 12-15 mos / Antibiotic- bacterial Nursing Care - Monitor and prevent increased ICP Wear helmets during contact sports, using car seats properly, avoid falls at home, and maintain a healthy lifestyle with a balanced diet and regular exercise  Kernig's sign 1. The patient lies on their back with their hips and knees bent at a 90 degree angle 2. The examiner slowly tries to straighten the patient's leg 3. The examiner notes if the patient experiences pain or resists extending their leg Brudzinski's sign 1. Have the patient lie on their back. 2. The examiner places one hand behind the patient's head and the other on their chest. 3. The examiner gently flexes the patient's neck Cerebral Palsy Is a group of disorders caused by a malfunction of motor sensors and neural pathways within the brain. Accompined by other neurological conditions as well, intellectual disability or seizures Causes: Prenatal – Maternal infections, teratogenic agents- (prenatal exposure during pregnancy) Perinatal – Anoxia, prematurity Postnatal – Infection, head trauma, neoplasms  Types Cerebral Palsy Types: No cure Spastic For Life Hyperactive stretch reflex Disciplinarity Team Overactive deep tendon reflexes- kick OT you in the face PT Contractures of extensor muscles (i.e. Speech heel cord)- heel does not stretch out Orthopedic doctor Scissoring- spastic Doctor Devices Athetoid- Constant movement Live a high equality of life best they can Involuntary, uncoordinated motion with muscle tension Ataxic- Abnormal gait Lack of coordination due to disturbances in kinesthetic and balance senses Rigidity Rigid posture and lack of active movement  Intellectual Disability Definition: Developmental Disability. Intellectual disability is characterized by significant limitations in intellectual functioning (IQ 7075 or lower) and concurrent deficits in adaptive behavior, usually identified before age 18. The causes are not fully known, but it can be associated with various factors. Onset – Usually before 18 years old Causes: Prenatal Perinatal Postnatal Classification review book Mild- A child with slight intellectual disability learns slowly but can still pick up basic skills. The child can learn to read, write, and do math at a fourth- or fifth-grade level, but they are slower than usual at learning how to walk, talk, and feed themselves. The condition might not be noticeable to people you know casually. With help and direction, this child can usually learn the social and job skills they need to take care of themselves. About 85% of children with intellectual disabilities fall into this group. Moderate- A child with moderate intellectual disability struggles to become independent and to learn academic skills, so they are called trainable. Motor skills and words are lagging, but it is still possible to train in self-help skills. This child might be able to learn simple tasks in special workshops. Some children can learn to travel by themselves, but not many can fully take care of themselves. About 10% of intellectual disabilities are considered mild. Severe- A child with serious intellectual disability develops much more slowly than normal during their first year of life. The child may not be able to learn school subjects, but could learn some self-care skills if they start getting hands-on help early on. This kid will likely learn to walk and talk eventually, but they will always need a safe environment and close supervision. About 3% to 4% of children with brain disabilities are classified as having a severe form. Nursing considerations – Promote self-care, communication, safety  Head Injuries Lose Conscious Are they acting different or sleepy Cry Vomiting Causes: Injury- pain head Falls- Loss of gait, what they hit their head on, How high was it ? Double their height is significant Head injuries symptoms do not occur right away First 6 hours are crucial time for monitoring the child Child abuse- shaking baby syndrome -colic baby Traumatic brain injuries Nursing considerations Close monitoring Neuro checks- Pupils assessment, reflexes, squeeze hands, Alert and Orientated Report any abnormalities Question #1 Chronic serous otitis media can destroy part of the eardrum or the ossicles. What does this lead to? a. Mixed hearing loss b. Sensorineural hearing Loss c. Conductive hearing loss –fluid in ears – antihistamine TX: 1st generation – Benadryl stronger 2nd generation- Claritin and Allegra d. Central auditory dysfunction Question #2 Is the following statement true or false? A child who is blind from birth has difficulty relating to the environment and may have difficulty meeting growth and development milestones. Question #3 You are the emergency department nurse admitting a 6-year-old male client who has come in by ambulance from his school. The paramedics inform you that the child has been having repeated seizures for approximately 35 minutes. What drug would you expect the health care provider to order? a. IV Dilantin b. IV Solumedrol c. IV Morphine d. IV Diazepam Question #4 Is the following statement true or false? Moderate technology has greatly improved the life of a child with cerebral palsy.  Question #5 Which age group is most likely to receive a head injury from child abuse? a. Toddlers b. Preschoolers c. School-aged kids d. Adolescents CHAPTER 36 – THE CHILD WITH A RESPIRATORY DISORDER Pediatric Respiratory Assessment Appearance of child- Cyanotic –late sign of hypoxia Retractions- Stomach is going in deeper Tracheal tugging- Trachea starts moving up and down Nasal flaring- when the nostrils widen while breathing, and it can be a sign of difficulty breathing Grunting- make a low, short guttural sound Belly breathing- Stomach breathing Vital signs- R 30-60, HR 110-160, O295%, Auscultation Respiratory System: Pediatrics vs. Adults Smaller size More prone to infections and other respiratory problems Abdominal muscles > thoracic muscles until 2-3 y/o Belly breathers 2-3 yrs old After 3 yrs chest breathers Acute Nasopharyngitis AKA common cold Viral Low-grade fever S/S = Rhinorrhea, sneezing, fussy, nasal congestion,; some have fevers; some also have vomiting/diarrhea Body is trying to clean its self- mucus lubricate the GI tract causes vomiting/diarrhea Tx = Self-limiting- Let it run its course, Tylenol & Ibuprofen, plenty of fluids, suctioning, pedialyte Complications – Acute otitis media- ear infection due to mucus Allergic rhinitis AKA hay fever/allergies Causes – Animals, pollen, mold, dust S/S – Rhinorrhea, postnasal drip, sneezing, allergic conjunctivitis, allergic shriners dark-circles/no blood circulation around their eyes, allergic salute-itchy nose Tx – Inhaled corticosteroids (Flonase)-decrease inflammation, oral antihistamines, Hyposensitization- Refer to allergist- inject to whatever the patient is allergic to in their body. How are they acting and do they have a low-grade fever? Cold Nursing care – Administer meds, patient education Pollen age -4-5 yrs old Skin- test Over age 2 – Corticosteroids Hypersensitization injections – Patients having pets at home  Fever Reduction Remove excess coverings Ibuprofen Can not have ibuprofen under 6 months Lower room temperature 5-10 mg/kg/per dose Remove access cover 6-8 hrs 3 months old take them to ER Acetaminophen & Ibuprofen (6 months or Sepsis-death older) Febrile Seizures - threshold went Alternate to keep fever down up to high / moves quickly 3 hrs A & 3 hrs I round the clock to keep the Tonic-clonic stiff and have fever down movements Acetaminophen Safe out the womb 10-15 mg/kg/per dose 4-6 hrs  Tonsillitis & Adenoiditis Inflammation of the (tonsils and adenoids) 3-4 yrs of Life help with Lymph system & immune system 4 yrs children do not need it 2 Types of Palatine Tonsils & Adenoids Palatine Tonsils- See the back of your throat Adenoids- Can not see unless you have a scope sits back of the nose Size and appearance Objective information- by # Scale: 0, 1+, 2+, 3+, 4+ 1+ and 2+ = Normal 3+= Starting to move midline 4+ =Kissing S/S – Fevers, sore throat, dysphagia, enlarged tonsils, tonsillar exudate – (strep and white patches) Strep: Rheumatic Fever or Acute glomerulonephritis Dx: Physical exam, rapid strep test, throat culture Tx = Analgesia, antipyretic, antibiotic (finish), surgery Tonsillectomy Nursing Care – MONITOR FOR BLEEDING, education ATI Monitor bleeding Scabs form pop-off – frequent swallowing & throat clearing No straws – 2 weeks after Heart rate – Increases (signs of bleeding) B/P-Decreases (signs of bleeding) No red foods for at least 2 weeks after Throw-up –Go to the hospital  Croup Types: Acute spasmodic laryngitis Acute laryngotracheobronchitis- worse Bacterial epiglottitis S/S – Rhinorrhea, hoarseness;, barky cough, inspiratory stridor(high-pitch breathing sound/airway blocked); can progress to difficulty breathing, rapid pulse, cyanosis. Viral Upper Respiratory Tract- is affected Tx = Humidifier, steamy shower, low-dose emetic, oxygen, antibiotics Humidifier- Cool moist & safety prevent burns Treat at home Take Child in bathroom for steam / DO NOT LEAVE CHILD ALONE Nursing care – Monitor respiratory status, administer oxygen and meds Only antibiotics if it is bacterial Epiglottitis Inflammation of the epiglottis. No more oral exams Cause – Haemophilus influenzae No oral thermometers type B – Bacteria Stop talking S/S – Sore throat, dysphagia, Risk for Epiglottitis closing off fevers, hot potato voice, drooling trachea Fever 103 to 104 Send straight to ICU Tripod position -Hands on Intubation is done knees for breathing Pt will start on an IV antibiotic If epiglottitis is a concern, do not swab. HIB Vaccine- 2, 4, and 12-15months Tx – Medical emergency!!!  Acute bronchiolitis Cause – Respiratory syncytial virus (RSV)- like a cold Affects 6 mos -65 yrs old vulnerable population S/S – Dyspnea, cough, shallow respirations, air hunger 90 bpm infant, cyanosis, retractions Dx – Nasopharyngeal swab for ELISA test or PCR Tx – Hospitalization, isolation precautions, oxygen, fluids, rest, Ribavirin Ribavirin, suction, 2 full weeks Antiviral drug / Nebulizer 1. Often not prescribed expensive 2. May not fix anything 3. Highly teratogenic – Pregnant women should stay away when nebulized Nursing care – Monitor respiratory status, suction PRN, oxygen as ordered Remove mucus to avoid pneumonia day 5 gets worse  Asthma Coming into contact with triggers can Dx: Depends on doctor, Pt situation, history, cause asthma exacerbation physical, signs & symptoms Problem getting air out / Pt has hard time 1st W/minor symptoms reactive airway exhaling disease Triggers: Food -milk & eggs, pollen, 2nd Asthma and pets Trail and error Acute onset: Small triggers Peak flow done 3 times stand test and Delay onset: Came down with blow out a cold and get signs & (Peak Flow) Ranged by gender & symptoms later height o Normal S/S: SOB, wheezing, dry cough, o Caution increased respirations, repeated signs o Severe & symptoms Depending where they fall will determine 1. Smooth muscles start to treatment options spams bronchi & bronchioles - narrow Intermittent- Here & there W/Exercise 2.Edema lungs Present- Symptoms frequently 3. Increase production of mucus Present- symptoms frequently o Mild 2&3 times a week o Moderate SABA- only under age 12 yrs o Severe- signs & symptoms every single day & night LABA- Over 12 yrs rescue inhaler and corticosteroids Tx – Prevention, SABA (Albuterol), inhaled corticosteroids (Fluticasone), After 5 days reduce oral steroids -only LABA (Advair), etc. adverse effects Prednisone- oral steroid reduce inflammation systemically Nursing care – EDUCATION IS KEY. Spacer Inhaler teach Status Asthmaticus Severe Asthma ER & ICU Oxygen -constantly Bronchodilator “other” o Ipratropium o Smooth muscle relaxant  Pneumonia – Bacteria PCV vaccine Causes – Pneumococcal bacteria, haemophilus influenzae bacteria S/S – Fevers, and respiratory compromise, chest-tightness, difficulty breathing, crackles, very sick. DX: Chest X-Ray Tx – Antibiotics Nursing care – Monitor and maintain respiratory function, administer fluids, prevent complications Education: Prevention The most vulnerable – youngest- 65 yrs – protects 20 strains of pneumonia Vaccine (PCV) - Is given 2, 4, 6 mos last dose is at 12-15 mos Offered again at 65 yrs again Cystic Fibrosis-LUNGS and attacks GI Hereditary condition. – both parents are carriers – pass gene to child S/S – 1st (baby’s bowel movement) Meconium ileus in newborns can have CYSTIC FIBROSIS Does not have BM will not be discharged, Chronic dry cough, Barrel chest Clubbing fingers Frequent lung infections Malnutrition/deficiency of fat-soluble vitamins Steatorrhea Infertility. Effects: ALL Exocrine glands, lungs, liver, pancreas Exocrine glands producing THICK TENACIOUS MUCUS clogs things up causing bacteria Clogs lungs, GI- does not absorb food, reproductive organs, infertility Unknown- Later on life S/S: Frequent lungs infections Malnourish, underweight, greasy bulky tools, infertility Dx – Sweat chloride test- Induce sweat in baby- kiss the body skin tastes salty Newborn Screen Test- BLOOD TEST –DRAWN FROM HEEL WITHIN 25 HRS SENT TO STATE LAB FOR GENETIC TESTING- Tx – No specific treatment genetic Hyperosmolar enemas, pancreatic enzymes (pill or sprinkle supplement), fat soluble vitamins, diet high in carbs/protein/salt, chest PT Pancreatic enzymes ADEK- Fat Soluble Keep up to date with VACCINES to prevent INFECTIONS from happening  Pulmonary Tuberculosis Bacterial infection caused by Mycobacterium tuberculosis Transmitted by tiny droplets – Sneezing, laughs, and talks Airborne Primary- Alveoli of lungs Immune Suppress Children – Invade other parts of the body Bones, Joints, Kidney, and Lymph nodes General S/S: Fever, night sweats, weight loss, and cough Primary vs. secondary TB Secondary TB- Adult pt’s/ Healed lesion becomes reactive Dx – Purified protein derivative test (PPD) skin-test screening within 48-72 hrs checked intradermal Tx – complainant INH(Isoniazid), Rifampin (orange body fluids) x 9-18 months- will stop once the medication is resolved BCG-Vaccine- come back positive- done in outside countries- preventive care 1. What is one of the major nursing interventions with a child who has had a tonsillectomy? a. Family teaching b. Preventing preoperative aspiration c. Preventing excessive fluid intake d. Family interactions 2.Tell whether the following statement is true or false. In the newborn, meconium ileus is the earliest sign/symptom of cystic fibrosis. Meconium ileus is treated with gently administered hyperosmolar enemas. Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Congenital & Acquired Congenital- Genetic factors & structure Acquired- Condition develops later abnormalities on in life Heart Anatomy 4 Chambers – L & R ventricle and L & Something is wrong with the cardiac R Atria system usually something wrong 4 Valves ( prevent back flow) respiratory system o Tricuspid valve o Pulmonary valve When a baby is in the womb, the o Mitral valve respiratory system is not fully o Aortic valve functional, so there are structures in At birth L & R Ventricle are the same the heart that help blood bypass the size lungs. L-Ventricle is bigger two sizes than R- ventricle – few months In utero, the baby's respiratory system Pumps blood to the lungs is not fully functional, so there are Heart rate is higher in infants structures in the heart that help blood ◦ Anything above 160 bpm bypass the lungs. These structures are being concerning unless the supposed to close shortly after the infant is crying or upset. baby takes their first few breaths, but ◦ Sleeping should not be 160 sometimes they don't close properly. bpm ◦ Age 5 yrs – developed like an adult heart ◦ Adolescence yrs HR 60 /100 bpm.  G+D of the Cardiovascular System At birth: The right and left ventricles are the same size, but after a few months, the left ventricle is 2x the size of the right ventricle. Structures should close at birth, or soon after. Infants HR is higher than the older child/adult because cardiac output has to provide adequate O2 to the body. When the infant has a fever, respiratory distress, etc. they will have an increased need for O2 → HR will increase Heart Flow Superior/Inferior Vena Cava Right Atrium Tricuspid valve Right Ventricle Pulmonic Valve Pulmonary Artery Lungs Pulmonary veins (return to the heart) Left Atrium Mitral Valve (Bicuspid Valve) Left Ventricle Heart Flow Deoxygenated Blood Deoxygenated blood enters the right atrium through the superior and inferior vena cava, then flows to the right ventricle, which pumps it to the lungs. Oxygenated blood returns from the lungs to the left atrium, then flows to the left ventricle, which pumps it out to the body through the aorta.  The Child with Cardio/Hematologic Disorders Conditions can be serious and/or chronic Many are genetic and present at birth Congenital Heart Conditions: The heart is not formed correctly, or structures have not closed completely at birth. Types of Congenital Heart Defects Some increase pulmonary blood flow Some decrease pulmonary blood flow Some obstruct the blood flow Some cause mixed blood flow Cyanotic defects occur when there is mixing of unoxygenated and oxygenated blood entering the body Two Types: Congenital heart defects can be classified as cyanotic (where deoxygenated and oxygenated blood mix, causing the person to turn blue) Acyanotic (where the person does not turn blue).  Atrial Septal Defect Cause: An opening between Atrial septal defect (ASD) DX: is a congenital heart condition where there is a hole in the septum between the left and right atrium. Chest X-ray- Enlargement of HR ◦ pressure on the left side of the heart is greater Echocardiography (echo) /Ultrasound- visualize the than the right side. structure of the heart shows abnormalities (ASDs) and assess blood flow through the heart chambers ASD -there is a hole in the septum between the left and and valves. right atria, allowing deoxygenated and oxygenated EKG- Electrical activity of the heart (function) / blood to mix. Usually Echo & EKG ordered together This causes the blood to pour back into the CT or MRI of the lungs may also be used to identify right side of the heart, disrupting the normal any additional issues like tumors. blood flow through the heart to the right Cardiac Markers atrium. CBC – Check Electrolyte Imbalance/ Infections/ If the hole is small enough, the person may be Hemoglobin asymptomatic. CMP Left to Right shunting Potassium Blood flows from the left side of the Holter monitors (extended heart monitoring heart (higher pressure) to the right "walking EKG“ monitors heart beats – palpations side of the heart (lower pressure) can't find that can’t find a cause This causes extra blood flow to enter the right atrium and right ventricle, resulting in a loud, harsh murmur. Loud, harsh murmur is a sign of an abnormal Complications without treatment: heart condition, such as atrial septal defect. Pulmonary artery hypertension, which is irreversible damage to the lungs Blood spills to right ventricle Clinical Manifestations: Enlargement of right ventricle Asymptomatic Loud, harsh systolic murmur Post-Surgical Nursing Care: Fixed split second heart sound Cardiac tamponade is a condition where fluid builds up in the pericardial sac surrounding the Treatment: heart, putting pressure on the heart and Surgical repair with implantation of a tissue device (if preventing it from filling properly. needed) Extra fluid between the myocardium and Cardiac catheterization procedure where a patch is pericardium threaded through the femoral artery and placed S/S: Fluctuating blood pressure, rapid breathing, over the hole If the catheterization procedure fails and a drop in blood pressure when taking deep or is not suitable, breaths. Open heart surgery is done to directly repair the The cardinal symptom is a muffled heart sound hole in the atrial septum to prevent this when listening with a stethoscope, as the fluid complication blocks the sound from translating. Device migration is a rare complication that can occur after ASD surgery, where the device used to cover the hole migrates to a different part of the heart. This is a medical emergency that typically happens within the first 72 hours after the procedure. Symptoms include chest pain, faint feeling, and low blood pressure.  Ventricular Septal Defect Cause: Hole between L & R ventricles o Causing blood to spill out and overflow into Post-Surgical Nursing Care: the right ventricle, leading to extra blood flow Cardiac tamponade is a condition where and symptoms. fluid builds up in the pericardial sac o Going into right ventricle surrounding the heart, putting pressure on the heart and preventing it from filling S/S: properly. Lung congestion left sternal border Shortness of breath Loud Device migration is a rare complication Harsh heart murmur coughing that can occur after ASD surgery, where the device used to cover the hole migrates DX: to a different part of the heart. This is a Cardiac workup medical emergency that typically happens Chest Xray within the first 72 hours after the ECG procedure. Symptoms include chest pain, Echocardiography to visualize the heart structure faint feeling, and low blood pressure. and blood flow Treatment: Surgical repair Catheterization procedure to patch the hole in the atrial septum Open heart surgery is done to directly repair the hole Complications like cardiac tamponade and device migration can occur after ASD surgery and require prompt medical attention.  Patent Ductus Arteriosus Structure that helps bypass blood flow to the lungs while the DX: baby is in the womb After birth, when the baby takes their Cardiac work up first breaths, the ductus arteriosus is supposed to close Ductus arteriosus does not close properly after birth, which Echo- will confirm there is a “HOLE” in the heart requires medical attention Clinical Manifestations: If the ductus arteriosus does not close properly, -patent Small: Asymptomatic ductus arteriosus Large: CHF, tachypnea, dyspnea, hoarse S/S: cry, ‘machine-like’ murmur Increased blood flow due to hole in heart causes Treatment: bounding, 4 1St - prostaglandin inhibitor medication- Require medical attention indomethacin to close the PDA Pulse pressure is obtained by measuring the difference Indomethacin – fails Surgical closure will be between systolic and diastolic blood pressure done ages 1 & 2 If it is wide, such as 100/50/40, due to increased blood flow through the unclosed ductus arteriosus / cause of Surgical Risks After - Bacterial Endocarditis / PDA Serious heart infection Normal B/P 120/80 120-80 subtract = 40 Bacteria entering the heart and settling in the Greater than 25 mmhg (millimeters of mercury) endocardium (lining of the heart) Assessed by a nursery nurse – listening to baby’s- Usually pt’s with this condition will always irregular heart rhythm. have to get a prophylactic antibiotics prevent bacterial endocarditis  Tetralogy of Fallot Cause: 4 defects: ventricular septal defect, right ventricular hypertrophy, overriding aorta, pulmonary stenosis (DROP) Clinical Manifestations: Severity of the symptoms depend of the degree of defects Cyanosis (Tech spells) hands and feet/ squatting position babies/ older child auto squat themselves, poor feeding, failure to thrive S/S: Stress Diagnosis: Cardiac workup Treatment: Temporary procedure: Blalock-Taussig- Thomas (BTT) Procedure Less invasive procedure for infants. Who are not ready for surgery. Increase blood flow to the lungs through a shunt connecting the aorta to the pulmonary artery. Surgical repair - Will be on a full bypass machine during this complex procedure. Most children are left without a pulmonary valve Chest Xray of a child with Tetralogy of Fallot (TOF) may show a "boot-shaped" heart, indicating the characteristic abnormalities of this congenital heart defect. Paroxysmal Hypercyanotic Episodes AKA “Tet spells” Cause: Occur during the first 2 years of children with Tetralogy of Fallot Triggered by stress Clinical Manifestations: Spontaneous cyanosis, respiratory distress, weakness, syncope. Can lead to LOC Treatment The pt will assume the squatting position for relief from breathlessness and cyanosis. Or, the nurse can place them into a knee-chest position. Morphine can relax the pulmonary valve and can help to relieve symptoms  Tricuspid Atresia-Cyanotic-condition Definition: Tricuspid valve is completely closed, no valve, and damage Congenital heart condition where the tricuspid valve is missing or underdeveloped, leading to cyanosis (bluish skin) in affected individuals. This condition causes a mixing of blood and affects oxygenation, requiring immediate medical intervention after birth. No Tricuspid valve –missing / blood mixing/ child turns blue. Corrected after child is born 20 Week Ultrasound – can be found SHUNTING- ABNORMAL BLOOD Signs & Symptoms: Infants: Cyanosis, dyspnea, tachycardia Older children: Hypoxemia, clubbing of fingers Additional openings in the heart VSD, VDA, PDA Treatment: SURGICAL PROCEDURES: Surgery in 3 stages: shunt placement-DRAIN EXCESSIVE FLUID, Glenn procedure- IMPROVE BLOOD FLOW, modified Fontan procedure -FINAL STAGE  Coarctation of the Aorta/Acyanotic condition Cause: Narrowing or stricture of the (descending arch of aorta found) Part of the Aorta that gets pinched off defect Blood flows fine throughout the body Entering the Aorta- Pinched of section not enough blood entering through the body. S/S: Decrease cardiac output – Blood will back up in the heart and lungs Upper extremities B/P high – hypertension symptoms headaches, dizziness, syncope, nosebleeds, and broken blood vessels. Lower extremities – Low B/P not enough blood flow. DX: Difference in BP between arms and legs TX: HTN meds Balloon Angioplasty procedure to inflate a balloon and widen the narrowed section of the aorta/ Fix before age 2 Reoccur again Open heart surgery  Pulmonary Stenosis Definition: Narrowing of the pulmonic valve Insufficient blood flow to the lungs S/S: heart murmur High B/P SOB DX: Cardiac Studies TX: Angioplasty Ballon –open the narrowing Aortic Stenosis Definition: Aortic valve is narrowed Insufficient blood flow from the left ventricle to the aorta. Dangerous than pulmonary stenosis, where the narrowing is in the pulmonary valve S/S: Decrease of cardiac output Decrease in blood in the body than the lungs Complications: Left ventricle has back-up with blood Risk –blood clots, left ventricle hypertrophy(enlarge), MI (Myocardial Infarction) TX: Angioplasty Ballon and Heart Surgery Transposition of the Great Arteries- cyanotic condition Definition: Cyanotic congenital heart condition where the aorta and pulmonary arteries are switched causing significant blood flow issues that require immediate stabilization. Arteries are switched S/S: Blue SOB Poor feeding DX: Cardiac workup TX: Arterial switch operation to correct the blood flow issues  Truncus Arteriosus Definition: Pulmonary artery not developed and leads to one trunk - left S/S: Cyanosis SOB Low cardiac output HR –failure Not compatible with life Septum never forms. DX: Echocardiogram giant hole blood mixing together (rich and poor blood) TX: Surgery right away Congestive Heart Failure Cause Blood/fluids accumulate in the organs and body tissues. The heart is not able to pump strong enough to have blood travel throughout the body Clinical Manifestations Infants: tachycardia, fatigue, feeding problems, respiratory distress (grunting, nasal flaring, retractions), periorbital edema, rapid weight gain. Feeding problems Children: Failure to gain weight, weakness/fatigue, irritable, pallor, tachypnea, dyspnea, blood sputum, enlarged liver, edema- Dysrhythmias Adolescents: Adult-like signs and symptoms left & right failure Diagnosis Signs & symptoms, cardiac workup, Echo, EKG, Chest x-ray, cbc, cmp, BNP (B-type natriuretic peptide) peptides get secreted by the ventricles of the heart when heart is damaged – most like lab will be elevated Treatment Decrease workload on the heart with meds, oxygen administration, limited physical activity. Medications Heart transplant  Wait! Do you know what these mean? Preload –filling -refers to the amount of ventricular stretch at the end of diastole, which is the heart's filling motion before the next contraction. Afterload-is the systemic vascular resistance that the heart has to overcome to open the aortic valve and push blood out to the body. Contractility-Heart Contraction Medications Used in Heart Failure Diuretics – Decreases preload/reducing the workload on the heart. Furosemide (Lasix)-Loop Diuretic Potassium-sparing- Used if you are losing too much potassium Chlorthalidone- commonly used as a Thiazide diuretic Hydrochlorothiazide (HCTZ) - Thiazide diuretic Loose Potassium –During urination Osmotic diuretics- ICP Digoxin – Therapeutic Range 0.5 to 2 Antidote( Digibind) Slows down the heart rate Check apical pulse for 1 minute before administering digoxin. Hold medication if heart rate is lower than 60 bpm Positive inotrope – Improves contractility. Improve the contractility (squeezing ability) of the heart, making it pump blood more effectively in patients with heart failure. High -dose 1st for therapeutic level then low Infants: Hold medication if heart rate is under 100 bpm Children: Hold medication if heart rate is under 70 bpm Side Effects Visual changes like seeing halo lights, double vision (opsia), or yellow/green vision can Fatigue, nausea, and gastrointestinal (GI) symptoms, as the neural and GI systems ACE Inhibitors – Decreases afterload – Lisinopril High B/P Reduce the resistance in the heart Vasodilates to reduce the pressure of the heart Beta Blockers Help manage heart failure by decreasing both preload (amount of blood filling the ventricles) and afterload (resistance the heart needs to overcome to pump blood out), with a greater effect on afterload. Selective beta blockers primarily target beta1 receptors in the heart Nonselective beta blockers affect both beta1 heart and beta2 heart & lungs receptors throughout the body Respiratory conditions like asthma or COPD-propranolol Blocks norepinephrine and other stimulants that affect beta receptors Decreases blood pressure and heart rate.  1. In a child with a diagnosis of congestive heart failure, what would chest radiographs show? a. Pigeon chest b. Enlarged heart c. Lung infiltrates d. Flail chest Discussion A child diagnosed with congestive heart failure has been admitted to the hospital. 1. What are the signs and symptoms of congestive heart failure in children? ◦ Failure to gain weight, weakness/fatigue, irritable, pallor, tachypnea, dyspnea, blood sputum, enlarged liver, edema ◦ Tachycardia ◦ Palpitations ◦ Dysrhythmias 2. What is the treatment for a child with congestive heart failure? ◦ Decrease workload on the heart with meds-Captopril or Enalapril- Metoprolol & Carvedilol ◦ Oxygen administration ◦ Limited physical activity ◦ Heart transplant Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Part 2  Rheumatic Fever An inflammatory disease that impacts the heart, joints, lungs, and brain. A significant complication is scarring of the mitral valve. Rheumatic fever can cause inflammation of blood vessels, putting patients at risk of developing a dangerous aneurysm, which typically resolves within 4 weeks. Group A beta hemolytic streptococcal infection Cause: Autoimmune reaction to strep infections Clinical Manifestations: 2-6 weeks after infection, slow progression Fatigue, poor feeding, pale, weight loss, muscle/joint pain, fever (Minor S/S) Carditis: inflammation of the heart – (Major S/S) Chorea: involuntary, unpredictable body movements (Major S/S) Polyarthritis: migratory arthritis; moves from one major joint to the next (Major S/S) Labs: ESR (erythrocyte sedimentation rate) and CRP (Creactive protein) are lab tests used to check for inflammation in the body. Treatment: Bed Rest to prevent residual heart disease, activity restriction, diuretics, low sodium diet. Ibuprofen- polyarthritis Aspirin: Reduces pain + inflammation from polyarthritis Chorea: Sedation (if necessary) Carditis- corticosteroids  Kawasaki Disease Cause: Diagnosis Immune system alteration caused by an infectious Fever + 4 symptoms agent. Labs: Elevated ESR/CRP Risk for heart damage- Echocardiogram The cause is not fully understood, but it may be Fever lasting 5 days plus 4 other symptoms triggered by a recent cold, flu, or other illness. Treatment Acute stage: High fever (103.5104°F), usually in High dose IV immunoglobulin 8-12 hrs, children under 5 and those of Asian descent Symptoms Redraw labs ESR & CRP & Redo Echo- BEFORE/ occur in After 8 weeks of treatment Inflammation of blood vessels, putting patients at risk of Aspirin therapy (aspirin is safe in this case) 8 weeks developing a dangerous aneurysm, which typically Immunoglobulin- can not get live vaccine until 6 resolves within 4 weeks. months after Skin changes, such as changes in the hands and feet, in Nursing Care addition to the risks of developing an aneurysm. Manage symptoms (pain, fever) Monitor I/O Kawasaki disease takes about 8 weeks total for the signs Promote rest and symptoms to resolve, with the Many children recover without long term effects. convalescent stage lasting 6-8 weeks after diagnosis where symptoms and lab values start to normalize. Subacute stage 2 higher risk of getting an aneurysm because of the inflammation in the blood vessels 3rd stage convalescence- still at risk for aneurysm Clinical Manifestations: Acute Stage: fever, irritability, conjunctivitis, strawberry tongue, dry/cracked lips, red/swollen joints, edema of hands/feet, lymphadenopathy Subacute stage: Resolution of the fever, but still irritable, takes about 4 weeks. Greatest risk of aneurysms at this phase Convalescent stage: Symptoms have resolved, labs will begin to normalize, can last 6-8 weeks, aneurysms at this phase, give aspirin – REYES SYNDROME-SEVERE VOMITING 1ST SIGN  Iron Deficiency Anemia Cause Insufficient production of hemoglobin Common between 9-24 months of age Babies who drink mostly milk and not other foods are at risk- Iron Deficiency Economic problems, knowledge deficit about nutrition Child- Should be on formula milk until 12 months 9-12 mos parents weening off breast milk or formula Clinical Manifestations: Pale, prone to infection, poor weight gain, concave or spooning fingernails, palpitation's Diagnosis: Labs → Low hemoglobin and hematocrit, CBC Treatment: Improve nutrition, iron rich food, red meat, lentils, organ meat, nuts, raisins, egg yolks ferrous sulfate administration, 6 months Iron-fortified or Iron-fortified oat cereal PICA- craving non-edible food -dirt, clay, or paper. -protein deficiency, leading to poor weight gain and changes in the fingernails. Nursing care: Education Black tarry stools Constipation Empty stomach iron pills Orange juice / Vitamin C increases absorption No milk decreases absorption Drink liquid form iron with a straw won’t stain teeth IM- Z track method – wont irritate skin or stain  Sickle Cell Disease Cause Diagnosis Abnormal production of hemoglobin Screening: finger prick RBCs will assuming a ‘sickling’ shape Genetic: Disease will only occur of Lab: Hemoglobin Electrophoresis (gold inherited the sickle cell trait from standard) both parents Treatment Clinical Manifestations Prevent crisis During crisis: pain management, fluids, O2~ S/S: Lead to cardiac failure Nursing Care clogs- up the blood Pain Symptom management hemoglobin S instead of normal hemoglobin A and education Fatigue and poor appetite during noncrisis periods. Symptoms typically appear in the second half of the first year Chronic anemia, fatigue, poor appetite Sickle Cell Crisis: Severe manifestation. Can be triggered by low O2. Symptoms include: Severe abdominal pain, muscle spasms, leg pain, jaundice, often triggered by low oxygen Oxygen Fluids Platelets  Thalessemia Cause Treatment Inherited: abnormal hemoglobin production Transfusions to maintain (heart failure and iron overload)hemoglobin levels Clinical Manifestations Anemia, fatigue, pallor, Prevention of heart failure irritability, anorexia. Bone marrow transplants Bone pain/fractures are common. Spleenectomy Organ involvement is possible Iron overload is possible from frequent Enlarged spleen, transfusions overstimulation of bone marrow, heart failure Nursing care Poor prognosis Brownze skin color – Mediterranean Child often dies from cardiac failure descent Die from cardiac failure Hemophilia Cause Clinical Manifestations Prolonged bleeding Common in males Nose bleeds - pinch nose 15-20 min Hereditary Nosebleed does not stop 15-20 min head to Delayed coagulation of blood hospital Hemophilia A Diagnosis Factor VIII deficiency Family history, type of bleeding, clotting Most common time, factor-specific assays Hemophilia B Treatment Factor IX deficiency Blood/plasma transfusions Christmas Disease Large amounts of plasma is needed DDAVP- Hemophilia A Von Willebrand Corticosteroids Missing von Willebrand factor protein; so the Apply ICE on nose to vasoconstrict platelets can’t aggregate. Nursing Considerations Prevent bleeding Education Special toothbrush Electric razor  Immune Thrombocytopenia (Idiopathic Thrombocytopenic Purpura - ITP) Cause ITP (immune thrombocytopenia) is a platelet deficit condition that can cause hemorrhages into the skin, leading to symptoms like nosebleeds, rash, fatigue, purpura (purple bruising). o Platelet deficit causing hemorrhages into the o Platelet levels under transfusion - 150,000 to 450,000 with symptoms o skin/mucous membranes o Can precede viral infections o Under 100,000 blood transfusion applied – low case Clinical Manifestations Generalized rash, acute bruising, hematuria, Epistaxis- nose bleeds Prevent -hemorrhage Resolves within a few weeks Treatment Corticosteroids reduces the length of the disease IVIG can help to increase platelets/ can not have a live vaccine Spontaneous remission can occur Nursing Care Education: Protect the child from falls and trauma  Acute Leukemia Pediatrics: Acute lymphoblastic leukemia (ALL) – More common Acute Myeloid Leukemia (AML) – Worse not good prognosis Cause Labs: CBC- Elevated white blood cell counts, as well as changes in red blood cells and platelets. Uncontrolled reproduction of deformed WBCs The most common type of childhood cancer Clinical Manifestations Appears abruptly Fatigue, pallor, fevers, bone/joint pain, petechiae (pinpoint hemorrhages beneath the skin), purpura (hemorrhages in the skin or mucous membranes), enlarged lymph nodes. Diagnosis H&P, symptoms, labs, bone marrow aspiration (Gold Standard) cbc Treatment Chemotherapy, bone marrow transplant What disease is a sex-linked recessive trait caused by a deficiency of factor IX? a. Hemophilia B b. Hemophilia A c. Factor VIII disease d. Christmas disease Is the following statement true or false? ALL often presents with abnormal bleeding after a minor injury. A preschool child is being seen in the emergency department. The care provider is trying to rule of the diagnosis of leukemia. ◦ What findings upon the nursing assessment would be indicative of possible leukemia? Draw- CBC Elevated white blood cell counts, as well as changes in red blood cells and platelets. Bone Marrow -Gold standard A child diagnosed with sickle cell anemia has been admitted with a sickle cell crisis. 1. What is the pathophysiology of a sickle cell crisis? 2. What might cause a sickle cell crisis to occur? 3. What are the clinical manifestations seen during a sickle cell crisis? 1. Severe low oxygen due to S shape cells 2. Stress, trigger, and high altitude 3. Clinical manifestations: Abdominal pain, muscle spasms, leg pain, jaundice, often triggered by low oxygen. Immunizations Birth-18yrs of age Immunizations  Side Effects vs. Adverse Effects Common or expected side effects: Adverse effects: Redness at the injection site Systemic rashes Swelling at the injection site Respiratory symptoms Low-grade fever Cardiovascular symptoms 100, 100.4, 101 Palpitations Fussiness/feeling tired How are vaccines given? Route – Oral, IM, SQ, intranasal Intranasal – Flu vaccine Oral Rotavirus vaccine Sites of injection – Vastus lateralis, deltoid SQ- MMR, IPV, Varicella VS- Given under the age of 1 yr Deltoid- 1 yr and up Sometimes vaccines will be given in both VS and deltoid Vaccines – prefill syringes or in vals – must be refrigerated until use Some require mixing – always use the correct diluent Some are refrigerated, some are frozen – None are stable for long at room temperature. Vaccines can be outside refrigerator up to 1 hr Hepatitis B Brand names: Energix-B, Pediarix Protects against hepatitis B 3 dose series Birth, 1-2 months, 6-15 months (typically completed by 6 months) Hep B Blood & Bodily Fluids Less life expected Keep on schedule follow IDP guidelines Engerix B Vaccine Pediarix vaccine  Rotavirus Brand names: Rotateq, Rotarix Protects against rotavirus Severe Gastroenteritis Given orally 2-3 dose series (2 months, 4 months, 6 S/S: Severe vomiting & diarrhea – watery months (if applicable) Found: Daycare centers & surface of table Should not be started after 15 weeks of age Types: and/or administered after 8 months old Rotateq- 3 series – 2,4,6 Rotarix- 2 series 2 & 4 Form: Given orally prefilled syringes The vaccine must be given before 15 weeks Cut- off 8 months / Not given after Diphtheria, tetanus, and acellular pertussis (DtaP) Brand names: Infanrix, Pediarix, Kinrix Protects against diphtheria, Tetanus- locks up jaw tetanus, pertussis Pertussis- Whooping cough Five dose series – 2 months, 4 Side effects months, 6 months, 15 months, Sorness 4-6 years old Massage arm or leg Pediarix-combination – Hep B Kinrix-Dtap-polio Infanrix-Dtap- only Inactivated Poliovirus (IPV) Brand names: Ipol, Pediarix, Kinrix, Pentacel Protects against polio 4 dose series 2 months, 4 months, 6-18 months (usually given at 6 months), 4-6 years old  Haemophilus Influenzae Type B (Hib) Brand names: PedvaxHib, Hiberix Protects against haemophilus influenzae type B 3-4 dose series (depending on manufacturer) 2 months, 4 months, 6 months (if applicable), 12-15 months Pneumococcal Conjugate Vaccine Brand names: Prevnar20 Other pneumonia vaccines: PCV15, Pneumovax 23 Protects against pneumonia 4 dose series 2 months, 4 months, 6 months, 12-15 months old Hepatitis A Brand name: Havrix Protects against hepatitis A 2 dose series – 6 months apart First dose usually given at 12-15 months old Measles, Mumps, Rubella (MMR) Brand name: MMR II, Proquad Protects against measles, mumps (rubeola), and rubella 2 dose series 12-15 months old, 4-6 years old Tetanus, diphtheria, and acellular pertussis (Tdap) Brand names: Adacel, Boostrix Protects against tetanus, diphtheria, and pertussis First dose given at 11-12 years old. Meningococcal (MCV4) Brand names: Menactra, Menveo Protects against meningitis A, C, W, Y 2 dose series (11 y/o, 16 y/o)  Human Papillomavirus (HPV) Brand name: Gardasil 9 Protects against human papillomavirus that can cause genital warts, cervical cancer. 2-3 dose series depending on the age of the patient o Before 15 y/o = 2 dose series o Second dose is given 6-12 months after first dose o 15 years old or older = 3 dose series Second dose given at least 4 weeks after first dose. Third dose given at least 12 weeks from the second dose, and at least 5 months from the first dose. Meningococcal B (MenB) Brand names: Bexsero, Trumenba Protects against meningococcal B 2 dose series Second dose depends on the brand given. Bexsero = Doses are 1 month apart. Trumenba = Doses are 6 months apart. Influenza o Protects against the flu o Given yearly o Begin at 6 months old. If under 8 years old, the first time patient gets flu vaccine, patient needs to get a second dose one month later. If patient already over 8 years old when receiving first flu vaccine, patient will only need one vaccine yearly. Injected vs. intranasal  Live Vaccines MMR Varicella Rotavirus Intranasal influenza Immunizations Birth 2 Months 4 Months 6 Months 12 Months 15 Months 18 Months Hep B #1 Hep B #2 Dtap #2 Dtap #3 MMR #1 Dtap #4 Hep A #2 Dtap #1 IPV #2 IPV #3 Varicella #1 Hib #3 or IPV #1 Hib #2 PCV20 #3 Hep A #1 #4* Hib #1 PImmunization Hep B #3 PCV20 #4 PCV20#1 Schedule Hib #3* pneumonia) PCV20 #2 Rotavirus #3* Rotavirus #1 Rotavirus #2 Flu** Immunizations 4-6 years 11-12 years 16 years old Dtap #5 Tdap (repeat in 10 MCV4 #2 IPV #4 years) Men B** MMR #2 HPV* Varicella #2 MCV4 #1