11 Notes

10-004_Binder Cover 10/8/04 3:05 PM Page 1
NWT Clinical
Practice
GuidElines
for Primary
Community Care Nursing
A d u lt a n d P e di at r ic G u i de l i n e s
September 2004
NWT Clinical Practice Guidelines for Primary Community Care Nursing
NWT Clinical Practice Guidelines for Primary

Community Care Nursing (Adult and Pediatrics)
Contents
Introduction, Acknowledgements, Preface (Adult)

Adult Chapter 1 The Eyes
Chapter 2 Ears, Nose and Throat (ENT)
Chapter 3 Respiratory System
Chapter 4 Cardiovascular System
Chapter 5 Gastrointestinal System
Chapter 6 Urinary and Male Genital Systems
Chapter 7 Musculoskeletal Systems
Chapter 8 Central Nervous Systems
Chapter 9 The Skin
Chapter 10 Hematology, Metabolism and Endocrinology
Chapter 11 Communicable Diseases
Chapter 12 Obstetrics
Chapter 13 Women’s Health and Gynecology
Chapter 14 General Emergencies and Trauma
Chapter 15 Mental Health
Introduction, Acknowledgements, Preface (Pediatrics)
Pediatrics Chapter 1 Guidelines for Pediatric Health Assessment
Chapter 2 Pediatric Procedures
Chapter 3 Prevention
Chapter 4 Fluid Management
Chapter 5 Child Abuse
Chapter 6 Dysfunctional Problems of Childhood
Chapter 7 Nutrition
Chapter 8 The Eyes
Chapter 9 Ears, Nose and Throat (ENT)
Chapter 10 Respiratory System
Chapter 11 Cardiovascular System
Chapter 12 Gastrointestinal System
Chapter 13 Genitourinary System
Chapter 14 Musculoskeletal System
Chapter 15 Central Nervous System
Chapter 16 The Skin
Chapter 17 Hematology, Endocrinology, Metabolism and Immunology
Chapter 18 Communicable Diseases
Chapter 19 Adolescent Health
Chapter 20 General Emergencies and Major Trauma
Appendix 1 – Change Request Form
Appendix 2 – Abbreviations
Appendix 3 – Bibliography
September 2004 1
Introduction
The original Clinical Practice Guidelines for Nurses in Primary Care (FNIHB, July 2000) contain
information on common health problems and common emergency conditions seen in the adult population. We
acknowledge the work of the First Nations and Inuit Health Branch of Health Canada in developing the
clinical guidelines and appreciate their permission to use their guidelines, review and update them again and
revise them specifically for the NWT.
The adult guidelines consist of 15 sections. Each one includes an assessment (history and physical
examination) of the body system in question, along with clinical practice guidelines on common disease
entities and emergency situations seen in that system. The most current resources available have been used in
the revision and are referenced where possible.
The adult and pediatric guidelines are intended to be used together and are consequently published in one
binder for the NWT.
These guidelines are intended for use, in conjunction with the NWT Health Centre Formulary (July 2003) as
well as the Community Health Nursing Program Standards and Protocols (March 2003) along with the
reference sources from each of these manuals and Clinical Practice Information Notices as they are issued by
the GNWT Department of Health and Social Services.
All drugs referenced in these guidelines are in the NWT Health Centre Formulary (July 2003), with the
exception of some drugs which have been used as examples of possible physician prescriptions. There are a
few situations where A or C class drugs should be prescribed by a physician only - in these cases the
classification will remain A or C but the text will clarify that these drugs in this circumstance should be
prescribed by a physician only (e.g. salicylates in treatment of rheumatic fever)
NWT Health Centre Formulary (July 2003) classifications have been used.
A class drug - RN initiated, based on nurse assessment of patient, no limitation on duration of treatment
B class drug - Physician initiated, based on consultation with MD, duration/frequency to be
specified by MD
C class drug - RN may initiate 1 course. A course is defined as several successive doses of medication over
time. The time is the period that the specific drug is expected to produce therapeutic effects.
A course may not exceed 2 weeks without consulting a physician. If the condition does not
resolve, the expectation is that the nurse will consult a physician. If further medication is
needed, a physician order is required.
D class drug - RN one dose - reassess patient, contact MD if further treatment is required
You will find that many drugs have been reclassified to a C classification. This is to emphasize the point that
if a patient returns with no resolution of the problem the RN should consult with a physician rather than
continue to treat ineffectively
September 2004 Adult 1

Acknowledgments
We wish to acknowledge the generous time and effort made by:
Brenda Kolasa Jo-Anne Hubert Marilyn Lidstone

David Cook Joanne Montgomery Marnie Bell
Don Giovanetto John Morse Rachel Munday
Elizabeth Cook Karen Graham Ross Wheeler
Ewan Affleck Len Smith Terri Farrell
Faye Stark Margaret Anne Woodside Wanda White
in helping to review and revise these guidelines
Preface
These Clinical Practice Guidelines are intended primarily for use by registered nurses working in health
centers located in the Northwest Territories.
All nurses are encouraged to use other current resources, text or internet, to supplement the information in
these guidelines. All nurses are reminded that this manual is a "guideline", however, nurses are encouraged to
base their practice on this guideline whenever possible.
It is also important to note that the guidelines contain useful information but are not intended to be
exhaustive. Consequently, the manual is to be used for reference and educational purposes only and should
not be used under any circumstances as a substitute for clinical judgment, independent research or the seeking
of appropriate advice from a qualified healthcare professional.
Nurses must consult with a physician whenever a situation warrants. Appropriate medical advice is to be
obtained by telephone in cases where the condition of the client is at all serious or in cases where the
condition of the client is beyond the scope of practice and expertise of the nurse to manage autonomously.
Although every effort has been made to ensure that the information contained in the guidelines is accurate and
reflective of existing healthcare standards, it should be understood that the field of medical science is in
constant evolution. Consequently, the reader is encouraged to consult other publications or manuals. In
particular, all drug dosages, indications, contraindications and possible side effects should be verified and
confirmed by use of the current edition of the Compendium of Pharmaceuticals and Specialties (CPS) or the
manufacturer's drug insert.
These guidelines will be available on the GNWT intranet website. In the printed version you will notice
adequate white space between subjects. This is partly for ease of future revisions, but also to encourage you
to make your own notes (e.g. mnemonics for remembering things, recent reference sources, cross references
to other DHSS GNWT documents), as needed, if you have your own copy of the guidelines.
Every effort will be made to keep these Clinical Practice Guidelines current. Appendix 1 provides the
opportunity for the Guidelines Users to submit suggested changes and so assist with the Guidelines update
process.
2 Adult September 2004

Chapter 1 - The Eyes

Assessment Of The Eyes ................................................................................................................................... 1
History Of Present Illness And Review Of System ........................................................................................ 1
General Physical Examination........................................................................................................................ 2
Differential Diagnosis Of Eye Symptoms Or Ocular Pain ............................................................................. 3
Common Problems Of The Eye ....................................................................................................................... 4

Red Eye........................................................................................................................................................... 4
Blepharitis....................................................................................................................................................... 5
Conjunctivitis.................................................................................................................................................. 7
Hordeolum Or Stye......................................................................................................................................... 9
Chalazion ...................................................................................................................................................... 10
Pterygium...................................................................................................................................................... 11
Cataracts........................................................................................................................................................ 12
Chronic Open-Angle Glaucoma ................................................................................................................... 14
Emergency Problems Of The Eye.................................................................................................................. 16

Corneal Abrasion .......................................................................................................................................... 16
Corneal Ulcer................................................................................................................................................ 18
Conjunctival, Corneal Or Intraocular Foreign Bodies .................................................................................. 19
Acute Angle-Closure Glaucoma ................................................................................................................... 21
Keratitis (Snow Blindness) ........................................................................................................................... 22
Herpetic Keratitis.......................................................................................................................................... 23
Chemical Burns............................................................................................................................................. 24
Blunt Or Lacerating Ocular Trauma ............................................................................................................. 26
Minor Soft-Tissue Contusion........................................................................................................................ 28
Uveitis (Iritis)................................................................................................................................................ 29
Note: The Eye Clinic in Yellowknife may be used as a resource at any time. Phone number: 1-867-873-3577

Assessment Of The Eyes

History Of Present Illness And Review Of System
General • Itching
The following characteristics of each symptom • Discharge
should be elicited and explored: • Ear pain
• Onset (sudden or gradual) • Nasal discharge
• Chronology • Sore throat
• Current situation (improving or deteriorating) • Cough
• Location • Nausea or vomiting
• Radiation • Urethral, vaginal or rectal discharge
• Quality • Pain or inflammation of the joints (or both)
• Timing (frequency, duration)
• Severity Medical History (Specific To Eyes)
• Precipitating and aggravating factors • Eye diseases or injuries
• Relieving factors • Eye surgery
• Associated symptoms • Use of corrective eyeglasses or contact lenses
• Effects on daily activities • Concurrent infection of the upper respiratory
• Previous diagnosis of similar episodes tract
• Previous treatments • Sexually transmitted infections
• Efficacy of previous treatments • Immunocompromise
• Exposure to eye irritants (environmental or
Cardinal Symptoms occupational)
In addition to the general characteristics outlined • Allergies (especially seasonal)
above, additional characteristics of specific • Current medications
symptoms should be elicited, as follows. • Systemic inflammatory disease (inflammatory
bowel disease, Reiter's syndrome)
Vision • Diabetes mellitus
• Recent changes • Hypertension
• Blurring • Chronic renal disease
• Halos • Bleeding disorders
• Floaters
• Corrective measures (glasses, contact lenses) Personal And Social History (Specific
To Eyes)
Other Associated Symptoms • Occupational exposure to irritants
• Pain • Use of protective eyewear
• Irritation • Housing and sanitation conditions
• Foreign-body sensation • School or daycare exposure to contagious
• Photophobia organisms (e.g. pinkeye)
• Diplopia
• Lacrimation
September 2004 Adult 1-1

General Physical Examination

Eye infection or if sexually transmitted infection
Examine the bony orbit, lids, lacrimal apparatus, (e.g. gonorrhea) is suspected.
conjunctiva, sclera, cornea, iris, pupil, lens and
fundi. Note the following: Lymphatic System
• Visual acuity (which is decreased in keratitis, Assess the lymph nodes of the head and neck if a
uveitis and acute glaucoma) systemic condition, such as a viral infection of the
• Swelling upper respiratory tract or a sexually transmitted
• Discharge or crusting infection, is suspected.
• Discoloration (erythema, bruising or
hemorrhage) Assess for pre-auricular adenopathy, which might
• Lipid deposits indicate chlamydial, viral or invasive bacterial
infection of the eye (e.g. gonorrhea).
• Arcus senilis (white circle) around iris
• Position and alignment of eyes
Abdomen
• Reaction of pupil and its accommodation to light
Assess liver for tenderness and enlargement if eye
• Extraocular movements (which are associated symptoms are associated with symptoms of a
with pain in uveitis)
sexually transmitted infection (e.g. disseminated
• Visual field by confrontation gonorrhea) (see chapter 5, "Gastrointestinal
• Corneal clarity, abrasions and lacerations System," for details of abdominal exam).
• Corneal light reflex
• Lens opacities (cataracts) Genitourinary System And Rectal
• Red reflex (which indicates intact retina) Area
• Hemorrhage or exudate Assess for urethral, cervical or vaginal discharge if
• Optic disk and retinal vasculature eye symptoms are associated with symptoms of a
sexually transmitted infection (e.g. disseminated
Palpate the bony orbit, eyebrows, lacrimal gonorrhea) (see chapter 6, "Urinary and Male
apparatus and pre-auricular lymph nodes for Genital Systems," and chapter 12, "Obstetrics,"
tenderness, swelling or masses. for details of these exams).
Apply fluorescein stain (to test for corneal Musculoskeletal System And
integrity).
Extremities
Examine the joints to assess for warmth, redness,
Measure intraocular pressure (by Schiøtz
pain or swelling if eye symptoms are associated
tonometry) (10 to 20 mm Hg is normal).
with joint symptoms (e.g. disseminated gonorrhea)
(see chapter 7, "Musculoskeletal System," for
The ear, nose and throat should also be examined
details of exam).
if there are symptoms of an upper respiratory tract
1-2 Adult
September 2004
Differential Diagnosis Of Eye Symptoms Or Ocular Pain

• Hordeolum • Ingrown lashes
• Chalazion • Abuse of contact lens
• Acute dacryocystitis • Scleritis
• Exposure to irritants • Acute angle-closure glaucoma
• Conjunctival infection • Uveitis (iritis)
• Corneal abrasion • Referred pain from extraocular sources such as
• Foreign-body irritation sinusitis, tooth abscess, tension headache,
• Corneal ulcers temporal arteritis or prodrome of herpes zoster

Common Problems Of The Eye

Red Eye
Red eye is common in a wide variety of ocular • Infection of lacrimal system
conditions (Table 1), some of which are a serious (e.g. dacryocystitis)
threat to vision and require immediate referral to
an ophthalmologist. Features Of Dangerous Red Eye
The first step is to differentiate major or serious
Causes causes of red eye from minor causes. The
• Infection: conjunctivitis, keratitis (bacterial, following danger signs call for referral to an
viral [herpetic or non-herpetic] or other) ophthalmologist.
• Ocular inflammation: uveitis, iritis, episcleritis, • Severe ocular pain (especially if unilateral)
scleritis • Photophobia
• Dry eyes • Persistent blurring of the vision
• Blepharitis with secondary conjunctivitis or • Proptosis (exophthalmos)
keratitis (or both) • Reduced ocular movement
• Allergy (e.g. allergic conjunctivitis) • Ciliary flush
• Glaucoma (e.g. acute angle-closure glaucoma) • Irregular corneal reflection of light
• Toxic, chemical or other irritants such as topical • Corneal epithelial defect or opacity
eye drugs, contact lens solution, acids or alkalis, • Pupil unreactive to direct light
smoke, wind or ultraviolet rays • Worsening of signs after 3 days of
• Traumatic injury (e.g. corneal abrasion, foreign- pharmacologic treatment for conjunctivitis
body irritation, hyphema, subconjunctival • Compromised host (e.g. neonate,
hemorrhage) immunosupressed patient, user of soft contact
• Pterygium or inflamed pinguecula lenses)
Table 1: Partial Differential Diagnosis of Red Eye
Conjunctivitis Corneal injury or
Uveitis (Iritis) Glaucoma
Bacterial Viral Allergic infection
Vision Normal Normal Normal Reduced or very Reduced Very reduced
reduced
Pain - - - + + +++
Photophobia +/- - - + ++ -
Foreign body +/- +/- - + - -
sensation
Itch +/- +/- ++ - - -
Tearing + ++ + ++ + -
Discharge Mucopurulent Mucoid - - - -
Pre-auricular - + - - - -
adenopathy
Pupils Normal Normal Normal Normal or small Small Moderately
dilated or fixed
Conjunctival Diffuse Diffuse Diffuse Diffuse with Ciliary flush Diffuse with
hyperemia ciliary flush ciliary flush
Cornea Clear Sometimes Clear Depends on Clear or lightly Cloudy
faint punctate disorder cloudy
staining or
infiltrates
Intraocular Normal Normal Normal Normal Reduced, Increased
pressure normal or absent
+, present (to various degrees); -, absent; +/-, may be present *Hyperthyroidism may cause conjunctival injection.
1-4 Adult
September 2004
Blepharitis
Definition • Skin cancer (unilateral) (e.g. sebaceous-cell
Inflammation of the eyelid margins. carcinoma)
Causes Complications
• Seborrhea or bacterial infection (with • Secondary bacterial infection common in
Staphylococcus aureus); both may be present in seborrheic form
some people (mixed form) • Recurrence
• Lice infestation of the lashes
Diagnostic Tests
History • Swab exudate for culture and sensitivity prn
• Burning, itching or irritation of lid margin
• Condition commonly chronic, with frequent Management
exacerbations Goals of Treatment
• Usually bilateral • Keep lid margin clean and free of scaly buildup
• History of seborrhea (of the scalp, brows or ears) • Prevent infection
• Loss of lashes
Appropriate Consultation
Physical Findings Consult a physician if the inflammation or
• Lid margin red, scaly infection is extensive (i.e. includes more than the
• Crusting may be present lid margins), as in orbital cellulitis.
• Visual acuity normal
Treat for several weeks, until the blepharitis is
• PERRLA
completely gone, to reduce chance of recurrence.
• Conjunctival redness may be present
Nonpharmacologic Interventions
Bacterial Form
Lid Hygiene (to be performed twice daily). First,
• Dry scales apply warm compresses for 5 minutes to soften the
• Lid margin red scales and crusts. Next, scrub the eyelid margin
• Ulceration may be present and the bases of the eyelashes with a solution of
• Lashes tend to fall out water and baby shampoo (90 mL [3 oz] water and
3 drops of shampoo). Rinse with clear water and
Seborrheic Form then remove lid debris with a dry, cotton-tipped
• Greasy scales applicator.
• Lid margins less red
• No ulceration Client Education
• Counsel client about appropriate use of
Mixed Form medications (dose, frequency, application)
• Dry and greasy scales • Instruct client in proper hygiene of eyelids
• Lid margins red • Recommend that client avoid rubbing or
• Ulceration may be present irritating eyelids
• Recommend avoidance of cosmetics, wind,
Differential Diagnosis smoke and other irritants
• Allergic blepharitis
• Hordeolum (stye)
• Chalazion
• Conjunctivitis

Pharmacologic Interventions Identify and manage underlying seborrhea (scalp,

Apply a topical antibiotic eye ointment to the lid eyebrows or other skin areas).
margins and into the lower conjunctival sac:
Monitoring and Follow-Up
polysporin ointment (A class drug), bid for 1-2 Follow up in 10-14 days.
months,
or Referral
erythromycin ointment (B class drug), bid for 1-2 Usually not necessary unless there is no response
months to therapy or if infection becomes more extensive
(e.g. orbital cellulitis).
1-6 Adult
September 2004
Conjunctivitis
Definition • Discharge: purulent, thin and watery, or thick
Inflammation of the conjunctiva. and stringy
• Crusts on lashes in viral and bacterial forms
Causes • Eyelids red or edematous
Conjunctivitis is usually one of three types: • Pre-auricular adenopathy present in gonococcal
• Bacterial: Chlamydia, Hemophilus influenzae, conjunctivitis and viral
Neisseria gonorrhoeae, Staphylococcus aureus,
Streptococcus pneumoniae Differential Diagnosis
• Viral: adenovirus, coxsackie virus, ECHO virus • Blepharitis
• Allergic: seasonal pollens or environmental • Corneal abrasion
exposure • Uveitis (iritis)
• Herpetic keratoconjunctivitis
Predisposing factors: contact with another person
who has conjunctivitis, exposure to a sexually Complications
transmitted infection, other atopic (allergic)
• Spread of infection to other eye structures
conditions.
• Spread of infection to other household members
History
Diagnostic Tests
Bacterial Conjunctivitis
• Measure visual acuity
• Acute redness and purulent discharge
• Swab and culture exudate
• Burning, gritty sensation in eyes
• Recent contact with others with similar
symptoms Management
Goals of Treatment
Viral Conjunctivitis • Rule out more serious infections such as
gonorrhea or chlamydial infection
• Acute onset of redness
• Watery discharge • Prevent household spread
• Foreign-body sensation • Chronic (>3 weeks) recurrent or atypical
conjunctivitis may be diagnosed as
• Lasts 1-4 days; infectious for up to 2 weeks
• blepharitis
• Systemic symptoms (e.g. sneezing, runny nose,
• dry eye
sore throat)
• chlamydial
• Recent contact with others with similar
symptoms
Consult a physician if any of the following pertain:
Allergic Conjunctivitis
• Significant associated eye pain
• History of seasonal allergies, eczema, asthma,
urticaria • Any loss in visual acuity
• Watery, red, itchy eyes, without purulent • Suspicion of kerato conjunctivitis or other more
drainage serious cause of red eye
• Client has periorbital cellulitis
Physical Findings • No improvement with treatment in 48-72 hours
• Vital signs normal (unless associated with • Client wears contact lenses (and would thus be
systemic illness) at high risk for Pseudomonas conjunctivitis and
keratitis)
• Visual acuity usually normal
• PERRLA; extraocular eye movements normal
• Unilateral or bilateral diffuse conjunctival
redness

• Suspicion of gonorrhea or chlamydial Bacterial Conjunctivitis

conjunctivitis, either of which requires systemic Topical antibiotic eye drop:
antibiotics (refer to current version of Canadian sulfacetamide 10% (C class drug), 2 or 3 drops
STD Guidelines [Health Canada]). q2h for 3 days followed by gradual tapering over
the next 4 days
http://www.hc-sc.gc.ca/pphb-dgspsp/publicat/std- or
mts98/ polymyxin B gramicidin eye drops (C class drug),
2 or 3 drops qid for 5-7 days if the infection is
Nonpharmacologic Interventions mild
Apply cool compresses to eyes, lids and lashes as
frequently as possible. An antibiotic eye ointment may be used at bedtime
in addition to the antibiotic eye drops prn:
Client Education gentamicin (C class drug), hs
• Counsel client about appropriate use of or
medications (dose, frequency, instillation) erythromycin 0.5% (B class drug), hs
• Advise client to avoid contamination of tube or
bottle of medication with infecting organisms Viral Conjunctivitis
• Suggest ways to prevent spread of infection to Boric acid washes often provide excellent
other household members and school or daycare symptomatic relief (antibiotics are not helpful and
contacts are not indicated). May cause irritation. Cool
• Instruct client about proper hygiene of hands and compresses only/vasoconstrictive drops.
eyes
• For allergic form: recommend that client avoid Allergic Conjunctivitis
going outside when pollen count is high and that Topical antihistamine eye drops are recommended
protective glasses be worn to prevent pollen if symptoms are not controlled by oral
from entering the eyes medications.
Vasocon A eye drops (A class drug)
• Do not allow client to use an eye patch
Consult a physician for any others.
Pharmacologic Interventions
Never use steroid or steroid-and-antibiotic
Clients with moderate or severe symptoms should
combination eye drops, because the infection may
be seen for follow-up at 24 and 48 hours.
progress or a corneal ulcer may rapidly form and
cause perforation.
Referral
Refer to a physician if condition deteriorates, if
symptoms persist despite treatment, or if
symptoms recur.
1-8 Adult
September 2004
Hordeolum Or Stye
Definition Appropriate Consultation
Acute infection of a hair follicle of an eyelash, a Usually not necessary for simple stye.
Zeis (sebaceous) gland or a Moll (apocrine sweat)
gland of the eyelid. Nonpharmacologic Interventions
Apply warm, moist compresses qid.
Cause
Bacterial infection (Staphylococcus aureus). Client Education
• Stress importance of not squeezing the
History hordeolum
• Pain • Teach the client eyelid hygiene: wash lid with
• Swelling of eyelid mild soap and water; use a separate area of
• Redness of eyelid washcloth for each eye
• Vision not affected • Stress importance of washing hands to prevent
spread of infection
• Similar eyelid infection in the past
• Recommend avoidance of cosmetics during
acute phase (current eye cosmetics should be
Physical Findings
discarded because they may harbor bacteria and
• Localized redness and swelling of eyelid cause recurrent infection)
• Mild conjunctival injection • Client should not wear contact lenses until
• Possible purulent drainage along the lid margin infection clears
• Acutely tender • Counsel client about appropriate use of
medications (dose, frequency, application)
Differential Diagnosis • Stress importance of follow-up if symptoms do
• Chalazion not improve with treatment or if inflammation
• Blepharitis extends to involve the periorbital tissues
• Dacryocystitis
• Orbital cellulitis Pharmacologic Interventions
gentamicin ointment (C class drug), qid for
Complications 10 days
• Conjunctivitis Antibiotic eye drops can be used, but they require
more frequent dosing, every 3-4 hours, and are
Diagnostic Tests generally less effective.
• Swab any drainage for culture and sensitivity
Follow up in 3-4 days if symptoms do not
Management respond; follow up sooner if infection spreads.
Goals Of Treatment
• Relieve symptoms Referral
• Prevent spread of infection to other eye Consult a physician if the lesion does not respond
structures to therapy or if there is evidence of infection of the
periorbital soft tissue.

Chalazion
Definition Management
Chronic inflammatory lipogranuloma of a Goals of Treatment
meibomian gland. It occurs deeper within the lid • Prevent infection and visual disturbances.
than a stye.
A small asymptomatic chalazion does not require
Cause treatment and usually resolves spontaneously in a
Results from obstruction of the meibomian gland few months. If the chalazion is large or if there is
duct. Secondary bacterial infection from secondary infection, treatment is needed.
Staphylococcus aureus may develop. Rare cause -
chemical cellulitis (e.g. make-up). Nonpharmacologic Interventions
Apply warm moist compresses qid for 15 minutes.
History
• Lump on the eyelid area Client Education
• Redness, swelling and pain, if secondary • Stress importance of not squeezing the chalazion
infection develops • Teach the client eyelid hygiene: wash lid with
• Blurry vision if chalazion is large (pressure on mild soap and water; use a separate area of
the eye globe may cause astigmatism) washcloth for each eye
• Conjunctival injection (if associated with • Stress importance of washing hands to prevent
conjunctivitis) spread if infection occurs
• Tearing may be present (if conjunctiva irritated) • Recommend avoidance of cosmetics during
acute phase (current eye cosmetics should be
Physical Findings discarded because they may harbor bacteria and
• Hard, non-tender nodule (tender if acute) on the cause recurrent infection)
middle portion of the tarsus, away from the lid • Client should not wear contact lenses until
border; may be pointing to the inner surface of infection clears
tarsus and causing pressure on the globe • Counsel client about appropriate use of
• Inflammation of the lids and conjunctiva may be medications (dose, frequency, application)
seen if secondary infection present • Stress importance of follow-up if symptoms do
not improve with treatment
Differential Diagnosis
• Hordeolum (stye) Pharmacologic Interventions
• Blepharitis gentamicin ointment (C class drug), qid for 7 days
• Sebaceous-cell carcinoma (rare)
Antibiotic eye drops can be used, but they require
more frequent dosing, every 3-4 hours, and are
Complications generally less effective.
• Secondary infection
• Astigmatism Monitoring and Follow-Up
Follow up in 1-2 weeks.
Diagnostic Tests
None. Referral
Refer to a physician if a large chalazion does not
respond to medical therapy. Incision and drainage
with excision may be necessary if the chalazion
does not resolve spontaneously within 2 or 3
months.
1-10 Adult
September 2004
Pterygium
Definition Diagnostic Tests
A triangular winglike growth of tissue that is a • Measure visual acuity
proliferation of the nasal or (rarely) the temporal
bulbar conjunctiva. It grows toward the cornea and Management
over its surface. Goals of Treatment
• Identify asymptomatic lesions
Causes • Prevent further growth
Chronic irritation of the eye from ultraviolet light,
dust, sand or wind. Appropriate Consultation
Arrange a non-urgent consultation with the
History physician.
• Usually painless
• Blurred vision if pterygium extends over cornea Client Education
• Usually occurs in people who spend a lot of time • Stress importance of preventing chronic
outdoors irritation
• Educate those at high risk
Physical Findings • Recommend use of protective eyewear in both
• Visual acuity normal summer and winter
• Bilateral or unilateral lesions may be present • Explain course of disease and expected outcome
• A mounded, injected triangular mass of • Ask client to return to the clinic for reassessment
conjunctival tissue arising from either canthus when signs of conjunctivitis are noticed or if
and possibly extending across cornea lesion interferes with vision
• Blood vessels may present within the tissue
Differential Diagnosis • Follow annually; note any changes in size
• Pinguecula (inflamed) • Test central and peripheral vision
Complications Referral
• Recurrent conjunctivitis Referral for definitive treatment (surgical removal)
by an ophthalmologist may be necessary if lesion
interferes with vision.

Cataracts
A decrease in the transparency of the crystalline Goals of Treatment
lens to the degree that vision is impaired. • Maintain optimal vision
• Prevent accidents (e.g. falls)
Causes
Protein coagulates in opaque areas in the lens for Appropriate Consultation
unknown reasons. Ninety-five percent of people Consult a physician on a non-urgent basis, unless
over age 65 have some degree of lens opacity. vision is significantly diminished and there is risk
Most cases (90%) occur as a natural process of of visual impairment, or cataract is related to
aging. Other cases are metabolic, congenital or ocular trauma or other eye disease process.
drug-induced, or are the result of ocular trauma or
an ocular condition such as chronic anterior Nonpharmacologic Interventions
uveitis. Non-surgical management includes changing lens
prescription and using strong bifocal eyeglasses,
Factors that influence the risk of cataract magnification and appropriate illumination.
development include exposure to ultraviolet B
radiation; diabetes mellitus; use of alcohol; use of Client Education
medications such as major tranquilizers, diuretics • Counsel client that progression of cataract
and systemic corticosteroids; and lack of formation may be slowed by decreasing sun
antioxidant vitamins. exposure, quitting smoking or increasing
ingestion of antioxidant vitamins (if diet is
History deemed deficient in this area)
• Diminished vision • Teach client how to prevent falls and accidents
• Increased perception of glare from lamps or sun in the home
or when driving at night • Recommend use of magnification and
• Altered perception of colour (loss of contrast appropriate illumination
sensitivity)
• Presence of risk factors (see "Causes," above) Monitoring and Follow-Up
Follow-up (by eye team) should be done at least
Physical Findings annually.
• Visual acuity may be decreased in affected eye
• Funduscopic exam reveals opacities of the lens Referral
(view red reflex through dilated pupil at 2-3 feet Referral to an ophthalmologist for evaluation is
with appropriate focus) necessary if client experiences increasing
functional impairment. Decision concerning
Differential Diagnosis surgery is based on the degree of functional
impairment.
• Macular degeneration
• Diabetic retinopathy
Follow-Up After Cataract Surgery
Complications Goals of Care
• Risks associated with loss of vision • Control inflammation
(e.g. falls, trauma) • Prevent infection
• Maintain eye comfort
Diagnostic Tests • Promote early visual rehabilitation
None.
1-12 Adult
September 2004
History Post-Operative Medication Review

• Post-operative pain is usually minimal, with • Antibiotics are used to prevent infection
mild foreign-body sensation • Anti-inflammatory agents such as steroid,
• Increased pain may be due to inadvertent ketorolac or diclofenac drops are used to reduce
trauma, infection or increased intracranial post-operative inflammation
pressure
• Itchy red eye Analgesic agents are used for discomfort:
• Changes in vision: darkening or loss of detail acetaminophen (A class drug), 500 mg, 1 or 2 tabs
(any significant post-operative change could q4h prn
indicate hemorrhage, retinal detachment, acute
glaucoma or infection) No changes to eye medications should be made
• Visual phenomena such as flashing lights or without consulting the treating ophthalmologist.
dark shadows require investigation
Client Education
Eye Examination • Counsel client about appropriate use of
• Redness or swelling of the conjunctiva or lids medication and side effects
suggests infection or allergic response to • Patient may engage in activity as tolerated,
medications except no lifting, bending or other activities that
• Red reflex (confirm with ophthalmoscopy) strain the intra-abdominal muscles
• Corneal opacity
• Hyphema (blood in the anterior chamber) Monitoring and Follow-Up
Client should be seen by ophthalmologist in 6
weeks.

Chronic Open-Angle Glaucoma

Acute angle-closure glaucoma usually presents Congenital
with acute symptoms and is a medical emergency • Family history of condition
(see "Emergency Problems of the Eye," below, this
chapter). History
Symptoms do not arise until disease is very
Definition advanced.
Glaucoma is a disease usually related to increased • Loss of vision (gradual and painless)
intraocular pressure, which may result in damage • Peripheral vision affected first
to the optic nerve that can lead to loss of vision. • Halos around lights (not open-angle)
A complete understanding of the pathogenesis of
• Presence of risk factors
glaucoma remains unknown; some people with
high intraocular pressure do not have glaucoma,
whereas others have glaucoma without elevated Physical Findings
intraocular pressure. • Peripheral field of vision decreased
• Central visual acuity decreased, in late stages
Causes • Cupping of the optic disk
• In chronic open-angle glaucoma, the secretion of
aqueous humor and its flow between the lens Differential Diagnosis
and the iris through the pupil into the anterior Vascular occlusive disease of the eye.
chamber is normal; however, the trabecular
meshwork does not allow rapid enough drainage Complications
of aqueous humor, with a resultant elevation in Blindness.
pressure
• Prevalence is about 1% of people over age 40, Diagnostic Tests
increasing to 3% among people older than 70 • Measure visual acuity
years; affects men and women equally • Determine extent of peripheral fields
• Measure intraocular pressure with Schiøtz
Risk Factors tonometry; if pressure > 21 mm Hg,
Primary investigations should be initiated, especially if
• Elevated intraocular pressure patient is symptomatic
• Advanced age
• Family history of condition Eighty-five percent of patients with intraocular
• Myopia pressure > 21 mm Hg do not have glaucoma and
• Diabetes mellitus will not develop this condition in the next 5 years.
• Systemic hypertension Unless tonometry is performed frequently and
accurately with precise instruments, the results
• African heritage
may be inaccurate; therefore the screening value
of tonometry has been challenged. The detection
Secondary (Acquired)
of glaucoma may be more appropriately based on
• Blunt or penetrating trauma the periodic screening of high-risk individuals
• Previous intraocular surgery with a thorough ophthalmological assessment.
• Previous intraocular inflammation
• Corticosteroid use Management
• Drugs that cause or worsen glaucoma: Goals of Treatment
corticosteroids (commonly); antihistamines,
• Prevent, slow or stop progressive vision loss
decongestants, antispasmodics, antidepressants
(rarely)
• Preserve a healthy optic nerve
• Early detection of those at risk
1-14 Adult
September 2004
Appropriate Consultation • People > 65 years of age should be assessed

Consult a physician if new-onset glaucoma is annually
suspected or symptoms of previously diagnosed
glaucoma have worsened. No lifestyle modifications have proven helpful
Refer to traveling eye clinic either before or after the use of drug therapy.
Surgical and laser procedures are options if drug
Nonpharmacologic Interventions therapy fails.
For early detection of glaucoma in the general
population, the Canadian Task Force on the Pharmacologic Interventions
Periodic Health Examination (1994) (now the Drug treatment for glaucoma is prescribed by an
Canadian Task Force on Preventive Health Care) ophthalmologist. The main aim of all drug
http://www.ctfphc.org/ gave funduscopic exam therapy is to reduce intraocular pressure. Any
and tonometry a C recommendation (i.e. poor or visual loss is usually irreversible.
insufficient research evidence to include or
exclude from the periodic health examination). Monitoring and Follow-Up
The Task Force prudently recommended that Ensure regular follow-up by a physician at least
anyone with risk factors for glaucoma undergo annually when stable.
periodic assessment by an ophthalmologist:
Referral
• People > 40 years of age should be assessed Refer back to the ophthalmologist annually or
every 3-5 years sooner if symptoms progress.

Emergency Problems Of The Eye

Corneal Abrasion
Superficial corneal defect due to scraping or Goals of Treatment
rubbing of the corneal epithelium. • Prevent secondary bacterial infection
• Prevent development of corneal ulceration
Causes
Usually trauma or a foreign body in the eye. Appropriate Consultation
Consult a physician if there is a large or central
History corneal abrasion or if a penetrating corneal ulcer is
• Foreign-body sensation found on initial examination, if pain is severe, if
• Sudden unilateral eye pain (sharp or worse with the abrasion does not respond to therapy after
blinking) 48 hours or if a residual rust ring is evident.
• Moderate to profuse tearing
• Mild photophobia Nonpharmacologic Intervention
• Mild blurred vision (due to tearing) may be Firm, comfortable double-patching of the eye may
present relieve pain associated with larger abrasions. One
day is usually sufficient.
Physical Findings Patching is contraindicated if abrasion is
• Vital signs normal associated with wearing contact lenses.
• Visual acuity may be slightly blurred in affected
eye Client Education
• Diffuse conjunctival injection • Advise client that daily follow-up is important to
• Pupils react briskly to light ensure proper healing
• Fluorescein staining will reveal area of abrasion • Counsel client about appropriate use of
• Presence of a foreign body under the upper or medications (type, dose, frequency, side effects)
lower eyelid must be ruled out • Instruct client to return to clinic immediately if
pain increases or vision decreases before 24-
Differential Diagnosis hour follow-up
Rule out other causes of red eye (see Table 1, in • Suggest that client wear protective glasses while
"Red Eye," above, this chapter). working to help prevent similar incidents in
future
Complications
• Corneal ulceration Pharmacologic Interventions
• Secondary bacterial infection Instill topical anesthetic eye drop:
• Corneal scarring if abrasion recurs tetracaine 0.5% eye solution (A class drug),
• Uveitis (iritis) 2 drops
Diagnostic Tests Complaints of irritation and foreign-body

• Measure visual acuity sensation should resolve in 1 or 2 minutes. Instill a
generous amount of antibiotic eye ointment in the
• Apply fluorescein stain: corneal cells that have
lower conjunctival sac:
been damaged or lost will stain green; cobalt
sulfacetamide 10% eye ointment (C class drug)
blue light allows easier visualization of the
abrasion
1-16 Adult
September 2004
Monitoring and Follow-Up Referral

• Follow-up at 24 hours to assess healing is Referral to an ophthalmologist is required within
imperative 24 hours for large or central defects and in 48-72
• If no symptoms or signs, patient can be sent hours if there is no response to therapy.
home with advice on preventing corneal
abrasions
• If client is still symptomatic but improving, the
eye should be re-treated as above with antibiotic
ointment or drops and re-examined daily with
fluorescein. The uptake of dye should be less
than on the previous day. Re-examine daily until
the abrasion has healed completely.

Corneal Ulcer
Definition • Blepharitis
An infection of the cornea results in breakdown of • Keratitis
the protective epithelial barrier. The ulcer may be
central or marginal. Complications
• Scarring of cornea
Causes • Permanent loss of vision
• Bacterial, viral or fungal invasion • Extension of infection to other ocular structures
• Common bacteria include Pseudomonas,
Staphylococcus, Streptococcus Diagnostic Tests
• Common virus is herpes simplex • Measure visual acuity
• Risk factors include any abrasive corneal injury, • Apply fluorescein stain
wearing of soft contact lenses, dry eyes, thyroid
disease, diabetes mellitus, imunosuppressive Management
conditions, long-term topical use of eye steroid
Goals of Treatment
medication
• Alleviate infection
• Prevent permanent loss of vision
History
• Eye pain Appropriate Consultation
• Blurred vision Consult a physician immediately if an ulcer is
• Foreign-body sensation detected.
• Photophobia
• Red eye Nonpharmacologic Interventions
• Explain diagnosis and disease process
Physical Findings • Provide reassurance and support
• Conjunctiva inflamed
• Eyelid may be inflamed Pharmacologic Interventions
• Mucopurulent discharge Apply a generous amount of an antibiotic drops in
• Ulcer visible on cornea, but usually only after the lower conjunctival sac:
fluorescein staining (whitening of cornea) gentamicin (C class drug) qid
Differential Diagnosis Referral

• Corneal abrasion Urgent; refer to an ophthalmologist within
• Conjunctivitis 24 hours.
1-18 Adult
September 2004
Conjunctival, Corneal Or Intraocular Foreign Bodies

• Presence of a foreign object on the conjunctiva • Measure visual acuity of both eyes
or cornea or intraocularly (within the globe) • Apply sterile fluorescein stain to identify any
• May be organic or inorganic associated corneal defect
Cause Management
Improper protection of eyes. Goals of Treatment
• Remove foreign body
History • Identify associated corneal abrasion
Get an accurate description of the material and the • Identify residual corneal rust ring
circumstances under which it entered the eye • Identify embedded corneal foreign body
(slow speed or high velocity); a rapidly moving
projectile object may penetrate the globe of the Appropriate Consultation
eye. This typically occurs when metal is Consult a physician immediately if the foreign
hammered upon metal. body cannot be dislodged with your treatment, if
there is suspicion of an intraocular foreign body or
With a penetrating eye injury, the eye may appear if there is continued foreign-body sensation
deceptively normal. (lasting 24 hours or longer) when no foreign body
• Sudden onset of unilateral eye pain has been detected.
• Irritation (foreign-body sensation)
• Tearing Nonpharmacologic Interventions
• Photophobia Remove a superficial, non-embedded conjunctival
• Visual disturbance may be present foreign body by gently irrigating with normal
saline or by gently wiping with a sterile cotton-
Physical Findings tipped applicator moistened with a topical
• Visual acuity usually normal anesthetic or sterile saline.
• PERRLA
Do not try to remove an obviously embedded
• Tearing
foreign body, because it may have penetrated more
• Foreign body will be found in lower deeply than expected.
conjunctival sac or under the upper lid; may
need to evert upper lid to find object
After removing the superficial foreign body, use
• Fluorescein stain may reveal associated corneal fluorescein stain to detect any remaining
abrasion fragments, a rust ring or corneal abrasion.
• If foreign body is metallic, look for a rust ring
around material Client Education
• Suggest that client wear protective glasses while
Differential Diagnosis working to help prevent similar incidents in
• Other causes of red eye (see Table 1, in "Red future
Eye," above, this chapter) • Stress that close follow-up is very important to
• Intraocular foreign body ensure proper healing
Complications Pharmacologic Interventions

• Corneal ulcer Instill a topical anesthetic eye drop:
• Secondary infection tetracaine 0.5% (A class drug), 2 drops
only for removal.
gentamycin ungt (C class drug), qhs

Monitoring and Follow-Up there is any concern that the globe has been
Follow up in 24 hours to ensure resolution of penetrated by a high-speed object.
symptoms.
Refer within 24 hours any client who continues to
Referral experience a foreign-body sensation even though
Refer immediately any client with a foreign body no foreign body is detected.
that cannot be dislodged with your treatment, if
there is a large or central corneal abrasion or if
1-20 Adult
September 2004
Acute Angle-Closure Glaucoma

A sudden increase in intraocular pressure due to • Measure central and peripheral visual acuity
blockage of drainage tissue by the iris • Measure intraocular pressure with Schiøtz
tonometry (normal range is 10-20 mm Hg); if
Causes pressure > 21 mm Hg, investigations should be
• Pre-existing narrow angle of anterior chamber initiated, especially if patient is symptomatic
• Spontaneous dilatation of pupil by drugs or
darkened environment
Management
Goals of Treatment
• Complication of penetrating intraocular foreign
body • Identify condition quickly
• Relieve pain
History • Preserve vision by reducing intraocular pressure
• Sudden onset of severe unilateral eye pain If the intraocular pressure is not reduced,
• Vision blurred, reduced or absent glaucoma may develop in the unaffected eye
• Nausea and vomiting may be present because of a sympathetic response.
• Tearing
• Coloured halos Appropriate Consultation
Consult a physician immediately.
Physical Findings Nonpharmacologic Interventions
• Heart rate may be elevated • Keep client at rest
• Blood pressure may be elevated • Support and reassure client to minimize anxiety
• Client may be in acute distress (from pain or • Explain disease process and management
fear)
• Visual acuity reduced in affected eye
For nausea and vomiting:
• Conjunctiva diffusely injected red dimenhydrinate (A class drug), 25-50 mg IM stat
• Perilimbal flush may be present
• Cornea appears steamy/cloudy For pain:
• Pupil mid-dilated and non-reactive to light meperidine (D class drug), 50-100 mg IM stat
• Funduscopic exam of affected eye may reveal To decrease pressure:
increased cupping of the disk (cannot see mannitol (B class drug) 1-1.5mg/kg IV
acutely)
• Peripheral field of vision decreased in affected To constrict the pupil:
eye pilocarpine 2% (B class drug), 2 drops q15min for
• Intraocular pressure elevated on tonometry 1 h, then 2 drops q30-60min for 4 h, then 1 drop
(normal range is 10-20 mm Hg) q4h
• Globe of eye is hard When pilocarpine is applied topically at frequent
intervals over a short period, there is a possibility
Differential Diagnosis of systemic toxic side effects (sweating, retching,
• Rule out other causes of red eye salivation and muscle tremors).
• Uveitis (iritis) Referral
• Macular degeneration Call ophthalmologist. Medevac as soon as
possible to ophthalmologist, after reducing
Complications pressure; this problem needs surgical intervention.
• Loss of vision, loss of eye May need pressurized aircraft.
• Development of glaucoma in other eye

Keratitis (Snow Blindness)

Definition • Determine the amount of uptake of the dye on
Inflammation of the cornea due to ultraviolet the cornea (an indicator of the degree of corneal
damage. involvement); usually the cornea will have a
punctate pattern of dye uptake across the lower
Causes half
• Prolonged, unprotected exposure to ultraviolet
light (e.g. welders not using protective eyewear, Management
people suffering from snow blindness) Goals of Treatment
• Relieve discomfort
History • Prevent recurrence
• Symptoms range from moderate to severe
• Vision blurred Appropriate Consultation
• Periocular pain Consult a physician if this disorder is suspected.
• Foreign-body sensation
• Severe photophobia Nonpharmacologic Interventions
Double-patch the eyes firmly but comfortably
• Lid spasm may be present
(remember, the client cannot see anything with
both eyes patched; provide reassurance and
Physical Findings assistance with all movements).
• Moderate to acute distress
• Various degrees of lid edema, spasm Client Education
• Tearing may be present Advise client that condition can be prevented by
• Conjunctiva injected red, may have ciliary flush wearing protective eyewear while outside,
• Pupils equal and reactive to light especially on sunny winter days, or when using
• Visual acuity should be normal, although it may welding equipment.
be blurred
• Fragmented corneal-light reflex Pharmacologic Interventions
• Punctate roughening of cornea seen with Instill a topical anesthetic eye drop to relieve
fluorescein staining discomfort for diagnosis only:
tetracaine 0.5% (A class drug), 2 drops
• Conjunctivitis Instill a generous amount of a topical antibiotic
• Uveitis (iritis) eye ointment into the lower conjunctival sac:
gentamicin (C class drug), qid
• Corneal abrasion
• Corneal foreign-body irritation Manage pain with simple analgesics:
acetaminophen (A class drug), 500 mg 1-2 tabs
Diagnostic Tests PO q4h prn
• Measure visual acuity of both eyes
• Stain tear film with sterile fluorescein strips or Referral
drops Daily follow-up.
1-22 Adult
September 2004
Herpetic Keratitis
Definition Complications
Viral infection of the cornea with ulcer formation. • Chronic scarring of the cornea with reduced
vision
Cause • Recurrent exacerbations
Herpes simplex or herpes zoster. • Uveitis (iritis)
• Perforation of cornea
History
• May be first episode or latest of series of Diagnostic Tests
episodes • Measure visual acuity
• Often preceded by upper respiratory tract • Apply fluorescein stain to confirm dendritic
infection with fever ulcer on cornea (the key physical clue to the
• Acute onset with severe unilateral pain diagnosis)
• With recurrence, pain becomes less severe
• Mild photophobia Management
• Blurred vision Goals of Treatment
• Tearing • Identify or prevent associated iritis or uveitis
• Relieve symptoms
Physical Findings • Preserve corneal function
• Heart rate may be mildly elevated
• Mild to moderate distress Pharmacologic Interventions
• Visual acuity normal Instill a topical anesthetic eye drop to relieve
• Diffuse redness of eye discomfort, for diagnosis only:
• Perilimbal flush may be present tetracaine 0.5% (D class drug), 2 drops
• Pupils react briskly to light
Manage pain with simple analgesics:
• Dendritic ulcer visible with fluorescein staining
acetaminophen (A class drug), 500 mg, 1-2 tabs
PO q4h prn
• Rule out other causes of red eye (see Table 1, in Referral
"Red Eye," above, this chapter). Call immediately to ophthalmologist because
diagnosis is complex, and expedient, specific
treatment is imperative to prevent loss of vision.

Chemical Burns
Definition Moderate Injury
Ocular injury from acidic or alkaline liquids or • Corneal opacity
powders. • Blurring of iris detail
• Minimal ischemic necrosis of conjunctiva and
Alkali burns can be more serious because tiny sclera (partial blanching)
particles may be left behind even after the agent • Intraocular pressure may become elevated
has been removed; these residues can cause
progressive damage to the eye. Severe Injury
• Marked corneal edema and haze
Cause • Blurring of pupillary outline
Improper protection of the eyes while working • Blanching of conjunctiva and sclera (marked
with these materials. whitening of the external eye)
• Intraocular pressure elevated
History
Institute first-aid treatment immediately upon With alkaline burns, there is often an immediate,
learning that a chemical has come in contact with rapid rise in intraocular pressure.
the eye. The detailed history can be obtained later.
• Name of the material (alkaline burns are more Complications
serious than acidic burns) • Various degrees of permanent loss of vision
• Time when accident occurred (as accurate as • Loss of eye
possible)
• Was irrigation attempted? For how long?
Diagnostic Tests
• Was exposure bilateral or unilateral?
• Measure visual acuity of both eyes
• Did material enter the eye or was it only
• Apply fluorescein stain
splashed on the lids?
• Severe pain and burning of the eye (there may
be no pain if burn is severe) Management
• Lid spasm Goals of Treatment
• Photophobia • Dilute the toxic chemical immediately
• Reduced vision • Minimize corneal damage
• If the client inhaled or swallowed any of the
substance, assess other body systems
Consult physician about further care once
(e.g. gastrointestinal, respiratory)
emergency first-aid irrigation has diluted the
chemical.
Physical Findings
• Heart rate may be elevated (because of pain or Nonpharmacologic Interventions
fear) • Irrigate the eye immediately with large amounts
• Blood pressure may be elevated (because of pain of normal saline IV solution; continue irrigation
or fear) for 20 minutes. Drip gently into the conjunctival
• Client may be in acute distress sac
• Have client shift gaze so that the entire cul-de-
Mild Injury sac can be flushed
• Haziness of cornea • After the eye has been well irrigated, inspect it
• Injection of conjunctiva for any residual chemical particles (e.g. small
• Intraocular pressure normal pieces of lime in the conjunctival sacs); try to
remove these with further irrigation or with a
moistened cotton-tipped applicator
1-24 Adult
September 2004
• If a corneal defect is noted on examination, Monitoring and Follow-Up

double-patch the eye with sterile eye pad and Monitor for the development of post-burn
protect with an eye shield glaucoma, usually within 25 hours.
Pharmacologic Interventions Referral

It may be necessary to instill a topical eye Refer to an ophthalmologist immediately after
anesthetic if lid spasm is severe. Do not force lid emergency treatment if you find one or more of
open or instill any drops if there is concern of a the following:
ruptured globe: • Acid or alkali burn
tetracaine 0.5% (A class drug), 2 drops • Subnormal visual acuity
• Severe conjunctival swelling
To control pain: • Corneal clouding
acetaminophen (A class drug), 325 or 500 mg, 1-2
tabs PO q4h prn
or
acetaminophen with codeine 30mg (C class drug),
1-2 tabs PO q4h prn if pain moderate or severe

Blunt Or Lacerating Ocular Trauma

Definition Physical Findings
Traumatic injury to the eye or surrounding Inspect only. Do not palpate the globe. It may be
structures. difficult or impossible to examine the globe
because of associated swelling. Do not force the
Causes lid open. Avoid putting direct pressure on globe
Blunt or lacerating trauma may cause a variety of and bony structures.
injuries to the eye and its surrounding structures. • Moderate to severe distress
Blunt trauma associated with fights, sports injuries • Pulse may be elevated
or motor vehicle crashes can also result in serious • Blood pressure may be elevated
damage. Most often, blunt trauma causes a • Swelling and bruising around the eye
contusion, but a strong impact may cause tissues • Deformity of the bone may be present
to be torn. • Visual acuity may be diminished (do not test if
doing so requires forcing the lid open or
There are 6 types of injuries: instilling drops)
• Contusion of globe and/or orbital tissues • Conjunctival ecchymosis and swelling
• Orbital fracture (contusions limited to the orbital • Pupil reaction to light should be normal; suspect
tissues and fractures of the orbits are much less globe damage if it is abnormal
threatening to vision but may be associated with • Red reflex should be present; suspect retinal
significant coincident facial and intracranial detachment or lens damage if it is abnormal
injuries)
• Note presence of hyphema (blood in the anterior
• Laceration of the ocular adnexa or globe, one of chamber)
the more serious injuries (a ruptured globe is the
• Extraocular movement should be normal;
most dangerous outcome of either blunt or
suspect a fracture of the floor of the bony orbit if
lacerating trauma)
there is some limitation of the upward gaze of
• Intraocular hemorrhage the affected eye
• Retinal detachment • Tenderness of bony structures
• Complicated eyelid lacerations (less dangerous
but potentially serious)
Complications
Lacerations of the globe may be hard to find. • Loss of vision
Presume rupture of the globe if it has occurred • Retinal detachment
before or if there is evidence of severe forceful • Dislocation of lens
trauma. • Acute angle-closure glaucoma
• Rupture of globe
History • Hyphema
• Note mechanism of injury: What hit the eye? • Fracture of orbital bone
Where did it hit (eye, forehead or cheek)? • Laceration of eyelid
• How hard was the blow? When did it occur?
• Determine whether a penetrating injury is Diagnostic Tests
possible or whether the injury is limited to the Measure visual acuity in both eyes (but do not
structures around eye perform this test if doing so requires forcing open
• Swelling and pain around eye the lid or use of anesthetic drops).
• Pain deep in the eye may be present
• Reduced vision due to lid edema, retinal
damage, corneal damage, dislocated lens,
ruptured globe
1-26 Adult
September 2004
Management Referral
Goals of Treatment Call eye team first. Medevac to the care of an
• Identify serious injuries to the eye or orbital ophthalmologist if any of the following are
bone suspected or confirmed after inspection:
• Protect the eye from further damage • Severe pain
• Subnormal visual acuity
Appropriate Consultation • Severe conjunctival ecchymosis
Consult a physician immediately if serious injuries • Hyphema (blood in the anterior chamber)
are identified or suspected. • Irregular pupil
• Corneal or scleral laceration
Nonpharmacologic Interventions • Deformation or laceration of globe
• Cover the eye loosely with a sterile gauze and • Laceration of lid
apply an eye shield to prevent further injury; do
not instill any medications into the eye
• Keep the client at rest in a half-sitting position

Minor Soft-Tissue Contusion

If serious injuries to the eyeball, eyelids or orbit • Use of protective eyewear when engaged in
have been ruled out, swelling or bruising of the high-risk activities or occupations such as
soft tissues around the eye is not considered contact sports, carpentry or sheet-metal work
serious.
Management Analgesia to control discomfort:
Goals of Treatment acetaminophen (A class drug), 325 or 500 mg,
• Symptomatic care 1-2 tabs PO q4h prn
• Prevent further injury or
ibuprofen (A class drug), 200 mg, 1-2 tabs PO
Nonpharmacologic Interventions q4h prn
• Cold compresses several times daily to reduce
the swelling Monitoring and Follow-Up
• Eye shield for 1-2 days to protect eye from See client in 2 or 3 days, once swelling goes down,
further injury to re-examine the eye thoroughly for injury.
1-28 Adult
September 2004
Uveitis (Iritis)
Definition • Posterior adhesions (synechiae)
Inflammation of the uveal tract (iris, ciliary body • Reduced vision
or choroid). This may involve one or all three
portions of the uveal tract. The most frequent form Diagnostic Tests
is acute anterior uveitis (iritis). Measure visual acuity, if possible.
Causes Management
Usually idiopathic, but may be associated with Goals of Treatment
systemic disease (Reiter's syndrome, ankylosing Early identification.
spondylitis, sarcoidosis, juvenile arthritis, herpes
simplex, herpes zoster) or may be a complication Appropriate Consultation
of ocular trauma such as corneal abrasion. Consult a physician immediately for a
management plan.
History
• Acute onset with moderate to severe unilateral Nonpharmacologic Interventions
periocular pain • Explain disease process and management plan
• Photophobia • Support and reassure client to reduce anxiety
• Tearing • Do not put any pressure on the eyeball
• Vision blurred and may be decreased • Client should wear sunglasses if a shield is
• Possible history of similar previous episodes unavailable
• History of other associated systemic disease
Physical Findings Initial management usually consists of a fast-
• Patient may appear to be in acute distress acting topical eye drop to dilate the pupil. This
• Heart rate may be elevated relieves pain (caused by spasm of ciliary and iris
• Visual acuity reduced in affected eye muscles) and prevents formation of a scar between
• Conjunctiva reddened the pupillary border and the anterior lens capsule
(posterior synechia):
• Perilimbal (ciliary) flush present
atropine 1% (B class drug),1 drop q12h
• Cornea clear with white precipitates or
• Border of iris may be blurred tropicamide 1% (B class drug), 1 drop q6h
• Pupil small, possibly irregular in shape and
poorly reactive to light The dilating and antispasmodic effects are
• Hypopyon (pus in the anterior chamber) may be maximal in 30-60 minutes, and usually last from 3
present to 6 hours.
Differential Diagnosis Steroids may be prescribed by ophthalmologist.

• Rule out other causes of red eye (see Table 1, in
"Red Eye," above, this chapter). Referral
Call eye team re: management plan
Complications
• Acute angle-closure glaucoma

Chapter 2 - Ears, Nose And Throat (ENT)

Assessment Of The Ears, Nose And Throat.................................................................................................... 1
Examination Of The Ears, Nose And Throat.................................................................................................. 2
Common Problems Of The Ears And Nose .................................................................................................... 3

Otitis Externa .................................................................................................................................................. 3
Acute Otitis Media.......................................................................................................................................... 5
Chronic Otitis Media (Purulent Draining Ear)................................................................................................ 7
Serous Otitis Media (Otitis Media With Effusion) ......................................................................................... 8
Cerumenosis (Impacted Cerumen) ................................................................................................................. 9
Labyrinthitis.................................................................................................................................................. 10
Menière's Disease ......................................................................................................................................... 12
Rhinitis.......................................................................................................................................................... 13
Anterior Epistaxis ......................................................................................................................................... 16
Acute Sinusitis .............................................................................................................................................. 18
Chronic Sinusitis........................................................................................................................................... 20
Common Problems Of The Mouth And Throat ........................................................................................... 21

Dental Abscess.............................................................................................................................................. 21
Laryngitis ...................................................................................................................................................... 22
Pharyngitis (Sore Throat).............................................................................................................................. 23
Emergency Problems Of The Ears, Nose And Throat................................................................................. 25

Mastoiditis .................................................................................................................................................... 25
Posterior Epistaxis ........................................................................................................................................ 26
Peritonsillar Abscess..................................................................................................................................... 27
Appendix 1 ....................................................................................................................................................... 29
An Alternative Approach To Sore Throat Management: The Sore Throat Score ........................................ 29

Assessment Of The Ears, Nose And Throat

General • Sense of smell
The following characteristics of each symptom
should be elicited and explored: Mouth and Throat
• Onset (sudden or gradual) • Dental status
• Chronology • Oral lesions
• Current situation (improving or deteriorating) • Bleeding gums
• Location • Sore throat
• Radiation • Dysphagia (difficulty swallowing, solids
• Quality vs. liquids, pain on swallowing)
• Timing (frequency, duration) • Hoarseness or recent voice change
• Severity
• Precipitating and aggravating factors Neck
• Relieving factors • Pain, swelling, enlarged glands
• Associated symptoms
Other Associated Symptoms
• Effects on daily activities
• Fever
• Previous diagnosis of similar episodes
• Malaise
• Previous treatments
• Nausea or vomiting
• Efficacy of previous treatments
Medical History (Specific To ENT)

Cardinal Symptoms
• Frequent ear or throat infections
In addition to the general characteristics outlined
above, additional characteristics of specific • Sinusitis
symptoms should be elicited, as follows. • Trauma to head or ENT area
• ENT surgery
Ears • Audiometric screening results indicating hearing
• Recent changes in hearing loss
• Compliance with and effectiveness of hearing • Allergies
aid • Prescription or over-the-counter medications
• Itching used regularly
• Earache • Smoking, chewing tobacco, alcohol use
• Discharge
• Tinnitus Family History (Specific To ENT)
• Vertigo • Others at home with similar symptoms
• Ear trauma • Seasonal allergies
• Asthma
Nose • Hearing loss
• Nasal discharge or postnasal drip, colour • Menière's disease
• Epistaxis • ENT cancer
• Obstruction of airflow
• Sinus pain
• Itching
• Nasal trauma

Personal And Social History (Specific • Exposure to smoke or other respiratory toxins
To ENT) • Recent air travel
• Frequent water exposure (swimmer's ear) • Occupational exposure to toxins or loud noises
• Use of foreign object to clean ear
• Crowded living conditions
• Dental hygiene habits
Examination Of The Ears, Nose And Throat

General Appearance
• Apparent state of health Palpation
• Degree of comfort or distress • Sinus and nasal tenderness.
• Colour (flushed or pale)
• Nutritional status (obese or emaciated) Percussion
• Match between appearance and stated age • Sinus and nasal tenderness.
• Difficulty with gait or balance
Mouth And Throat
Inspection
Ears
• Lips: colour, lesions, symmetry
Inspection
• Pinna: lesions, abnormal appearance or position • Oral cavity: breath odor, colour, lesions of
buccal mucosa
• Canal: discharge, swelling, redness, wax, foreign
bodies • Teeth and gums: redness, swelling, caries
• Ear drum: colour, landmarks, bulging or • Tongue: colour, texture, lesions, tenderness of
retraction, perforation, scarring, air bubbles, floor of mouth
fluid level • Throat: colour, tonsillar enlargement, exudate
• Estimate hearing with a watch or whisper test;
perform screening audiometry or tympanometry Neck
(if equipment available). Inspection
• Symmetry
Palpation • Swelling
• Tenderness over tragus or mastoid process • Masses
• Tenderness on manipulation of the pinna • Redness
• Pre- or post-auricular nodes • Thyroid enlargement
Nose/Sinuses Palpation
Inspection • Tenderness, enlargement, mobility, contour and
• External: inflammation, deformity, discharge, consistency of nodes and masses
bleeding • Thyroid: size, consistency, contour, position,
• Internal: colour of mucosa, edema, deviated tenderness
septum, polyps, bleeding points
• Transilluminate sinuses for dulling facial
swelling
2-2 Adult
September 2004
Common Problems Of The Ears And Nose

Otitis Externa
Infection or inflammation of the ear canal. • Usually afebrile but temperature may be
elevated
Mild otitis externa • Redness and edema of ear canal and
Inflammation confined to the canal. No significant occasionally the pinna
narrowing of the canal. May or may not be • May have purulent exudate or debris in canal
purulent. • Tympanic membrane may be slightly reddened
or thickened
Moderate otitis externa • If edema and debris are severe, it may be
Significant narrowing of the canal and significant impossible to visualize the tympanic membrane
swelling of soft tissue.
• Manipulation of pinna or pressure on tragus
causes pain in acute otitis externa
Severe otitis externa
Significant obstruction, due to inflammation and • Peri-auricular and anterior cervical nodes may
swelling, of the canal. Invasion of soft tissues, be enlarged and tender
especially along the floor of the canal and
extending medially, as is often seen in malignant Differential Diagnosis
otitis externa. • Acute otitis media with perforation
• Skin condition involving the ear
Causes • Mastoiditis
• Gram-negative rods: Proteus, Pseudomonas • Furuncle in canal
• Gram-positive cocci (less common): • Foreign-body irritation
Staphlylococcus, Streptococcus
• Fungal infection (e.g. candidiasis, aspergillosis) Complications
• Predisposing factors: hearing aids, narrow ear • Severe otitis externa with closure of canal
canal, use of cotton-tipped applicators, use of • Cellulitis of the external ear and face
ear plugs, swimming
• Risk factors: immunocompromise Diagnostic Tests
(e.g. in patients with diabetes or cancer and Swab for culture and sensitivity if there is any
those who have undergone transplantation, or exudate (so that antimicrobial therapy can be
have had head and neck radiotherapy), use of tailored to the organism, should initial treatment
systemic steroid medication fail).
History Management
• Ear pain (otalgia) Goals of Treatment
• Pruritis or irritation • Relieve pain
• Purulent discharge from canal (cheesy white, • Prevent recurrence
greenish blue or gray) • Prevent extension of infection
• Recent exposure to water or mechanical trauma
• Reduced hearing or feelings of fullness in ear Appropriate Consultation
may be present Consultation usually not needed, unless cellulitis
• Will not have all of them all of the time of the external ear or face is present, the problem
is recurrent or the client is immunocompromised,
or significant debris in canal that cannot be safely
removed.

Client Education Moderate Otitis Externa

• Counsel client about appropriate use of If inflammation and purulence are more
medications (if possible, have another family significant, or if therapy described above has
member instill drops and clean the ear) failed, start ear drops consisting of a combination
• Counsel client about proper ear hygiene before of an antibiotic and an anti-inflammatory agent
instilling medications (steroid):
• Advise client about preventing recurrent hydrocortisone/neomycin/polymyxin B
irritation (e.g. client should not use cotton- (C class drug), 3-4 drops tid or qid for 7-10 days
tipped applicators in the ears)
• Recommend proper drying of ears after If perforation of the tympanic membrane is
swimming or use of ear plugs while swimming suspected, use of aminoglycosides such as
• Counsel client about proper hygiene of hearing gentamicin, should be avoided, because of the risk
aids and ear plugs of ototoxicity if used for more than 7 days in the
presence of such perforation.
For recurrent episodes, start the client on
prophylactic measures: Severe Otitis Externa
hydrogen peroxide 1/2 strength (A class drug), 2 or 3 See "Referral," below.
drops tid or qid
Pharmacologic Interventions • Follow up in 1-3 days (instruct client to return
Manage pain with simple analgesics: sooner if pain increases, or if fever develops
acetaminophen (A class drug), 325 or 500 mg, despite therapy)
1-2 tabs PO q4-6h prn • Follow up 10 days after course of therapy is
complete
Mild Otitis Externa
If condition very mild (i.e. no exudate and only Referral
mild inflammation), consider topical antiseptic: • Immediately refer cases of severe otitis externa
hydrogen peroxide 1/2 strength (A class drug), • Debriding the canal requires urgent referral
2 or 3 drops tid or qid • Consult a physician for clients with recurrent
or episodes of otitis externa, regardless of cause
vinegar/sterile water/hydrogen peroxide 1:1:1
Some studies show no difference in clinical

outcome between topical antiseptic and topical
gentamicin antibiotic drops.
2-4 Adult
September 2004
Acute Otitis Media

For further information see web sites
http://icarus.med.utoronto.ca/carr/manual/otitisatlas.html
http://www.albertadoctors.org/resources/cpg/guidelines/acute_otitis_media.pdf
http://www.hlth.gov.bc.ca/msp/protoguides/gps/otitaom.pdf
Definition
Infection of the middle ear. Differential Diagnosis
• Acute otitis externa
Causes • Transient middle-ear effusion (non-infection)
• Viral forms (found in up to 48% of middle ear • Mastoiditis
fluid) due to human rhinovirus, RSV and • Trauma or foreign-body irritation
coronavirus • Referred ear pain from dental abscess or
• Bacterial forms (absent in up to 38% of middle temporomandibular joint dysfunction
ear fluid) due to Hemophilus influenzae,
Moraxella catarrhalis, Staphylococcus aureus, Complications
Streptococcus pneumoniae, Streptococcus • Reduced hearing
pyogenes (Pitkaranta A et al, 1998, Detection of
• Serous otitis media
Rhinovirus.... Pediatrics: 102:291-6)
• Mastoiditis
• Active or passive smoking is a predisposing
• Chronic otitis media
factor.
• Meningitis
• Epidural abscess
History
• General malaise and fever
Diagnostic Tests
• Ear pain (throbbing) (may be sharp needle pain)
• Sensation of fullness
• Hearing decreased
• Tinnitus or roaring in ear, vertigo (rare) Management
• Purulent discharge if drum perforated Goals of Treatment
• Infection of the upper respiratory tract may be • Relieve pain
present concurrently or may precede the otitis • Prevent complications
media
• Cigarette smoking
Usually not necessary if condition is
• Allergies
uncomplicated.
Physical Findings Client Education

• Temperature may be elevated • Recommend increased rest in the acute febrile
• Client may be mildly or moderately ill phase
• Tympanic membrane red, dull, bulging • Counsel client about appropriate use of
• Bony landmarks obscured or absent medications (dosage, compliance, follow-up)
• Possible perforation and purulent discharge in • Explain disease course and expected outcome
canal (serous otitis media may persist for several
• Decreased mobility of tympanic membrane weeks)
• Bullae seen on tympanic membrane (but only in • Recommend avoidance of flying until symptoms
cases of mycoplasm infection) have resolved

Pharmacologic Interventions Monitoring and Follow-Up

To relieve pain and fever: • Instruct client to return in 3 days if symptoms do
acetaminophen (A class drug), 325 or 500 mg, not improve, or if symptoms progress despite
1-2 tabs PO q4-6h prn therapy
• Follow up in 10-14 days: look for development
Antibiotic therapy: of serous otitis media
amoxicillin (C class drug), 250 mg PO tid for 10
days Referral
or Not necessary if condition is uncomplicated.
cotrimoxazole (C class drug), 800/160 mg PO bid
for 10 days
2-6 Adult
September 2004
Chronic Otitis Media (Purulent Draining Ear)

Definition Client Education
Chronic tympanic perforation with non-resolving • Explain disease process and expected course
or recurrent low-grade infection of the middle ear. • Counsel client about appropriate use of
medications (including compliance)
Causes • Counsel client about ear hygiene: ear canal
• Proteus, Pseudomonas or Staphylococcus should be cleaned with 3% hydrogen peroxide
• Water contamination of the middle ear or half strength vinegar solution, before
instilling medication to remove any exudate or
debris (demonstrate the procedure to a family
History member and have this person perform the
• Hearing decreased routine as instructed)
• Continuous foul-smelling discharge from the ear • No swimming
• Tinnitus • Counsel client about proper hygiene of hearing
• Usually no pain aids and ear plugs
• No fever • To prevent recurrence, recommend that ear canal
be cleaned with hydrogen peroxide 1/2 strength,
Physical Findings or a solution of half vinegar and half sterile
• Client appears generally well water, 4-6 drops in the ear after exposure to
• Foul-smelling purulent drainage from ear canal water
• Perforation of tympanic membrane
Mild and moderate chronic otitis media
Differential Diagnosis Topical antibiotic ear drop alone is sufficient.
• Chronic otitis externa
• Subacute otitis media If there is significant soft-tissue involvement,
systemic antibiotics are indicated, culture prior to
Complications systemic antibiotics:
• Permanent, severe hearing loss
• Mastoiditis cotrimoxazole (C class drug), 800/160 mg PO bid
• Cholesteatoma for 14 days
• Meningitis or
• Brain abscess amoxicillin/clavulanate (B class drug),
• Epi/subdural abscess 250 mg PO tid for 14 days
Oral antibiotics should be used in combination

Diagnostic Tests with consistent cleansing of the canal and topical
• Swab any drainage for culture and sensitivity, administration of antibiotic otic drops as described
before treatment for mild chronic otitis media, above. Long-
standing drainage implies need for culture and
Management appropriate treatment.
Goals of Treatment
• Prevent complications Monitoring and Follow-Up
• Avoid unnecessary use of antibiotics Follow up in 7-14 days.
Appropriate Consultation Referral

Consult a physician if symptoms do not respond to Referral to ENT specialist may be necessary if
therapy. treatment fails or complications develop. Surgical
intervention is sometimes required.

Serous Otitis Media (Otitis Media With Effusion)

Presence of non-infective fluid in the middle ear Goals of Treatment
without symptoms or signs of acute infection, with • Identify underlying cause
intact tympanic membrane. • Relieve symptoms
• Prevent hearing loss
Causes
• Dysfunction of eustachian tube Appropriate Consultation
• Predisposing factors: viral infection of the upper Consult a physician if effusion with significant
respiratory tract, allergies, barotrauma, hearing loss (more than 20 dB) persists for more
enlargement of adenoids, recent acute otitis than 2-3 months.
media
Client Education
• Explain disease process and expected outcomes
History • Offer support and reassurance, as symptoms can
• Exposure to one of the predisposing factors last a long time (2-3 months)
• Reduced hearing in affected ear • Counsel client about appropriate use of
• Sensation of fullness in ear medications (dosage and compliance)
• Nose and ears may be itchy • Recommend avoidance of flying until signs and
• Pain mild or absent symptoms have resolved
• Fever absent • Discuss signs and symptoms of purulent otitis
media; advise client to return to clinic if they
Physical Findings occur
• Tympanic membrane dull, retracted, hypomobile • Instruct client to gently try to equalize pressure
or normal position between middle ear and throat, using a simple
• Presence of fluid, air bubbles or air-fluid level maneuver (e.g. yawning, chewing gum,
behind the tympanic membrane plugging nose and blowing)
• Bony landmarks usually accentuated because of
retraction of the tympanic membrane Pharmacological Interventions
• Audiometric screening may show a decrease in Most studies indicate that antihistamines and
hearing decongestants are ineffective.
• Abnormal hearing test results (conductive loss)
Monitor any improvement in hearing or decrease
Differential Diagnosis in tinnitus.
• Dysfunction of eustachian tube
• Nasopharyngeal tumor (if problem Reassess hearing, preferably with screening
longstanding) audiometry (if available).
Complications Referral
• Secondary infection (purulent acute otitis media) Refer to an ENT physician if effusion persists after
• Chronic serous otitis media 3 months.
• Hearing loss
Diagnostic Tests
Tympanometry if available
2-8 Adult
September 2004
Cerumenosis (Impacted Cerumen)

Obstruction of the ear canal by cerumen (ear wax). • None
Causes Management
Cerumen is produced naturally by the ear canal Goals of Treatment
and is normally cleared by the body's own • Remove wax
mechanisms. Occasionally, cerumen is produced • Treat any underlying irritation of the canal
in excessive amounts and partially or totally
occludes the ear canal. Appropriate Consultation
Consulting a physician is usually not necessary.
History
• Ear pain Nonpharmacologic Interventions
• Sensation of fullness • Ensure no tympanic membrane perforation -
• Itching Inject lukewarm water with an ear syringe until
• Conductive hearing loss wax is cleared
• Sometimes it is helpful to soften the wax with a
few drops of slightly warmed olive oil or
Physical Findings Auralgan (A class drug) before attempting to
• Hardened wax blocks canal irrigate the ear
• Canal may be reddened and swollen • To prevent cerumenosis, anyone who produces
large amounts of cerumen can periodically
Differential Diagnosis (once or twice weekly) instill 3 drops of a 1:1
• Foreign-body irritation solution of hydrogen peroxide and water into
• Otitis media each ear to decrease the likelihood of impaction.
• Otitis externa One or two drops of baby oil once or twice
weekly will help to keep wax soft.
Complications
• Hearing loss Advise client to return as necessary if symptoms
• Otitis externa recur.

Labyrinthitis
Disorder of the vestibular labyrinth in the inner • Vestibular maneuvers may be helpful in
ear. diagnosis of the syndrome.
• Nylen-Bárány maneuver: While the patient is
Causes seated at the end of the examining table, quickly
• Viral infection lay back and carefully hyperextend the patient
• Mismatch of vestibular, visual and onto the back, while support is provided to the
somatosensory systems, triggered by an external head.
stimulus, such as a stop after whirling turns or • First, turn the head toward one shoulder.
motion sickness • Repeat the maneuver; however, the second time,
• Tumors within the vestibular pathways turn the head toward the other shoulder.
• Ototoxic drugs, especially aminoglycosides • Hallpike maneuver: While the patient is seated
• Head injury in the middle of the examination table, carefully
• Neuronitis provide support to the head and neck while
• Vasculitis quickly laying the patient on one side and then
the other.
• Repeat the maneuvers several times in a period
History of 5-10 minutes, as tolerated by the patient.
• Vertigo (most prominent symptom) with sudden • Note the reproducibility of the vestibular
movement symptoms, including vertigo, nausea, and
• Dizziness malaise.
• Nausea and vomiting
• Fluctuating hearing loss http://www.emedicine.com/EMERG/topic290.htm
• Tinnitus #target1
• Malaise
• Perspiration Management
• Recent respiratory tract infection (mostly upper) Goals of Treatment
• Identify and treat underlying disorder if anything
Physical Findings other than viral labyrinthitis is suspected
• Diaphoresis • Supportive treatment of symptoms only
• Increased salivation
• Nystagmus Appropriate Consultation
Consult a physician if the client's symptoms
persist for more than 1 week with therapy or if
Differential Diagnosis anything other than a simple viral illness is
• Benign positional vertigo suspected.
• Menière's disease
• Chronic bacterial mastoiditis Nonpharmacologic Interventions
• Drug-induced damage to the vestibular labyrinth Advise client to rest in a darkened room with eyes
• Acoustic neuroma closed during acute attacks (otherwise activity as
• Multiple sclerosis tolerated).
• Temporal-lobe epilepsy
Complications Treat nausea and vomiting:
• Permanent hearing loss dimenhydrinate (A class drug), 50-75 mg q6h prn
• Falls potentially leading to injury
2-10 Adult
September 2004

Follow up in 1 or 2 days to monitor symptom Refer to a physician if anything other than viral
control. Ensure that the client remains hydrated if labyrinthitis is suspected, especially if attacks are
nausea or vomiting is significant. severe or recurrent. A neurology consult may be
necessary to identify and treat underlying disorder.

Menière's Disease
Definition Differential Diagnosis
An inner-ear disorder involving an increase in • Viral labyrinthitis
volume and pressure of the innermost fluid in the • Benign positional vertigo
middle ear, which results in recurrent attacks of a • Acoustic tumor
cluster of symptoms. • Syphilis
• Multiple sclerosis
Causes • Vertebrobasilar disease
• Unknown, but the best theory suggests that it is
an inner-ear response to an injury (e.g. reduced Complications
inner ear pressure, allergy, endocrine disease, • Hearing loss
lipid disorder, vascular disorder, viral infection) • Injury from falls during attacks
• A more recent theory suggests that it results • Inability to work
from intracranial compression of a balancing • Failure to diagnose acoustic neuroma
nerve by a blood vessel
Diagnostic Tests
Risk Factors
• None
• Caucasian heritage
• Stress
• Allergy Management
Goals of Treatment
• High salt intake
• Control symptoms
• Exposure to noise
• Ascertain underlying cause
History Appropriate Consultation
• Occurs as attacks with intervening periods of Consult physician for help with diagnosis (not
remission urgent so long as client is stable and symptoms are
• Fluctuating loss of low-frequency hearing controlled with treatment).
• Vertigo (spontaneous attacks lasting from 20
minutes to several hours) Client Education
• Sensation of fullness in the ear Counsel client about prevention of attacks: stress-
• Nausea, vomiting reduction strategies, avoidance of excessive salt
• Falling intake, smoking cessation, avoidance of prolonged
• Prostration (inability to stand up because motion exposure to noise (client should use ear
increases symptoms) protectors), avoidance of ototoxic medications.
Physical Findings For acute attack, control nausea and vomiting:
• Pallor dimenhydrinate (A class drug), 50 mg IM or PO
• Sweating q4h prn
• Distress, prostration
• May be some measure of dehydration if Monitoring and Follow-Up
vomiting is severe Assess hearing at least annually in clients with
• Audiometry testing with pure tones may show stable symptoms.
low-frequency sensorineural nerve loss and
impaired speech distinction Referral
• Tuning fork tests (Weber and Rinne) confirm Refer to a physician if symptoms are not
validity of the audiometry results controlled or if hearing loss is evident. A
neurology consult may be necessary to identify
and treat underlying disorder.
2-12 Adult
September 2004
Rhinitis
There are 3 types of rhinitis to consider in the • Snoring and dry cough at night may be present
differential diagnosis of nasal congestion and
rhinorrhea (runny nose). Vasomotor Rhinitis
• Sudden onset of nasal congestion
Definition • Perennial symptoms
Allergic rhinitis: Reactive inflammation of the • Persistent postnasal drip
nasal mucosa. • Intermittent throat irritation
Vasomotor rhinitis: Perennial inflammation of the • No response to environmental controls and
nasal mucosa, which represents a hyper reactive medications
state of the nasal mucosa (nonallergic). • Sensation of constantly needing to clear throat
Viral rhinitis (infection of upper respiratory tract): • Changes in acuity of hearing or smell
Viral infection confined to the upper respiratory • Snoring at night
tract. Usually mild and self-limiting. • Fatigue
Causes Viral Rhinitis (Infection of Upper

Allergic Rhinitis Respiratory Tract)
Sensitivity to inhaled allergens (pollens, grasses, • Non-productive cough or cough that produces
ragweed, dust, molds, animal dander, smoke). clear sputum
• Low-grade fever
Vasomotor Rhinitis • Nasal congestion with clear nasal discharge
• Unknown; symptoms do not correlate with • Sneezing
exposure to specific allergens • Postnasal drip
• Attacks may be triggered by abrupt changes in • Scratchy throat
temperature or barometric pressure, odors or • Mild headache and general malaise
emotional stress. • Pressure in ears
Viral Rhinitis (Infection of Upper
Respiratory Tract) Physical Findings
Numerous viral agents. Allergic Rhinitis
• Injected conjunctiva may be present
• Eyes may tear
History
Allergic Rhinitis • Edema of the eyelids and periorbital area may be
• Seasonal or perennial symptoms present
• History of familial allergies • Pale, edematous nasal mucosa is pink, with clear
thin secretions
• Asthma or eczema may be present
• Skin around nose may be irritated
• Paroxysmal sneezing
• Itchy nose
Vasomotor Rhinitis
• Nasal congestion • Nasal turbinates may be enlarged
• Excessive, continuous, clear, watery nasal • Throat may be slightly reddened because of
discharge irritation from postnasal drip
• Eyes may be itchy or watery
• Ears may be itchy Viral Rhinitis (Infection of Upper
• General malaise and headache may be present Respiratory Tract)
• Symptoms worst in the morning and least during • Temperature may be slightly elevated
the day, worsening again during the night • Client appears mildly ill
• Postnasal drip • Clear nasal discharge
• Breathing through the mouth • Skin around nares slightly irritated

• Ears normal • Recommend avoidance of known allergens

• Throat normal, mild erythema (client should keep living area clear of dust,
• Sinuses may feel tender avoid going outside when pollen count is high
and use synthetic fibers in bedding and clothing)
Differential Diagnosis (All Types) and removal of pets (to eliminate animal dander)
• Acute or chronic sinusitis • Counsel client about preventing spread of viral
rhinitis to other household members
• Abuse of nose drops
• Abuse of drugs or solvents (e.g. cocaine, gas,
glue) Allergic and Vasomotor Rhinitis
• Foreign body in nares Normal saline nasal drops, prn, to wash out mucus
• Nasal polyps and any inhaled allergen.
• Deviated septum
• Hypothyroidism as a cause of the nasal Oral antihistamines to treat acute symptoms of
congestion runny nose, sneezing, itch, and conjunctival
• Nasal congestion induced by pregnancy or use symptoms (but these will not help nasal
of oral contraceptives congestion):
cetirizine (A class drug), 10 mg od
Complications (All Types)
• Otitis media Antihistamines can cause drowsiness, dry mouth
• Nasal polyps and urinary retention, and have additive effects
• Epistaxis with sedative drugs. Use with caution in elderly
patients.
• Enlargement of tonsils and adenoids
• Sinusitis
Topical nasal steroids are the mainstay of therapy
for chronic allergic rhinitis and chronic vasomotor
Diagnostic Tests (All Types) rhinitis and for maintenance and prophylactic
• Consider skin testing for allergies treatment of these conditions. They can be used
alone or in combination with the antihistamine and
Management (All Types) decongestant regimen.
Goals of Treatment
• Relieve and suppress symptoms Consult a physician about the use of inhaled nasal
• Identify the underlying allergen(s) steroids if antihistamines and decongestants are
• Prevent complications not effective.
fluticasone (B class drug), 50 µg/spray, 2
Nonpharmacologic Interventions sprays/nostril daily may be prescribed.
Environmental control is important. Eliminate or
reduce known allergen(s) in the environment Viral Rhinitis
wherever possible, or avoid them altogether. The first step in relieving symptoms is to use a
nasal decongestant for 3 or 4 days - consult a
Client Education physician.
• Recommend frequent hand-washing, appropriate
disposal of used facial tissues, and covering of Salinex nasal spray (A class drug) may be of
mouth and nose when coughing or sneezing benefit.
• Recommend increasing fluid intake to improve Antihistamines have little proven benefit in the
hydration treatment of the common cold.
Do not prescribe decongestants for elderly
medications (dose, frequency, side effects,
clients, for people with hypertension, heart
avoidance of overuse)
disease, peripheral vascular disease,
• Recommend avoidance of caffeine
hyperthyroidism, previous acute angle-closure
2-14 Adult
September 2004
glaucoma or previous urinary retention, or for Referral

anyone taking monoamine oxidase inhibitors or Refer to a physician if symptoms of rhinitis are not
antidepressants. controlled with initial treatment. Allergy testing,
sinus radiography or other medications may be
Manage fever: required.
tabs PO q4-6h prn

Instruct client to return for further assessment if
fever develops, or if symptoms have not resolved
within 14 days.

Anterior Epistaxis
Localized bleeding from the anterior portion of the • Mild infection of nasal mucosa
nasal septum. • Dryness and irritation of nasal mucosa
• Nasal fracture
Causes • Foreign body
• Raised blood pressure • Malignant lesion
• Trauma and irritation • Blood dyscrasias
• Foreign-body irritation • Hypertension
• Neoplasm (rare)
• Predisposing factors: allergic rhinitis, deviated Diagnostic Tests
nasal septum, infection of the upper respiratory • None
tract, local vascular lesions
• Dry air Management
Goals of Treatment
History • Stop loss of blood
• Exposure to one or more of the predisposing • Prevent further episodes
factors
• Usually unilateral Appropriate Consultation
• Profuse bleeding or blood-streaked nasal Usually not necessary unless complications arise
discharge or serious underlying pathology is a concern.
• Determine duration, amount and frequency of
bleeding Nonpharmacologic Interventions
• Use of anticoagulants, ASA products or other Most bleeding will be stopped by application of
medications pressure to both sides of the nose, with firm
• History of easy bruising or bleeding elsewhere pressure against the nasal septum for
(e.g. melena, heavy menstrual periods) 5-15 minutes.
• Family history of bleeding disorders (e.g. von
Willebrand's disease) Client Education
• Inhaled substance abuse (e.g. cocaine, gas) • Recommend increasing room humidity (client
should keep a pot of water on the stove at all
times, especially in winter)
Physical Findings • Counsel client about appropriate use of
Examine client sitting up and leaning forward so medications (dosage and side effects; avoidance
that the blood will flow forward. of overuse)
• Blood pressure normal unless bleeding is severe • Recommend avoidance of known irritants and
enough to cause loss of volume local trauma (nose-picking, forceful nose-
• Heart rate may be elevated because of fear or if blowing)
bleeding is severe enough to cause loss of • Instruct client about first-aid control of recurrent
volume epistaxis (sitting up and leaning forward;
• Obvious deformity or displacement may be applying firm, direct pressure to nasal septum)
present • Recommend use of ice packs to control acute
• Bleeding from anterior portion of septum may bleeding
be present • Recommend liberal use of lubricants such as
• Inspect throat for posterior bleeding Vaseline® in the nares to promote hydration of
• Sinuses may feel tender the nasal mucosa
• Septum may be deviated • Advise client not to pick nose
• Advise BP control, if appropriate
2-16 Adult
September 2004
Note: for management of posterior epistaxis, Monitoring and Follow-Up

refer to Emergency Problems of Ears, Nose and Follow up as necessary if problem is recurrent or
Throat there is concern about a serious underlying
problem.
If direct pressure alone is insufficient to stop the Referral
bleeding: Refer to a physician to rule out other pathologies if
Merocel nasal pack the problem is recurrent or if the client is older.
Next, apply a silver nitrate stick firmly, for 1-2 If there has been trauma (e.g. a fist fight), it is
minutes, to the site of bleeding. Cauterize as small important to rule out septal hematoma.
an area as possible. Do not cauterize both sides of Management of hematoma of the nasal septum is
septum at the same time. Promote healing and surgical, and medevac is necessary.
prevent further bleeding by applying a nasal
lubricant (petroleum jelly) in both nostrils tid or
qid.

Acute Sinusitis
Definition • Infection of upper respiratory tract
Infection of the sinuses. • Allergic rhinitis
• Vasomotor rhinitis
Causes • Cluster headache
• Common: Hemophilus influenzae, Moraxella • Migraine headache
catarrhalis, Streptococcus pneumoniae
• Less common: Chlamydia pneumoniae, Complications
Streptococcus pyogenes, viruses, fungi • Contiguous spread of infection to intraorbital or
• Predisposing factors: common cold, allergies, intracranial structures
deviated nasal septum, smoking, adenoidal • Chronic sinusitis
hypertrophy, dental abscess, nasal polyps, • Periorbital cellulitis
trauma, foreign body, diving or swimming,
neoplasms, cystic fibrosis
Diagnostic Tests
• None
History
• Exposure to one or more of the predisposing
Management
factors
Goals of Treatment
• Headache • Identify predisposing factors
• Facial pain • Identify underlying dental abscess
• Pressure over involved sinuses increases when • Relieve symptoms
bending forward
• Purulent nasal discharge, which may be tinged Nonpharmacologic Interventions
with blood Apply moist heat (such as with steam inhalation or
• Dental pain, especially of upper incisor and warm compresses) to sinuses to help relieve
canine teeth pressure by loosening and liquefying thickened
• General malaise may be present secretions. Normal saline nasal irrigation also
• Fever may be present helps to do this.

• Temperature may be mildly elevated • Recommend increased rest during acute phase
• Client appears mildly to moderately ill • Recommend increasing hydration (8-10 glasses
• Irritation of skin around nares of fluid per day)
• Swollen nasal mucosa may be pale or dull red • Counsel client about appropriate use of
• Nasal polyp may be present medications (dose, frequency, side effects)
• Dental abscess may be present • Recommend protection of sinuses from changes
• Tenderness over involved sinuses in temperature
• Tenderness over a tooth • Recommend avoidance of irritants (e.g. smoke)
• Anterior cervical nodes may be enlarged and • Recommend avoidance of swimming, diving or
tender flying during acute phase
Differential Diagnosis Nasal decongestant sprays or drops may be used
• Dental abscess for the first 24-48 hours if congestion is marked.
• Nasal polyp(s) Topical decongestants are more effective than oral
• Tumor ones. Consult physician.
• Presence of foreign bodies
• Periorbital cellulitis
2-18 Adult
September 2004
Client should not use antihistamines (unless or

there is an allergic component to the ibuprofen (A class drug), 200 mg, 1-2 tabs PO
symptoms), because these dry and thicken the q4h prn
secretions.
Oral antibiotics:
Salinex nasal spray (A class drug) may be helpful amoxicillin (C class drug), 500 mg PO tid for 10
days
It is very important to limit the use of a nasal or
decongestant spray to a period of 4 days to avoid cotrimoxazole (C class drug), 800/160 mg PO bid
development of "rebound" nasal congestion when for 10 days
the nasal spray is withdrawn (a complication
called rhinitis medicamentosa). Monitoring and Follow-Up
Follow up in 10-14 days. Instruct client to return
Manage pain and fever with simple analgesics: sooner if symptoms progress despite therapy or if
acetaminophen (A class drug), 325 or 500 mg, 1-2 symptoms fail to respond to therapy.
tabs PO q4h prn

Chronic Sinusitis
Non-resolving inflammation of the sinuses. • Recurrent acute sinusitis
• Spread of infection to the intraorbital or
Causes intracranial structures
• Polymicrobial infection (bacterial anaerobes,
Staphylococcus aureus, viruses) Diagnostic Tests
• Structural abnormalities • None initially
• Consider referral to physician for further
History diagnostic tests such as sinus x-ray or CT scan
• Prolonged nasal congestion (more than 30 days) of sinuses if initial therapy fails.
• Nasal discharge, intermittently purulent
• Postnasal drip may be present Management
• Early-morning hoarseness may be present Goals of Treatment
• Sinus pain across the middle of the face • Relieve symptoms
• Headache may be present • Identify predisposing or underlying factors
• Popping of ears • Prevent spread of infection to other structures
• Eye pain
• Halitosis Client Education
• Chronic cough • Recommend increasing hydration (8-10 glasses
• Fatigue of fluid per day)
• No fever • Recommend inhalation of steam or warm
compresses to relieve pressure on sinuses
• History of allergies may be present
• Smoking
medications (dosage and side effects)
• Recommend avoidance of irritants (e.g. smoke)
Physical Findings and allergens
• Client appears well • Recommend avoidance of diving, swimming or
• Nasal mucous membranes may appear pale and flying if symptoms are acute
"boggy"
• Poor transillumination of sinuses Pharmacologic Interventions
• Tenderness may be present over sinuses Individuals with chronic sinusitis may need a
longer course of oral antibiotic therapy. Consult
Differential Diagnosis with a physician for appropriate treatment.
• Allergic rhinitis
• Vasomotor rhinitis Monitoring and Follow-Up
Follow up in 2 weeks.
• Nasal polyp
• Infection of upper respiratory tract
Referral
• Tumor Refer to a physician for all acute episodes for
• Migraine headache management, to rule out underlying pathology
• Cluster headache (e.g. nasal polyps, deviated nasal septum, chronic
• Dental abscess allergies). Refer to a dentist if underlying dental
disease is suspected.
2-20 Adult
September 2004
Common Problems Of The Mouth And Throat

Dental Abscess
Infection of the soft tissue surrounding a dead Goals of Treatment
tooth. • Relieve symptoms
• Prevent spread of infection
Causes
• Progressive dental decay causing pulpitis from Consult a physician if a large fluctuant abscess is
gram-positive anaerobes and Bacteroides present, if client is acutely ill or if the infection has
• Predisposing factors: deep caries, poor dental spread to the soft tissues of the neck.
hygiene, dental trauma
History Warm saline oral rinses qid.
• Localized tooth pain
• Constant, deep, throbbing pain Client Education
• Pain worsens with mastication or exposure to • Counsel client about appropriate use of
extreme temperatures medications (dosage and side effects)
• Tooth may be mobile • Recommend dietary modifications (liquids or
• Gingival or facial swelling (or both) may be soft diet)
present • Recommend improvements to dental hygiene
Physical Findings Oral antibiotics:
• Fever (rare but possible) penicillin V potassium (C class drug), 300-600 mg
• Facial swelling may be present PO qid for 7-10 days
• Carious tooth
• Gingival edema and erythema For clients with penicillin allergy:
• Tooth may be loose erythromycin (C class drug), 250 mg PO qid for
• Localized tenderness over affected area of jaw 10 days
• Anterior cervical nodes enlarged and tender
• Localized tooth pain Simple analgesics for mild to moderate dental
pain:
Differential Diagnosis ibuprofen (A class drug), 300 mg, 1tab PO q4h
prn x 72 hr (not with history of gastric problems)
• Disease of the salivary gland (e.g. mumps)
or
• Sinusitis
• Cellulitis tabs PO q4-6h prn
Complications For moderately severe dental pain:

• Cellulitis acetaminophen with codeine phosphate, 30 mg
• Recurrent abscess formation (C class drug), 1-2 tabs PO q4-6h prn (maximum
15 tabs)
Diagnostic Tests
• None Monitoring and Follow-Up
Follow up in 48-72 hours.
Referral
Refer to a dentist for definitive therapy.

Laryngitis
Inflammation of the mucosa of the larynx and • Cancer of the throat or larynx
vocal cords. (if condition prolonged or recurrent)
• Polyps of vocal cords
Causes
• Viral infection (common cold) Diagnostic Tests
• Bacterial infection (Streptococcus) • None
• Chronic mouth breathing
• Overuse of voice Management
• Chronic sinusitis Goals of Treatment
• Excessive smoking (or exposure to secondhand • Relieve symptoms
smoke) • Identify and remove contributing factors
• Aspiration of caustic chemical (e.g. smoking)
• Gastroesophageal reflux
• Changes due to aging (e.g. muscle atrophy, Appropriate Consultation
bowing of cords) Consult a physician immediately if client has
• Alcohol abuse stridor and shortness of breath.
• Long-term exposure to dust or other irritants
• Voice rest is the mainstay of treatment
History
• Removal of contributing factors
• Presence of risk factors (see "Causes," above)
(e.g. smoking and alcohol) is also important
• Concurrent infection of the upper respiratory
• Increase humidity of room air
tract may be present
• Increase fluid intake if febrile
• Hoarseness or loss of voice, abnormal-sounding
voice • Increase rest until any fever settles
• Throat pain, tickle or rawness
Client Education
• Aphonia
• Explain disease course and expected outcomes
• Dysphagia (trouble swallowing)
• Cough
medications (dosage and side effects)
• Fever
• Stress importance of follow-up if not resolved in
• Malaise 3 weeks
Physical Findings Pharmacologic Interventions

• Temperature may be elevated Usually none.
• Client appears mildly ill
• Throat may be mildly to moderately injected Monitoring and Follow-Up
• No exudate Follow up in 3 weeks if not resolved.
• Lymph nodes may be enlarged
Referral
Refer to a physician if symptoms persist for longer
than 3 weeks.
2-22 Adult
September 2004
Pharyngitis (Sore Throat)

Definition • Mild malaise
Inflammation or infection of mucous membranes • Persistent, recurrent
of pharynx (may also affect the palatine tonsils). • Pain on swallowing
Causes Physical Findings

Infectious Bacterial
• Viruses (e.g. rhinovirus, adenovirus, • Temperature elevated
parainfluenza, coxsackievirus, Epstein-Barr • Pulse elevated
virus, herpes virus) • Client appears acutely ill
• Bacteria (e.g. group A ß-hemolytic • Posterior pharynx red and swollen
Streptococcus [most common]), Chlamydia, • Tonsils enlarged
Corynebacterium diphtheriae, Hemophilus • Purulent exudate may be present
influenzae, Neisseria gonorrhoeae
• Tonsillar and anterior cervical nodes enlarged
• Fungi (e.g. Candida); rare except in
and tender
immunocompromised people (e.g. those with
• Rash (scarlatina form in group A streptococcal
HIV or AIDS)
infection)
Non-infectious
Viral
• Allergic rhinitis
• Temperature may be elevated
• Sinusitis with postnasal drip
• Posterior pharynx red and swollen
• Mouth breathing
• Purulent exudate may be present
• Trauma
• Tonsillar and cervical nodes may be enlarged
• Gastroesophageal reflux disease
and tender
• Risk factors: contact with a person with group A
• Petechiae on palate (in mononucleosis)
streptococcal infection, crowded living quarters,
• Vesicles (in herpes)
immunosuppression (e.g. HIV/AIDS), fatigue,
smoking, excess consumption of alcohol, oral
Non-infectious
sex, diabetes mellitus or use of steroids (oral or
• Posterior pharynx red and swollen
inhaled)
• Tonsillar and anterior cervical nodes may be
enlarged and tender
History • Exudate may be present
Bacterial
• Abrupt onset of sore throat It is often impossible to distinguish clinically
• Pain on swallowing between bacterial and viral pharyngitis. See
• Fever or chills Appendix 1 (this chapter) for the clinical tool "The
• Malaise Sore Throat Score" to help decide whether a
• Skin rash may be present patient has a group A streptococcal throat
• Headache infection and needs antibiotics.
• Anorexia
Viral • Distinguish bacterial from viral infection
• Slow, progressive onset of sore throat • Infectious mononucleosis
• Mild malaise • Sexually transmitted infection (for chronic
• Nasal congestion pharyngitis, investigate sexual practices)
• Vincent's angina (necrotic tonsillar ulcers)
Non-infectious
• Distinguish reactive inflammation from an
• Slow, progressive onset of sore throat underlying disorder (see "Causes," above)

Complications • Avoidance of irritants (e.g. smoke)

• Rheumatic fever (group A Streptococcus only) • Gargling with warm saline qid
• Glomerulonephritis (group A Streptococcus
only) Pharmacologic Interventions
• Peritonsillar abscess For pain and fever:
acetaminophen (A class drug), 325 or 500 mg,
1-2 tabs PO q4h prn
Diagnostic Tests or
• CBC ibuprofen (A class drug), 200 mg, 1-2 tabs q4h
• Monospot prn
• Swab the throat for culture and sensitivity (see
Appendix 1, this chapter, for indications to Treat with antibiotics if streptococcal disease is
swab) suspected:
• Rapid Strep A testing penicillin V potassium (C class drug), 300 mg PO
qid for 10 days
Management
Goals of Treatment For clients with penicillin allergy:
• Relieve symptoms erythromycin (C class drug), 250 mg PO qid for
• Prevent complications 10 days
• Prevent spread of group A Streptococcus to
contacts Do not use ampicillin or amoxicillin, because
these drugs may cause a generalized red "drug
Appropriate Consultation rash" if infectious mononucleosis is present.
Consult a physician if the client has significant
dysphagia or dyspnea (signalling obstruction of Monitoring and Follow-Up
the upper airways) or if there is concern about an Instruct client to return to clinic for reassessment if
underlying pathology such as HIV. symptoms do not improve in 48-72 hours.
Nonpharmacologic Interventions Referral

• Bed rest during febrile phase Referral may be necessary if condition is recurrent
• Adequate oral intake of fluids (8-10 glasses of or persistent or an undiagnosed underlying
fluid per day) pathology is suspected.
2-24 Adult
September 2004
Emergency Problems Of The Ears, Nose And Throat

Mastoiditis
Definition • Benign or malignant neoplasm
Acute suppurative inflammation of mastoid • Infection of deep neck space (Ludwig's angina)
antrum and air cells. • Post-auricular lymph node
Causes Complications
• Complication of inadequately treated acute otitis • Residual hearing loss
media, cholesteatoma or blockage of outflow • Meningitis
tract of mastoid air cells • Intracranial abscess
• Most common organisms: Hemophilus • Subperiosteal abscess
influenzae, group A Streptococcus,
Streptococcus pneumoniae
Diagnostic Tests
Swab for culture and sensitivity if ear is draining.
Risk Factors
• Recurrent otitis
• Cholesteatoma Management
• Immunocompromise Goals of Treatment
• Relieve pain and swelling
• Prevent spread of infection
History
• Ear pain Appropriate Consultation
• Non-resolving otitis media Consult a physician concerning IV antibiotic
• Spiking fever therapy.
• Post-auricular redness, swelling and pain
• Tinnitus Adjuvant Therapy
• Otorrhea if ear drum is perforated Start IV therapy with normal saline. Adjust rate
according to state of hydration.
Physical Findings
• Temperature moderately to severely elevated
IV antibiotics:
• Client appears moderately ill
ampicillin (C class drug), 1.0-2.0 g IV q6h
• Post-auricular swelling and erythema
• Pinna may be displaced anteriorly if edema For clients with penicillin allergy:
severe clindamycin (B class drug) 300mg IV q6h
• Manipulation of pinna and otoscopic exam of or
the ear causes acute pain cefuroxime (B class drug), 750 mg IV q8h
• Purulent drainage if tympanic membrane
ruptured Analgesics for pain and fever:
• Post-auricular warmth acetaminophen (A class drug), 325 or 500 mg,
• Tenderness over mastoid process 1-2 tabs PO q4-6h
• Anterior cervical and peri-auricular nodes
enlarged and tender Referral
Medevac to hospital as soon as possible; client
Differential Diagnosis may need several days of IV drug therapy and
• Severe otitis externa surgery.
• Post-auricular cellulitis

Posterior Epistaxis
Definition • Infection (e.g. chronic sinusitis)
Bleeding from the posterior portion of the nose • Neoplasm (rare)
(usually occurs in the elderly).
Complications
Causes • Hypotension or shock (hypovolemic)
• Idiopathic (cause unknown) • Anemia
• Hypertension
• Vascular abnormalities (hereditary hemorrhagic Diagnostic Tests
telangiectasia) • None
• Trauma: deviation or perforation of the septum
• Infection (e.g. chronic sinusitis)
Management
• Neoplasm (rare) Goals of Treatment
• Stop bleeding
History • Maintain circulating blood volume
• Sudden onset of brisk, bright bleeding from nose
• May be unilateral or bilateral Appropriate Consultation
• Blood running down back of throat Consult a physician if initial management fails to
• May be a history of hematemesis if client has control bleeding or there is significant potential of
swallowed a large quantity of blood underlying pathology.
• History of easy bruising, bleeding elsewhere
(e.g. melena, heavy menses), family history of Adjuvant Therapy
bleeding tendencies, use of anticoagulants, use • Start IV therapy with normal saline or Ringer's
of ASA products lactate solution; adjust IV rate according to
pulse and blood pressure response and rate of
bleeding
Physical Findings
• Heart rate elevated
• Blood pressure may be reduced if loss of blood • Keep client at rest with head at a 90° angle
is significant
• Apply pressure to the nose
• Client appears anxious
• Insert a posterior nasal pack; use a posterior
• Client may be pale, sweaty if loss of blood is nasal pack balloon system if available
significant
• An effective alternative is to use a 10-14 Fr.
• Bright red bleeding from nares (unilateral or Foley catheter system using water in the
bilateral) balloon.
• Bleeding site not visible • Bilateral packing is sometimes required to
• Blood observed in pharynx achieve adequate compression. The bleeding
• Sinuses may feel tender should stop after the nasal packs are in place.
Differential Diagnosis Monitoring and Follow-Up

• Hypertension • Monitor vital signs and loss of blood closely
• Trauma • Remove packs and balloons in 48-72 hours
• Vascular abnormalities (e.g. hereditary
hemorrhagic telangiectasia) Referral
• Deviation of the septum Medevac to hospital.
• Perforation of the septum
2-26 Adult
September 2004
Peritonsillar Abscess
Definition Management Of Mild-To-Moderate
Abscess that forms behind the tonsil in the Condition
posterolateral pharyngeal wall as a complication of Treat on an outpatient basis.
bacterial tonsillitis.
Goals of treatment
Causes • Relieve symptoms
Bacterial infection, usually related to group A • Prevent complications
Streptococcus pyogenes.
Client Education
History • Advise client to return immediately if pain
• Recent episode of pharyngitis becomes worse, or if drooling, difficulty
• Gradually increasing unilateral ear and throat swallowing, difficulty breathing or inability to
pain open mouth develops
• Fever • Recommend increased fluid intake
• Malaise • Recommend increased rest until fever settles
• Dysphagia (difficulty swallowing) • Recommend frequent gargling with warm saline
• Dysphonia for 48 hours
• Drooling
• Trismus (difficulty opening mouth)
Antibiotics:
penicillin V potassium (C class drug), 300 mg PO
Physical Findings qid for 10 days
• Fever or
• Heart rate increased penicillin G (B class drug), 1.2 million units IM
• Client may appear acutely ill or distressed
• Diaphoretic; flushed if feverish For clients with penicillin allergy:
• Affected tonsil grossly swollen medially and clindamycin (B class drug), 300 mg PO qid for 10
reddened days
• Tonsil may displace uvula and soft palate to the
opposite side of pharynx Analgesics for pain and fever:
• Swelling and redness of the soft palate acetaminophen (A class drug), 325 or 500 mg, 1-2
• Trismus (difficulty opening mouth) tabs PO q4h prn
• Tonsillar lymph nodes enlarged and very tender or
q4h prn
• Epiglottitis Monitoring and Follow-Up
• Gonococcal pharyngitis Follow up if no improvement in 48-72 hours.
Complications Management Of Moderate-To-Severe

• Obstruction of the airways Condition
• Sepsis Client appears acutely ill and has difficulty
• Deep neck infection swallowing.
Diagnostic Tests Goals of Treatment

Swab for culture and sensitivity of any exudate if • Relieve symptoms
the client is being treated as an outpatient (mild to • Prevent complications
moderate symptoms).

Appropriate Consultation Pharmacologic Interventions

Consult a physician if the abscess is significant in Antibiotics:
size and the client appears acutely ill; immediate penicillin G sodium (B class drug), 500 000 to
referral to hospital and examination by an ENT 2 million units IV q6h
specialist are in order. Consult with a physician
concerning choices for IV antibiotic treatment. For clients with penicillin allergy:
clindamycin (B class drug), 600mg IV q8h
Adjuvant Therapy
• Start IV therapy with normal saline; adjust rate Monitoring and Follow-Up
according to age and state of hydration Monitor client to ensure adequate airway is
maintained.
• Bed rest at high Fowler’s position Referral
• Give sips of cold liquids only Medevac to hospital; client may require surgical
• Give nothing by mouth if drooling incision to drain abscess.
2-28 Adult
September 2004
Appendix 1
An Alternative Approach To Sore Throat Management: The Sore
Throat Score
In 1994, a group of community-based family physicians and general practitioners from Stratford, Ontario,
began a joint project with researchers from the Institute for Clinical Evaluative Sciences in Toronto, Ontario,
to improve the accuracy of identifying people with Group A streptococcal pharyngitis and thus reduce the
number of antibiotic prescriptions. They identified a "sore throat score" that had been tested in trials and
seemed practical for an office-based setting.
The score was originally developed by a group of US emergency physicians. Using a mathematical model, the
physicians identified 4 clinical characteristics that could be used to assess the likelihood of group A
streptococcal pharyngitis:
• exudate
• swollen tonsillar anterior cervical nodes
• a history of a fever of more than 38ºC
• lack of cough
Using the Sore Throat in Clinical Practice
No of characteristics % of patients with Group % of sore throats seen in a

present A Streptococcus practice setting
None 2.5 15
One 6-7 30
Two 14-17 25
Three 30-34 20
Four 56 10
Among people who have no or only one clinical finding, fewer than 10% will have a group A streptococcal
infection. Because a routine throat culture will miss 10% of cases of group A streptococcal infection, this is a
reasonable cut-off for stating that these people do not need a throat culture and should not receive an
antibiotic.
Among patients with two or three clinical findings, it is suggested that a throat sample be taken for culture
but that antibiotics not be prescribed until the culture result is available.
There are three reasons for this recommendation:
1. The risk of rheumatic fever is not increased if antibiotics are delayed 48-72 hours.
2. The results of culture will be negative for most patients in this group, so symptom relief may be
adequate with ASA or acetaminophen.
3. Early antibiotic treatment may predispose a person to further group A streptococcal pharyngitic
infections.
Using this approach should substantially reduce the use of antibiotics for disease not caused by group A
Streptococcus.
Patients with all four clinical findings are likely to be sicker and have the highest chance of having group A
streptococcal pharyngitis, although those with this type of infection constitute only about 10% of cases of sore
throat. For these patients, it is suggested that a throat swab be taken for culture and that a decision to institute

antibiotics be made on clinical grounds, as the relief of symptoms may be greatest for this group. However,
anyone who has been ill for 3 days before seeking care is likely past the point at which antibiotics will
provide symptom relief.
Until further validation is done for pediatric populations, this rule should be applied to adult populations only
(defined as those 15 years of age or older).
The score is invalid in any community in which an outbreak or epidemic of group A streptococcal pharyngitis
is occurring and should not be applied in this type of situation.
Sources
A "sore throat score" for use in the office. Institute for Clinical Evaluative Sciences, Toronto, ON, 1998.
McIsaac, W.; White, D.; Tannenbaum, D.; et al. A clinical score to reduce unnecessary antibiotic use in
patients with sore throat. Canadian Medical Association Journal 1998;158(1):75-83.
2-30 Adult
September 2004
Chapter 3 - Respiratory System

Assessment Of The Respiratory System.......................................................................................................... 1
Examination Of The Respiratory System ....................................................................................................... 3
Differential Diagnosis Of Respiratory Symptoms .......................................................................................... 4
Common Problems Of The Respiratory System ............................................................................................ 6

Chronic Asthma .............................................................................................................................................. 6
Acute Asthma Exacerbation ......................................................................................................................... 11
Chronic Obstructive Pulmonary Disease (COPD)........................................................................................ 14
Acute COPD Exacerbation ........................................................................................................................... 17
Acute Bronchitis ........................................................................................................................................... 19
Pneumonia .................................................................................................................................................... 21
Emergencies Of The Respiratory System ..................................................................................................... 24

Pneumothorax ............................................................................................................................................... 24
Acute Foreign-Body Obstruction Of An Airway.......................................................................................... 26
Pulmonary Embolism ................................................................................................................................... 27
Inhalation Of Toxic Materials....................................................................................................................... 29

Assessment Of The Respiratory System

General Chest Pain
The following characteristics of each symptom • Onset (sudden or gradual)
should be elicited and explored: • Location
• Onset (sudden or gradual) • Radiation
• Chronology • Quality
• Current situation (improving or deteriorating) • Timing
• Timing (frequency, duration) • Severity
• Severity • Aggravating and relieving factors
• Precipitating and aggravating factors • Associated symptoms
• Relieving factors
• Associated symptoms Wheeze
• Effects on daily activities • Timing (e.g. at rest, at night, with exercise)
• Previous treatments Other Associated Symptoms
• Efficacy of previous treatments • Fever
• Malaise
Cardinal Symptoms • Fatigue
In addition to the general characteristics outlined • Night sweats
above, additional characteristics of specific • Weight loss
symptoms should be elicited, as follows.
Medical History (Specific To
Cough Respiratory System)
• Quality (e.g. dry, hacking, loose, productive) • Frequency of colds or asthma and treatment used
• Severity • Other respiratory illnesses (e.g. nasal polyps,
• Timing (e.g. at night, with exercise) chronic sinusitis)
• Bronchitis, pneumonia, chronic obstructive
Sputum pulmonary disease (COPD), tuberculosis (TB)
• Color (disease or exposure), cancer, cystic fibrosis
• Amount • Seasonal allergies or allergies to drugs such as
• Consistency acetylsalicylic acid (ASA)
• Medications such as angiotensin-converting
Hemoptysis enzyme (ACE) inhibitors, ß-blockers, ASA,
• Amount of blood (frank vs. streaking) steroids, nasal sprays, antihistamines,
• Association with leg pain, chest pain, shortness • Alternative therapies (e.g. herbal, traditional
of breath, epistaxis medicine)
• Admissions to hospital for respiratory illness
Shortness of Breath • Date and result of last Mantoux test and chest x-
• Exercise tolerance (number of stairs client can ray
climb or distance client can walk) • Vaccination history (e.g. pneumococcal, annual
• Orthopnea (number of pillows used for sleeping) influenza)
• Association with paroxysmal nocturnal dyspnea
(waking up out of sleep acutely short of breath;
attack resolves within 20 to 30 minutes of sitting
or standing up)

Family History (Specific To • Exposure to secondhand smoke

Respiratory System) • Occupational or environmental exposure to
• Allergies, atopy respiratory irritants
• Asthma, lung cancer, TB, cystic fibrosis • Exposure to pets
• Heart disease • Crowded living conditions
• COPD • Personal or environmental cleanliness
• Institutional living
Personal And Social History (Specific • Injection drug use
To Respiratory System)
• Smoking history (number of
packages/day,number of years)
• Alcohol abuse
• HIV risks
3-2 Adult September 2004

Examination Of The Respiratory System

Examination of the ear, nose, throat and Palpation
cardiovascular system should also be carried out • Tracheal position (midline)
because of the interrelatedness between these • Chest wall tenderness
systems and structures and the functioning of the • Chest expansion
lower respiratory tract (see chapter 2, "Ears, Nose
• Tactile fremitus
and Throat," and chapter 4, "Cardiovascular
System," for details of these examinations).
• Spinal abnormality
• Nodes (axillary, supraclavicular, cervical)
General Appearance • Masses
• Acutely or chronically ill • Subcutaneous emphysema
• Degree of comfort or distress
• Degree of sweatiness Percussion
• Ability to speak a normal-length sentence • Resonance (dull or hyperresonance)
without stopping to take a breath • Location and excursion of the diaphragm
• Color (e.g. flushed, pale, cyanotic)
• Nutritional status (obese or emaciated) Auscultation
• Hydration status • Assist client to breathe effectively
• Listen for sounds of normal air entry before
trying to identify abnormal sounds
Vital Signs
• Temperature
Breath Sounds
• Pulse
• Degree of air entry throughout the chest (should
• Pulse oximetry be equal)
• Respiratory rate • Quality of breath sounds (e.g. bronchial,
• Blood pressure bronchovesicular, vesicular)
• Length of inspiration and expiration
Inspection
• Color (e.g. central cyanosis) Adventitious Sounds
• Shape of chest (e.g. barrel-shaped, spinal • Wheezes: continuous sounds, ranging from a
deformities) low-pitched snoring quality to a high-pitched
• Movement of chest (symmetry) musical quality, may clear with coughing
• Rate, rhythm and depth of respiration • Crackles: discrete, crackling sounds heard on
• Use of accessory muscles (sternocleidomastoid inspiration
muscles) • Pleural rub: a creaking sound from pleural
• Intercostal indrawing irritation, heard on inspiration or expiration
• Evidence of trauma
• Chest wall scars
• Clubbing of the fingers

Differential Diagnosis Of Respiratory Symptoms

Acute Cough Dyspnea
• Infection: viral or bacterial, upper or lower • Asthma
respiratory tract • COPD
• Lung abscess • Pneumothorax
• Asthma • Pneumonia
• Exacerbations of chronic bronchitis • Interstitial lung disease (e.g. sarcoidosis)
• Bronchogenic carcinoma • Lung cancer
• Foreign-body inhalation • Pulmonary emboli or infarction
• Esophageal reflux with aspiration • Cardiac failure, congestive heart failure
• Left-sided heart failure • Anxiety with hyperventilation
Chronic Cough Hemoptysis

Common Causes • Bronchitis
• Smoking • Bronchiectasis
• Exposure to environmental irritants (second • TB
hand smoke) • Bronchogenic cancer
• Postnasal drip • Lung abscess
• Asthma • Pneumonia, necrotizing form (e.g. caused by
• COPD or chronic bronchitis Klebsiella)
• Gastroesophageal reflux with aspiration • Pulmonary contusion
• Lung tumors • Pulmonary embolism
• Mitral valve prolapse • Primary pulmonary hypertension
• Mitral stenosis
Less Common Causes • Cardiac failure, congestive heart failure
• Carcinoma of the upper or lower respiratory • Vascular anomalies (e.g. aneurysm)
tract • Chest trauma
• Interstitial lung disease • Inhalation of toxic material
• Medications (e.g. ACE inhibitors) • Bleeding disorders
• Chronic lung infections (e.g. bronchiectasis,
cystic fibrosis, TB) Wheeze
• Occult left heart failure • Acute bronchitis
• Disorders of the pleura, pericardium, diaphragm, • COPD
stomach
• Asthma
• Idiopathic (e.g. psychogenic)
• Bronchopneumonia (due to aspiration)
• Pressure from an external mass • Lung neoplasm obstructing a bronchus
(e.g. goitre, aortic aneurysm)
• Pulmonary emboli
• Foreign-body aspiration
Cough And Sputum Production
• Acute bronchitis
Chest Pain (Pleuritic)
• Pneumonia
Diseases of the Lungs or Pleura
• Asthma
• Pneumonia
• TB
• Pleurisy
• COPD
• Pleuritis associated with connective tissue
• Bronchiectasis diseases
• Lung abscess • Pneumothorax
• Lung cancer

• Hemothorax Other Diseases

• Empyema • Psychoneurosis
• Pulmonary infarction
• Lung cancer Chest Pain (Nonpleuritic)
• TB Diseases of the Pulmonary Vessels
• Pulmonary embolism
Diseases of the Pericardium • Primary pulmonary hypertension
• Pericarditis • Disease of the aorta
• Trauma • Dissecting aortic aneurysm
Diseases of the Chest Wall Muscle, Diseases of the Myocardium

Bone, Nerves, Skin • Myocardial infarction
• Chest wall contusion • Angina
• Fractures of ribs, sternum
• Inflammation of chest wall muscles Referred Pain from Gastrointestinal
(costochondritis) Structures
• Herpes zoster neuropathies • Reflux esophagitis, ulceration
• Bone tumor • Esophageal motility disorders (e.g. achalasia)
• Esophageal perforation or rupture
Gastrointestinal Diseases • Esophageal spasm
• Liver abscess • Esophageal neoplasm
• Pancreatitis • Esophageal diverticula
• Subdiaphragmatic abscess • Gastric or duodenal ulcer
• Cholelithiasis, cholecystitis
• Pancreatitis, pancreatic neoplasm

Common Problems Of The Respiratory System

Chronic Asthma
For further reading on asthma and current dyspnea, chest tightness, wheeze, sputum
guidelines please refer to: production and cough) with variable airflow
www.asthmaguidelines.com limitation and a variable degree of airway
www.pulsus.com/Respir/08_02/guide-ed.htm hyperresponsiveness to a variety of stimuli.
where Boulet et al (1999) Canadian Asthma
Consensus Guidelines, updates and treatment Airway inflammation and its consequences are the
flowcharts and checklists can be found. important features in the pathogenesis of asthma
(Boulet et al, 1999).
Definition
A disorder of the airways characterized by
paroxysmal or persistent symptoms (including
Table 1: Characteristics of various forms of asthma

Mild Asthma Moderate Asthma Severe Asthma
Respiratory symptoms (wheeze, cough, Respiratory symptoms > 2 times Respiratory symptoms so frequent
dyspnea) up to 2 times weekly and/or weekly, with exacerbations that they interfere with activities of
respiratory symptoms lasting less than 30 affecting sleep and activity and daily living
minutes with activity often lasting several days
Minimal or no shortness of breath at rest; Shortness of breath at rest or with Daily symptoms and frequent
exercise increases cough or wheeze and mild exertion; tightness in the nighttime symptoms
usually causes shortness of breath; chest; wheezing at rest; increased
nighttime cough, worse in early predawn cough at night or with exercise
hours
Able to do usual tasks without difficulty Some difficulty speaking and Occurrence of a prior near-fatal
sleeping episode (intubation needed)
PEFR and FEV1 >80% of predicted PEFR 60% to 80% of predicted PEFR <60% of predicted
Asymptomatic between exacerbations Occasional visits to emergency Frequent admissions to hospital or

department visits to emergency department
Intermittent use of β2-agonist Need for inhaled β2-agonists several

inhaler times per day or at night. Use of
more than one inhaler in 2 week
period
PEFR = peak expiratory flow rate FEV1 = forced expiratory volume in the first second
Note: cough at night or during times of emotional stress or physical activity may be the only sign of asthma.
Causes [NSAIDs], tartrates, ß-blockers and ACE

• Unknown in many cases inhibitors), smoke and other occupational,
• Allergic airway hyperreactivity to airborne industrial and environmental substances
pollens, molds, house dust mites, animal dander, • Common trigger factors: intercurrent
feather pillows gastroesophageal reflux disease (GERD)
• Nonallergic asthma triggered by drugs (such as
ASA, nonsteroidal anti-inflammatory drugs

Risk Factors Management

• Positive family history Goals of Treatment
• Frequent, severe viral infections of the lower • Maintain normal activity
respiratory tract in infancy, respiratory tract • Prevent symptoms
infections, cold air, exercise, emotional stress, • Maintain normal pulmonary function
sinusitis. • Prevent exacerbations
• Avoid side effects of therapy (given that side
Determining Severity effects may lead to poor adherence to treatment
The severity of asthma is determined by the plan)
frequency and chronicity of symptoms, the
presence of persistent airflow limitations and the The five most important aspects of asthma care are
medication needed to maintain control of the considered to be:
condition. 1. Achievement of acceptable control of the
disease s the main goal of treatment
Severity is best evaluated after an aggressive trial
of therapy with inhaled corticosteroids 2. Control of the environment
(see Table 1 above).
3. Asthma education, favouring self-management
Differential Diagnosis and the use of an action plan
• Mechanical airway obstruction (foreign body)
• Severe allergic reaction 4. Inhaled glucocorticosteroids as the first-line
• COPD with chest infection anti-inflammatory therapy for all ages
• Congestive heart failure
• Pulmonary edema 5. Additional therapy (e.g. long-acting ß2-agonists,
• Inhalation of toxic material leukotrienes-receptor antagonists [LTRAs] etc.)
can be added to moderate doses of
• Inspiratory stridor
glucocorticosteroids if acceptable asthma control
• Cough secondary to drugs such as ACE- is not obtained
inhibitors, ß-blockers
(Boulet et al, 1999)
Complications
• Severe acute attack: hypoxia, respiratory failure, Appropriate Consultation
atelectasis, pneumothorax, death Consult a physician to discuss appropriate
• Chronic: interference with activities of daily medication therapy at first diagnosis and as
living, COPD necessary thereafter until symptoms have
stabilized.
Diagnostic Tests
Objective measurements are needed to confirm a Adjuvant Therapy
diagnosis of asthma and to assess severity in all • Administer annual influenza vaccine
but the most minimally symptomatic clients. • Administer pneumococcal vaccine
• Determine peak expiratory flow rate (PEFR)
• Arrange baseline pulmonary function tests Nonpharmacologic Interventions
• Recommend that client avoid known
Referral to physician for consideration of the precipitating factors such as environmental
following tests: allergens and occupational irritants
• Methacholine challenge test
• Allergy testing (Canadian Asthma Consensus
Conference guidelines [Boulet et al, 1999])

• Allergens to which a person is sensitized Table 2: Measures to minimize environmental

should be identified factors contributing to asthma
• A systematic program to eliminate or at least Avoid respiratory irritants, particularly tobacco smoke
Minimize exposure to relevant allergens, particularly
substantially reduce, allergen exposure indoor allergens
should be undertaken
• Measures to control household dust mites can Household dust mites
be effective in decreasing exposure and • Maintain relative humidity below 50%
relieving asthma • Encase mattress, box spring and pillows in mite and
• Humidity in the home, including the mite allergen impermeable covers
bedroom, should be kept below 50% • Launder bed linens in hot (55°C) water
• Reduction of exposure to pet allergens • Remove carpeting, where possible
cannot be effective without removing the pet
from the home Note: air filters do not affect reservoir levels of
• Compliance with avoidance measures must
household dust-mite allergen
be reviewed repeatedly and its importance
emphasized Pet allergens
• Removal of pet from the home is the most effective
(Boulet et al, 1999) approach
• Exclude pet from the bedroom
• Use HEPA room air cleaner
• Offer counseling for smoking cessation (if • Use mattress and pillow covers
applicable) to client and family • Remove carpeting
• Recommend that client avoid NSAIDs and ASA • Vacuum upholstered furniture with a HEPA-filtered
products (if allergic) vacuum frequently
• Washing the pet may temporarily reduced allergen
Client Education load, but this must not be done by the allergic
• Discuss diagnosis and expected course of illness person
• Teach client about measures to minimize (Boulet et al, 1999)
exposure to allergens (see table 2)
• Counsel client about appropriate use of Pharmacologic interventions
medications (dose, frequency, side effects) Medications used to treat asthma are classified as
• Advise client on proper use of aerosol delivery controllers and relievers. Except in cases of
device, aerochamber or spacer emergency treatment all asthma medications will
• Teach client how to monitor for symptoms and be prescribed by a physician.
how to use peak flow meter (if deemed
beneficial to managing symptoms)
• Advise client on an action plan to increase
medication from maintenance level at first sign
of exacerbation
• Counsel client on how to minimize local side
effects (oral candidiasis) by careful rinsing of
the mouth and gargling
• Process to re-order medications

Table 3: Asthma medication categories

Relievers (for intermittent symptoms) salbutamol (C class drug), 100 mcg, 1 or 2 puffs
short acting ß2-agonists q4h prn
ipatroprium (rarely)
Long-Acting ß2-Agonists
Controllers (for maintenance therapy) The long-acting ß2-agonists (e.g. salmeterol,
formoterol B class drug) can be used as an
Anti-inflammatory medications additional treatment for people whose asthma is
Steroidal - inhaled (and oral) glucocorticosteroids not adequately controlled with optimum inhaled
Non-steroidal - leukotriene receptor antagonists steroids, particularly when there are nocturnal
symptoms. These drugs should never be used to
Anti-allergic agents – cromoglycate and nedocromil rescue patients with significant symptoms of an
acute asthma attack.
Bronchodilators - long-acting inhaled ß2-agonists
(salmeterol, formoterol B class drugs)
Leukotriene Receptor Antagonists
Theophylline (LTRA)
LTRAs have been developed recently as it has
Ipatroprium been recognized that leukotrienes play a
significant role in the inflammatory
(Boulet et al, 1999) pathophysiology of asthma. Their use at present,
however, is limited to add-on therapy to inhaled
Inhaled Corticosteroids glucocorticosteroids, until more is known about
Inhaled corticosteroids are the best agents for their long-term effects on disease modification.
bringing and keeping asthma under control, and They should not be used as first line therapy.
their use may improve the overall prognosis for
clients with this condition. Anticholinergics
The anticholinergic drugs (e.g. ipratropium
Initial recommended doses of inhaled bromide C class drug) act more gradually than ß2-
corticosteroid for mild to moderate asthma: agonists to offer modest bronchodilation in stable
fluticasone (B class drug), 100-500 mcg bid asthma patients. They are of greatest value in
or treating older patients and patients with a
budesonide (B class drug), 40 mcg bid combination of asthma and COPD. During acute
exacerbations they are used as an adjunct to
Once best results are achieved (i.e. symptoms are optimal doses of short-acting ß2-agonists.
controlled), the dose of inhaled steroid is reduced
to identify the minimum dose required to maintain Monitoring and Follow-Up
control. • Follow up every 3-6 months once stabilized
• Assess adherence to the medication regimen
Inhaled steroids are safe for use during pregnancy
• Review inhaler technique periodically
and lactation, but the lowest dose possible to
maintain control of asthma is recommended. • Watch for complicating conditions such as
GERD, sinusitis, nasal polyps
• Carefully monitor clients taking more than
Short-Acting ß2-Agonists
Short-acting ß2-agonists are the drugs of choice to • 2000 mcg daily of inhaled steroids to watch for
relieve asthma symptoms that break through long-term effects on bone metabolism
maintenance therapy. They are most effective for (osteoporosis)
preventing and treating exercise-induced • Review strategies to reduce environmental
bronchospasm. Their use should be limited to allergens if applicable
rescue medication and they should be used less
than 3 times a week.

Referral
Referral to a specialist is recommended for adults Consider referral for respiratory assessment (if
when more than 1000 mcg daily of inhaled available) for clients whose activities of daily
beclomethasone or its equivalent is required on an living are significantly compromised by poorly
ongoing basis. Ideally, a physician should review controlled symptoms despite adequate therapy and
the client at least annually if stable and more often adequate compliance with the treatment plan.
if symptoms are not well controlled.

Acute Asthma Exacerbation

Exacerbations should be treated promptly to The findings depend on the acuteness and severity
reverse the symptoms and prevent them from of the attack, which can range from mild to very
becoming severe. severe.
Table 4: Signs, symptoms and management of mild, moderate and severe asthma attacks.
Feature Mild Moderate Severe
History • Exertional dyspnea • Dyspnea at rest • Acute respiratory distress
• No acute distress • Congested cough • Agitated, diaphoretic
• Cough • Tightness of chest • Difficulty speaking
• Nocturnal symptoms
• ß2-agonists needed > q4h
Physical findings • RR normal or minimally • Appears short of breath • Heart rate > 110 bpm
elevated • RR elevated • Marked use of accessory
• Heart rate < 100 bpm • Heart rate > 100 bpm muscles of respiration
• Low-pitched wheezes, • Some use of accessory • Blood pressure elevated
inspiratory, expiratory or muscles of respiration • Breath sounds decreased in
both • Audible wheeze intensity
• FEV1 and PEFR > 60% • High-pitched wheezes in all • Diffuse, high-pitched wheezes,
predicted or best lung fields, inspiratory, inspiratory, expiratory or both
• PEFR > 300 L/min expiratory or both • FEV1 and PEFR: unable to
• Good response to short- • FEV1 and PEFR 40-60% perform test or < 40% predicted
acting ß2-agonists predicted or best or best
• PEFR 200-300 L/min • PEFR < 200 L/min
• ß2-agonists provide only • Oxygen saturation < 90%
partial relief • No pre-clinic relief from
• ß2-agonists
Management Consult a physician if client Consult a physician Consult a physician as soon as
is not already taking inhaled possible
steroids
Adjuvant None Oxygen to keep saturation • Oxygen to keep saturation ≥
therapy ≥ 97% 97%
• Start IV therapy with normal
saline, adjust rate to maintain
hydration
• Aggressive fluid administration
can help liquefy bronchial
secretions unless otherwise
contraindicated (e.g. pulmonary
edema)

Pharmacologic • If client on inhaled salbutamol (C class drug) by salbutamol (C class drug) by

interventions steroids increase to 2-4 MDI and Aerochamber, 100 MDI and Aerochamber, 100 mcg
times usual dose. mcg/puff, 4-8 puffs q15-20min, /puff, 4-8 puffs q15-20min, 3
• If has not been taking 3 times; then increase to 1 puff times; increase to 1 puff q30-60s
medications recently, q30-60s (for 4-20 puffs) prn (for 4-20 puffs) prn
restart usual dose or or
salbutamol solution (C class salbutamol solution (C class
• Bronchodilators prn for drug) by nebulizer, 5.0 mg (1 drug) by nebulizer, 2.5-5.0 mg
bronchospasm
mL in 3 mL normal saline) (0.5-1.0 mL in 3 mL normal
q15-20min, 3 times, continuous saline) q15-20min, 3 times,
salbutamol (C class drug) by
if necessary continuous if necessary; + titrate
MDI 1-2 puffs q4h prn, to a
maximum of 2-4 puffs q4h ± to client response
ipratropium bromide (C class +
drug) by MDI and ipratropium bromide (C class
Aerochamber, 20 mcg /puff, 4- drug) by MDI and Aerochamber,
8 puffs q15-20min, 3 times; 20 mcg /puff, 4-8 puffs q15-
then increase to 1 puff q30-60s 20min, 3 times; increase to 1 puff
(for 4-20 puffs) prn q30-60s (for 4-20 puffs) prn
or or
ipratropium bromide (C class ipratropium bromide (C class
drug) by nebulizer, 0.25-0.50 drug) by nebulizer, 0.25-0.50
mcg (1-2 mL in 3 mL normal mcg (1-2 mL in 3 mL normal
saline) q15-20min, 3 times, saline) q15-20min, 3 times,
continuous if necessary (may continuous if necessary (may be
be mixed with salbutamol; mixed with salbutamol; decrease
decrease in recovery phase) salbutamol during recovery
± phase)
prednisone (B class drug), +
1 mg/kg (40-60 mg) PO od or methylprednisolone sodium
bid for 5-7 days succinate (B class drug) IV
People with steroid-dependent

asthma and those who are
already receiving inhaled
steroids should also receive
oral steroid therapy.
Monitoring and Advise follow-up in 24 • PEFR and FEV1 should be Assess response to medication by
follow-up hours if symptoms not checked frequently to continuously monitoring oxygen
controlled. evaluate response to saturation and by measuring
bronchodilator therapy PEFR and vital signs frequently.
For exercise or cold-induced • Client may be discharged
asthma: after initial emergency Monitor heart rate for tachycardia
salbutamol (C class drug) treatment if there is good
1-2 puffs 15 minutes before response and there has been
exercising or going out in no attack within the previous
the cold air 24 hours
Referral As needed Medevac after treatment if Medevac as soon as possible
FEV1 is < 60% predicted value
or there has been another
attack within the previous 24
hours

Patients at risk Previous near death episode

of relapse Recent emergency room visit for acute exacerbation
Frequent admissions to hospital
Dependent on steroids and recent use of oral steroids
History of sudden attacks
Allergic or anaphylactic triggers
Recent attack of prolonged duration
Poor understanding of illness and poor adherence to therapy
No removal of environmental triggers
MDI – metered dose inhaler RR – respiratory rate

Chronic Obstructive Pulmonary Disease (COPD)

Definition Initially, cough and sputum are present only in the
A functional disorder of the lung characterized by morning (especially in the winter). Eventually the
progressive and incompletely reversible airflow symptoms are present throughout the day and
obstruction and actual destruction of lung tissue. throughout the year. There are frequent episodes
The clinical presentation depends on which of the of acute chest infections superimposed on the
following pathophysiologic processes are chronic condition.
prominent:
Emphysema
• Inflammatory narrowing of the bronchioles Chronic shortness of breath, initially with exercise.
• Proteolytic digestion of the connective tissue Cough is only a minor problem and sputum
framework of the lung, resulting in decreased production is limited. The shortness of breath
parenchymal tethering of the airways gradually becomes worse until the person is short
• Loss of alveolar surface area and capillary bed of breath even at rest.
• Lung hyperinflation caused by loss of elastic
recoil History
• Increased pulmonary vascular resistance caused • Client almost always a smoker
by vasoconstriction and loss of capillary bed • 40 years of age or older
• Frequent chest infections
Source: Guidelines for the Assessment and • Weight loss and fatigue (in the advanced stages)
Management of Chronic Obstructive Pulmonary • Shortness of breath
Disease (Canadian Thoracic Society Workshop • Cough with sputum (clear, white, yellow-green)
Group 1992) • Wheeze
Causes Physical Findings

• Usually a combination of factors Physical findings vary, depending on extent of
disease and whether exacerbation is acute.
Risk Factors
• Smoking The upper respiratory tract (e.g. ears, nose and
• Secondhand smoke throat) (see chapter 2) and the cardiovascular
• Severe viral pneumonia early in life system (see chapter 4) should be examined, and
• Aging neuromental status should be determined (to check
• Genetic predisposition for hypoxia) (see chapter 8).
• Air pollution • Temperature may be elevated with
• Occupational exposure to respiratory irritants superimposed infection
• Heart rate may be elevated
Former Classification • Respiratory rate elevated, depth of respiration
Most clients with COPD have a combination of may be decreased
chronic bronchitis and emphysema. However, one • Expiratory phase is prolonged
pattern is predominant: people with COPD either • Oxygen saturation may be reduced
tend to have more cough and sputum production • Client may appear thin or wasted
and less shortness of breath (chronic bronchitis) or • Degree of respiratory distress varies
tend to have more shortness of breath and less • May be using accessory muscles of respiration
cough and sputum production (emphysema). • Cyanosis may occur
• Clubbing of fingers may be present
Chronic Bronchitis • Chest diameter is usually increased ("barrel
Chronic productive cough that is present for at chest")
least 3 months each year, for 2 years in a row. • Breathing may be pursed-lipped

• If hypoxia is significant, confusion, irritability Client Education

and diminished level of consciousness may • Early public education about the hazards of
result smoking can prevent COPD
• Tactile fremitus decreased • Counsel client about smoking cessation
• Chest excursion decreased (if applicable)
• Hyperresonance • Recommend adequate hydration (8-10 glasses of
• Decreased diaphragmatic excursion (chronically fluid per day; there is no evidence that drinking
hyperinflated lungs) more than this quantity is of any benefit)
• Air entry reduced • Increase humidity in the air (kettle, humidifier or
• Breath sounds distant (if barrel chest is present) pot of water on the stove)
• Scattered wheezes and crackles may be present • Recommend adequate nutrition: small, frequent
• Decreased FEV1 on peak flow testing meals high in protein and calories
• Recommend an exercise program (e.g. walking)
Differential Diagnosis to improve general fitness and sense of well-
• Bronchitis (acute) being
• Bronchiectasis • Recommend a weight-loss program (if
applicable)
• Asthma
• Discuss natural history, expected course and
• Bronchogenic carcinoma
prognosis of disease
Complications medications (purpose, dose, frequency, side
• Acute bronchitis effects)
• Pneumonia • Counsel client about proper use of inhaler
• Pulmonary hypertension • Perform chest physiotherapy if increased sputum
• Cor pulmonale (right heart failure) production (deep breathing and coughing,
• Respiratory failure pursed-lip breathing, abdominal breathing and
• Polycythemia (abnormally high hemoglobin) postural drainage)
due to hypoxemia • Teach client symptoms and signs of
exacerbation and acute infection to encourage
Diagnostic Tests self-monitoring and early presentation when
• If productive cough >3 weeks sputa for AFB and condition deteriorates
C&S. • Counsel client to avoid travel at high altitudes;
• Arrange for baseline pulmonary function testing when air travel cannot be avoided, the client
at some point and baseline CXR should have access to oxygen (especially when
traveling in an unpressurized aircraft)
Management
Goals of Treatment Adjuvant Therapy
• Reduce or eliminate dyspnea • Give yearly influenza vaccine
• Reduce sputum production • Give pneumococcal vaccine
• Maintain exercise tolerance • Consider home oxygen therapy for clients with
• Prevent progression of disease advanced disease (it can increase lifespan by 6
• Reduce frequency of exacerbations to 7 years [Canadian Thoracic Society
• Keep oxygen saturation > 90% Workshop Group 1992]).
Consult a physician for previously undiagnosed
clients, those whose symptoms are not controlled
with their current therapy and those with an acute
exacerbation.

Fig 2: Recommended Drug Treatment for Chronic COPD (Source: Therapeutic Choices. Gray 1998,
2003)
salbutamol (D class drug) by MDI and AeroChamber,

100 mcg, 1 or 2 puffs q4h prn
yes
Improvement?
Continue therapy
suboptimal
Add ipratrprium bromide (B class drug) by MDI with

spacer, 40 mcg tid or qid
no yes
Discontinue
Improvement? Continue therapy
ipratropium
suboptimal
Add a long-acting theophylline (B class drug)
no yes
Discontinue Improvement?
Continue therapy
theophylline
suboptimal
Add trial of oral corticosteroids (B class drug)
no yes Add inhaled steroid,

Improvement (>
Discontinue reduce oral drugs to
20% in FEV)
corticosteroids minimum possible

• For clients using oral theophylline medications, The physician should assess the client at least
measure serum levels of drug every 3-6 months annually if condition is stable, and as soon as
and teach client the symptoms and signs of toxic feasible if symptoms are not controlled.
effects
• Follow-up every 6 months if stable
• Follow-up monthly if symptoms poorly
controlled

Acute COPD Exacerbation

Definition Exacerbations should be treated with appropriate
Recent deterioration of the patient's clinical and supplemental oxygen, aggressive bronchodilator
functional state due to a worsening of his or her therapy, corticosteroids and antibiotics.
COPD.
History Consult a physician as soon as possible.
• Worsening dyspnea, sometimes at rest
• Increased cough Adjuvant Therapy
• Increased sputum production, often with change • Oxygen 4-6 L/min or more prn; keep oxygen
in character from mucoid to purulent saturation at 90% to 92%
• Development of or increase in wheezing • Start IV therapy with normal saline; adjust IV
• Loss of energy rate according to state of hydration
• Loss of appetite
The choice of medications and dosages (Fig. 3)
Physical Findings depends on the current drug regimen and the
• Fever (superimposed infection) client's compliance with it, as well as the severity
• Anxiety level of the exacerbation (particularly the degree of
• Increase in respiratory rate respiratory distress).
• Tachycardia
• Increase in cyanosis The maximal effective doses of short-acting ß2-
• Use of accessory muscles agonists (e.g. salbutamol) and long-acting ß2-
• Peripheral edema agonists (e.g. ipratropium bromide) in COPD
• Loss of alertness exacerbation are unknown.
• Worsening of airflow obstruction, as indicated
by FEV1 or PEFR For severe exacerbation, the American Thoracic
• Worsening of oxygen saturation, as indicated by Society (1995) recommends 6-8 puffs every 2
pulse oximetry hours.
Evidence Of Severe Exacerbation Monitoring and Follow-Up

Monitor vital signs, oxygen saturation and PEFR
Loss of alertness or a combination of two of the
frequently to assess response to bronchodilator
other typical symptoms and signs of COPD
therapy.
exacerbation (see above) suggests severe
exacerbation and a need for referral to the
emergency department. These criteria are not Referral
intended to replace a healthcare provider's Medevac any client who shows moderate to severe
judgment about the need for referral. signs of respiratory distress.
Management
The decision as to whether to manage a client at
home or to refer him or her for evaluation depends
on many factors: the severity of the exacerbation;
the severity of the underlying COPD; comorbid
conditions; the medical sophistication, judgment
and reliability of the client and caregivers; and the
distance the client lives from the health center or
clinic.

Fig 3: Recommended Drug Treatment for Acute Exacerbation of COPD

Bronchodilators
e.g. salbutamol (C class drug), 3 or 4 puffs q4h prn; may increase to 6-8 puffs q2h in
severe exacerbation
+
Anticholinergics
e.g. ipratropium bromide (C class drug), 3 or 4 puffs q4h prn; may increase to 6-8
puffs q2h in severe exacerbation
+
Oral steroids
e.g. prednisone (B class drug) 40-60mg PO od for 2 weeks
or
methylprednisolone (B class drug) 125mg IV q8h
+
Oral antibiotics
e.g. amoxicillin (C class drug), 500mg PO tid for 10 days
or
cotrimoxazole (C class drug) 800/160 mg, PO bid for 10 days
or
clarithromycin (B class drug) 500mg PO bid
or
IV antibiotics
e.g. ampicillin (C class drug) 500-1000mg IV q6h
or
cefuroxime (B class drug) 750mg IV q8h
For clients with penicillin allergy use

erythromycin (C class drug) 500mg IV q6h
Sources: Guidelines for the Assessment and Management of Chronic Obstructive Pulmonary Disease
(Canadian Thoracic Society Workshop Group 1992), Breathing to Live (Chapman and Tames 1991, 1994)

Acute Bronchitis
Definition • Heart rate may be mildly elevated if febrile
Inflammation of trachea and bronchi (larger • Respiratory rate may be slightly elevated
airways). • Spasmodic cough
• Rhinitis may be present
Causes • Expiratory phase may be slightly prolonged
• Acute bronchitis is almost exclusively viral in • Wheezes (scattered, low pitched) may be present
etiology
• Viral infection: influenza A or B, adenovirus, Differential Diagnosis
rhinovirus, parainfluenza • Influenza
• Bacterial infection: Hemophilus influenzae, • Acute sinusitis
Moraxella catarrhalis, Mycoplasma, • Pneumonia
Streptococcus pneumoniae • Acute exacerbation of chronic bronchitis
• Asthma
Risk Factors
• Inhaled or aspirated chemical irritants
• Chronic sinusitis
• TB or lung cancer (if recurrent)
• COPD
• Pertussis
• Bronchiectasis
• Allergies
• Immunosuppression
• Smoking
Complications
• Secondhand smoke
• Pneumonia
• Air pollutants
• Postbronchitis cough
• Alcoholism
• GERD
Diagnostic Tests
Nasopharyngeal swab
History
• Previous infection of upper respiratory tract Management
• General malaise Goals of Treatment
• Fever • Relieve symptoms
• Cough; initially dry, later productive of white, • Prevent pneumonia
yellow or green sputum
• Muscular aching in the chest wall or discomfort Appropriate Consultation
with coughing Consultation is usually not necessary if the person
• Wheezing may be present is otherwise healthy.

The presentation of acute bronchitis and • Increased rest (especially if febrile)
pneumonia are often similar. In general, clients • Adequate hydration (8-10 glasses of fluid per
with pneumonia are sicker and usually have more day)
chest abnormalities. The organisms that cause • Increased humidity in the environment
bronchitis can also cause pneumonia. The
• Avoidance of pulmonary irritants (e.g. stop or
difference is in where the infection lies
decrease smoking)
anatomically. Bronchitis involves the larger
airways, whereas pneumonia involves the smaller
airways and air sacs.
Client Education
Recommend hand washing to prevent spread of
infection throughout a household.
• Temperature may be mildly to moderately
elevated

Pharmacologic Interventions cotrimoxazole (C class drug), 800/160 mg PO bid

For fever or pain: for 7 days
acetaminophen (A class drug),
325 or 500 mg, 1 tab q4h prn If bronchospasm is significant, short-acting ß2-
Clients who have been unwell for more than 5-7 agonist bronchodilators can be used until acute
days and have purulent sputum, or those with symptoms resolve:
underlying health concerns (e.g. asthma) may
require a course of antibiotics. salbutamol (C class drug), 1 or 2 puffs q4h prn
Use the following: Monitoring and Follow-Up

erythromycin (C class drug), 250 mg PO qid for 7 Arrange for follow-up in 5-7 days if not resolving.
days
or Referral
tetracycline (C class drug), 250 mg PO qid for 7 Usually not necessary.
days
or

Pneumonia
Definition • Chest pain: sharp, localized pleuritic chest pain
Infection of the distal airways, air sacs or both. is seen in acute lobar type only
• Shortness of breath may be present
Causes
In the past, cases of pneumonia were divided into In elderly or chronically ill clients, the symptoms
two categories, bacterial or atypical. In may not be as acute or as obvious. These clients
community-based practices, the following may present with only confusion or a deterioration
classification of community-acquired pneumonia of pre-existing medical problems.
is now commonly used.
• If the patient was previously well or is under As a general rule, pneumonia caused by
65 years of age (or both): Streptococcus Mycoplasma, Chlamydia, viruses and P. carinii
pneumoniae (pneumococcal) and Mycoplasma have a slower, more insidious onset. The client
are the most common causes in younger healthy may not appear as acutely ill and may have a
adults; also, less frequently, Chlamydia lower fever, dry cough and scanty sputum
pneumoniae and Hemophilus influenzae, production.
mycobacterium tuberculosis
• If the patient has comorbid illness or is 65 years Physical Findings
of age or older (or both): Hemophilus • Temperature elevated
influenzae, Klebsiella pneumoniae, Legionella • Heart rate elevated
pneumophila, Moraxella catarrhalis, • Respiratory rate increased
Mycobacterium tuberculosis, Staphylococcus • Oxygen saturation decreased
aureus and, less commonly, Streptococcus • May or may not appear acutely ill
pneumoniae • Flushed, diaphoretic if fever is high
• Viral pneumonia uncommon except in outbreaks • May "splint" the affected side if there is pleuritic
of influenza A and respiratory syncytial virus or pain
as a complication of atypical measles • Variable level of respiratory distress
• Cytomegalovirus and herpes simplex viruses are • Dullness on percussion if there is consolidation
treatable causes of pneumonia in
• Air entry may be decreased
immunocompromised patients
• Inspiratory crackles
• Pneumocystis carinii pneumonia may occur in
immunocompromised patients, especially those
• Wheezes may be present
with HIV or AIDS • Bronchial breathing
• Aspiration of oral pharyngeal secretions, gastric • Pleural rub may be present (rarely)
contents or chemicals may predispose a patient
to bacterial pneumonia. Those at risk for this In elderly clients, the clinical presentation of the
problem include alcoholic people, elderly various types of pneumonias is often atypical or
people, those who have difficulty swallowing, obscured. Overt respiratory signs may be absent.
those with motility or neuromuscular disorders, They may present with changes in level of
and stroke victims consciousness, confusion, functional impairment
such as loss of energy, a decease in appetite or
• No cause is identified in approximately one-
vomiting. These clients are at increased risk of
third to one-half of all cases
death from bacterial pneumococcal disease.
History
There is considerable overlap in the symptoms of
the various types of pneumonias. • TB
• Fever, chills • COPD
• Cough • Acute bronchitis
• Sputum may be yellow, green, blood-tinged • Underlying lung cancer

• Aspiration pneumonia For fever, pain and muscle ache:

• Lung abscess acetaminophen (A class drug), 325 or 500 mg, 1-2
• Atelectasis tabs PO q4-6h prn
Complications Antibiotics:
erythromycin (C class drug), 500 mg PO bid or
• Decompensation of other medical problems
250 mg qid for 10 days
• Respiratory failure from hypoxia or
• Sepsis (bacteremia) clarithromycin (B class drug), 500 mg PO qid for
• Metastatic infection such as meningitis, 10 days
endocarditis, pericarditis, empyema
• Cardiac failure Client > 65 years of age with comorbid illness and
mild-to-moderate pneumonia
Diagnostic Tests cotrimoxazole (C class drug), 800/160 mg PO bid
• Chest x-ray (postero-anterior and lateral) always for 10 days
• Sputum for AFB if history of cough >3 weeks or or
history of previous TB infection amoxicillin/clavulanate (B class drug) if there is
• Sputum for C&S if cough is productive contraindication to sulpha
Management Monitoring and Follow-Up

Goals of Treatment Arrange follow-up within 24-48 hours for
• Relieve symptoms reassessment if shortness of breath develops and
again after the course of antibiotics is completed.
• Improve or prevent respiratory distress
• Prevent complications
Referral
Usually not necessary for patients with mild to
Appropriate Consultation moderate symptoms unless their condition is
Consult a physician for any client with severe
worsening, complications occur or they have
symptoms (e.g. appears acutely ill or has
significant comorbid conditions.
hemoptysis, significant respiratory distress or a
significant comorbid condition such as diabetes
mellitus, heart disease, renal disease or cancer) or Management Of Severe Pneumonia
for any client who has not responded to initial oral Appropriate Consultation
treatment and whose condition is worsening. Consult a physician for any client with severe
symptoms (e.g. appears acutely ill or has
Nonpharmacologic Interventions hemoptysis, significant respiratory distress or a
significant comorbid condition such as diabetes
• Increased bed rest
mellitus, heart disease, renal disease or cancer) or
• Adequate fluid intake (8-10 glasses of fluid per for any client who has not responded to initial oral
day)
treatment and whose condition is worsening.
• Increased humidity in the air (kettle, humidifier
or pot of water on the stove)
Adjuvant Therapy
• Oxygen to keep saturation > 97%
Client Education
• Start IV therapy with normal saline; adjust the
• Explain diagnosis and expected course of illness rate to maintain hydration
medications (dose, frequency, side effects)
IV antibiotics of choice:
Pharmacologic Interventions cefuroxime (B class drug), 750 mg q8h
Client < 65 years of age with no comorbid or
conditions and mild-to-moderate pneumonia clarithromycin (B class drug) 500 mg bid


Monitor oxygen saturation (with pulse oximeter if Medevac to hospital.
available) and vital signs closely.

Emergencies Of The Respiratory System

Pneumothorax
Definition • Penetrating chest trauma (e.g. knife or gunshot
Pneumothorax is partial or complete collapse of a wound)
lung because of the presence of air in the pleural • Blunt chest trauma (e.g. rib fracture)
space. There are 2 categories: spontaneous and
traumatic. History
• Recent trauma
There are 3 mechanisms: closed, open and tension. • Known COPD
Closed pneumothorax: Air from the lung itself • Young, tall, healthy, thin, male, 20-40 years of
leaks into the pleural space through a tear in the age (idiopathic)
lung tissue (e.g. when a fractured rib end tears the
• Smoking
lung), causing the lung to collapse.
• Sudden onset of one-sided chest or shoulder pain
Open pneumothorax (a sucking chest wound): Air • Shortness of breath
from the outside enters the pleural space through a • Symptoms may develop more slowly if the
hole in the chest wall (such as a knife wound), collapse is gradual and the person is able to
causing the lung to collapse. partially compensate.
Tension pneumothorax: This is a special form of Physical Findings

closed pneumothorax, and it is life threatening. Air Physical findings vary, depending on the extent of
is trapped under pressure in the pleural space. It the lung tissue that has collapsed and the
collapses the lung, then pushes on the heart and mechanism of the pneumothorax.
the opposite lung. If the pressure is not quickly
released, the client will become hypotensive and • Heart rate elevated
die. • Respiratory rate elevated
• Blood pressure variable: normal to hypotensive
Causes • Mild to severe respiratory distress, oxygen
• Perforation of the visceral pleura and entry of air saturation decreased
from the lung • Movement of air may be felt over an open chest
• Penetration of the chest wall, diaphragm, wound
mediastinum or esophagus • Hyperresonance (hollow) over the
• Idiopathic (cause unknown, a spontaneous pneumothorax
occurrence) • Breath sound decreased or absent over the
pneumothorax
Risk Factors • Cyanosis (late feature of hypoxia)
• COPD (rupture of an emphysematous bulla or • Decreasing level of consciousness with
bleb) progression
• TB • Loss of radial pulse on affected side
• Cystic fibrosis
• Asthma Late sign: The trachea deviates toward the side of
• Lung neoplasm an open or a closed pneumothorax, but away from
• Flying the side of a tension pneumothorax; the
• Diving mediastinum (apex of the heart) shifts in the same
• Spontaneous vigorous exercise direction as the trachea.
Reference: BTLS
• Smoking

Differential Diagnosis • Locate the puncture site. The second or third

• Pleurisy intercostal space in the midclavicular line on the
• Pericarditis same side as the pneumothorax is recommended
• Pulmonary embolism as the site of approach. An alternate site is the
• Myocardial infarction fourth intercostal space midaxillary line.
• Dissecting aneurysm • Prepare the area with an antiseptic such as
povidone-iodine (Betadine)
Diagnostic Tests • Make a one-way valve by inserting a 13- or
14-gauge angiocatheter through a condom
• Chest x-ray
• Insert the catheter into the skin over the third rib
and direct it over the top of the rib into the
Management interspace (if using the alternate site go over the
Goals of Treatment top of the fifth rib)
• Relieve pressure in the pleural space (tension • Can use a Fisherman’s Chest Seal® over the
pneumothorax) decompression needle, which provides an
• Improve oxygenation ongoing valve.
• Re-expand the collapsed lung
Open Pneumothorax
Appropriate Consultation • Cover the hole in the chest with loose sterile
Consult a physician as soon as possible. gauze taped on three sides
• If a foreign body (e.g. a knife) is protruding
Adjuvant Therapy from the chest wall, do not remove it; stabilize it
• Oxygen to keep saturation > 97% and leave it in place
• Ventilatory assistance as needed with Ambu bag
or mask Monitoring and Follow-Up
• Start IV therapy with normal saline to keep the • Place client on bed rest
vein open; if there has been trauma, start 2 IVs. • Monitor ABC (airway, breathing, circulation)
Volume replacement. (See "Shock" in chapter and lung sounds frequently
14, "General Emergencies and Major Trauma.")
Referral
Nonpharmacologic Interventions Medevac as soon as possible in a pressurized
Tension Pneumothorax aircraft.
This condition is life threatening. The pressure
build-up must be released immediately by needle
decompression of the affected side.

Acute Foreign-Body Obstruction Of An Airway

Complete or partial blockage of the airway with a • Retention of fragment of foreign material
foreign body. • Fracture of ribs or internal injury as a result of
abdominal thrusts
Causes • Decompensation of pre-existing medical
Aspiration (due to eating too quickly, eating and conditions
talking at the same time, neurological disorders, • Death
motility disorders of the esophagus, esophageal
stricture). Management
Goals of Treatment
History And Physical Findings • Dislodge and remove the foreign body
Partial Airway Obstruction • Improve oxygenation
• Clear history of sudden aspiration
• Symptoms of respiratory distress Nonpharmacologic Interventions
• Air entry variable, ranging from adequate to • Perform abdominal thrusts to dislodge foreign
poor body (Basic CPR guidelines)
• With poor air entry, client has limited ability to • Do not use abdominal thrusts when the person is
breathe, talk and cough; cough is weak and able to cough forcefully, breathe and speak
ineffective; severe respiratory distress is present (which indicates partial obstruction with
• With adequate air entry the client can cough adequate air entry); allow the person to clear his
forcefully, talk and breathe; frequently there is or her own airway with spontaneous coughing
wheezing between coughs; severe respiratory and breathing
distress is not present.
Adjuvant Therapy
Complete Airway Obstruction • Assist ventilation as necessary with Ambu bag
• Client unable to speak or breathe or mask once the obstruction has been removed
• Severe respiratory distress • Administer oxygen as necessary once the
• The hands are usually put around the throat in a obstruction has been removed
classic choking signal • Start IV therapy with normal saline to keep vein
• Loss of consciousness will occur if the open if client shows evidence of continuing
obstruction is not quickly relieved respiratory distress
• The victim may be unconscious
• Cyanosis Monitoring and Follow-Up
Monitor the client for development of respiratory
Differential Diagnosis distress (which may indicate retention of fragment
• Anaphylaxis with laryngeal edema (acute of the foreign body).
allergy)
• Airway trauma Appropriate Consultation
• Acute asthmatic attack Consult a physician if the client shows evidence of
continuing respiratory distress (which may
• Any condition that can cause sudden respiratory
indicate retention of fragment of the foreign body).
failure (e.g. stroke, epilepsy, myocardial
infarction, drug overdose)
Referral
Medevac as required for further investigation and
management of continuing respiratory distress.

Pulmonary Embolism
Definition
Sudden obstruction of pulmonary circulation. Older clients may present with increasing
shortness of breath, confusion and restlessness
Causes (which indicate hypoxia).
• Blood clot embolizing from deep pelvic or leg
veins Physical Findings
• Fat embolus (related to fractured femur or The physical findings, like the history, are
pelvis), variable. The results of the examination can be
• Air embolus deceptively normal or obviously abnormal.
Consider pulmonary embolism in any person with
unexplained dyspnea.
Risk Factors
• Prolonged bed rest • Heart rate elevated
• Advanced age • Respiratory rate elevated
• Obesity • Blood pressure normal, elevated or low
(corpulmonale)
• Lower limb trauma
• Mild-to-severe respiratory distress, oxygen
• Oral contraceptives
saturation decreased
• Recent surgery
• Anxiety
• Stroke
• Sweating, pallor and cyanosis may be present
• Pregnancy
• Distension of neck veins with cor pulmonale
• Swelling, redness of calf infrequently present
• Malignant disease
• Calf tenderness may be present
• Peripheral pitting edema may be present
History
• Dullness to percussion may be present (with
Symptoms vary greatly in severity. Pulmonary
infarction and if associated with pleural
embolus may present as three different syndromes.
effusion)
Acute cor pulmonale (right-sided heart failure) is • Air entry may be reduced in affected area
due to massive embolus obstructing 60% to 75% • Crackles and wheezes may be present (with
of the pulmonary circulation. infarction)
• S3 (gallop rhythm) may be present with
Pulmonary infarction occurs in patients with corpulmonale
massive embolism and complete obstruction of a • Loud second heart sound may be present where
distal branch of the pulmonary circulation. not expected
Acute unexplained shortness of breath occurs in Differential Diagnosis

patients who do not have cor pulmonale or • Acute congestive heart failure
infarction. • Myocardial infarction
• Pneumonia
• Sudden onset of shortness of breath (may be the • Viral pleuritis
only symptom) • Pericarditis
• Pleuritic chest pain with infarction
• Cough (rare) Complications
• Hemoptysis may be present in infarction • Pulmonary infarction
• Syncope (faintness) may be present in cor • Cor pulmonale (right heart failure)
pulmonale • Left heart failure with pulmonary edema
• Leg pain (infrequent) • Recurrent emboli
• Anxiety • Death

Diagnostic Tests • If hypotension is present, resuscitate with

• Electrocardiography; results are often normal, appropriate fluid volumes (see "Shock" in
except for tachycardia, but can help rule out chapter 14, "General Emergencies and Major
myocardial ischemia Trauma")
• Chest X-ray
Management Bed rest.
Goals of Treatment
• Prevent death Monitoring and Follow-Up
• Prevent recurrent embolization • Monitor ABC and vital signs frequently if
abnormal
Appropriate Consultation • Assess lung sounds periodically for signs of
Consult a physician as soon as possible. cardiac failure
Adjuvant Therapy Referral

Medevac as soon as possible.
• Oxygen to keep saturation > 97%
If the client has evidence of pulmonary edema,
• Start IV therapy with normal saline; adjust rate refer to "Pulmonary Edema" in chapter 4,
according to state of hydration
"Cardiovascular System."

Inhalation Of Toxic Materials

Inhalation of gases, fumes or particulate matter. • Bronchospasm
• Pulmonary edema
Causes • Acute laryngeal edema
• Household or industrial fires • Obstruction of the upper airway
• Leaky vehicle muffler • Deterioration of pre-existing heart or lung
• Suicide attempt disease
• Chemical exposure in the work place • Death
• Agents: toxic gases, toxic byproducts from the
burning of plastics Diagnostic Tests
• Chest x-ray
History • Baseline blood work (CBC, liver enzymes)
• Exposure to any of the agents listed above NB: time and date on requisitions
• Cough and sputum (which may be black)
• Shortness of breath Management
• Sore throat, hoarseness Goals of Treatment
• Altered consciousness or confusion before • Improve oxygenation
admission • Identify associated injuries to underlying lung
Physical Findings Appropriate Consultation

• Heart rate elevated Consult a physician.
• Respiratory rate increased
• Blood pressure may be elevated Adjuvant Therapy
• Oxygen saturation with pulse oximeter is not • Oxygen 10-12 L/min or more by mask
accurate for carbon monoxide poisoning • Higher-flow oxygen is needed for carbon
• Level of consciousness variable monoxide poisoning -- consult physician
• Degree of respiratory distress variable • Start IV therapy with normal saline; adjust the
• Facial burns, singed eyebrows and nasal hair rate according to the state of hydration
• Soot around or in the nose
• Mucosal irritation or thermal injury of the Pharmacologic Interventions
mouth with erythema and carbon deposits (soot) Bronchospasm is treated with inhaled salbutamol
(See sections on management of asthma, above,
• Other cutaneous burns
this chapter, for details.)
• Irritation of the mucous membranes (eyes)
• Air entry may be reduced Monitoring and Follow-Up
• Stridor or wheeze may be heard Monitor ABC and lung sounds closely.
• A flushed face and rosy red cheeks are
characteristic of carbon monoxide poisoning Referral
Medevac as soon as possible, if indicated
• Drug overdose
• Alcohol intoxication
• Asthma
• Bronchitis
• Acid reflux

Chapter 4 - Cardiovascular System

Assessment Of The Cardiovascular System.................................................................................................... 1
Examination Of The Cardiovascular System.................................................................................................. 3
Differential Diagnosis Of Cardinal Cardiovascular Symptoms...................................................................... 5
Common Problems Of The Cardiovascular System ...................................................................................... 9

Dyslipidemia (Hyperlipidemia) ...................................................................................................................... 9
Angina Pectoris............................................................................................................................................. 11
Congestive Heart Failure .............................................................................................................................. 14
Deep Vein Thrombosis ................................................................................................................................. 18
Hypertension................................................................................................................................................. 20
Dysrhythmias ................................................................................................................................................ 23
Atrial Fibrillation .......................................................................................................................................... 27
Acute Pericarditis.......................................................................................................................................... 29
Arterial Peripheral Vascular Disease ............................................................................................................ 31
Venous Insufficiency (Chronic).................................................................................................................... 33
Aortic Aneurysm (Pulsatile Abdominal Mass)............................................................................................. 34
Emergencies Of The Cardiovascular System ............................................................................................... 35

Myocardial Infarction ................................................................................................................................... 35
Pulmonary Edema......................................................................................................................................... 37
Acute Arterial Occlusion Of A Major Peripheral Artery.............................................................................. 39

Assessment Of The Cardiovascular System

History Of Present Illness And • Associated symptoms (e.g. pain, palpitations,
shortness of breath, lightheadedness, nausea,
Review Of System sweating)
General • Relation to postural changes, vertigo or
The following characteristics of each symptom neurologic symptoms
should be elicited and explored:
• Onset (sudden or gradual) Palpitations
• Chronology • Description: fast or slow, irregular or regular
• Current situation (improving or deteriorating) • Relation to exercise
• Location
• Radiation Sputum
• Quality • Colour (white/pink)
• Timing (frequency, duration) • Consistency (e.g. frothy)
• Severity
• Precipitating and aggravating factors Cyanosis
• Relieving factors • Observation of blue colour of the lips or fingers
(under what circumstances, when first noted,
• Associated symptoms
recent change in this characteristic)
• Effects on daily activities
• Previous diagnosis or history of similar episodes Extremities
• Previous treatments • Site of edema (e.g. in dependent body parts)
• Efficacy of previous treatments • Relation of edema to activity or time of day
• Intermittent claudication
Cardinal Symptoms (exercise-induced leg pain)
• Distance client can walk before onset of pain
above, additional characteristics of specific
related to claudication
• Time needed to rest to relieve claudication
Chest Pain
• Temperature of affected tissue
(warm, cool or cold)
• Associated symptoms (e.g. faintness, shortness
of breath)
• Tingling
• Relation to effort, exercise, meals, bending over • Leg cramps or pain at rest
• Presence of varicose veins
Shortness of Breath
• Relation to exercise (level ground, uphill, stairs) Other Associated Symptoms
• Relation to posture • Sweating
• Orthopnea (number of pillows used for sleeping) • Nausea
• Paroxysmal nocturnal dyspnea • Vomiting
• Associated swelling of ankles or recent weight
gain Medical History (Specific To
Cardiovascular System)
Fainting or Syncope • Age
• Weakness, lightheadedness, loss of • Increased cholesterol level
consciousness • Hypertension
• Coronary artery disease (angina)
• Myocardial infarction

• Cardiac murmurs • Myocardial infarction (especially in family

• Rheumatic fever members < 50 years of age)
• Valvular heart disease • Sudden death from cardiac disease
• Diabetes mellitus • Hypercholesterolemia
• Thyroid disease • Hypertrophic cardiomyopathy
• Chronic renal disease • Rheumatic fever
• Chronic obstructive pulmonary disease (COPD)
• Systemic lupus erythematosus Personal And Social History (Specific
• Recent viral illness (e.g. viral cardiomyopathy) To Cardiovascular System)
• Smoking
Family History (Specific To • Exposure to secondhand smoke
Cardiovascular System) • Obesity
• Diabetes mellitus • High stress levels (personal or occupational)
• Hypertension • Chronic abuse of cocaine, amphetamines,
• Coronary artery disease (ischemic) anabolic steroids
• Heart disease • Alcohol abuse
• Diet - caffeine intake

Examination Of The Cardiovascular System

An examination of the cardiovascular system Heart Sounds
involves more than just examining the heart. The • Determine rate and rhythm
examination generally covers two systems: the • Determine if there is an underlying rhythm or if
central cardiovascular system (head, neck and rhythm is completely irregular
precordium [anterior chest]) and the peripheral • Identify and describe intensity of first and
vascular system (extremities). Examination of the second heart sounds
cardiovascular system must also include a full
• Identify extra sounds (S3, S4, splitting of second
assessment of the lungs and neuromental status
sound, rubs)
(for signs of confusion, irritability or stupor).
Murmurs
Vital Signs
• Timing (in relation to the cardiac cycle)
• Temperature
• Quality
• Pulse
• Intensity (loudness)
• Respiratory rate
• Location where murmurs sound loudest
• Oxygen saturation
• Radiation
• Blood pressure (lying and standing,
in both arms)
• Pitch
Head And Neck Bruits

• Central cyanosis • Carotid
• Colour of conjunctiva • Abdominal
• Iliac
• Jugular venous pressure
• Carotid bruits • Femoral
Inspection Of Precordium (Anterior Extremities

Hands
Chest)
• Colour of skin, nail beds
• Look for visible pulsations of the chest wall
• Nicotine stains
• Clubbing of fingers
Palpation • Temperature
• Location of apical beat (point of maximum • Equality of pulses (brachial, radial)
impulse [PMI])
• Synchrony of radial and femoral pulses
• Quality and intensity of apical beat (normal, • Capillary refill time
diffuse, weak, forceful)
• Heave (abnormally forceful PMI) Legs
• Thrill (a palpable murmur that feels like a purr) • Colour (pigmentation, discoloration),
• Identify and assess pulsations and thrills in distribution of hair
aortic, pulmonic, mitral and tricuspid areas, • Temperature, texture
along left and right sternal borders, in
• Capillary refill time
epigastrium and along left anterior axillary line
• Changes in foot colour with changes in leg
position (e.g. blanching with elevation, rubor
Auscultation with dependency)
• Listen to normal heart sounds before trying to • Ulcers, varicose veins, edema (check sacrum if
identify murmurs client is bedridden)
• Use diaphragm of stethoscope first, then bell of • Presence and equality of pulses (femoral,
stethoscope, when listening to the heart popliteal, posterior tibial, dorsalis pedis)
• Listen at apex, in aortic and pulmonic areas, and
along left sternal border

Other Assessments
For a client whose condition is not of an urgent
nature, assess the following:
• Evidence of hypertensive or diabetic
retinopathies (funduscopic exam)
• Colour, temperature, rashes, lesions, xanthoma
of skin
• Abdominal bruits, enlargement of liver,
tenderness in right upper quadrant of abdomen

Differential Diagnosis Of Cardinal Cardiovascular Symptoms

Chest Pain
Table 1: Differential Diagnosis of Chest Pain

Myocardial
Characteristic of infarction or acute
Angina Unstable Angina Pneumonia
chest pain coronary
insufficiency
Onset Sudden, patient at With exertion New onset, or Gradual or sudden
rest changing pattern
Location Retrosternal, Retrosternal, Anterior, lateral
anterior chest anterior chest and/or posterior
lung field(s)
Radiation Left arm, left Left arm, left Anterior chest,
shoulder, neck, jaw, shoulder, neck, jaw, shoulder, neck
back, upper back, upper
abdomen abdomen
Duration >20min Usually 1-2 min Increasing Hours
Intensity Severe Mild to moderate Increasing Moderate
Quality Sensation of Sensation of Constant ache, with
squeezing, pressure tightness, pressure intermittent knife-
like pain
Relief None Rapid relief with Not relieved by rest None
rest and/or or sublingual
sublingual nitroglycerin
nitroglycerin
Precipitating or None may be Exertion, heavy Increased pain with
aggravating obvious meal, walking uphill coughing or deep
factors against a cold wind inspiration; recently
ill with a cold
Associated signs Nausea, sweating, Typically none Fever, cough,
and symptoms shortness of breath, sputum, shortness of
anxiety, palpitations breath

Esophageal,
Musculo- Stress or
Characteristic Pulmonary gastric or
Pericarditis skeletal emotional
of Chest Pain embolism* duodenal
disorder disorder
disorder
Onset Sudden Gradual or Gradual or Gradual or Gradual or
sudden sudden sudden sudden
Location Retrosternal, Retrosternal, Anterior, lateral Retrosternal, Variable,
anterior chest, anterior chest and/or posterior epigastric, left anterior chest,
lateral chest chest wall chest, left or left chest
right upper
quadrant
Radiation Variable Variable; Arm, shoulder, May be felt in Usually none
shoulder tip, neck, back, back or arm
neck abdomen
Duration Variable Hours to days Minutes or hours Minutes or hours Minutes or hours
Intensity Absent or mild Usually Mild to moderate Moderate Mild to moderate
to moderate moderate, but
may be severe
Quality Dull ache; knife- Sharp Dull ache; sharp Burning Achy, stabbing
like pain may pain may also be (usually),
also be present present tightness
Relief None Sitting up and Rest, mild Antacids, milk, Rest, relaxation,
leaning forward analgesics sitting up or distraction
often helps; other standing up
position may
alter the pain
Precipitating or Immobilization; Previous History of Certain foods, a Stressful
aggravating none may be infection of unaccustomed large meal, situations,
factors obvious; pain upper respiratory physical work; bending over; fatigue
may be worse tract; pain worse pain worse with pain may awaken
with deep with deep arm action person from
inspiration or inspiration or sleep and may
coughing coughing occur when
stomach is empty
Associated signs Shortness of Symptoms of Localized chest- Regurgitation of Tightness in
and symptoms breath, sweating, infection of wall tenderness, acid in mouth, neck and
hemoptysis, leg upper respiratory tender belching, shoulder(s),
pain (rare) tract may be costochondral difficulty headaches,
present; malaise; area swallowing, reduced appetite,
usually occurs in sticking mild weight loss,
younger adults sensation when fatigue, sleep
food swallowed, disturbance,
cough (rare); test palpitations,
of stool for dizziness,
occult blood may hyperventilation
be positive symptoms
*Chest pain may be absent in pulmonary embolism

Dyspnea function and are usually precipitated by a

Cardiac Causes reduction in cerebral perfusion.
• Congestive heart failure (right, left or
biventricular) Vascular Causes
• Coronary artery disease • Vasovagal hypotension (common faint)
• Myocardial infarction (recent or past history) • Postural hypotension
• Cardiomyopathy • Cerebrovascular disease (transient ischemic
• Valvular dysfunction attack, stroke, vertebral-basilar insufficiency,
• Left ventricular hypertrophy carotid insufficiency)
• Asymmetric septal hypertrophy
• Pericarditis
Neurological Causes
• Seizure
• Arrhythmias
• Head trauma
Pulmonary Causes
• COPD Cardiac Causes
• Abnormally slow heart rate and rhythm
• Asthma
• Abnormally rapid heart rate and rhythm
• Restrictive lung disorders
• Reduced cardiac output
• Hereditary lung disorders
• Acute blood loss (gastrointestinal hemorrhage)
• Pneumothorax
• Valvular heart disease (aortic or pulmonic
stenosis)
Mixed Cardiac and Pulmonary Causes
• COPD with pulmonary hypertension and cor • Pulmonary hypertension
pulmonale
• Deconditioning Other Causes
• Hyperventilation (syncope rare, faintness
• Chronic pulmonary emboli
common)
• Trauma
• Hypoxia
Noncardiac or Nonpulmonary Causes
• Metabolic conditions (e.g. acidosis) Palpitations
Primary Arrhythmic Causes
• Pain
• Sinus tachycardia or arrhythmia
• Neuromuscular disorders
• Premature supraventricular or ventricular
• Otorhinolaryngeal disorders
ectopic contractions
• Bradycardia-tachycardia syndrome ("sick sinus
Functional Causes
syndrome")
• Anxiety
• Supraventricular tachycardia
• Panic disorders
• Multifocal atrial tachycardia
• Hyperventilation
• Atrial fibrillation, flutter or tachycardia
• Exertion
• Atrioventricular nodal re-entrant tachycardia
• Atrioventricular reciprocating tachycardia
Faintness And Syncope (Wolff-Parkinson-White syndrome)
Faintness is characterized by transient symptoms
of lack of strength associated with an impending
• Accelerated junctional rhythm
sense of loss of consciousness. Syncope is • Ventricular tachycardia
characterized by transient symptoms of • Bradycardia due to advanced atrioventricular
generalized weakness associated with loss of block or sinus node dysfunction
consciousness and loss of muscle tone. Symptoms
are due to a temporary impairment of cerebral

Extracardiac Causes • ß2-Agonists

• Changes in contractility, heart rate or stroke • Antiarrhythmics
volume
• Fever Psychiatric Causes
• Hypovolemia • Panic attack
• Anemia • Hyperventilation
• Hypoglycemia
• Pulmonary disease Other Cardiac Causes
• Pheochromocytoma • Changes in contractility or stroke volume
• Thyrotoxicosis • Valvular disease such as aortic insufficiency or
• Vasovagal episodes stenosis
• Atrial or ventricular septal defect
Drug-Related Causes • Congestive heart failure
• Vasodilators • Cardiomyopathy
• Substance abuse (e.g. cocaine, alcohol, tobacco, • Congenital heart disease
caffeine) • Pericarditis
• Digoxin • Pacemaker-mediated tachycardia
• Phenothiazine • Pacemaker syndrome
• Theophylline
Leg Edema
Table 2: Differential Diagnosis of Leg Edema
Mechanism Disease or syndrome Usual clinical features
Increased capillary pressure
Obstruction of inferior vena cava Thrombosis, malignancy Bilateral, severe (may be mild if
partial obstruction)
Deep venous obstruction in leg Thrombosis, extrinsic compression Unilateral, mild
Reduced venous channels or venous Coronary bypass grafting, stroke, Unilateral or bilateral, mild
valve incompetence varicosities
Right atrial hypertension Left ventricular dysfunction Bilateral

Pulmonary disease Bilateral
Valve disease Bilateral
Renal dysfunction Bilateral, mild
Reduced lymphatic clearance Lymphadenopathy, filariasis Unilateral or bilateral
(lymphatic obstruction)
Decreased capillary oncotic Severe malnutrition; liver, renal, Bilateral, mild or severe, generalized,
pressure (hypoalbuminemia) gastrointestinal disease poor prognosis
Increased capillary permeability Calcium-channel blockers Bilateral, mild

Idiopathic cyclic edema Bilateral, mild, premenstrual female

Common Problems Of The Cardiovascular System

Dyslipidemia (Hyperlipidemia)
Definition • Previously identified hypercholesterolemia (total
Cholesterol has three clinically significant cholesterol > 6.2 mmol/L)
components: high-density lipoprotein (HDL), low- • Previously identified low levels of HDL
density lipoprotein (LDL) and very-low-density cholesterol (< 0.9 mmol/L)
lipoprotein (VLDL). Elevation in serum • Smoking
lipoproteins are a major risk factor for coronary • Hypertension: blood pressure of 140/90 mm Hg
artery disease. confirmed on repeated determinations or while
client is taking antihypertension medication
The two main lipids in blood are cholesterol and
• Antecedent cardiovascular disease or family
triglyceride. Triglyceride is found in VLDL
history of premature myocardial infarction (in
particles, but its role in atherosclerosis is not clear.
people < 55 years of age)
A high level of triglycerides (> 11.0 mmol/L)
carries a risk for pancreatitis. • Endocrine disease (diabetes mellitus or
secondary causes, including hypothyroidism,
Dyslipidemia is one of the primary causes of renal disease or medications)
atherosclerotic plaque. Up to 75% of patients with • Men > 45 years of age are at greater risk
coronary artery disease have dyslipidemia. • Postmenopausal women (> 55 years of age) and
Normalization of lipid values will both lower the younger women with artificial menopause and
rate of symptomatic coronary artery disease and no hormonal replacement are at greater risk
improve overall survival. Dyslipidemia is strongly
associated with recurrence of symptomatic Physical Findings
coronary artery disease. • Blood pressure may be elevated if hypertensive
• Arcus corneae (significant in a younger person)
Causes • Retinopathies (seen on funduscopy)
Primary Hyperlipidemia • Xanthomas (lipid deposits)
Primary (genetic) single-gene disorders are • Arterial bruits may develop if atherosclerosis is
transmitted by simple dominant or recessive present
mechanism.
• Peripheral pulses may be diminished if
Secondary Hyperlipidemia atherosclerosis is present
Secondary hyperlipidemia occurs as part of a • Obesity
constellation of abnormalities in certain metabolic
pathways. Complications
• Hypothyroidism • Cardiac disease or atherosclerosis (e.g. angina,
• Pregnancy myocardial infarction)
• Excess weight • Pancreatitis (hypertriglyceridemia)
• Excess alcohol intake
• Obstructive liver disease Diagnostic Tests
• Nephrotic syndrome Guidelines for Lipid Testing
• Medications (e.g. thiazide diuretics, some ß- Screening for dyslipidemia by means of a fasting
blockers, oral contraceptives, corticosteroids) lipid profile (total cholesterol, HDL cholesterol,
triglycerides and LDL cholesterol) is suggested for
History the following groups.
• Ask about risk factors and possible causes of
secondary hyperlipidemia. Patients with atherosclerotic vascular disease:
Every 1-3 years, as clinically indicated,
up to age 75

Patients with xanthomas or a family history of Optimal Control of Other Diseases Related to
atherosclerotic vascular disease: the Development of Heart Disease
One-time measurement when young. If previous • For hypertension, target blood pressure: systolic
test results are normal, repeat at age 30 and resume < 140 mm Hg, diastolic < 90 mm Hg
testing every 5 years from age 40 for men and age • For diabetes mellitus, aim for optimal, realistic
50 for women blood glucose level
• Diet and lifestyle modification
Patients with diabetes mellitus: • Appropriate pharmacologic agents
Every 1-3 years, as clinically indicated
Men 40-70 years of age, women 50-70 years of • Refer to physician
age, even those with no other risk factors: • Fibrates (e.g. gemfibrozil)
Every 5 years • HMGCoA reductase inhibitors ("statins,"
Lipid test results should be interpreted in light of e.g. lovastatin, simvastatin, pravastatin)
other risk factors for coronary artery disease.
• Bile acid sequestrants (e.g. cholestyramine)
• Nicotinic acid (niacin)
Management
Goals of Treatment Combinations of several drugs can be used, and it
• Decrease cardiovascular disease by modifying is safe to use resins in all combinations. However,
serum cholesterol combinations of statins with fibrates or niacin
• Prevent pancreatitis from severe should be used with caution because of an
hypertriglyceridemia increased frequency of more severe muscle and
liver complications.
Primary prevention is aimed at identifying
dyslipidemia before complications occur Monitoring and Follow-Up
Target: LDL cholesterol < 4.1 mmol/L if client has Follow-up is important; check the response to
< 2 cardiovascular risk factors treatment within 6 weeks (safety blood tests
Target: LDL cholesterol < 3.4 mmol/L if client has should be carried out early) and, if the results are
> 2 cardiovascular risk factors satisfactory, continue follow-up at regular
intervals thereafter (every 3-12 months).
Secondary prevention is directed at reducing the
Monitor liver function, cytokinase, complete blood
impact of dyslipidemia for people with previous
count and creatinine 3, 6 and 12 months after
cardiovascular disease. These targets are aimed
initiation of lipid-lowering drugs and annually
specifically at high-risk patients and are more
thereafter.
stringent than those recommended for the general
Frequency of testing to monitor treatment of
population.
dyslipidemia:
Target: LDL cholesterol < 2.6 mmol/L
Patients on diet therapy only:
Nonpharmacologic Interventions Initiation: Every 3-6 months to 1 year
• Dietary modification aimed at lowering lipid Maintenance: Every 6-12 months
levels should always be the first approach to
treating dyslipidemias (a 6-month dietary trial is Patients on diet and drug therapy:
mandatory before medications are prescribed) Initiation of drug therapy: Every 6-8 weeks to 6
• During dietary modification, repeat lipid months, depending on severity
measurements 2 or 3 times Maintenance: Every 3 months in the first year,
• Weight reduction every 6-12 months thereafter
• Smoking cessation Referral
• Increased physical activity Refer all clients diagnosed with hyperlipidemia to
a physician for evaluation and to determine
whether lipid-lowering medications are needed.

Angina Pectoris
Definition area, radiating down one or both arms for 5
Heart disease that occurs as a result of inadequate minutes or less, precipitated by exercise or
oxygen and blood supply to the myocardium. emotional stress and relieved by rest or
nitroglycerin.
Types
Stable Angina Unstable Angina
Predictable pattern of exertional pressure sensation More severe anginal pain that lasts more than 30
in the anterior chest relieved by rest or minutes or that occurs during rest and is not
nitroglycerin. No change in frequency, severity or relieved by rest or sublingual nitroglycerin.
duration of angina episodes during the preceding 6
weeks. Associated Symptoms
• Dyspnea
Unstable Angina • Nausea or vomiting
Angina that is of new onset, or is changing, so that • Sweating
it is occurring with increasing severity, frequency • Weakness
or duration or is occurring at rest. • Palpitations
Myocardial Infarction Physical Findings

For details of this type of angina, refer to • Diaphoresis
"Emergencies of the Cardiovascular System," • Apprehension
below, this chapter. • Oxygen saturation (may be normal or abnormal
in myocardial infarction)
Causes • Blood pressure (may be elevated or reduced in
Angina pectoris is the result of myocardial myocardial infarction)
ischemia, which occurs when the cardiac workload
• Tachycardia
and myocardial oxygen demands exceed the
• S4 gallop
ability of the coronary arteries to supply
oxygenated blood. It is the main clinical
These findings are transient in stable angina and
expression of coronary artery disease (subintimal
disappear when the pain resolves. People with
deposition of atheromas in the large and medium-
stable angina are usually seen in a clinic after an
sized arteries serving the heart).
attack because of the mild, short, episodic nature
of the discomfort. After an episode there are
Risk Factors usually no significant physical findings.
• Hypertension
• Hyperlipidemia Differential Diagnosis
• Diabetes mellitus • Chest-wall pain
• Cigarette smoking • Other musculoskeletal discomfort
• Family history of premature coronary artery • Peptic ulcer disease
disease (e.g. father died of coronary artery
• Gastroesophageal reflux
disease before reaching 60 years of age)
• Use of oral contraceptives • Esophageal spasm
• Sedentary lifestyle • Indigestion
• Obesity (particularly with a truncal distribution) • Anxiety attack
• Pulmonary emboli
History • Pericarditis
Stable Angina • Aortic dissection
Chest pain described as tightness, pressure or • Pneumothorax (spontaneous)
aching that is typically located in the substernal

Complications Monitoring and Follow-Up

• Unstable angina • Follow up every 6 months once client's
• Future myocardial infarction symptoms are stable
• Monitor symptoms and identify any changes,
Diagnostic Tests especially increases
• Electrocardiogram (ECG) changes (depression • Monitor weight and smoking
of ST segment, inversion of T wave) • Monitor blood pressure and pulse
• Compare current ECG tracing with previous • Obtain regular blood work as directed
one, if available; look for signs of ischemia • Monitor adherence and response to long-term
(depression of ST segment, inversion of T wave, lifestyle modifications and medications (e.g. ß-
new changes) blockers)
• Obtain complete blood count, and determine
blood glucose, creatinine and cholesterol levels Referral
Refer all previously undiagnosed clients and any
Management Of Stable Angina clients whose symptoms are not controlled on
Goals of Treatment current therapy to a physician for a thorough
• Decrease or prevent recurrence of pain evaluation. Once the condition has been stabilized,
the client should be assessed by a physician at
• Identify and manage risk factors
least annually.
• Improve exercise tolerance
Management Of Unstable Angina
For anyone who has pain on presentation at the
Appropriate Consultation clinic, anyone with a history of angina of recent
Consult a physician as soon as possible for help
onset or anginal symptoms at rest, and anyone
with diagnosis and treatment options.
with known heart disease and an increase or
change in anginal pattern and ECG changes.
Client Education
• Ensure that client understands disease process Appropriate Consultation
• Encourage client to make lifestyle changes (e.g. Consult a physician as soon possible.
dietary modifications to reduce fat and
cholesterol) Adjuvant Therapy
• Encourage client to reduce weight, stop • Oxygen to keep saturation > 97%
smoking, avoid strenuous exercise but increase
• Start IV therapy with normal saline to keep vein
moderate exercise (e.g. walking)
open
Pharmacologic Interventions Nonpharmacologic Interventions
For prophylaxis against thrombus formation:
Bed rest for clients experiencing pain on
enteric-coated acetylsalicylic acid (ASA) (A class
presentation.
drug), 325 mg od, if not contraindicated and client
is not already using
nitroglycerin (C class drug), 0.3-mg SL tab stat;
For acute episodes of angina:
repeat dose twice, q5min
nitroglycerin (C class drug), 0.3- to 0.6-mg SL
tabs or lingual spray (0.4 mg) prn
If the client is hypotensive or has bradycardia on
presentation, do not give nitroglycerin without
For long-term prophylaxis: according to physician
first consulting a physician. If pain is not relieved,
order.
treat as myocardial infarction (see "Myocardial
Infarction," this chapter).


Continue to closely monitor pain, vital signs Medevac as soon as possible.
(including oxygen saturation), heart and lung
sounds, and ECG results. Coronary artery bypass surgery or angioplasty
may be indicated for any client who continues to
have significant symptoms despite maximal
medical therapy.

Congestive Heart Failure

Definition • Chronic, nonproductive cough, worse at night or
A clinical syndrome caused by an accumulation of when lying down
fluid peripherally (right ventricular failure) or in • Ankle edema
the lungs (left ventricular failure), or both, from • Recent weight gain
inadequate functioning of the heart. Congestive • Nocturia
heart failure is a complication of an underlying • Chronic fatigue
disease process. • Palpitations
• Symptoms of intercurrent illness (e.g.
Systolic heart failure (the more common form) is pneumonia)
due to impaired systolic pumping action of the
• Anxiety may aggravate condition
heart. Diastolic heart failure occurs when the
systolic function is normal but the filling of the
• Alterations of mental status in elderly clients
may be present as chronic heart failure
heart is impaired.
progresses
• Increased number of pillows to sleep
Causes (Precipitating Factors In
(orthopnea)
Acute Heart Failure)
Increased Myocardial Demand Physical Findings
• Stress (physical, environmental or emotional) There is a broad range in severity of findings.
• Infection or fever • Heart rate elevated
• Anemia • Respiratory rate increased
• Hyperthyroidism • Blood pressure may be normal, elevated or low
• Hypertension • Weight increased (reflecting fluid retention)
• Pregnancy • Minimal to extreme distress when client lies
• Renal disease down
• Jugular venous distension may be present
Compliance and Lifestyle • Jugular venous pressure elevated (> 3 cm)
• Inadequate or improper medication intake (i.e. • Edema may be present (pedal, ankle or tibial;
NSAIDs) sacral if bedridden)
• Dietary indiscretion (e.g. excess consumption of • Hepatomegaly
salt or water)
• Hepatojugular reflux
• Heavy alcohol consumption • Ascites (rare)
• Lung bases may be dull (pleural effusion)
Decreased Pump Function of the
bilaterally, but only rarely
Ventricles
• Fine crackles in the bases of lungs
• Negative inotropic medications: ß-blockers,
calcium-channel blockers, antiarrhythmics,
• S3, S4 or gallop rhythm may be present;
murmurs may be present if there is associated
chemotherapeutic agents
valvular dysfunction
• Arrhythmias
• Ischemia or infarction
• See "Causes," above.
• Radiation treatment
• Acute bronchitis in COPD or asthma
• Other causes of edema (renal disease, liver
History disease, local venous stasis, lymphedema)
• Shortness of breath (initially induced by • Pulmonary embolism
exercise)
• Later progression to orthopnea, paroxysmal
nocturnal dyspnea and dyspnea at rest

Complications underlying or precipitating cause (e.g. atrial

• Arrhythmias fibrillation).
• Hepatomegaly (ascites)
• Acute pulmonary edema Appropriate Consultation
• Hypokalemia from use of diuretics Consult a physician as soon as possible.
• Angina
Client Education
• Decreased renal function, decreased renal
clearance of drugs (digoxin toxicity) • Ensure client understands disease process and
outcome (progressive, can be controlled but not
cured)
• Side effects of medication
• Recommend dietary modifications: reduce
sodium, increase dietary potassium (if renal
Diagnostic Tests function has been adequate in the past), reduce
• Perform ECG and compare with any previous fat and cholesterol
tracings • Recommend limited fluid intake to
• Look for signs of ischemia (depression of ST 1.2-2.0 L/day
segment, inversion of T wave), atrial fibrillation, • Recommend restriction of alcohol use
bradycardia • Recommend weight loss, if applicable
• Recommend that client monitor weight at home,
Do the following diagnostic tests only if the
and see the nurse if he or she gains more than
person is not ill enough to require hospitalization:
1.5 kg (3 lb) in a day
• Complete blood count
• Recommend rest after meals
• Blood glucose level
• Encourage client to start an exercise program
• Thyroid function (walking) to improve exercise tolerance
• Liver function • Stress the importance of long-term follow-up
• Ferritin level (every 3-6 months when stable)
• Creatinine level • Counsel client about appropriate use of
• Electrolyte levels medications (dose, frequency, compliance,
• Digoxin level (if applicable) and if not side effects)
determined recently (within past 3 months) • Teach clients taking digoxin, or family member,
• Chest x-ray (for cardiomegaly, pulmonary to monitor pulse
edema, pleural effusions), if available
Adjuvant Therapy
Management Of Chronic Heart • Pneumococcal vaccine
Failure • Influenza vaccine annually
Goals of Treatment
• Control symptoms Pharmacologic Interventions
• Identify and manage underlying cause Four classes of drugs are currently recommended
• Limit factors that precipitate or aggravate to manage congestive heart failure: angiotensin-
condition converting enzyme (ACE) inhibitors, diuretics,
• Prevent progression cardiac glycosides, and nitrates or direct
• Improve quality of life and survival vasodilators, prescribed by physician.
Because there is a broad range of severity, Nitrates

assessment of severity will help guide A long-acting nitroglycerin preparation to reduce
management. Definitive and precise medical the workload of the heart is often recommended to
management depends on whether the failure is due reduce symptoms and improve exercise tolerance
to systolic or diastolic dysfunction and the in clients who cannot tolerate ACE inhibitors or
who remain symptomatic despite maximal therapy

with ACE inhibitors, diuretics and digoxin or if Long-Term Monitoring and Follow-Up
there is myocardial ischemia (i.e. systolic blood • Review cardiac and respiratory systems for
pressure > 100 mm Hg). symptoms
• Weigh client and chart weight every visit (client
Vasodilators weight chart)
Vasodilators such as hydralazine may also be used • Review current medications for use, dosage,
in combination with nitrates in clients with frequency, compliance, side effects, drugs with
refractory symptoms despite use of ACE sodium-retaining effects (e.g. NSAIDs)
inhibitors, diuretics and digoxin or those who • Instruct client to return to clinic if symptoms
cannot tolerate ACE inhibitors. worsen or chest pain develops
• Laboratory tests every 3-6 months: complete
ß-Blockers blood count, creatinine level, electrolyte levels,
ß-Blockers such as metoprolol can be used in uric acid level (if taking a thiazide diuretic),
clients with chronic congestive heart failure to urinalysis for proteinuria, digoxin level
preserve or improve ventricular function. They can
be used to control symptoms of ischemia in clients Referral
with congestive heart failure and angina. Refer client to a physician for a thorough
evaluation and tailoring of drug therapy regimen.
ß-Blockers should be avoided in clients with low
cardiac output and should be used only with
extreme caution in clients with obstructive lung
Management Of Acute
disease (e.g. asthma). Decompensated Heart Failure
Calcium-Channel Blockers Consult a physician as soon as possible.
Calcium-channel blockers may be used in clients
with diastolic congestive heart failure to control Adjuvant Therapy
arterial blood pressure and to help induce • Oxygen to keep saturation > 97%
regression of myocardial hypertrophy. They are • Start IV therapy with normal saline to keep vein
also useful in client with hypertrophic open
cardiomyopathy.
Calcium-channel blockers are generally Bed rest with head elevated.
contraindicated in systolic heart failure and in
clients who have had myocardial infarction with Pharmacologic Interventions
left ventricular dysfunction. Diuretics:
furosemide (D class drug), 40-80 mg IV
Antiarrhythmic Drugs
Antiarrhythmic drugs are generally used for The dose may have to be higher in a person who is
symptomatic clients with sustained ventricular already taking this drug on a maintenance basis for
arrhythmias or to help maintain sinus rhythm in congestive heart failure; one guideline is to double
atrial fibrillation. the client's usual maintenance dose. Adjust the
diuretic dose according to client's response. Look
Anticoagulation for improvement in respiratory status.
Anticoagulation is strongly recommended for all
clients with heart failure and associated atrial Nitrates (long-acting) to reduce the workload of
fibrillation. the heart:
topical nitroglycerin (B class drug), 1.25-2.5 cm
q6-8h, provided systolic blood pressure > 100 mm
Hg

Monitoring and Follow-Up • Record intake and urinary output

• Monitor vital signs, pulse oximetry • Monitor response to therapy
• Airway, breathing and circulation (ABC)
• Level of consciousness Referral
• Listen to heart and lung sounds Medevac as soon as possible.

Deep Vein Thrombosis

Acute formation of a blood clot or thrombus • Variable; depend on size and location of clot and
within a vein resulting in obstruction of venous severity of venous obstruction
return. • Heart rate may be elevated
• Minimal to moderate distress
Causes • Difficulty walking
Unknown, but the triad of venous stasis, injury to • Minimal to marked swelling of lower leg
vessel intima and altered blood coagulability are • Redness of affected calf or leg may be present
central to the process. • Superficial leg veins may be distended
• Mild to moderate calf tenderness: flexion of the
Risk Factors ankle may increase pain
• Prolonged bed rest/decreased activity for any • Localized warmth may be present
reason
• Peripheral pulses (compare sides for symmetry)
• Paralysis
• Malignant disease
• Childbirth
• Calf-muscle strain
• Pregnancy
• Trauma with hematoma
• Use of oral contraceptives
• Cellulitis
• Leg trauma
• Ruptured Baker's cyst (popliteal cyst)
• Major surgery
• Infection after orthopedic surgery
Complications
• Acute myocardial infarction
• Stroke
• Chronic venous insufficiency
• Old age (related to decreased activity)
Diagnostic Tests
History None.
• Symptoms may be subtle, variable or vague
• Usually occurs in leg or deep pelvic veins Management
(popliteal, femoral, iliac) Goals of Treatment
• Presence of one or more risk factors (see above) • Early detection
• Recent leg injury • Prevent complications
• Leg pain may be mild or absent
• Pain described as a dull ache or tightness, rarely Appropriate Consultation
severe Consult a physician immediately if you have any
• Leg discomfort worse when walking suspicion of this disorder.
• Swelling of lower leg
• Fever Nonpharmacologic Interventions for
Acute Symptoms
Symptoms may be absent or minimal until • Bed rest
shortness of breath and other pulmonary • Elevation of leg above level of the heart
complaints appear because of embolism to the • Anti-embolic stockings
lungs. The risk of pulmonary emboli is low when • Monitor vital signs closely
only the calf veins are involved but increases to
40% when the thigh veins are involved.

Nonpharmacologic Interventions over Monitoring and Follow-Up

the Long Term Acute Symptoms
Client Education Observe client for shortness of breath or
• Counsel client about appropriate use of unexplained tachycardia (signs of pulmonary
medications (dose, frequency, side effects) embolism).
• Recommend use of anti-embolic stockings
• Recommend avoidance of restrictive clothing Long Term
around knees (e.g. socks, garters) • Follow up every 3-6 months when stable
• Ensure bedridden clients are turned and • Review prevention strategies, medication use,
repositioned frequently (q2h) side effects
• Recommend active or passive leg exercises
while in bed Referral
Medevac the acutely symptomatic client as soon
Pharmacologic Interventions as possible.
Heparin therapy may be instituted on advice of
physician before transfer.

Hypertension
Definition • Usually asymptomatic
Persistently elevated blood pressure from • Headache on rising in the morning gradually
increased peripheral arterial resistance related to subsiding during the day (rare)
salt or water retention or endogenous pressure • Fatigue
activity. • Transient ischemic attack
• Nausea or vomiting
Causes • Altered level of consciousness
Cause of essential hypertension (which accounts • Palpitations
for 90% of cases of hypertension) is unknown. • Angina
• Symptoms of cardiac failure
Risk Factors for Primary (Essential) • Epistaxis
Hypertension
• Heredity Physical Findings
• Obesity Diastolic Blood Pressure Readings
• High salt intake • High-normal diastolic pressure (85-89 mm Hg)
• Smoking • Mild diastolic hypertension (90-99 mm Hg)
• High alcohol consumption • Moderate diastolic hypertension
• Chronic stress (100-109 mm Hg)
• Age • Severe diastolic hypertension (110-119 mm Hg)
• Hyperlipidemia • Very severe hypertension (> 120 mm Hg)
Risk Factors for Secondary Hypertension Systolic Blood Pressure Readings
(10% of Cases) • Normal systolic pressure (< 140 mm Hg)
• Renal disease • Mild systolic hypertension (140-159 mm Hg), if
• Polycystic kidneys diastolic readings are within normal range
• Renal vascular disease • Moderate systolic hypertension
• Estrogen use (160-179 mm Hg)
• Pregnancy • Severe systolic hypertension (180-209 mm Hg)
• Hyperthyroidism (Cushing's syndrome) • Very severe hypertension (> 210 mm Hg)
• Primary hyperaldosteronism • Isolated systolic hypertension (> 160 mm Hg), if
• Pheochromocytoma diastolic readings are within normal range
• Coarctation of aorta
• Use of oral contraceptives Other Findings
• Chronic alcohol abuse • Ocular funduscopic exam may reveal retinal
changes
History • Enlarged heart (left ventricular hypertrophy)
• Presence of one of the risk factors (see above) • Bruits (carotid, abdominal aortic, renal and
• Client usually > 35 years of age femoral)
• Condition usually discovered on routine
screening of blood pressure; the Canadian Task Differential Diagnosis
Force on Preventive Health Care (1994) • Essential hypertension
suggests screening everyone between 21 and 64 • Secondary hypertension
years of age at every office visit
(B recommendation; i.e., good evidence to
include in the periodic health examination)
www.ctfphc.org (last accessed August 2003)

General Clues to Secondary Nonpharmacologic Interventions

Hypertension Lifestyle modifications are first-line therapy for
• Severity of high blood pressure: severe mild elevation of blood pressure.
hypertension is more likely secondary to a
specific underlying cause Client Education
• Speed of onset: if hypertension develops rapidly, • Ensure that client understands disease process
it should be considered secondary until proven and prognosis
otherwise • Encourage client to lose weight if appropriate
• Age at onset: rapid onset in people younger than • Recommend dietary modifications (e.g. reduce
25 years or older than 55 years should suggest salt to < 150 mmol/day, reduce cholesterol, and
secondary hypertension reduce intake of stimulant substances and
• The presence of hypertension in an individual in caffeine)
whom an abdominal bruit is heard suggests • Recommend smoking cessation (refer for
stenosis of the renal arteries treatment)
• Recommend restriction of alcohol consumption
Complications • Recommend regular exercise
• Congestive heart failure • Counsel client about appropriate use of
• Angina medications (dose, frequency, side effects and
• Stroke or transient ischemic attacks importance of compliance)
• Hypertensive crisis • Ask client to return to clinic if any unusual
• Kidney disease symptoms occur or there is a change in status
• Retinal disease
• Peripheral disease Pharmacologic Interventions in
• Complications related to therapy (e.g. thiazide Moderate to Severe Hypertension
diuretics increase risk of gout, poor response) Antihypertensive medications should be started.
The physician will determine the therapy of choice
(which depends on the person's age and the
Diagnostic Tests
presence of other medical problems) and will
• Urinalysis (routine and for microalbuminuria in include drugs from the classes described below.
diabetic clients)
• Complete blood count ß-Blockers
• Blood glucose, cholesterol and triglyceride A ß-blocker is the drug of first choice to lower
levels (while fasting) blood pressure in patients with angina pectoris.
• Creatinine and electrolyte levels Although evidence is lacking, it also seems
• Baseline ECG and chest x-ray if > 50 years of reasonable to use a ß-blocker as the drug of first
age choice in clients for whom the drug can be used to
treat more than hypertension, e.g. those with
Management frequent recurrent migraine, sympathetic
Goals of Treatment hyperactivity, resting tachycardia or palpitations.
• Decrease morbidity and mortality associated
with high blood pressure ß-Blockers should not be used in clients with
• Control symptoms with an effective, well- asthma or other forms of obstructive airways
tolerated treatment regimen disease.
Appropriate Consultation ACE Inhibitors

Consult a physician if there is a need to treat ACE inhibitors have been clearly shown to
hypertension with medications. prolong survival in patients with congestive heart
failure. Watch for patients with non-productive
cough. They are therefore the obvious first choice
for patients with hypertension and congestive heart

failure. It has not yet been established whether The physical examination should include the
ACE inhibitors have a unique renal protective following:
effect in diabetic nephropathy. • Blood pressure (supine and standing)
A recent study suggests that ACE inhibitors • Neck examination (carotid artery for bruits,
increase the risk of hypoglycemia in treated JVP [jugular venous pressure] for congestive
diabetic patients. There are no proven therapeutic heart failure)
differences among ACE inhibitors. • Cardiovascular examination
• Respiratory examination
Calcium-Channel Blockers • ECG (annually)
• Chest X-ray (annually)
Monitoring and Follow-Up • Ophthalmologic exam
Follow up three or four times yearly if
hypertension is well controlled or more frequently
• Blood work q3-6months: complete blood count,
blood glucose level, creatinine level, electrolyte
if client's condition warrants. Encourage self-
levels, uric acid level (if client is taking thiazide
monitoring and recording of blood pressure.
diuretics)
Routine Follow-up Assessment Related to • Urinalysis (for protein)
Hypertension
Determine history related to the following: Referral
• Headaches Arrange follow-up with physician at least yearly if
the client's hypertension is stable or as soon as
• Dizziness
possible if poorly controlled.
• Angina
• Congestive heart failure/non-productive cough Repeat physician consultation is necessary for
• Transient ischemic attack chronically hypertensive clients if any of the
• Stroke following situations apply:
• Nausea and vomiting • Client not responding to therapy
• Vision changes • Target organ damage caused by poorly
• Medication compliance controlled blood pressure
• Drug side effects • Symptoms and signs of complications

Dysrhythmias
Definition Atrial Fibrillation (A.Fib)
Abnormal heart rhythm. The most common types This is the commonest arrhythmia. There are three
are as follows: classifications of A.Fib.
1. Paroxysmal - which is self-terminating
Sinus arrhythmia 2. Persistent - which can be converted to sinus
A cyclic increase in heart rate associated with rhythm
inspiration and decrease in heart rate with 3. Chronic
expiration. No clinical significance and is
common in the elderly and children. (Current Atrial Fib. is the only common arrhythmia in
Medical Diagnosis and Treatment, 38th edition, which the ventricular rate is rapid and the rhythm
1999, p389) is highly irregular. The atrial rate can be > 350
bpm, most are not conducted through the AV
Sinus Bradycardia node. The ventricular rate can be normal or > 150
Heart rate < 60 bpm; impulse originates in SA bpm and there is usually a difference between the
node, but is slowed through the AV node. Usually radial rate and the apical rate (Rosenthal, R., 2002.
bradycardia is an accidental finding and can be Atrial Fibrillation, eMedecine Journal, 3:1)
normal for the young or for athletes. Severe
bradycardia can be an indication of sinus node Atrial Flutter
pathology, such as sick sinus syndrome or heart This is less common than A.Fib and is most often
block, wherein the SA node does not generate or associated with COPD. Atrial rates can be as high
transmit a signal to the atria as 250-300 bpm with transmission of every second
(Livingston, M., 2001, eMedecine Journal, 2:7) impulse through the AV node, which gives a
ventricular rate of about 150 bpm. Ventricular
Sinus Tachycardia rate is usually regular and the P waves have a
Heart rate >100-160 bpm; is caused by rapid distinct saw-tooth appearance, especially in leads
impulse formation from the SA node (Current II, III and AVF. (Ganz, L., Ahluwalia, M., 2002,
Medical Diagnosis and Treatment, 38th edition, eMedecine Journal, 3:1)
1999, p389)
Wide QRS Complex Tachycardias:
Narrow QRS Complex Tachycardias: Premature Ventricular Contractions
Paroxysmal Supraventricular These beats have a wide QRS complex, are not
Tachycardia (PSVT) usually preceded by a P wave, usually there is a
The most commonly occurring paroxysmal pause before the next normal beat. Bigeminy and
tachycardia. Episodes may last from seconds to trigeminy are rhythms in which every second or
hours. Rate is usually 160-220 bpm and are third beat is a PVC. Usually benign in patients
regular even with exercise and position changes. without heart disease.
Supraventricular Tachycardia (SVT) Ventricular Tachycardia (VT)

Accessory pathways between atria and ventricles Three or more consecutive ventricular premature
allow an avoidance of the delay at the AV node, beats. The rate is > 100 bpm (usually 150-200)
thus predisposing the heart to re-entry tachycardia. and is moderately regular. The complexes are
The QRS is usually narrow and the P wave occurs wide and there is AV dissociation. There are also
after the QRS (the PR interval is greater than the fusion beats. It is either sustained - lasting > 30
RP interval) (1999, The Merck Manual, Sec. 16, seconds, or unsustained - lasting < 30 seconds.
p205) VT may be asymptomatic or can be associated
with syncope, dizziness, diaphoresis or nausea.
VT can quickly deteriorate into ventricular
fibrillation. (Ernoehazy, W. Jnr., 2001, eMedecine
Journal, 2:12)

Torsades de Pointes waveform that resembles a squiggle that fades to a

This is a variant of VT. The complexes are wide flat line. (Kazzi, A., 2001 eMedecine Journal, 2:8)
and bizarre and look like the axis is changing
(QRS from positive to negative and back). Pulseless Electrical Activity (PEA)
Usually associated with drugs or conditions that A clinical condition "characterized by loss of
increase the QT interval. (Ernoehazy, W. Jnr., palpable pulse (or ventricular contraction) in the
2001, eMedecine Journal, 2:12) presence of recordable cardiac electrical activity."
ECG recording may show myocardial infarction,
Ventricular fibrillation (VF) signs of hyperkalemia, prolonged QT interval
VF is a pulseless arrhythmia that is irregular and related to tricyclic drug overdose. PEA is caused
chaotic. The heart can no longer pump blood by an inability to generate a strong contraction in
around the body. VF is the primary cause of spite of adequate electrical impulse. "PEA is
sudden cardiac death. VF is most commonly seen always caused by a profound global cardiac
following an MI. VF can be coarse or fine. The insult." (Verma, S., Marks, D., 2001, Pulseless
heart rate is irregular, usually > 300 bpm, and a Electrical Activity, eMedicine Journal 2:9
Predisposing Factors
Bradycardia PSVT Ventricular Fibrillation
• Increased vagal tone • Gender (more common in females) • Severe coronary artery disease
• Decreased sympathetic drive • Rheumatic heart disease • Acute myocardial infarction with
• Ischemia to sinoatrial node • Pericarditis shock
• Drug use: digoxin, beta blockers • Myocardial infarction • Myocardial reperfusion after
thrombolysis
• Athletic activity (normal variant in • Mitral valve prolapse
athletes) • Preexcitation syndrome Premature Ventricular Contractions
• Injury or other insult • Stress
Atrial Fibrillation
• Acute myocardial infarction
• Myocardia ischemia Pulseless Electrical Activity
• Hypothermia • Respiratory failure with hypoxia
• Thyrotoxicosis
• Electrolyte abnormality • Massive pulmonary embolus
• Alcohol
• Acidosis • Cardiac tamponade
• Sick sinus syndrome
Tachycardia • PACs • Cardiac rupture
• Decreased vagal tone • Massive myocardial infarction
Atrial Flutter
• Increased sympathetic tone • Pulmonary-respiratory arrest
• Chronic hypertension
• Myocardial infarction • Hemothorax
• Valvular heart disease
• Hypoxia • Tension pneumothorax
• Left ventricular hypertrophy
• Hypovolemia • Prolonged acidosis
• Coronary artery disease
• Fever • Decreased availability of calcium
• Diabetes
• Anxiety • Sepsis
• CHF
• Pain • Severe CHF
• Post-op revascularization
• Hypothyroidism with elevated TSH • Hyperkalemia
• Digitalis toxicity
• Exercise • Hypothermia
• Caffeine • Drug ingestion (TCA, digoxin,
Ventricular tachycardia calcium and beta blocker in
Supraventricular tachycardia
• Coronary heart disease overdosage)
• Digoxin toxicity • Post defibrillation PEA
• Structural heart disease
• Catecholamines
• Caffeine Torsades de Pointes
• Gender (more common in males 2:1) • Congenital elongated QT intervals
• Antiarrhythmic drugs
• Electrolyte imbalances

History complexes. Pulse volume is diminished or absent

• Not all symptoms may be present during PVC
• Client may note irregular heartbeat
• Palpitations Ventricular tachycardia: ECG abnormal, rhythm
may be regular or irregular. There are no
• Chest discomfort
comprehensive ECG criteria for diagnosing VT,
• Shortness of breath but the presence of a rate
• Dizziness > 150 bpm, wide and bizarre QRS complexes,
• Diaphoresis atrioventricular dissociation and presence of
• Weakness fusion beats, suggest ventricular tachycardia.
• Syncope Hypotension, dyspnea, diaphoresis may also be
• Nausea present.
Physical Findings Torsades de pointe: ECG abnormal, rhythm

Sinus bradycardia: ECG normal, heart rate regular or irregular. QRS complexes appear to
< 60 bpm. A heart rate below 40 bpm is usually a change appearance and size, looks like they are
junctional rhythm originating in the ventricle. twisting. Hypotension, dyspnea, diaphoresis may
Look for irregular PR intervals to determine heart also be present.
block or sick sinus syndrome.
Ventricular fibrillation: ECG abnormal,
Sinus tachycardia: ECG normal, heart rate > 100 unintelligible, no identifiable waves, complexes or
bpm, blood pressure constant rhythms. No heart rate detectable,
hemodynamically very unstable.
PSVT (Atrioventricular nodal re-entrant
tachycardia): ECG abnormal - rhythm regular, Differential Diagnosis
fast, atrioventricular block usual as seen by a • Multifocal atrial tachycardia
prolonged PR interval, systolic BP constant, • Sinus tachycardia with multiple premature atrial
electrical alternans rare contractions
• Sick sinus syndrome
SVT (Orthodromic atrioventricular re-entrant • Wolfe-Parkinson-White syndrome
tachycardia): ECG abnormal - rhythm regular,
• Atrioventricular block
atrioventricular block not present, systolic BP
constant, electrical alternans common especially at
high heart rates Complications
• Heart failure
Atrial fibrillation: ECG abnormal, rhythm • Myocardial infarction
irregular, P waves not visible, systolic BP • Cerebrovascular accident
changing. At high rates there is risk of developing • Thromboembolism
Wolfe-Parkinson-White syndrome in some • Wolff-Parkinson-White syndrome
individuals - look for delta waves on the Q wave • Cardiac arrest
(slurred QRS)
Diagnostic Tests
Atrial flutter: ECG abnormal, ventricular rhythm • 12 lead ECG
is usually regular, P waves have a well defined • Arrange for 24-hour Holter monitoring
saw-tooth pattern. If rate is
• Bloodwork - TSH, CBC, INR, PTT CK,
< 120 bpm, there may be no symptoms, if > 120
Troponin T
bpm, there may be hemodynamic instability
Premature ventricular contractions (PVC): ECG

normal with occasional wide and bizarre QRS

Management Pharmacologic Interventions

Goals of Treatment Initial treatment prescribed only by a physician.
• Convert to sinus rhythm
• Relieve symptoms Selection of treatment modality should be based
• Prevent recurrence on underlying pathophysiology.
• Prevent complications (e.g. CHF, MI,
Chronic atrial fibrillation is also treated with
life-threatening dysrhythmias)
anticoagulants such as warfarin.
Therapy is started as soon as possible if there is a
Consult a physician if client has abnormal ECG
history of underlying heart disease.
pattern, refractory atrial fibrillation, suspicion of
Wolff-Parkinson-White or "sick sinus" syndrome.
Nonpharmacologic Interventions • For clients taking antiarrhythmic agents, liver
Identify and remove any contributing factors. enzyme levels should be measured during first
4-8 weeks of therapy
Client Education • Clients with risk factors for cardiac
complications of therapy should undergo ECG
• Teach client and family members the signs of
during first weeks of therapy and every 3-6
hemodynamic compromise, including rapid
months thereafter
heart rate, unexplained weight gain, worsening
dyspnea on exertion or in the night, decreased • Clients taking digoxin should be monitored
exercise tolerance carefully for toxic effects
• Teach client about long-term medication and its • Evaluate INR on a regular basis to monitor
side effects therapeutic response to warfarin
Referral
Medevac clients with hemodynamic instability.

Atrial Fibrillation
Atrial fibrillation is a cardiac arrhythmia in which • Angina
chaotic electrical activity replaces the orderly • CHF
activation sequence of normal sinus rhythm. • Embolic stroke
• Peripheral arterial embolization
Associated Conditions • Bradycardiac arrhythmias due to pharmacologic
• Hypertensive heart disease therapy
• Valvular or rheumatic heart disease • Inherent risk of bleeding with anticoagulation
• Coronary artery disease
• Acute myocardial infarction Diagnostic Tests
• Pulmonary embolus For asymptomatic people:
• Cardiomyopathy • ECG
• Congestive heart failure • TSH
• Pericarditis • INR and PTT
• Increased thyroid hormone • Chest x-ray
• Misuse of street drugs, alcohol
Management
History Goals of Treatment
• Palpitations • Search for and treat all predisposing factors (see
• Lightheadedness, poor capacity for exercise "Associated Conditions," above)
• Fatigue • Reduce symptoms
• Dyspnea • Prevent complications
• Angina
• Syncope or near syncope Appropriate Consultation
• Stroke Consult a physician
• Arterial embolization
Client Education
Physical Findings • Ensure that client understands disease process
Do a complete cardiovascular and respiratory and prognosis
examination. Also assess the eyes for lid lag • Counsel client about appropriate medication use,
(hyperthyroid sign) and the neck for thyroid including side effects
enlargement. • Teach client signs and symptoms of
• Irregular pulse complications that require immediate follow-up
• Tachycardia (rapid heart rate, palpitations, edema, shortness
• Possible heart failure (see page 16) of breath on exertion, chest pain)
• Hypotension • Recommend avoidance of alcohol, caffeine
• ECG shows rapid, irregular atrial rate and no P • Recommend referral to smoking cessation (if
waves applicable)
• Counsel client to avoid sleep deprivation
• Multifocal atrial tachycardia Pharmacologic Interventions
• Drug therapy is directed at
• Sinus tachycardia with frequent atrial premature
beats
1. Correcting the atrial arrhythmia: examples of
• Atrial flutter antiarrhythmic agents are quinidine,
procainamide and disopyramide.

2. Slowing the ventricular rate: ß-Blockers, such as • Clients on anticoagulation must have INR levels
amiodarone, and calcium-channel blockers, such monitored regularly, q1w x 1month, q2w x 3
as diltiazem and verapamil, are used to control months, then q1m if stable
ventricular rate.
3. Effecting anticoagulation - warfarin therapy is Referral
recommended to prevent stroke and other Medevac clients who are hemodynamically
embolic complications. unstable. Electrical cardioversion is sometimes
necessary if symptoms are severe.
• Clients with stable atrial fibrillation should be Refer stable symptomatic clients to a physician for
followed regularly to assess for symptoms and thorough evaluation and initiation of therapy as
signs of recurrence, complications, compliance soon as possible.
with therapy and side effects of medication
• ECG should be done every 3-6 months

Acute Pericarditis
Definition • Anxiety
An inflammatory process of the pericardium with • Mild distress
many causes, occurring with or without effusion. • Flushing
The most common cause is idiopathic or non- • Splinted breathing
specific pericarditis. • Shortness of breath (only in cases of pericardial
tamponade or constrictive pericarditis)
Causes • Pericardial friction rub
• Idiopathic (unknown) • Localized lung crackles (may be present due to
• Viral infection (e.g. coxsackievirus, ECHOvirus, shallow breathing)
adenovirus, Epstein-Barr virus, mumps, HIV) • Pulsus paradoxus
• Bacterial infection: Hemophilus influenzae
(especially children), Meningococcus, Differential Diagnosis
Pneumococcus, Salmonella, Staphylococcus, • Acute myocardial infarction
PCP related to AIDS • Pneumonia with pleurisy
• Fungal infection: Aspergillus, Candida, • Pulmonary emboli
Histoplasmosis, Nocardia
• Aortic dissection
• Mycobacterial infection: Mycobacterium
• Pneumothorax
tuberculosis
• Mediastinal emphysema
• Neoplasm: breast, lung, lymphoma
• Drug-induced: procainamide, hydralazine,
phenytoin and others
Complications
• Connective-tissue disease: systemic lupus
• Pericardial tamponade
erythematosus, rheumatoid arthritis, • Recurrence of pericarditis
scleroderma, acute rheumatic fever • Noncompressive effusion
• Radiation therapy • Chronic constrictive pericarditis
• Post-myocardial infarction (Dressler's
syndrome) Diagnostic Tests
• Chest trauma • ECG
• Uremia • Chest x-ray (if available), to rule out
• Myxedema complications such as pericardial effusion or
• Aortic dissection enlarged heart
• Sarcoidosis
• Pancreatitis Management
Goals of Treatment
History • Prevent complications
• Chest pain, typically sharp; retrosternal with • Identify and treat underlying causes
radiation to the trapezial ridge
• Pain frequently sudden in onset Appropriate Consultation
Consult a physician if you suspect this diagnosis.
• Pain reduced by leaning forward and sitting up
• Splinted breathing The otherwise healthy client is safely treated on an
• Pain on swallowing outpatient basis.
• Fever
Client Education
Physical Findings • Ensure that client understands disease process
• Low-grade fever and prognosis
• Respiration fast and shallow

• Counsel client about appropriate medication use In some clients, the condition becomes refractory
and side effects and corticosteroids or pericardiectomy may be
• Recommend avoidance of heavy physical labor required.
• Teach client about symptoms and signs of
complications, and instruct client to report any Monitoring and Follow-Up
that occur • Follow up in 2 or 3 days, to make sure no
• Stress the importance of follow up complications develop, and then again in 2
weeks
Pharmacologic Interventions • Repeat ECG and chest x-ray should be
Anti-inflammatory medication for at least two considered at about 4 weeks
weeks: • In most clients complete resolution occurs after
ASA (A class drug), 650 mg q4h 2 weeks of therapy
or
ibuprofen (A class drug), 200 mg, 2-3 tabs q6h

Arterial Peripheral Vascular Disease

Definition • Capillary refilling time slowed (> 2 seconds)
Chronic decrease in blood flow to one or more • Peripheral pulses decreased or absent
extremities, caused by atherosclerotic narrowing • Pulsating abdominal mass (aortic aneurysm)
of aorta and large arteries supplying the lower • Arterial bruits may be present (abdominal aortic,
limb and leading to ischemia of the leg muscles. iliac, femoral, popliteal)
Causes Differential Diagnosis

• Atherosclerosis, congenital lesions, trauma • Acute arterial occlusion
• Predisposing factors: smoking, hypertension, • Raynaud's disease
hyperlipidemia, diabetes, obesity, genetics • Raynaud's phenomenon
• Venous stasis
History • Scleroderma
• Warning signal that oxygen demands of the leg • Embolism
exceed oxygen supply
• Symptoms initially intermittent, reversible, Complications
reproducible (intermittent claudication) • Ischemic ulcer
• Pain, ache, cramp located in calf, instep, • Infection of ischemic ulcer
buttock, hip or thigh (rarely in an arm)
• Loss of distal ischemic limb
• Pain precipitated by exercise
• Acute arterial occlusion
• Discomfort quickly and consistently relieved
with rest (in 2-5 minutes)
Diagnostic Tests
• Distance client can walk before experiencing
claudication (should be documented)
• Complete blood count
• As disease progresses, symptoms occur with less
• Electrolyte and creatinine levels
effort and last longer • Fasting blood glucose, cholesterol and
triglyceride levels
• With advanced disease, foot pain occurs at night
• Nocturnal pain relieved by placing the leg into a
• ECG (if a recent one is not available)
dependent position or by standing on a cold
floor Management
• With severe disease the involved area becomes Goals of Treatment
chronically ischemic, and pain is present at rest • Slow progression of disease
• Impotence may occur • Identify, modify and treat risk factors
• Associated vascular disease of other target • Promote formation of collateral circulation
organs may be present (angina, previous stroke • Prevent complications
or transient ischemic attacks)
Physical Findings Consult a physician immediately if any of the
• Blood pressure may be elevated if client is also following are present: angina, ischemic ulcer, pain
hypertensive at rest, nocturnal pain, recent transient ischemic
• Ischemic skin changes in foot and distal limb attack, pulsatile abdominal mass.
may be present (thin, fragile skin; loss of hair on
distal leg; shiny and atrophic skin; leg muscle Client Education
atrophy) • Refer for smoking cessation
• Arterial ulcers on shins, toes or feet • Recommend weight loss (if appropriate)
• Toenails may be hypertrophic • Recommend daily exercise to improve fitness
• Rubor of foot with dependency, blanching of and exercise tolerance of the leg muscles, which
foot with elevation

will also help to improve collateral circulation Monitoring and Follow-Up

(walking is the best exercise) • Identify new symptoms or changes in existing
• To reduce skin irritation, client should put symptoms
sheepskin or bubble pads on the bed • Assess control of diabetes and encourage
• Teach proper foot care: avoid clipping nails too compliance with medication and diet
close to the skin, avoid tight-fitting shoes, keep • Advise client to attend clinic if foot injury
feet dry and protected from injury (no slippers or occurs, no matter how small
bare feet, even in the house) • Refer to Home Care
• For diabetic clients, teach proper foot care to a
family member, if possible, so that this person Referral
can carry out the necessary tasks; alternatively, Refer to a physician as soon as feasible to
have the client attend a clinic on a monthly basis establish whether there are indications for surgery
for care of nails and feet (intolerable pain in low-risk client, pain at rest,
ulcers, impending gangrene). A consult with a
vascular surgeon may be necessary.

Venous Insufficiency (Chronic)

Impairment of the venous system that inhibits • Stasis dermatitis
normal return of blood from the legs to the heart. • Cellulitis
• Stasis ulcer
Causes • Thrombophlebitis
Incompetent valves in veins of the legs. • Deep vein thrombosis (if deep veins involved)
Risk Factors Diagnostic Tests
• Familial predisposition None.
• Prolonged standing
• Pregnancy Management
• Obesity Goals of Treatment
• Constricting garments worn over a long period • Facilitate venous return
of time • Prevent complications
History Client Education
• Dull aching heaviness or fatigue in legs, often • Teach client proper skin hygiene and care of
occurring at the end of the day and relieved by lesions
elevation of the legs • Recommend support hose or support stockings
• Mild edema at end of day • Recommend elevation of legs above the level of
• Cramps in legs at night the hip when sitting
• Itching may be present (due to stasis dermatitis) • Recommend avoidance of prolonged standing
• Stasis dermatitis, brownish red discoloration (client should sit with legs elevated whenever
possible and should avoid crossing legs)
Physical Findings • Recommend avoidance of restrictive clothing
• Dilated, tortuous, elongated varicose veins in around the knees (e.g. knee socks, garters)
foot, lower leg, medial thigh or behind knee • Recommend weight loss (if appropriate)
• Varicose veins seen better when standing • Recommend smoking cessation (if appropriate)
• Skin changes may be present (erythema, • Instruct client to return to clinic if signs of skin
brownish pigmentation, flaking and scaling, skin breakdown or skin irritation occur, or if a vein
breakdown) becomes sore and tender
• Venous ulcers may be present on medial side of • Instruct client to do leg exercises qid in bed to
lower leg just above medial malleolus or on prevent deep vein thrombosis
medial aspect of ankle
• Edema of foot and ankle may be present Monitoring and Follow-Up
• Dilated veins easily palpable when person is Arrange follow-up in 1 month to assess adherence
standing to and efficacy of interventions.
Differential Diagnosis Referral

• Chronic occlusive arterial disease with arterial Refer to a physician if condition does not improve
ulcers with conservative treatment or if complications
• Orthopedic problems arise.

Aortic Aneurysm (Pulsatile Abdominal Mass)

Definition Monitoring and Follow-Up
Weakening of the wall of the abdominal aorta. A • Annual follow-up by physician
pulsatile abdominal mass is considered and treated • Annual abdominal ultrasonography to measure
as an abdominal aortic aneurysm until proven size
otherwise. It may be asymptomatic and discovered
by accident. Referral
Referral to physician for vascular surgery
History
If an aneurysm is leaking: Management Of Symptomatic Client
• Sudden onset of pain in mid-abdomen or back Goals of Treatment
(or both) • Replace blood loss
• Sudden weakness and faintness
Physical Findings Consult a physician immediately.
• Pulse rapid and weak, pulsus paradoxus
• Blood pressure low-normal to low Adjuvant Therapy
• Blood pressure may drop with change in posture • Oxygen to keep oxygen saturation > 97%
• Pulsating mid or upper abdominal mass • Large bore IV (14- to 16-gauge) with normal
saline (or lactated Ringer's solution) x2
If an aneurysm has ruptured:
• Shock (hypovolemia) Nonpharmacologic Interventions
• In severe distress, client may be unconscious • Bed rest
• Pulse diminished or absent • Maintain "nothing-by-mouth" order
• Blood pressure low or cannot be determined • Insert a nasogastric tube (paralytic ileus is
• A pulsating abdominal or flank mass may be common)
palpable • Insert a urinary catheter
• Increased abdominal girth
• Subcutaneous bruising may be present Monitoring and Follow-Up
• Death usually occurs • Monitor ABC and vital signs closely, including
oxygen saturations
Management Of Asymptomatic Client • Aim for pulse < 100 bpm and systolic blood
Goals of Treatment pressure >100 mm Hg
• Identify and monitor the asymptomatic • Monitor urinary output
abdominal aneurysm
Referral
Appropriate Consultation Medevac as soon as possible.
Consult a physician when an asymptomatic aortic
aneurysm is suspected or detected.

Emergencies Of The Cardiovascular System

Myocardial Infarction
Definition • Diaphoresis
Interruption of blood supply to the heart, resulting • Cyanosis (central or peripheral, or both)
in ischemic injury and necrosis of a portion of the • Client may be unconscious
myocardium. As many as 15% to 25% of cases are • Skin may be cool and clammy
silent or atypical in presentation. • Lungs are usually clear; crackles present if
congestive heart failure develops
Causes • S1, S2 normal; S3 and/or S4, murmurs,
• Atherosclerosis/blockage of coronary arteries, pericardial friction rub may be present if there
coronary artery spasm, hypovolemia are complications
Risk Factors Differential Diagnosis

• Smoking • Peptic ulcer disease
• Family history of heart disease • Esophageal spasm or esophagitis
• Hypertension • Gallbladder disease
• Dyslipidemia • Large pulmonary embolism
• Obesity • Indigestion
• Diabetes mellitus • Pancreatitis
• Sedentary lifestyle • Acute anxiety attack
• Acute pericarditis
History • Dissecting aortic aneurysm
• Acute retrosternal chest pain (heaviness, aching, • Spontaneous pneumothorax
squeezing)
• Pain may radiate into left arm, neck, fingers, Complications
shoulders, epigastrium, right chest, right upper • Arrhythmias and conductive disturbances
quadrant, right arm or upper back, jaw, gums • Hypotension
• Pain usually occurs at rest, with gradual or • Congestive heart failure
sudden onset, and can be precipitated by stress
• Pericarditis
• Pain not relieved by nitroglycerin
• Thromboembolism
• Pain lasts longer than 30 minutes
• Cardiogenic shock
• Shortness of breath
• Cardiac arrest
• Rupture of the heart
• Diaphoresis
• Death
• Weakness
• Loss of consciousness may occur
Diagnostic Tests
• Obtain a 12-lead ECG tracing; compare with a
Physical Findings previous tracing, if available
• Respiration rapid and shallow • Identify new changes if possible; check for Q
• Pulse variable (rapid or slow, regular or waves, elevation of ST segment and inversion of
irregular, full volume, "thready") T wave (signs of myocardial infarction)
• Blood pressure increased, decreased or normal • Check for depression of ST segment, inversion
• Oxygen saturation may be abnormal if client is of T wave (unstable angina) or a non-Q wave MI
in shock or has congestive heart failure • If the patient has continuing or changes in pain,
• Acute distress repeat 12-lead ECG twice more at 30-minute
• Pale intervals, noting any evolving changes

• Blood may need to be drawn for baseline cardiac Observe BP

enzymes (troponin) before transferring client
Every client who presents with acute myocardial
Management infarction should be considered for IV
Goals of Treatment thrombolytic therapy. If onset of pain occurred
• Improve oxygenation of myocardium within the past 6 hours there is a definite benefit to
• Prevent complications thrombolytic therapy.
• Keep infarct from extending
Other Pharmacologic Measures (Prescribed by
Appropriate Consultation a Physician)
To reduce workload on the heart:
Consult a physician.
topical nitroglycerin (B class drug), 1.25-2.5 cm
immediately, then q4-6h, but only if systolic blood
Adjuvant Therapy
pressure >100 mm Hg
• Oxygen to keep oxygen saturation > 97%
• Start IV therapy with normal saline to keep vein For arrhythmias, particularly sustained bouts of
open ventricular tachycardia:
• Urinary catheter lidocaine (B class drug), 1 mg/kg to a maximum of
100 mg as a single IV bolus; reduce dose by 50%
Nonpharmacologic Interventions in people > 65 years of age
• Bed rest with head elevated (unless hypotensive)
• Offer support and reassurance to reduce anxiety When using lidocaine, watch for disorientation,
confusion, twitching, seizure
Pharmacologic Interventions For hypotension associated with bradycardia
Nitrates: (heart rate < 60 bpm):
nitroglycerin (C class drug), 0.3-mg SL tab or atropine sulfate (B class drug), 0.4 mg IV q5min,
spray stat, but only if systolic blood pressure >100 until heart rate > 60 bpm and systolic blood
mm Hg pressure > 100 mm Hg (maximum dose 2 mg)
Observe response and monitor severity of pain; if IV diuretics (only if shortness of breath and lung
pain not relieved, repeat: crackles are present, i.e., heart failure):
nitroglycerin, 0.3-mg SL tab q3-5min for another furosemide (D class drug), 40 mg IV bolus
2 doses, but only if systolic blood pressure
remains >100 mm Hg Monitoring and Follow-Up
• Monitor vital signs (including pulseoximetry)
Nitroglycerin can cause hypotension. • Repeat ECG (to check for arrhythmias)
• Monitor lungs and heart sounds frequently for
Then give: signs of heart failure
uncoated ASA (A class drug), 80 mg, 2 tabs stat • Intake and output
PO, unless ASA contraindicated
If pain unrelieved by nitrates, administer
Referral
analgesia: Medevac as soon as possible.
morphine (D class drug), 2-5 mg IV; repeat dose
only under the direction of a physician

Pulmonary Edema
Definition • Hypotension, shock
Accumulation of fluid within the lungs that • Respiratory failure
interferes with ventilation and oxygenation.
Diagnostic Tests
Causes • Obtain ECG: look for signs of myocardial
Acute left-heart failure, with or without right-heart ischemia or infarction
failure (see "Differential Diagnosis," below)
Management
• Severe shortness of breath • Improve oxygenation
• Orthopnea, paroxysmal nocturnal dyspnea • Promote diuresis of accumulated fluids
(left ventricular failure) • Reduce venous return to the heart
• Fluid retention peripherally and weight gain • Treat any reversible precipitants (e.g. cardiac
(right heart failure) may also be present ischemia, hypertension, arrhythmia)
• Cough productive of frothy pink sputum
Physical Findings Consult a physician immediately.
• Pulse rapid and may be "thready" or weak
• Respiratory rate elevated Adjuvant Therapy
• Blood pressure normal, elevated or decreased • Oxygen to keep oxygen saturation > 97%
• Acute respiratory distress • Start IV therapy with normal saline to keep vein
• Diaphoresis open
• Central cyanosis may be present
• Peripheral cyanosis with cool, mottled Nonpharmacologic Interventions
extremities • Bed rest with head elevated
• Swelling of ankles may be present • Insert an indwelling urinary catheter
• JVP may be elevated
• Hepatojugular reflux and hepatomegaly may be Pharmacologic Interventions
present IV diuretics:
• Peripheral pitting edema may be present furosemide (D class drug), 40-80 mg IV push
• Crackles and wheezes in lower half of lung
fields For any client who receives this drug regularly, a
much larger dose may be required (a quick guide
• S3 gallop rhythm in the heart
is to double the usual PO daily total to determine
the acute IV dose).
• Chronic congestive heart failure To reduce workload on the heart (discuss with
• Acute myocardial infarction physician, preferably before administering):
• Acute pulmonary embolism morphine (D class drug), 2-5 mg IV over several
• Atrial fibrillation minutes; this can be repeated under the direction
• Valvular heart disease of a physician
• Adult respiratory distress syndrome
• TB To reduce venous return and workload on the
heart, the physician may order topical nitrates:
Complications nitroglycerin topical (B class drug), 1.25-2.5 cm
• Dependent on underlying disease process stat, then q4-6h, but only if systolic blood pressure
>100 mm Hg
• Angina


• Monitor vital signs (watch for hypotension) and Medevac as soon as possible.
ABCs frequently, including oxygen saturation
• Monitor urine output hourly (if not diuresing,
the client requires more IV diuretics)

Acute Arterial Occlusion Of A Major Peripheral Artery

Sudden obstruction of a peripheral artery with • Ischemic muscular contracture
acute ischemia of the distal limb. • Loss of limb
Causes • Sepsis
• Acute thrombosis of an artery, trauma or arterial
embolus Management
• Predisposing factors: peripheral vascular Goals of Treatment
disease, atrial fibrillation, recent myocardial • Improve oxygenation of the limb
infarction, prosthetic heart valve • Prevent injury to or loss of limb
• Sudden onset of severe pain in distal part of a Consult a physician immediately.
limb
• Paresthesia, coldness and pallor in distal limb Nonpharmacologic Interventions
follow later • Bed rest
• Previous symptoms of intermittent claudication • Prevent injury to limb: handle carefully, protect
• History of cardiac disease from pressure or injury
• Do not elevate ischemic limb (keep horizontal or
Physical Findings slightly dependent)
• Pulse may be irregular Adjuvant Therapy
• Respiratory rate normal or increased • Oxygen to keep saturation > 97%
• Blood pressure normal or increased • Start IV therapy with normal saline to keep vein
• Anxious, in acute distress open
• Signs of longstanding peripheral vascular
disease in the opposite limb Pharmacologic Interventions
• Colour of limb normal initially, becomes pale Analgesia for pain:
later morphine (D class drug), 2-5 mg IV
• Skin temperature may be normal initially,
becomes cool or cold later Give dimenhydrinate (A class drug) with
• Peripheral pulses are less palpable than in morphine to prevent nausea and vomiting.
opposite limb or absent altogether
• Cutaneous sensation decreased or absent Monitoring and Follow-Up
Monitor vital signs, general condition, cardiac and
• Tenderness in calf on dorsiflexion of foot
respiratory status frequently.
• Arterial bruits may be present (aortic, iliac,
femoral, popliteal)
Referral
Medevac as soon as possible. There is only a 4 to
The 5 P's of acute arterial occlusion are pain,
6-hour window of opportunity to perform surgical
pallor, pulseless, paresthesia and paralysis.
intervention to save limb from irreparable damage.
• Compartment syndrome if trauma has been
involved

Chapter 5 - Gastrointestinal System

Assessment Of The Gastrointestinal System................................................................................................... 1
Examination Of The Abdomen....................................................................................................................... 3
Problems Of The Gastrointestinal System...................................................................................................... 5

Dehydration (Hypovolemia) ........................................................................................................................... 5
Anal Fissure .................................................................................................................................................... 7
Hemorrhoids ................................................................................................................................................... 8
Constipation.................................................................................................................................................. 10
Diarrhea ........................................................................................................................................................ 13
Gastroesophageal Reflux Disease (GERD) .................................................................................................. 16
Peptic Ulcer Disease ..................................................................................................................................... 18
Gallbladder Disease: Biliary Colic And Cholecystitis.................................................................................. 20
Abdominal Hernia......................................................................................................................................... 23
Irritable Bowel Syndrome............................................................................................................................. 24
Diverticulitis ................................................................................................................................................. 26
Emergencies Of The Gastrointestinal System .............................................................................................. 27

Abdominal Pain (Acute) ............................................................................................................................... 27
Pancreatitis (Acute)....................................................................................................................................... 31
Appendicitis .................................................................................................................................................. 33
Obstruction Of The Small Or Large Bowel.................................................................................................. 35
Gastrointestinal Bleeding (Upper And Lower)............................................................................................. 37

Assessment Of The Gastrointestinal System

N.B. When assessing the GI system and there are symptoms of abdominal pain, it is important to
remember that symptoms may be related to involvement of other systems.

General Jaundice
The following characteristics of each symptom • History of hepatitis A, hepatitis B or hepatitis C,
should be elicited and explored: alcohol use
• Onset (sudden or gradual) • Tea-coloured urine
• Chronology • Clay-coloured bowel movements
• Current situation (improving or deteriorating) • Itchy skin
• Location
• Radiation Dysphagia
• Quality • Solids or liquids, is the pattern consistent
• Timing (frequency, duration) • Site where food gets stuck
• Severity
• Precipitating and aggravating factors Other Associated Symptoms
• Relieving factors • Fever
• Associated symptoms • Malaise
• Effects on daily activities • Headache
• Previous diagnosis of similar episodes • Dry skin
• Previous treatments • Dehydration
• Efficacy of previous treatments • Dry mouth
• Diet recall, appetite and foods avoided
Cardinal Symptoms (including reasons for avoidance), food
In addition to the general characteristics outlined preferences (e.g. raw foods, wild meat),
above, additional characteristics of specific nutritional supplements
symptoms should be elicited, as follows. • Meal pattern (e.g. small, frequent meals)
• Anorexia, bulimia, fasting
Abdominal Pain • Recent weight loss or gain that is not deliberate
Ask about all of the characteristics listed in the
section above (see "General," above). Medical History (Specific To
Gastrointestinal System)
Nausea and Vomiting • Gallbladder disease
• Frequency, severity • Diabetes mellitus
• Presence of blood and its colour (e.g. bright red, • Liver disease (hepatitis A, hepatitis B, hepatitis
dark, colour of coffee grounds) C or cirrhosis)
• Triggers • Esophageal cancer
• Inflammatory bowel disease
Bowel Habits • Hiatus hernia
• Frequency, colour and consistency of stool • Irritable bowel syndrome (IBS)
• Presence of blood or melena • Gastroesophageal reflux disease (GERD)
• Pain before, during or after defecation • Peptic ulcer disease (PUD)
• Use of laxatives/enemas • Pancreatitis
• Hemorrhoids • Diverticulosis
• Belching, bloating and flatulence

• Abdominal surgery Personal And Social History (Specific

• Presence of hernia, masses To Gastrointestinal System)
• Blood transfusion • Alcohol use
• Past and current use of medications: over-the- • Smoking
counter medications (e.g. acetylsalicylic acid • Caffeine use
[ASA], acetaminophen), estrogen, progesterone, • Use of street drugs, including injection drugs
calcium-channel blockers, anticholinergics, • Use of anabolic steroids
antacids, triple therapy for peptic ulcer disease,
• Travel to area where infectious gastrointestinal
thiazide diuretics, steroids, digoxin
conditions are endemic
• Diagnosis of H. pylori, treated and untreated • Body piercing or tattoos
• Stress at work, home or school
Family History (Specific To • Dietary intake of nitrates (e.g. smoked foods)
Gastrointestinal System) • High-fat diet
• Alcoholism • Obesity
• Household contact with hepatitis A • Exposure to untreated drinking water
or hepatitis B
• Sanitation at home or community
• Household contact with gastroenteritis
• Dieting
• Food poisoning
• Abdominal trauma
• GERD
• Peptic ulcer disease
Occupational Or School Environment
• Gallbladder disease
• Healthcare occupation
• Gastric or colon cancer
• Institutional environment -- workers or residents
• Polyps (e.g. nursing home)
• Pancreatitis • Environmental exposure
• Metabolic disease (e.g. diabetes mellitus, • Chemical exposure
porphyria)
• Cardiac disease
• Renal disease

Examination Of The Abdomen

General • Spleen: confirm presence of normal resonance
• Apparent state of health over lowest rib interspace in anterior axillary
• Appearance of comfort or distress line
• Colour (e.g. flushed, pale, jaundiced) • Bladder: identify distension and fullness
• Nutritional status (obese or emaciated) • Identify other areas of dullness, increased
• State of hydration (skin turgor) resonance or tenderness
• Match between appearance and stated age
Light Palpation
Vital Signs • Tenderness, muscle guarding, rigidity
• Temperature and pulse • Superficial organs or masses
• Blood pressure Deep Palpation
• Weight • Tender areas, rebound tenderness
• Liver: size, tenderness, whether edge is smooth
Abdominal Inspection or irregular, firm or hard
• Abdominal contour, symmetry, scars, dilatation • Spleen: enlargement, tenderness, consistency
of veins • Kidney: tenderness, enlargement, tenderness of
• Movement of abdominal wall with respiration costovertebral angle
• Visible masses, hernias, pulsations, peristalsis • Masses: location, size, shape, mobility,
tenderness, movement with respiration,
• Jaundice (scleral icterus, skin)
pulsation, hernias (midline, incisional, groin)
• Spider nevi on face, neck or upper trunk
• Inguinal lymph nodes: enlargement, tenderness
• Palmar erythema, Dupuytren's contracture
(associated with chronic liver disease)
• Consider GU
• Clubbing of fingers (late sign associated with
inflammatory bowel disease) Rectal Examination
• For occult blood (which would indicate
gastrointestinal [GI] bleeding)
Auscultation
Auscultation should be performed before • For referred pain (which occurs in appendicitis)
percussion and palpation so as not to alter bowel • For masses, hemorrhoids, anal fissures,
sounds. sphincter tone, etc.
• Presence, character and frequency of bowel • Prostate exam
sounds • Cervical/uterine exam
• Presence of bruits (renal, iliac or abdominal
aortic) Cardiovascular And Pulmonary
Examination
Percussion A cardiovascular and pulmonary exam should also
• Percuss from resonant to dull areas be performed.
• Liver: define upper and lower borders, measure • Tachycardia, lungs (crackles)
span • Abdominal pain (may be referred from the lungs
in pneumonia)
• ECG

Fig 1: Location of pain: Clues to diagnosis

The location of pain may provide clues to common causes of abdominal pain.
Adapted from: Uphold C R, Graham M V. Clinical Guidelines in Family Practice (Third Edition) Barmarrge
Books Inc.
Diffuse pain or variable location:
• gastroenteritis
• intestinal obstruction
• hemolytic crisis (sickle cell disease)
• peritonitis
• endocrinologic disorders (diabetic
ketoacidosis, Addison’s disease,
hyperparathyroidism)
Right Upper Quadrant:

• cholecystitis
• cholelithiasis
• acute hepatitis Left Upper Quadrant:
• hepatic abscess • gastritis
• subphrenic abscess • acute pancreatitis
• right lower lobe • splenic enlargement/
pneumonia • hematoma
• myocardial ischemia
Right Lower Quadrant: • left lower lobe pneumonia
• appendicitis
• cecal diverticulitis Left Lower Quadrant:
• ectopic pregnancy • all GU conditions listed
• ovarian cyst/torsion under right lower quadrant
• pelvic inflammatory • diverticulitis
disease
• Mittelschmerz
• endometriosis
Epigastric or Midline:
• abdominal aortic aneurysm (may
also present as back, flank, or hip
pain, or as diffuse pain
• cardiac disease (may be confused
with pain from reflux disease)
• peptic ulcer (gastric or duodenal)

Problems Of The Gastrointestinal System

Dehydration (Hypovolemia)
Definition • Inadequate intake of food or fluids (because of
Decrease in volume of circulating plasma. immobility, loss of consciousness, cognitive
impairment, medications that blunt the thirst
Causes response such as antipsychotics, heat, exercise)
• Excessive urine production (e.g. use of diuretics,
unexplained polyuria or polydipsia) Physical Examination
• Excessive GI losses (through vomiting, diarrhea, • Search for orthostatic hypotension if supine
third spacing of fluid in the abdomen as a result blood pressure appears normal
of ascites or pancreatitis) • Estimate volume deficit (see Table 1)
• Excessive losses through the skin (because of
burns, fever, exfoliative dermatitis)
Table 1: Physical findings in association with degree of dehydration

Moderate
Clinical sign Mild dehydration Severe dehydration*
dehydration*
Fluid loss (% of body weight) < 6% 6% to 10% > 10%
Radial pulse Normal Rapid, weak Very rapid, feeble
Respiration Normal Deep Deep, rapid
Systolic blood pressure Normal Low Very low or undetectable
Skin turgor Retracts rapidly Retracts slowly Retracts very slowly
Eyes Normal Sunken Very sunken
Mentation Alert Restless Drowsy, comatose
Urine output Normal Scant Oliguria
Voice Normal Hoarse Inaudible
* If dehydration is moderate to severe, there may be associated electrolyte disturbances.
Types • Usually occurs as a result of using

Hypotonic Dehydration inappropriately high solute load as replacement,
• Symptomatic earlier than isotonic or hypertonic or because of renal concentrating defect with
dehydration (use estimated weight loss as a large free-water losses or heat exposure with
guide: 3% = mild dehydration, 6% = moderate large insensible losses
dehydration, 9% = severe dehydration) • Typical symptoms include thick, doughy texture
• Usually results from replacing losses (vomiting to skin (tenting is uncommon), tachypnea,
and diarrhea) with low-solute fluids, such as intense thirst
dilute juice, weak tea • Shock is very late manifestation
• Lethargy and irritability are common, and
vascular collapse can occur early Management
Goals of Treatment
Isotonic Dehydration • Restore normal state of hydration
Symptoms less dramatic than in hypotonic • Identify and rectify cause of dehydration
dehydration (use estimated weight loss as a guide:
5% = mild dehydration, 10% = moderate General Principles of Treatment
dehydration, 15% = severe dehydration) • Fluid composition depends upon type of
dehydration
Hypertonic Dehydration

• Be sure to add ongoing losses to maintenance • For moderate-to-severe dehydration caused by

+ deficit fluids and electrolytes GI or renal losses, potassium replacement is
• In hypotonic or isotonic dehydration, calculate usually required (B class drug)
total fluids and electrolytes (maintenance
+ deficit replacement) for the first 24 hours, and Mild Dehydration
give half this amount over the first 8 hours, and • Administer 50 mL/kg of oral rehydration
the other half over the next 16 hours solution over the first 4 hours of treatment; give
• In hypertonic dehydration, correct the fluid and frequently, in small amounts
electrolyte deficits slowly (over about 48 hours) • Re-evaluate at 4 hours for maintenance fluid
• Do not add potassium (B class drug) to IV line requirements (general daily maintenance fluid
until urine output established (diabetic requirement for an adult is 2000-2400 mL)
ketoacidosis may be an exception, where • Fluid intake in the first 24-48 hours should be
correction of hyperglycemia and acidosis may enough to replace the initial deficit plus any
lead to rapid development of hypokalemia) ongoing loss of fluid through the GI and
• Increase maintenance fluids by 12% for each genitourinary tracts and the skin
degree Celsius of fever • If condition unresolved consult with physician
• If GI losses continue, replace with 10 mL/kg for
each diarrheal stool and 2 mL/kg for each Moderate Dehydration
episode of vomiting (this should approximate • Consult with physician
losses) • Administer 100 mL/kg of oral rehydration
solution over the first 4 hours of treatment; give
The search for the underlying cause of the frequently, in small amounts
dehydration should be concurrent with rehydration • Re-evaluate at 4 hours for maintenance fluid
therapy to prevent the re-emergence of requirements (general daily maintenance fluid
dehydration from ongoing fluid losses. requirement for an adult is 2000-2400 mL)
• Fluid intake in the first 24-48 hours should be
Pharmacologic Interventions enough to replace the initial deficit plus any
Oral rehydration therapy is the initial method of ongoing loss of fluid through the GI and
treatment unless the volume of the deficit and the genitourinary tracts and the skin
resulting severity of symptoms or the lack of
feasibility of oral intake make IV therapy Severe Dehydration
necessary. • Consult with physician
• Start 2 large-bore IV lines (14- or 16-gauge)
Oral rehydration fluids are effective, and with normal saline
rehydration should be attempted in clients with • Give 20 mL/kg IV rapidly as a bolus
adequate blood pressure who are able to take • Assess for overload
fluids orally.
• Reassess for signs of continuing hypovolemic
Oral rehydration fluids should contain both shock
sodium and sugar to maximize absorption of these • If shock persists, continue to administer fluid in
two components. boluses and reassess
• Adjust IV rate according to clinical response
An oral rehydration solution can be made at home (ongoing IV therapy is based on response to
with table salt and sugar: 1/2 tsp (2.5 mL) salt, 8 initial fluid resuscitation, continuing losses and
tsp (40 mL) sugar, 4 cups (1 L) water. underlying cause of dehydration)
Commercially prepared solutions (e.g. • Aim for pulse rate < 100 bpm and systolic blood
Gastrolyte®, Rehydralyte® are also available. pressure > 90 mm Hg
Potassium Client Education, Monitoring and

• For mild dehydration, potassium may not be Follow-Up
required Refer to section on diarrhea

Anal Fissure
Painful, linear tear in anal mucosa. Goals of Treatment
• Relieve pain
Causes • Relieve underlying constipation
• Chronic constipation • Prevent recurrence
• Trauma to anal canal
History • Most fissures are superficial and will heal
• Acute pain during and after defecation spontaneously
• Spotting of bright red blood with defecation • Sitz baths 3 or 4 times daily for 20 minutes with
• Bleeding tends to be minimal warm salt water
• Constipation caused by fear of pain
• Tends to occur in young and middle-aged adults Client Education
• Most common cause of chronic perianal pain • Instruct client about proper perianal hygiene and
• Recent childbirth prevention of infection
• Counsel client about lifestyle and diet (e.g.
dietary fiber, fluids, exercise)
Physical Findings
• Firm retraction of buttocks is required for • Condom use, if anal sex, also use lubricant
adequate visualization
• May be concealed by overlying anal mucosa
Local topical preparations without corticosteroids
• Usually one fissure
may be useful:
• Usually in midline zinc sulfate 0.5% ointment (A class drug), bid and
• Digital rectal exam causes acute pain after each bowel movement
An ointment is better than a suppository because it
Differential Diagnosis remains within the affected area.
• Thrombosed external hemorrhoids Start stool-bulking agents and stool softeners if
• Perianal or perirectal abscess constipated (see "Constipation," below, this
• Crohn's disease or sexually transmitted chapter).
infections (if fissures fail to heal)
Complications Follow up in 1-2 weeks.
• Constipation
• Chronic anal fissure Referral
Arrange consultation with a physician if fissure
does not heal in 4-6 weeks.
Diagnostic Tests
None.

Hemorrhoids
Definition • Typically 1 to 3 swellings around anal opening,
Blood vessels beneath the anal canal mucosa the size of a finger tip; pink, purple or blue in
(internal) and perianal skin (external) that enlarge colour
and protrude. • Rectal examination may reveal concealed
internal hemorrhoids
Causes • Assess whether prolapsing hemorrhoids are
• Pregnancy and childbirth easily reducible
• Chronic constipation with straining at bowel
movements Differential Diagnosis
• Prostatic enlargement with chronic straining to • Rectal polyp or prolapse
urinate • Skin tag
• Prolonged sitting • Other causes of pruritus ani and perianal
• Anal infection dermatitis
• Perianal or perirectal abscess
History • Anal fissure
Rule out bowel pathology such as inflammatory • Complicated hemorrhoid
bowel disease, carcinoma. • Tumor
Internal Hemorrhoid Complications

• Sensation of something "sticking out" of rectum • Thrombosed or strangulated internal hemorrhoid
• Bright red bleeding with bowel movements • Thrombosed external hemorrhoid
• Blood on stool surface only, not mixed in with
stool; often seen on toilet tissue Diagnostic Tests
• Anal itching or discharge may be present • Stool may test positive for occult blood
• Painless unless complications present
Management
External Hemorrhoid (Perianal Lump) Goals of Treatment
• Soft skin tags may be present • Relieve symptoms
• Discomfort or irritation frequently present • Keep anal region clean
• Tendency to thrombose • Promote easy passage of stool on a regular basis
• Sudden acute pain if thrombosed
Physical Findings If unable to reduce the prolapsed internal
To examine anal area, have client lie on left side hemorrhoid, contact a physician.
with the knees drawn up to the chest; retract the
buttocks. Nonpharmacologic Interventions
• Both internal and external hemorrhoids may be • Gently try to reduce painful prolapsed internal
present hemorrhoid
• Usually located in left lateral, right anterior and • Apply a topical anesthetic (e.g. lidocaine jelly
right posterior positions 2% A class drug), wait 15 minutes, then gently
• Internal hemorrhoids covered by thin, pink anal try to reduce it. Do not use force!
mucosa • Instruct client to gently reduce (push back up)
• External hemorrhoids covered by skin (Note: a painless prolapsed internal hemorrhoid(s)
thrombosed external hemorrhoid is a bluish • Instruct client to cleanse the perianal area after
purple, globular, irreducible, tender lump at the each bowel movement with plain water, salt
edge of the anus) water or medicated witch-hazel cotton pads
(Tucks)

• Instruct person to take Sitz baths 3 or 4 times Pharmacologic Interventions

daily for 15 to 20 minutes to cleanse the area, For mildly sore and edematous "inflamed"
soothe local irritation and relax the anal external hemorrhoid, treat with hemorrhoidal
sphincter ointments or suppositories without steroids
• Manage underlying constipation (see (ointments are better):
"Constipation," below, this chapter) zinc sulfate 0.5% ointment or suppository (A class
drug) every morning and evening and after each
Client Education bowel movement for 3-6 days
medications (dose, frequency, dangers of For perianal dermatitis, hemorrhoidal ointment
overuse) with steroids (for anti-inflammatory properties)
• Teach client proper perianal hygiene may be used to reduce itch and discharge (these
• Instruct client to return to clinic for reassessment preparations may cause local irritation if misused):
if severe pain or bleeding develops (incision zinc sulfate 0.5% ointment (A class drug)
drainage of thrombosed external hemorrhoid every morning and evening and after each bowel
may be required) movement for 3-6 days
• Instruct client to apply an ice pack (20 minutes
on, 20 minutes off) to help reduce swelling and Monitoring and Follow-Up
pain if a thrombosed hemorrhoid is suspected Follow up in 1 week to determine if symptoms
have improved.
Referral
For acute pain of recent onset (1-2 days) that is
increasing despite treatment, contact a physician
for advice and to rule out an abscess.

Constipation
Definition • Recent change in pattern of defecation,
Condition in which diminished frequency or consistency of stool or other features
incomplete evacuation of or stool is hard, dry, • Any associated rectal blood, melena
often small and round; difficult and painful to • Diarrhea (overflow)
pass. Constipation is a symptom, not a diagnosis. • Abdominal pain, cramping and bloating
A careful, accurate history and physical • Difficulty or pain on defecation
examination are mandatory to establish the • Ineffective or painful straining
underlying cause. • Time of most recent bowel movement
• Fluid intake
Causes • Dietary intake
• Ignoring urge to defecate • Activity and exercise patterns
• Insufficient fiber and fluid in diet • Current medication, previous and current use of
• Physical inactivity laxatives
• Pregnancy • Stressors and psyche
• Side effect of medications • Depression
• Chronic abuse of laxatives • Eating disorders
• Anal fissure • Pregnancy (current)
• Hemorrhoids • Endocrine disorders (e.g. diabetes mellitus,
• Cancer of colon or rectum hypothyroidism)
• Other diseases of large bowel • Neurological disease (e.g. Parkinson's disease,
• Endocrine problems multiple sclerosis)
• Neurological diseases • Collagen vascular disease (e.g. systemic
sclerosis)
Medications Associated with
Constipation Physical Findings
• Aluminum antacids • Usually no distress
• Tricyclic antidepressants • Client looks well
• Antipsychotics • Abdomen may be distended
• Anticholinergics • Bowel sounds normal but may be reduced in
• Antiparkinsonian drugs chronic constipation
• Opiate narcotics • Bowel sounds may be normal to dull in lower
• Seizure medication (phenobarbital, phenytoin, quadrants
carbamazepine) • Stool may be palpable in left or right lower
• Antihypertensive medications quadrant
(e.g. calcium-channel blockers) • Left and right lower quadrant may be tender
• Iron preparations • Hard, pebbly stool in rectum, or rectum may be
• Sympathomimetics (e.g. pseudoephedrine) empty
• Terbutaline • Hemorrhoids and anal fissures may be present
• Bismuth products (e.g. Pepto-Bismol)
History • Irritable bowel syndrome
The consistency of the movement and the ease • Diverticular disease
with which stool is passed are more important then • Partial bowel obstruction
the frequency of bowel movements. • Rectal fissure
• Duration of constipation (recent or chronic • Anal fissure or hemorrhoids
problem) • Physical inactivity

• Side effects of medications or laxative abuse and dietary changes must be maintained over the
• Cancer of colon, rectum or other organ long term)
• Diseases of the large bowel
• Endocrine problems (e.g. hypothyroidism) Pharmacologic Interventions
• Neurological diseases (e.g. Parkinson's disease) To relieve initial constipation, medications may be
required. Avoid starting client on a long-term
Complications course of laxatives.
• Chronic abdominal pain
• Hemorrhoids Acute Constipation
• Anal fissure Step 1: Start a bulk-forming agent:
psyllium hydrophilic mucilloid (A class drug),
• Fecal impaction
1 tsp (5 mL) in 8 oz (250 mL) fluid bid or tid
• Fecal and urinary incontinence Step 2: If bulk-forming agent not tolerated or
• Urinary retention ineffective, add or substitute osmotic saline
• Inguinal hernia from straining laxative agents for a short period (3-4 days):
• Intestinal obstruction stimulant laxatives such as bisacodyl (A class
drug), 5-15 mg hs
Diagnostic Tests or
Test stool for occult blood. senna (A class drug), 2-4 tabs hs to bid
Step 3: If no relief, consult a physician regarding
Management orders for:
Goals of Treatment electrolytes or polyethylene glycol (B class drug)
• Establish regular bowel function or
• Eliminate contributing factors Fleet® phosphosoda (oral Fleet®)
• Identify and manage underlying disease For clients with difficulty initiating evacuation,
• Prevent and treat complications (e.g. fecal add:
impaction, hemorrhoids, anal fissures, rectal glycerin suppository (A class drug), 1 or 2 prn
or
prolapse, fecal incontinence, bowel obstruction)
Fleet® enema (A class drug) prn
• Eliminate need to strain and prevent adverse
When fecal impaction is present, disimpact as
effects of straining (e.g. hernia,
necessary. Use enemas (e.g. Fleet®, saline, oil
gastroesophageal reflux, coronary and cerebral
retention). Follow up closely until regular bowel
dysfunction in the elderly, vasovagal)
function is achieved.
Nonpharmacologic Interventions Docusate sodium, a stool softener, is better than a
• Client should increase dietary fluids to laxative for use in situations where straining needs
1.5-2.0 L/day to be avoided for a prescribed period.
• Client should increase dietary fiber to
20-30 g/day: bran, whole grains, fruits and Chronic Constipation
vegetables should be encouraged; prune juice, The following medications may be used in
stewed prunes and figs can be tried conjunction with nonpharmacologic approaches if
• Encourage physical exercise if client is able these interventions are unsuccessful after a
• Discontinue medications with constipating 1-month trial:
effects if possible Step 1: Regular use of bulk-forming agent:
• Establish regular time for toileting to help psyllium hydrophilic mucilloid (A class drug),
develop a conditioned reflex for bowel action 1 tsp (5 mL) in 8 oz (250 mL) fluid bid or tid
(e.g. immediately after breakfast) Step 2: Intermittent use of osmotic saline laxatives
• Encourage relaxation exercises for the pelvic for short periods (e.g. 3-4 days):
floor and external anal sphincter muscles magnesium hydroxide (Milk of Magnesia) (A class
• Advise client that bowel retraining may take drug), 1.2-3.2 g (15-40 mL) od
months (patience and persistence are required

Monitoring and Follow-Up • There is evidence of other organic disease

Follow up regularly every 2-4 weeks until regular • This constipation represents a new change in
bowel function is achieved. Review and adjust bowel habit in a person > 50 years of age
dose of bulking agents to obtain a soft, formed • the constipation is not resolving with appropriate
stool. treatment.
Referral Severe straining at stool or a continued sensation

Refer to a physician to arrange further of rectal fullness even when rectum is empty
investigation if warrants a more thorough evaluation.
• Testing of stool for occult blood is positive
• Hemoglobin is low

Diarrhea
Definition • Abdominal pain, possibly crampy
Change in bowel habits characterized by frequent • Current or recently used medications
loose or liquid stool (may be of large or small • Recent travel
volume). Diarrhea is a symptom, not a diagnosis. • Dietary and fluid intake in past 24 hours
A careful, accurate history and physical • Nausea or vomiting
examination are mandatory to establish the • Fever
underlying cause. • Headache
• Thirst
Causes • Decreased urine output (may be present if
Acute Diarrhea diarrhea is severe or prolonged)
• Viral infection (most common cause): such as
rotavirus, adenovirus or (less commonly) If the client is passing bloody diarrhea, consider
hepatitis A infection with Shigella or Salmonella, or
• Bacterial infection: Campylobacter, Clostridium inflammatory or ischemic bowel disease.
difficile, Escherichia coli (0157:H7),
Salmonella, Shigella, Yersinia Physical Findings
• Inflammatory bowel disease (e.g. ulcerative • Temperature may be elevated (if cause is
colitis, Crohn's disease) infectious)
• Medications (e.g. antibiotics, antacids, laxatives) • Heart rate may be increased (if dehydration,
• Parasitic infection (e.g. Giardia, hookworm, fever or metabolic derangement)
cryptosporidium, amebiasis) • Weight loss (if chronic)
• Blood pressure low if severely dehydrated
During "spring break-up" and in late summer,
• Postural blood pressure drop if moderately
community outbreaks of bacterial and parasitic
dehydrated
origin diarrhea are common if water quality is
poor. E. coli and parasites may be involved if there • Client appears mildly to severely ill (depending
has been recent travel. on cause and severity)
• Mucous membranes may be dry
Chronic Diarrhea • Eyes may be sunken with dark circles
• Poor nutrition underneath
• Inflammatory bowel disease (e.g. ulcerative • Sclera or skin may be jaundiced (in hepatitis)
colitis, Crohn's disease) • Skin may feel dry, turgor may be poor
• Malabsorption syndromes (e.g. lactase • Abdomen may be slightly distended with gas
deficiency, post-abdominal surgery) • Bowel sounds hyperactive
• Endocrine conditions (e.g. hyperthyroidism, • Abdomen hyperresonant if excess gas is present
diabetes mellitus) • Abdomen may be mildly tender in all areas
• AIDS • Abdominal mass may be present (depending on
• Irritable bowel syndrome underlying cause)
• Acute diverticulitis • Rectal exam reveals tenderness and mass
• Fecal impaction (overflow)
History • Viral infection
• Sudden onset of frequent, loose, watery bowel • Bacterial infection
movements • Parasitic infection
• Blood, pus or mucus may be present • Excess consumption of alcohol or fruit
• Melena • Antibiotic use (current or recent)
• Steatorrhea (fatty, greasy, bulky stool) • Laxative abuse

• Irritable bowel syndrome fluids (e.g. water, juices, soft drinks) may be the
• Inflammatory bowel disease best strategy for managing acute diarrhea
• Fecal impaction with overflow diarrhea
• AIDS Elderly and debilitated clients in particular are at
risk for dehydration, and early use of oral
• Malabsorption syndrome (e.g. lactase
rehydration fluids is recommended.
deficiency)
Water, juices and soft drinks do not replace
Complications electrolytes because they are low in sodium. Too
• Dehydration much of these hypotonic fluids can lead to
• Systemic infection (sepsis) hyponatremia.
Diagnostic Tests Client Education

• Test stool for occult blood • Teach client to recognize symptoms and signs of
• Test stool for culture and sensitivity, ova and dehydration and advise client to return to clinic
parasites, and C. difficile (if recent antibiotic if they occur
therapy) • Witch-hazel cotton pads (Tucks) may provide
• Test for HIV (in chronic diarrhea or if risk relief to the raw perianal area
behaviors present) • Teach client that proper hand washing prevents
the spread of infection
Management • Teach client how to prevent recurrent diarrhea
Goals of Treatment (by boiling drinking water for at least 20
• Establish normal bowel function minutes)
• Prevent complications (e.g. dehydration)
• Avoid complications of antidiarrheal Pharmacologic Intervention
medications (e.g. constipation, toxic megacolon) Refer to Page 7, this section, Dehydration
Management
Appropriate Consultation Control nausea and vomiting if significant:
Consult a physician if the client is moderately or dimenhydrinate (A class drug), 25-50 mg IM,
severely dehydrated. single dose, then 50 mg PO q4-6h prn
Avoid antidiarrheals until diagnosis confirmed and
Nonpharmacologic Interventions infectious disease ruled out.
Dietary Adjustments Antidiarrheals may help to relieve symptoms.
• Client should avoid coffee, alcohol, most fruits, loperamide hydrochloride (C class drug), 4 mg to
vegetables, heavily seasoned foods start, then 2 mg after each loose bowel movement
• Client should stop eating dairy products (except to a maximum of 16 mg/day, then 2-4 mg bid
yogurt, aged cheese) for 7-10 days
• Client may need to stop solid foods for a brief Monitoring and Follow-Up
period (6 hours) if stool is frequent and watery Monitor hydration, general condition and vital
or if vomiting occurs in association with signs frequently until stable. Follow up in 24 hours
diarrhea (sooner if oral intake is not keeping up with
• There is evidence that early reinstitution of a losses).
lactose-free general diet will decrease the
duration and severity of diarrhea
• Gradually reintroduce solid foods (e.g. salted
crackers, dry toast or bread), and then move on
to bland foods (e.g. baked potato, poultry, baked
fish, noodles)
• A combination of clear broths, oral rehydration
solutions and a modest amount of hypotonic

Referral • is unable to tolerate fluids by mouth

Refer any client who • in whom bowel sounds are absent
• is dehydrated by more than 6% to 10%, if he or • has abdominal tenderness or rebound tenderness
she does not respond rapidly to rehydration • has high fever and appears acutely ill.
therapy
• is elderly and has multiple medical problems

Gastroesophageal Reflux Disease (GERD)

Reflux of gastric contents into the esophagus, • Esophagitis
which results in esophageal irritation or • Esophageal ulcer
inflammation. • Upper GI bleeding
• Esophageal stricture
Causes • Nocturnal aspiration
Presence of acidic stomach contents in the • Barrett's esophagus
esophagus due to laxity of the lower esophageal
• Adenocarcinoma of esophagus
sphincter.
Predisposing Factors Barrett's Esophagus

People who have had regular or daily heartburn for
• Defective esophageal clearance, such as
more than 5 years may be at risk for Barrett's
stricture, hiatal hernia, incompetent gastric
esophagus, a condition that develops in some
sphincter
people with chronic GERD or inflammation of the
• Obesity
esophagus (esophagitis). In Barrett's esophagus,
• Pregnancy the normal cells that line the esophagus, called
• Estrogen therapy squamous cells, change into a type of cell not
• Medications usually found in humans, called specialized
• Tobacco use columnar cells. Damage to the lining of the
• Alcohol use esophagus, by acid reflux, causes these abnormal
• Genetic factors changes.
• Hypersecretion of gastric acid
• Delayed gastric emptying Once the cells in the lining of the esophagus have
become columnar cells, they will not revert to
History normal. The goal of treatment is to prevent further
• Heartburn damage by stopping any acid reflux from the
• Retrosternal burning sensation radiating upward stomach.
(may radiate as far up as the throat)
An increase in cancer of the esophagus occurs.
• Acidic stomach contents may be regurgitated
Because of the risk of cancer, people with Barrett's
• Associated with large meals, lying down and esophagus should be screened regularly for
bending over
esophageal cancer.
• Often awakens client during the night
• May be associated with cough, sore throat, Diagnostic Tests
hoarseness, painful swallowing
• Stool for occult blood
• Hypersalivation (water brash)
• Hemoglobin level
• Aggravating factors identifiable
• Refer to physician for test for Helicobacter
• Relief with antacids and sitting up pylori (by serology or breath test)
• Stress makes condition worse
Management
Physical Findings
Goals of Treatment
Mild epigastric tenderness may be present.
Differential Diagnosis • Promote healing of the esophagus
• Peptic ulcer disease • Prevent complications such as stricture,
bleeding, Barrett's esophagus
• Esophageal motility disorder
• Prevent recurrence
• Esophageal tumor
• Cardiac chest pain


Consult a physician if the following are detected: Antacids as needed to control symptoms:
• Weight loss due to severity or duration of aluminum hydroxide/magnesium hydroxide
symptoms (A class drug), 30 mL PO pc and hs, increase prn
• Difficult or painful swallowing or
• Sticking of solids or liquids aluminum/magnesium/simethicone (A class drug),
• Persistent vomiting 30 mL PO pc and hs, increase prn
• Nocturnal cough or shortness of breath H2-receptor antagonists:
ranitidine (C class drug), 150 mg PO bid for 6
• Anemia
weeks
• Stool positive for occult blood In elderly clients and those with reduced renal
• Client with new onset of symptoms function, the doses should be one-half to one-
quarter the usual doses.
• Elevate the head of the bed using 4-6 inch (10- Refer to physician if symptoms not controlled with
15 cm) wooden blocks H2-receptor antagonists for evaluation for proton
• Encourage weight loss (if appropriate) pump inhibitors.
• Eliminate (when possible) drugs that impair
esophageal motility and lower esophageal Proton Pump Inhibitors (by physician order)
sphincter tone (e.g. calcium-channel blockers, Proton pump inhibitors (e.g. rabeprazole B class
ß-blockers, tricyclic antidepressants, drug) are a class of drugs used to treat refractory
anticholinergics, theophyllines) symptoms of GERD. They are more effective for
• Offer smoking cessation healing esophageal ulceration and maintain the
remission of symptoms much better than
Client Education H2-receptor antagonists. These drugs do not
• Counsel client about appropriate use of reverse Barrett's esophagus, but may prevent
medications (dose, frequency) worsening of the disease.
• Recommend dietary modifications (decrease or
eliminate coffee, tea, chocolate, alcohol, fatty Maintenance therapy for moderate to severe
foods, citrus fruits, mints) GERD is often needed, as the recurrence rate is
• Recommend small, frequent meals to prevent high (75% to 90%). Cost and safety are concerns
overdistension of the stomach with long-term use of proton pump inhibitors. The
• Recommend avoidance of eating for 2-3 hours lowest dose possible should be used.
before bedtime
• Recommend postural modifications (daytime Antireflux Surgery
and nocturnal) to prevent acid from entering the Antireflux surgery is effective in controlling
esophagus GERD in 90% of well-selected clients. Indications
• Recommend that client avoid bending at the for surgery include intractable reflux esophagitis
waist or lying down immediately after a meal (in a young person) and major complications such
as aspiration, recurrent stricture or major GI
• Recommend avoidance of tight-fitting clothing
bleeding.
• No tobacco
Follow up in 2-3 weeks; if better, continue to treat
for another 6-8 weeks.
Referral
Refer to a physician if symptoms are not
controlled with therapy.

Peptic Ulcer Disease

Definition • Diverticulitis
An ulceration of the mucous membrane of the • Pancreatitis
upper digestive tract. Usually refers to a duodenal
or gastric ulcer. Complications
• Chronic blood loss, anemia
Causes • Severe pain
Bacterial infection with Helicobacter pylori. • Sudden hemorrhage, which can lead to
NSAID hypotension
• Perforation
Risk Factors • Obstruction of the gastric outlet
• Severe stress • Malnutrition
• Chronic gastritis
• Smoking Diagnostic Tests
• Genetic factors • Stool for occult blood
• Hemoglobin level
History • Refer to physician for diagnostic testing to
• Symptoms may be vague or absent, classical or confirm presence of H. pylori
atypical (some people with a duodenal ulcer
have no symptoms, whereas some with ulcer- Management
like symptoms have no ulcer)
Goals of Treatment
• Chronic benign disease with exacerbations and
• Relieve pain
remissions
• Reduce stomach acid
• Epigastric burning, gnawing, heartburn
• Promote healing
• Discomfort varies, from mild to severe
• Discomfort located near midline between
xiphoid and umbilicus or in right upper quadrant
• Symptoms begin 1-3 hours after meals, when
If condition not resolved, consult.
stomach becomes empty
Consult a physician if complications are identified
• May awaken person from sleep or active bleeding is present (see "Gastrointestinal
• Quickly relieved by food, milk or antacids Bleeding," under "Emergencies of the
• Nausea may be present Gastrointestinal System," below, this chapter).
• Melena or hematemesis indicates complications
• Assess use of alcohol, ASA, anti-inflammatory Nonpharmacologic Interventions
drugs, tobacco (smoking and chewing) Client Education
• Dietary habits • Explain the nature of the disease and the
expected outcome
The natural history of a benign ulcer is that two- • Counsel client about appropriate use of
thirds will recur in the first year after treatment. medications (dose, frequency, purpose and
importance of compliance)
Physical Findings • Recommend small, frequent meals that are
Epigastric tenderness. lightly spiced or not spiced at all
• Recommend avoidance of all foods known to
Differential Diagnosis increase pain (e.g. large fatty meals, very sweet
• Gastritis foods)
• GERD • Recommend avoidance of all caffeinated
• Irritable bowel syndrome beverages (tea, coffee, colas)
• Malignant gastric ulcer • Recommend avoidance of alcohol

• Recommend avoidance of ASA and other anti- Triple Therapy for H. pylori
inflammatory drugs Anyone testing positive for H. pylori will need to
• Recommend tobacco cessation undergo triple-drug therapy for eradication, as
• Counsel client about reducing stress at home and ordered by a physician.
at work
• Teach client the signs of complications that Monitoring and Follow-Up
should be followed up immediately Follow up in 2 weeks to assess response to
therapy. Follow up again in 4-6 weeks.
Pharmacologic Interventions Discontinue medications if symptoms have
Antacids as needed to control symptoms: resolved.
aluminum hydroxide/magnesium hydroxide or
aluminum/magnesium/simethicone Referral
(A class drug), 30 mL PO 1 and 3 h pc, hs and prn Refer to a physician if there is no improvement
with treatment or if complications develop.
Reduce production of stomach acid:
ranitidine (C class drug), 150 mg PO bid for 6
weeks

Gallbladder Disease: Biliary Colic And Cholecystitis

Definition Rates of gallstones, cholecystitis and stones of the
The spectrum of gallbladder disease ranges from common bile duct increase with age. Elderly
asymptomatic gallstones to biliary colic, clients are more likely to have asymptomatic
cholecystitis, choledocholithiasis and cholangitis. gallstones that result in serious complications
without gallbladder colic.
Cholecystitis is inflammation of the gallbladder
caused by obstruction of the cystic duct, usually The causes of gallstones in teenagers are the same
by a gallstone (calculous cholecystitis). The as for adults, and there is a higher prevalence
inflammation may be sterile or bacterial. The among girls and during pregnancy.
obstruction may be acalculous or caused by
sludge. History
Most gallstones (60% to 80%) are asymptomatic.
Choledocholithiasis occurs when the stones Small stones are more likely to be symptomatic
become lodged in the common bile duct; from than large ones. Almost all patients experience
this, cholangitis and ascending infections can symptoms before complications occur.
occur. Indigestion, belching, bloating and intolerance of
fatty food are thought to be typical symptoms of
Causes gallstones; however, these symptoms are just as
Biliary Colic common in people without gallstones and
Gallstones temporarily obstruct the cystic duct or frequently are not cured by cholecystectomy.
pass into the common bile duct.
Biliary Colic
Cholecystitis • 1-5 hours of constant pain, commonly in the
The cystic duct or common bile duct becomes epigastrium or right upper quadrant
obstructed for hours, or gallstones irritate the • Pain may radiate to the right scapular region or
gallbladder. Bacterial infection is thought to be a back
consequence, not a cause, of cholecystitis. • Client tends to move around to seek relief from
pain
The most common organisms are E. coli, • Onset of pain occurs hours after a meal,
Klebsiella spp. and enterococci. Stones of the frequently at night, waking the client from sleep
common bile duct (occurring in 10% of patients • Peritoneal irritation by direct contact with the
with gallbladder disease) are secondary (from the gallbladder localizes the pain to the right upper
gallbladder) or primary (formed in the bile ducts). quadrant
• Pain is severe, dull, or boring and constant (not
Risk Factors colicky)
The phrase "fair, fat and fertile female" • Associated symptoms include nausea, vomiting,
summarizes the major risk factors for gallstones. pleuritic pain and fever
Although gallstones and cholecystitis are more
common in women, men with gallstones are more Cholecystitis
likely to experience cholecystitis than women with • Persistence of the biliary obstruction leads to
gallstones. It is unknown if women who are cholecystitis
pregnant or have multiple pregnancies are more
• Persistent right upper quadrant pain
likely to have gallstones or if they simply have
more symptoms of the stones. • The character of the pain is similar to the pain
associated with gallbladder colic, except that it
Some oral contraceptives and estrogen is prolonged and lasts for hours or days
replacement therapy may increase the risk of • Nausea, vomiting and low-grade fever are more
gallstones. commonly associated with cholecystitis

Physical Findings Acute Cholecystitis

• Vitals signs parallel the degree of illness • Perforation
• Clients with biliary colic have relatively normal • Gangrene
vital signs • Peritonitis
• Clients with cholangitis are more likely to have • Cholangitis
tachycardia or hypotension (or both) and fever • Abscess
• Fever may be absent, especially in elderly • Fistula
clients • Pancreatitis
• Jaundice (in < 20% of patients) • Ileus
Abdominal Examination in Gallbladder Diagnostic Tests

Colic and Cholecystitis The choice of laboratory tests will depend on
• Epigastric or right upper quadrant tenderness whether the client is well enough to be treated as
• Murphy's sign (an inspiratory pause on palpation an outpatient or requires admission to hospital.
of the right upper quadrant; specific but not The results of lab tests should be completely
sensitive for gallbladder disease) normal if the client has cholelithiasis or
• Guarding on palpation gallbladder colic.
• Fullness in the right upper quadrant may be • White blood cell (WBC) count and liver
palpated function tests (LFTs) (AST, ALT, bilirubin and
alkaline phosphate levels) may be helpful in the
As in anyone with abdominal pain, a complete diagnosis of cholecystitis
physical examination must be performed • An elevated WBC count is expected; however, a
(including rectal and pelvic examinations in normal value does not rule out cholecystitis
women). In elderly and diabetic clients, occult • Bilirubin >3.5 µmol/L may indicate stone in the
cholecystitis or cholangitis may be the source of common bile duct or ascending cholangitis
fever, sepsis or changes in mental status. • Mild elevation of amylase (up to 3 times normal
level) may be present in cholecystitis, especially
Differential Diagnosis if there is gangrene
• Appendicitis • Urinalysis
• Acute bowel obstruction • Pregnancy test for women of childbearing age
• Ascending cholangitis
• Cholelithiasis Management Of Biliary Colic
• Diverticular disease Goals of Treatment
• Gastroenteritis • Relieve pain, nausea and vomiting
• Hepatitis • Prevent complications
• Inflammatory bowel disease
• Mesenteric ischemia Appropriate Consultation
• Myocardial infarction Consult physician if pain does not resolve, if fever
• Pancreatitis develops or if significant vomiting continues, as
• Bacterial pneumonia these symptoms indicate that a complication may
• Eclampsia be developing.
• Hyperemesis gravidarum
• Urinary tract infection
• Bed rest
• Renal calculi
• Clear fluids if vomiting
Complications
Biliary Colic
• Cholecystitis

Client Education • Oxygen, if client is unstable on presentation

• Explain disease process and prognosis • IV therapy with normal saline, rate adjusted
• Counsel client about appropriate use of according to age, state of hydration and pre-
medications (dose, frequency) existing medical problems
• Recommend low-fat food as tolerated, once pain
resolves Nonpharmacologic Interventions
• Bed rest
Pharmacologic Interventions • Nothing by mouth
Analgesia
Primary pain should be controlled with Pharmacologic Interventions
anticholinergic antispasmodics: Analgesia
hyoscine butylbromide (B class drug), Pain control should be given early, without
10 mg IM q6h prn (max 100mg/day) waiting for the diagnosis or surgical consult.
hyoscine butylbromide (C class drug), Primary pain control should be with
10mg, 1-2 tabs, PO q6h (max 6 tabs/day) anticholinergic antispasmodics:
hyoscine butylbromide (B class drug),
Secondary pain should be controlled with 10 mg IM q6h prn (max 100mg/day)
meperidine; do not use morphine, which may Secondary pain control should be with meperidine;
increase tone in the Oddi's sphincter: do not use morphine, which may increase tone in
meperidine (D class drug), 50-100 mg IM q3-4h the Oddi's sphincter:
prn meperidine (D class drug), 50-100 mg IM
q3-4h prn
Consult physician for IV order
Antiemetics
Antiemetics to relieve vomiting and nausea: dimenhydrinate (A class drug), 25-50 mg IM
dimenhydrinate (A class drug), 25-50 mg IM q4- q4-6h
6h prn Meperidine and dimenhydrinate can be mixed in
the same syringe, but should be used immediately.
Monitor for a few hours. When nausea and Antibiotics
vomiting have resolved, push clear fluids. For mild cholecystitis, where inflammation is the
Follow-up in 24 hours is recommended. If pain primary process, antibiotics are not usually used.
increases, fever develops, or the client is unable to For acute cholecystitis (if client is febrile and
tolerate intake by mouth because of vomiting, acutely ill), draw a blood sample for culture and
manage as for acute cholecystitis. consult physician for IV antibiotics.
For clients with allergy to penicillin use only
Management Of Cholecystitis metronidazole.
Goals of Treatment
• Relieve pain, nausea and vomiting Monitoring and Follow-Up
• Prevent complications Monitor pulse oximetry, vital signs (frequent),
blood glucose, intake and output.
Appropriate Consultation Severe cholecystitis can evolve into sepsis or
Consult physician if pain does not resolve, if fever cholangitis, especially in diabetic or elderly clients
develops or if significant vomiting continues in whom the diagnosis may be delayed.
indicating that a complication may be developing.
Referral
Adjuvant Therapy Medevac as soon as possible; surgical consult is
For clients with severe pain prehospital care required.
should include the following:

Abdominal Hernia
Protrusion of part of the abdominal contents None.
through a weakness in the abdominal wall.
Management
Causes Goals of Treatment
• Weakness of abdominal wall muscles • Reduce swelling
• Predisposing factors: abdominal surgery, age, • Support weak abdominal wall
heavy lifting, chronic cough, chronic straining to • Relieve discomfort
pass stool or to urinate • Prevent recurrence and further enlargement

• Presence of predisposing factor Consult a physician immediately if the hernia is
• Soft, non-tender swelling on abdominal wall not reducible, if it is painful, or if it is associated
• Pain absent with symptoms and signs of bowel obstruction.
• Hernia usually appears when client is standing Consult a physician immediately if a painless
or when straining at bowel movements femoral hernia is suspected.
• Hernia may disappear when client is lying down
• Pain indicates development of complications Nonpharmacologic Interventions
• Inguinal (groin), abdominal (incisional) hernias With client lying down, attempt to reduce the
common inguinal or incisional hernia with gentle manual
reduction.
Physical Findings • Do not use force
• Swelling may be seen in groin, may extend into • Do not attempt to reduce a femoral hernia
scrotum
• Swelling may be seen on upper anterior thigh Client Education
(femoral hernia) or abdomen • Explain disease process, expected course and
need for follow-up
• Hernia disappears upon lying down, reappears
upon standing up or bearing down • Demonstrate proper lifting techniques
• Defect in abdominal wall may be palpable • Teach client signs and symptoms of
complications and advise him or her to return to
• Hernia can be pushed back (reduced) through
the nursing station if these occur
the opening into the abdomen
A painful or non-reducible inguinal mass should Monitoring and Follow-Up

Follow as necessary until surgical consult takes
be considered a strangulated hernia until it is
place. Monitor for the development of bowel
proven otherwise.
obstruction. See "Obstruction of the Small or
Large Bowel," under "Emergencies of the
Differential Diagnosis Gastrointestinal System," below, this chapter).
• Enlarged inguinal lymph node
• Hydrocele Referral
• Testicular mass Arrange elective follow-up with physician for
• Dilated vein surgical consult. Medevac if there are symptoms
of strangulation or bowel obstruction.
Complications
• Strangulated hernia
• Bowel obstruction

Irritable Bowel Syndrome

Functional disturbance of intestinal motility. • Stool for occult blood
• Stool for culture and sensitivity, ova and
Cause parasites
• Largely unknown • Hemoglobin level
• Predisposing factors: insufficient dietary fiber,
emotional stress, food sensitivity, laxative abuse Management
Goals of Treatment
History • Relieve symptoms
• Usually begins before age 40 • Establish regular bowel habits
• More common in women • Identify or modify precipitating stresses
• Symptoms vague and long term
• Chronic condition with remissions and Nonpharmacologic Interventions
exacerbations Client Education
• Altered stool frequency and/or consistency • Recommend dietary modifications (e.g. regular
• Diffuse lower-abdominal pain or discomfort meals, gradual increase of fiber)
• Pain of variable intensity; may persist for hours • Recommend increase in fiber content of diet
or days (e.g. raw bran, brown bread, popcorn, All-Bran,
• Looser, more frequent bowel movements may Puffed Wheat or Shredded Wheat cereal); when
occur with onset of pain raw (miller's) bran is used, start with a small
• Pain exacerbated by meals, bowel movements or amount and increase gradually to 1/4 to 1/2 cup
stress daily to avoid bloating and flatulence
• Pain relieved by defecation • Recommend avoidance of foods that are known
• Weight loss, malaise, may have a fever to cause symptoms (these vary from person to
• Interference with daily activities person)
• No rectal bleeding or blood in stool • Recommend that client consume an adequate
amount of fluid when using bulking agents
• White mucus frequently present
• Recommend elimination of nicotine and
codeine-containing drugs
Physical Findings
• Teach relaxation techniques and emphasize the
• Client may appear quite well or in mild distress
importance of exercise to help with stress-
• Abdomen may be distended induced symptoms
• Bowel sounds present and may be increased or • Assist client to identify specific stress factors
decreased that exacerbate symptoms
• Colon may be tender and "rope-like" • Assist client to gain insight into identifiable
• Compression of colon may reproduce symptoms emotional factors
• Offer understanding and support, as this is an
Differential Diagnosis incompletely and poorly understood syndrome
• Constipation
• Gastroenteritis Pharmacologic Interventions
• Lactose intolerance Start a stool-bulking agent:
• Inflammatory bowel disease psyllium hydrophilic mucilloid (A class drug),
• Drug-induced diarrhea or constipation 1-2 tsp (5-10 mL) bid or tid with 8 oz (250 mL)
• Biliary colic fluid
Complications
• Chronic abdominal symptoms


• Follow up in 1-2 weeks Refer to a physician if symptoms or signs of
• Adjust the dose of fiber depending on organic disease are present or if symptoms do not
response improve with management.
• Use less fiber temporarily if gas and bloating
are prominent
• Use more fiber if there has been little clinical
response

Diverticulitis
Inflammation and infection in one or more • Stool for occult blood
diverticula. • Urinalysis
History Management
• Abdominal pain may present acutely, but more Goals of Treatment
often develops over hours to days, with left • Rest the bowel
lower quadrant pain • Relieve symptoms
• Fever and chills • Prevent complications
• Tachycardia
• Anorexia Appropriate Consultation
• Nausea and vomiting Consult a physician.

• Fever • Nothing by mouth
• Tachycardia • Nasogastric tube
• Abdominal tenderness to palpation with possible
rebound tenderness Adjuvant Therapy
• Palpable mass may be present, representing an Start IV therapy with normal saline to maintain
abscess or inflammatory phlegmon hydration in client with moderate to severe
• Bowel sounds may be active if there is partial symptoms.
obstruction, or hypoactive or absent if peritonitis
has developed Pharmacologic Interventions
• Rectal exam may help to identify the abscess or • Broad-spectrum antibiotics such as ampicillin,
inflammatory mass gentamicin, clindamycin or cefoxitin are used;
consult a physician before starting IV antibiotics
Differential Diagnosis • Antibiotics should be continued for 7-10 days
• Appendicitis
• Inflammatory bowel disease Referral
• Ischemic colitis Medevac. Surgery may be required if there is
peritonitis, with or without evidence of
• Colon cancer
perforation, unresolved obstruction or
• Other causes of bowel obstruction development of a fistula. Other indications for
• Urologic or gynecologic disorders surgical intervention are failure to improve after
several days of medical treatment and recurrence
Complications after successful treatment.
• Abscess
• Perforation
• Fistula
• Peritonitis
• Sepsis

Emergencies Of The Gastrointestinal System

Abdominal Pain (Acute)
History • Medications, especially digoxin, theophylline,
The area of the pain, including its origin and steroids and tetracycline (for esophageal ulcers),
pattern of radiation, time of onset, nature and analgesics, antipyretics, antiemetics,
associated symptoms, will frequently help in barbiturates, diuretics, alendronate (for
making the diagnosis. A menstrual history should esophageal ulcers)
be obtained.
Physical Examination
Associated Symptoms Vital Signs
• Weight loss may indicate malignancy or • Signs of shock, infection (elevated temperature)
malabsorption • Signs of dehydration, with dry mucous
• Vomiting may be associated with small-bowel membranes and decreased skin turgor
obstruction or volvulus
• Diarrhea and constipation may suggest Abdominal Examination
inflammatory bowel disease, cancer, Inspection
constipation, malabsorption Scaphoid appearance or distension, point of most
• Melena or blood per rectum indicates GI severe pain, hernia, scars.
bleeding, which may be associated with peptic
ulcer disease, esophageal varices or colon Auscultation
cancer, or may be drug induced • High-pitched bowel sounds suggest obstructive
• Check stool by hemoculture; if negative, process
consider foods (e.g. Kool-Aid, beets) or • Absent bowel sounds suggest ileus
medicines (iron) as cause
• Jaundice may suggest pancreatic cancer Palpation and Percussion
(painless), hepatitis, hemolysis, sickle cell • Muscle rigidity (voluntary or involuntary)
anemia (G6PD [glucose-6-phosphate • Localized tenderness, masses, pulsation, hernias,
dehydrogenase] deficiency), alcoholic hepatitis, peritoneal irritation (cough or jumping may also
choledocholithiasis or primary biliary cirrhosis elicit "rebound")
• Urinary symptoms (dysuria, frequency, urgency, • Involuntary guarding
hematuria) • Murphy's sign (right upper quadrant pain when
• Renal problems often present with abdominal breathing in and pressing over the liver)
pain; consider urolithiasis, urinary tract infection • Liver dimension and spleen dimension
or testicular torsion • Tenderness of costovertebral angle
• Sexual activity, last period, birth control use, • Pelvic exam in women
history of sexually transmitted infection, vaginal • Rectal exam to rule out GI bleeding, prostatitis,
discharge, spotting or bleeding: consider etc.
pregnancy or ectopic pregnancy, pelvic
• Absence of rectal tenderness does not preclude
inflammatory disease, ovarian torsion or
or confirm diagnosis of appendicitis
ruptured ovarian cyst
Medical History
• Other major illnesses
• Prior surgery
• Prior studies performed for evaluation of
abdominal problems
• Family history of similar complaints

Diagnostic Tests (If Available) • Pregnancy test for all reproductive-age females,
• Stool for occult blood unless status is post-hysterectomy
• Hemoglobin • Chest x-ray (if available) to rule out pneumonia
• WBC count • ECG
• Urinalysis

Table 2: Differential Diagnosis of Abdominal Pain

Diagnosis Usual location of pain Comments
Hepatitis, subphrenic RUQ Elevated liver enzymes
abscess, hepatic abscess may radiate to right shoulder Jaundice
Cholecystitis, RUQ, mid-epigastric region; radiates Sudden onset associated with nausea
cholelithiasis, cholangitis to back and right scapula
Pancreatitis mid-epigastric region; radiates to May have signs of peritonitis
back
Duodenal ulcer or mid-epigastric region, LUQ;
gastric ulcer radiation to back if posterior ulcer;
peritonitis with perforation
Splenic hematoma or LUQ Hypotension and peritonitis if ruptured
enlargement
Aortic aneurysm Peri-umbilical, especially into back May be colicky; hypotension if ruptured
flanks; may present as epigastric or
back pain, flank or hip pain
Appendicitis Early; periumbilical; late: RLQ May present with peritoneal signs, especially
in elderly people
Crohn’s disease or RLQ, but may be LLQ Diarrhea (bloody in ulcerative colitis), cramps,
ulcerative colitis elevated sedimentation rate
Mesenteric adenitis RLQ Pain secondary to enlarged mesenteric nodes
from streptococcal pharyngitis
Spontaneous bacterial Generalized, with peritoneal signs Usually in alcoholic people, people with
peritonitis indwelling catheters and those on dialysis
Diverticulitis Generally LLQ, very rarely RLQ; Clinical diagnosis (pain + diarrhea, vomiting,
may be generalized fever)
Meckel’s diverticulum Below or to left of umbilicus May be recurrent; presents with rectal bleeding
or intestinal obstruction
Urolithiasis or Either flank; may radiate to labia or Colicky; may have blood in urine; need
nephrolithiasis testicles intravenous pyelogram
Cystitis Suprapubic Urinalysis may show blood and leucocytes
Gynecologic disease, Pain in pelvis, either adnexal area; Pregnancy test, cervical cultures,
including ovarian cyst, radiation to groin; may also radiate ultrasonography to rule out ectopic pregnancy
ovarian torsion, ectopic to right shoulder if free if this possibility exists
pregnancy, intraperitoneal bleeding
Mittelschmerz, PID
Metabolic disease such as Pain may be diffuse; may have Associated with nausea and vomiting
diabetic ketoacidosis, guarding
Addison’s disease
Pneumonia May mimic appendicitis Cough and chest pain may also be present
Cardiac disease May present as epigastric pain ECG to rule out cardiac disease, especially if
risk factors present; may be confused with
esophageal reflux

Management Adjuvant Therapy

Initial Decision • Start IV therapy with normal saline and hydrate
Decide whether to admit and observe, discharge, accordingly
or refer for surgical opinion.
Appropriate Consultation Choice of medication will depend on the
Consult a physician if the diagnosis is unclear and presentation and the severity of the pain as judged
the presentation appears serious. by the client.
Nonpharmacologic Interventions Monitoring and Follow-Up

• Nothing by mouth until diagnosis is clear • Monitor pain, vital signs, managment and any
• Consider nasogastric tube for vomiting, bleeding associated fluid losses closely with intake and
or suspected bowel obstruction output
• Consider Foley catheter
Referral
Medevac for evaluation if diagnosis is uncertain
and the client's condition warrants urgent
evaluation.

Pancreatitis (Acute)
Inflammation of the pancreas. • Hypotension
• Shock
Causes • Paralytic ileus
• Excessive or chronic alcohol abuse • Sepsis
• Recent alcohol binge • Hyperglycemia
• Acute cholecystitis • Adult respiratory distress syndrome
• Abdominal trauma • Death
• Penetrating duodenal ulcer
Diagnostic Tests
History • Blood glucose level (may be elevated)
• Steady, boring abdominal pain • Urinalysis
• Pain located in epigastrium and periumbilical • WBC count (if possible)
area
• Pain radiates through to back, flanks, lower Management
abdomen and chest Goals of Treatment
• Pain is relieved by sitting up and leaning • Relieve symptoms
forward, aggravated by lying down • Maintain hydration
• Nausea, vomiting, abdominal distension present • Prevent complications
• History of biliary disease or gallstones
• Past or current use of thiazide diuretics, Appropriate Consultation
estrogen, azathioprine steroids, sulfasalazine Consult a physician for help with diagnosis and
treatment plan, for pre-hospital care.
Physical Findings
• Temperature elevated Nonpharmacologic Interventions
• Heart rate elevated • Bed rest
• Blood pressure may be low • Nothing by mouth
• Postural blood pressure drop may be present • Insert a nasogastric tube
• Client anxious, in acute distress • Insert a urinary catheter
• Distress increased when lying down
• Abdomen may be distended Adjuvant Therapy
• Bowel sounds reduced to absent (paralytic ileus) • Start a large-bore IV (14- or 16-gauge) with
• Respiratory findings may be present: basal normal saline; replace volume deficits (see
crackles, left-sided atelectasis, pleural effusion "Shock," in chapter 14, "General Emergencies
• Acutely tender with muscle guarding and and Major Trauma")
rigidity • Adjust rate according to pulse, postural blood
• Rebound tenderness present pressure drop, systolic blood pressure
• Aim for pulse < 100 bpm, systolic blood
Differential Diagnosis pressure >100 mm Hg
• Peptic ulcer disease
• Severe gastritis Pharmacologic Interventions
Analgesia:
• Acute cholecystitis
meperidine (D class drug), IM or IV as per
• Lower lobe pneumonia physician order
• Intestinal obstruction
Antiemetics:
dimenhydrinate (A class drug), 50 mg IM q6h prn

Monitoring and Follow-Up • Observe for alcohol withdrawal if a recent binge

• Measure hourly urinary output; adjust IV rate to is a known cause of pancreatitis
maintain urine output
• Monitor blood glucose (hyperglycemia is Referral
common) Medevac as soon as possible.
• Monitor pulse and blood pressure frequently
until the client's condition stabilizes--watch for
shock

Appendicitis
Inflammation of appendix. Appendicitis is known as the "great mimic." The
actual signs and symptoms depend on the location
Cause of the appendix within the abdomen.
Obstruction of the opening of the appendix by • Gastroenteritis
stool. Infection may occur later. • Crohn's disease
• Stone in ureter
History • Mittelschmerz (ruptured follicular cyst)
The following outlines the classic pattern for acute • Ectopic pregnancy
appendicitis; however, the client may complain of • Pelvic inflammatory disease
various forms of abdominal, rectal and back pain • Twisted ovarian cyst
depending on the location of the appendix. • Pyelonephritis
• Vague, diffuse periumbilical or epigastric pain • Biliary colic
• Pain shifts within hours to right lower quadrant • Cholecystitis
• Anorexia • Peptic ulcer disease
• Nausea
• Vomiting usually occurs a few hours after onset Complications
of pain, but may not be present • Abscess
• Low-grade fever may be present • Localized peritonitis
• Urinary frequency, dysuria and diarrhea may • Perforation
develop if tip of appendix irritates the bladder or
• Generalized peritonitis
bowel
• Sepsis
• In women, date of the last normal menstrual
period and any history of recent menstrual
irregularity should be noted Diagnostic Tests
• WBC count, if possible
Physical Findings • Urinalysis
Presentation is variable, depending on whether the
client presents early or late in the evolution of the Management
disease process. Goals of Treatment
• Temperature mildly elevated • Maintain hydration
• Heart rate elevated (may be normal in early • Prevent complications
stage)
• Variable level of distress Appropriate Consultation
• Client holds abdomen, walks slowly and slightly Consult a physician as soon as possible.
bent over
• Bowel sounds variable: hyperactive to normal in Nonpharmacologic Interventions
early stages; reduced to absent in later stage • Bed rest
• Localized tenderness in right lower quadrant • Nothing by mouth
• Muscle guarding in right lower quadrant
• Rebound tenderness may be present Adjuvant Therapy
• Rectal exam: tenderness in right lower quadrant • Start IV therapy with normal saline
if tip of appendix is near the rectum • Adjust IV rate according to age and state of
hydration


Analgesia: Monitor vital signs and general condition
meperidine (D class drug), IM or IV as per frequently.
physician order
If transfer is delayed, discuss starting IV Referral
antibiotics as per physician order: Medevac as soon as possible; surgical consult is
required.

Obstruction Of The Small Or Large Bowel

Definition Paralytic Ileus
Blockage of small or large bowel (partial or • Obstruction of the bowel due to paralysis of the
complete, mechanical or paralytic). muscle of the bowel wall, caused by generalized
peritonitis, any acute inflammation of the
Causes abdomen, severe chest injury or any acute illness
• Small bowel: strangulated hernia (40%), • Major symptom is distension, resulting in
adhesions (30%), cancer, Crohn's disease moderate discomfort
• Large bowel: cancer (70%), volvulus, • Pain absent
diverticulitis, fecal impaction • Frequent vomiting or regurgitation of gastric
contents
History • "Silent" distended abdomen on examination
• Pain
• Vomiting Physical Findings
• Inability to pass stool or gas • Heart rate normal or increased
• Bloating • Respiration normal or increased
• Other symptoms, depending upon underlying • Blood pressure normal or low
disease process • Postural blood pressure drop may be present
• Client appears mildly to severely ill
The exact symptoms of obstruction depend on the • Client doubles over with waves of pain in small-
location and severity of the obstruction. The bowel obstruction
higher the level of obstruction, the more acute and • Client pale, sweaty, anxious
rapid the onset of symptoms. • Various degrees of abdominal distension
• Hernia may be visible
Small-Bowel Obstruction • Contractions of bowel wall (peristalsis) may be
• Pain moderate to severe seen
• Intermittent waves of pain • Bowel sounds increased in early stages
• Relative comfort between waves of pain • Peristaltic rushes, high-pitched tinkling sounds
• Vomiting frequent, violent, bilious when present
obstruction is high • Later, bowel sounds are diminished or absent
• Vomiting feculent when obstruction is lower • Tenderness due to distension may be present
• Abdominal bloating variable; prominent when • Tender localized mass or hernia may be present
obstruction is low • Rebound tenderness and rigidity not present
• Reduced rectal gas and stool unless perforation, peritonitis or strangulation
• Weakness have occurred
• Rectal exam: blood or stool may be present,
Large-Bowel Obstruction rectum may be empty
• Pain moderately severe (generally less acute • Examine all hernial orifices, including both
than in small-bowel obstruction) femoral rings
• Colicky
• Distension present, occurs early, may be severe Differential Diagnosis
• Vomiting usually late and infrequent, may be • Gastroenteritis
feculent • Appendicitis
• Reduced or absent rectal gas and stool • Inflammatory bowel disease with distension
• Sudden, severe pain characteristic of volvulus • Perforated ulcer
• Pancreatitis

Complications Adjuvant Therapy

• Perforation • Start a large-bore IV (14- or 16-gauge) with
• Peritonitis normal saline; replace volume deficits
• Strangulated segment of bowel • Adjust IV rate according to pulse, postural blood
• Sepsis pressure drop, blood pressure, state of hydration,
• Hypotension, shock age, pre-existing medical problems (see
• Death "Shock," in chapter 14, "General Emergencies
and Major Trauma")
• Aim for pulse < 100 bpm, systolic blood
Diagnostic Tests
pressure > 100 mm Hg
• Stool for occult blood
• Urinalysis Pharmacologic Interventions
• Hemoglobin (optional; may help with diagnosis • If transfer is delayed, discuss starting IV
and treatment) antibiotics as per physician order.
• Analgesia may be necessary:
Management meperidine (D class drug), IM or IV as per
Goals of Treatment physician order
• Relieve distension
• Maintain hydration Monitoring and Follow-Up
• Prevent complications Monitor ABC, vital signs, urinary output and
general condition frequently.
Consult physician as soon as possible. Referral
• Bed rest
• Nothing by mouth
• Insert a nasogastric tube, attach to low suction or
to straight drainage
• Insert urinary catheter; measure hourly urinary
output

Gastrointestinal Bleeding (Upper And Lower)

Definition
Sudden, rapid loss of blood from the gastrointestinal tract. GI bleeding is a complication of some other
disease process.
Table 3: Causes of gastrointestinal bleeding

Category Upper GI bleeding Lower GI bleeding
Inflammatory Peptic ulcer Diverticulitis
Severe gastritis Crohn’s disease
Esophagitis Ulcerative colitis
Stress ulcer Enterocolitis
Mechanical Mallory Weiss tear Anal fissure
Hiatal hernia Diverticulosis
Vascular Esophageal varices Hemorrhoids
Neoplastic Carcinoma Carcinoma and polyps
Systemic Blood dyscrasias Blood dyscrasias
History Differential Diagnosis

• Usually a prior history of GI disease Upper GI Bleeding
• Hematemesis (vomiting of bright red blood or • Peptic ulcer
coffee-ground emesis) • Esophageal varices
• Melena (black, tarry stools) • Severe gastritis
• Hematochezia (passage of bright red blood from
rectum) Lower GI Bleeding
• Sudden weakness or fainting • Diverticular disease
• Peptic ulcer disease: there may be a history of • Inflammatory bowel disease
increasingly severe abdominal pain before onset • Cancer colon
of vomiting; vomiting will abruptly relieve pain
Complications
Physical Findings • Hypotension
• Signs of shock if bleeding is significant • Shock
• Pulse rapid and weak • Peritonitis
• Respirations rapid • Death
• Blood pressure low-normal or decreased
• Postural blood pressure drop Diagnostic Tests
• Client pale and anxious • Measure hemoglobin
• Client weak and sweaty • Test stool for occult blood
• Bright red blood in vomitus or stool • Check stool for gross blood
• Bowel sounds initially hyperactive due to blood
in bowel Management
• Bowel sounds may become reduced or absent Goals of Treatment
• Mild-to-severe tenderness may be present • Replace circulating blood volume
• Signs of peritonitis may be present
Consult a physician as soon as possible.

Nonpharmacologic Interventions • Adjust IV rate according to estimated volume

• Bed rest depletion, pulse rate, blood pressure, postural
• Nothing by mouth blood pressure drop and age
• Insert nasogastric tube and empty the stomach
for upper GI bleeding Monitoring and Follow-Up
• Insert urinary catheter; monitor hourly urinary Monitor ABC, vital signs and general condition
output closely, as active re-bleeding can occur.

• Oxygen prn; to keep oxygen saturation > 97% Medevac as soon as possible.
• Large-bore IV (14- to 16-gauge) with normal
saline
• Start a second IV line for volume replacement if
there are signs of hypovolemia (see "Shock," in
chapter 14 "General Emergencies and Major
Trauma")

Chapter 6 - Urinary And Male Genital Systems

Assessment Of The Urinary And Male Genital Systems ............................................................................... 1
Physical Examination Of The System ............................................................................................................ 3
Common Problems Of The Male Genitourinary System .............................................................................. 4

Benign Prostatic Hyperplasia.......................................................................................................................... 4
Epididymitis.................................................................................................................................................... 6
Prostatitis (Acute) ........................................................................................................................................... 8
Balanitis ........................................................................................................................................................ 10
Common Problems Of The Urinary System................................................................................................. 11

Asymptomatic Bacteriuria ............................................................................................................................ 11
Cystitis .......................................................................................................................................................... 13
Pyelonephritis ............................................................................................................................................... 15
Renal Colic (Calculi) .................................................................................................................................... 17
Urinary Incontinence .................................................................................................................................... 19
Emergencies Of The Urinary And Male Genital Systems........................................................................... 21

Testicular Torsion ......................................................................................................................................... 21
Acute Urinary Retention............................................................................................................................... 22

Assessment Of The Urinary And Male Genital Systems

Female Genital Tract
This examination is covered in chapter 13, "Women's Health and Gynecology."

General
The following characteristics of each symptom Male Genital System
should be elicited and explored: • Difficulty in starting or stopping urinary stream
• Onset (sudden or gradual) • Voluntary bearing down (straining) to urinate
• Chronology • Nature of stream (speed, strength, volume)
• Current situation (improving or deteriorating) • Post-void dribbling or post-void fullness
• Location • Discharge from penis, itching
• Radiation • Lesions on the external genitalia
• Quality • Genital, groin, suprapubic or low-back pain
• Timing (frequency, duration) • Testicular pain or swelling
• Severity • Painful intercourse
• Precipitating and aggravating factors • Sexual orientation
• Relieving factors • Number of sexual partners
• Associated symptoms • Libido
• Interference with daily activities • Erectile dysfunction
• Previous diagnosis of similar episodes • Sexual practices, including risk behaviors
• Previous treatments (e.g. unprotected oral, anal or vaginal
• Efficacy of previous treatments intercourse)
• Fertility (number of children)
Cardinal Symptoms • History of sexually transmitted infection (STI),
In addition to the general characteristics outlined including HIV and hepatitis B
above, additional characteristics of specific • Testicular self-examination (frequency,
symptoms should be elicited, as follows. regularity)
• History of hydrocele, epididymitis, prostatism,
Urinary System varicocele, hernia, undescended testis,
• Frequency of urination spermatocele, recent vasectomy
• Amount of urine (large or small)
• Urgency (client's sense that he or she must void Other Associated Symptoms
now, cannot wait) • Fever, chills, malaise
• Dysuria and its timing during voiding • Nausea, vomiting
(at beginning or end, throughout, internal versus • Diarrhea, constipation
external dysuria • Decrease in appetite
• Nocturia (new onset or increase in usual pattern) • Change in sleep pattern
• Retention
• Incontinence Medical History (Specific To
• Colour and odor of urine Genitourinary System)
• Hematuria • Cystitis, pyelonephritis
• Colicky pain • Renal disease
• Pain in costovertebral angle, flank or abdomen • Congenital structural abnormalities in the
• Suprapubic pain genitourinary (GU) tract
• Perineal, genital, groin or low-back pain • Renal stones

• Recent onset of or increase in sexual activity • Renal disease (e.g. renal cancer, polycystic
• Recent GU tract instrumentation (e.g. catheter, kidneys)
urethral dilatation, cystoscopy) • Diabetes mellitus
• Menopause (with no hormone replacement • Kidney stones
therapy)
• Use of tampons, douches Personal And Social History (Specific
• Diabetes mellitus To Genitourinary System)
• Immunocompromised • Personal hygiene, toileting habits
• STI (repeated) • Sexual practices (risk behaviors, sexual
• Sexual abuse orientation)
• Allergies • Symptomatic sexual partner
• Exposure to chemical irritants • Use of contraceptive creams, foam, condoms,
• Medications (e.g. immunosuppressants, oral etc.
contraceptives, antihypertensives, • Use of bubble bath, douches
antipsychotics) • Tight-fitting underwear or other clothing
• Risk behaviors (e.g. unprotected sex, alcohol or • Multiple sexual partners
drug abuse, use of illicit injection drugs) • Disruption in sex life (from GU symptoms)
• Fear, embarrassment, anxiety
Family History (Specific To • Missing work, school or social functions
Genitourinary System) because of GU symptoms (e.g. incontinence)
• Urinary tract infections (e.g. due to
environmental sensitivities or structural
abnormalities)

Physical Examination Of The System

General Percussion
• Apparent state of health • Suprapubic or costovertebral angle tenderness
• Appearance of comfort or distress • Level of kidney
• Colour (e.g. flushed, pale) • Bladder distension
• Nutritional status (emaciated or obese)
• Match between appearance and stated age Male Genital Tract
Inspection
Remember to also examine the following areas as • Penis, scrotum and pubic area: inflammation,
part of your assessment: discharge, lesions, swelling, asymmetry,
• Head, eyes, ears, nose, throat: assess for changes in hair distribution, nits, warts
pharyngitis and conjunctivitis (chlamydial • Rectum: lesions, discharge, swelling,
infection, gonorrhea) hemorrhoids
• Skin: assess for skin lesions, rashes, • Inguinal and femoral areas (for hernia)
polyarthralgias of systemic gonorrhea and
hydration status Palpation
• Penis: tenderness, induration, nodules, lesions
Vital Signs • Testes and scrotal contents: size, position,
• Temperature atrophy of testes, tenderness, swelling, warmth,
• Heart rate masses, hydrocele
• Respiratory rate • Rectum: anal sphincter tone, rectal wall tumors,
• Blood pressure prostate gland
• Prostate: size, shape, contour, consistency,
Urinary System (Abdominal tenderness or nodules
Examination) • Superficial inguinal ring (for hernia)
Inspection • Inguinal and femoral areas (for hernia)
• Previous abdominal or flank surgical scars
• Edema (facial, peripheral) Laboratory Evaluation
• Urine: colour, cloudy or clear
Palpation • Dipstick testing: blood, protein, white blood
• Suprapubic tenderness cells (WBC), nitrites, pH
• Bladder distension • Microscopic (spun urine): white and red blood
• Abdominal tenderness or masses cells, bacteria or casts, epithelial cells
• Costovertebral angle tenderness • Culture and sensitivity of urethral discharge or
• Enlargement of kidney (normal kidneys are prostatic secretions
usually not palpable unless client is thin)
• Inguinal nodes or swellings

Common Problems Of The Male Genitourinary System

Benign Prostatic Hyperplasia
Definition • Continued sense of bladder fullness even after
Benign enlargement of prostate gland, which may voiding
result in obstruction of the bladder outlet. • Frequent urination in small amounts
• Sense of urgency
Causes • Loss of stream force
• Unknown • Hesitancy
• Predisposing factor: age > 55 years • Straining to start flow
• Overflow incontinence
History • Post-void dribbling
Urinary symptoms occur when the prostate gland • Nocturia
has enlarged to a size that produces partial • Hematuria may be an early symptom.
obstruction of the bladder outlet. • Urinary tract infection or urinary retention may
be the presenting complaint.
Table 1: American Urological Association symptom index for benign prostatic hyperplasia
Less than Less than About More
Almost
Questions to be answered Not at all one time half the half the than half
always
in five time time the time
1. Over the past month, how often have you
had a sensation of not emptying your bladder
0 1 2 3 4 5
completely after you finish urinating?

had to urinate again in less than 2 hours after
0 1 2 3 4 5
you finished urinating?

found you stopped and stopped several times
0 1 2 3 4 5
when you urinated?

found it difficult to postpone urination? 0 1 2 3 4 5

had a weak urinary stream? 0 1 2 3 4 5

had to push or strain to begin urination? 0 1 2 3 4 5
7. Over the past month, how many times did

0 1 2 3 4 5
you most typically get up to urinate from the
time you went to bed at night until the time
None 1 time 2 times 3 times 4 times 5 times
you got up in the morning?
- sum of 7 circled numbers equals the symptom score
- Interpretation 0-7 = Mild - Candidate for watchful waiting with periodic evaluation
8-19 = Moderate - Candidate for treatment options
20-35 = Severe - Candidate for treatment options

Physical Findings Management

• Abdomen: bladder may be enlarged if acute Goals of Treatment
urinary retention present; enlarged bladder may • Improve or eliminate symptoms
be palpable • Prevent the complications of long-term
• Rectal exam: prostate gland enlarged obstruction of bladder outlet (e.g. urinary tract
• Prostate: normal consistency, top or margins infections, bladder stones, hydronephrosis)
may not be palpable, median sulcus may be
indistinct Appropriate Consultation
Consult a physician if client's symptoms are severe
The clinical size of the prostate gland correlates and bothersome enough that he wants immediate
poorly with the severity of symptoms. A client treatment or if there is hematuria, nodularity of the
with mild clinical enlargement may present with prostate or unexpected back pain to rule out
very troublesome symptoms. prostatic carcinoma.
Differential Diagnosis Nonpharmacologic Interventions

• Cystitis • Instruct client to avoid fluids -- especially tea,
• Cancer of the prostate coffee and alcohol -- before bedtime, as they
• Bladder tumor tend to cause diuresis in the night
• Calculi • Review any medications that the client is taking;
• Prostatitis (chronic) discontinue if possible
• Urethral stricture • Cold remedies with decongestants,
antihistamines, anticholinergics, antipsychotics,
antidepressants and anxiolytics can cause poor
Complications
bladder emptying and increase obstruction of the
• Recurrent urinary tract infections
bladder outlet
• Acute urinary retention • Advise client to report any sudden change in
• Hemorrhoids or hernias caused by straining with symptoms for re-evaluation
urination
• Renal damage secondary to chronic obstruction Pharmacologic Interventions
To improve symptoms, as ordered by physician
Diagnostic Tests
• Obtain urine for urinalysis (routine and Monitoring and Follow-Up
microscopy, culture and sensitivity) If symptoms are mild, arrange elective follow-up
• Rule out infection, hematuria and glycosuria with a physician. Client's symptoms should be
• Determine creatinine level monitored every 6 months, and a digital rectal
• Prostate surface antigen (PSA): use screening exam performed annually. If symptoms are
test according to NWT PSA CPG (March 2002) moderate to severe, refer for consultation
found in Laboratory Manual or refer to Clinical (see "Referral," below).
Practice Information Notice (2002-04-19)
Referral
Refer for urological consultation if symptoms are
moderate to severe, causing inconvenience to the
client, or if there are complications.

Epididymitis
Bacterial infection of epididymis. • Spread of infection to testis
• Abscess
Causes • Sterility
• Client < 35 years of age: usually an STI
(Neisseria gonorrhea, Chlamydia) Diagnostic Tests
• Client > 35 years of age: usually caused by • Urinalysis (routine and microscopy, culture and
urinary tract pathogen (Escherichia sensitivity)
coli,Klebsiella, Proteus) or tuberculosis (TB) • Urethral swabs for culture (N. gonorrhea and
• Risk factors in older age group: urinary tract Chlamydia)
infection, outflow obstruction, prostatic • HIV, Hepatitis B testing
infection, instrumentation of the lower GU tract • RPR testing
(e.g. catheterization), STI, prostatic surgery
Management
History In general, mild infections are treated on an
• Unilateral scrotal pain and swelling outpatient basis; more severe infections, which are
• Elevation of scrotum may provide relief of pain associated with fever and chills, require inpatient
• Fever, chills, malaise may be present care.
• Symptoms of cystitis or urethritis may be
present (frequency, urgency, dysuria) Goals of Treatment
Physical Findings • Prevent complications of infection
• Temperature may be elevated • Prevent recurrence
• Moderate distress
• Client walks slowly and carefully, sometimes Mild Infection
holding scrotum Appropriate Consultation
• Unilateral scrotal swelling and redness Consult a physician if there is concern about
• Urethral discharge may be present underlying non-infectious pathology, especially in
• Scrotum acutely tender and warm to touch a client > 35 years of age, or if symptoms are
• Epididymis enlarged, cord-like and acutely moderate to severe.
tender in early stages
Differential Diagnosis • Bed rest during acute phase (1-2 days)
• Testicular torsion - very important to rule out • Elevation of scrotum to relieve pain
• Infected sebaceous cyst, folliculitis • Client should use a scrotal support when
• Trauma ambulatory
• Mumps orchitis • Ice should be applied to scrotum for 20 minutes
q2-3h to relieve pain
• Testicular tumor
• Client should avoid heavy lifting, straining with
• Spermatocele
stool and sexual intercourse during acute phase
• Hydrocele
• Advise client to return to the clinic for
• Varicocele reassessment if symptoms worsen
• Tuberculosis

Client Education Monitoring, Follow-Up and Referral

• Explain disease process and expected course • Follow up in 48 hours and note response to
• Counsel client about appropriate use of therapy
medication (dose, frequency, side effects, • Follow up again in one week or when the course
completion of entire course prescribed) of antibiotics is completed
• Counsel client about preventing spread of STIs
to sexual partners Severe Infection
Pharmacologic Interventions Consult a physician regarding choice of IV
Analgesia and antipyretics for fever and pain: antibiotics.
PO q4-6h prn Non pharmacologic Interventions
• Bed rest
Antibiotics for young client with sexually • Ice packs should be applied to scrotum
transmitted infection (direct observed therapy by
nurse): (Canadian STD Guidelines 1998 edition) Pharmacologic Interventions
cefixime (A class drug), 400 mg, 2 tabs PO stat Start IV therapy with normal saline to keep vein
and one of the following: open.
azithromycin (C class drug), 1 g PO (single dose)
tetracycline (A class drug) 500mg PO qid for 10 Analgesia and antipyretics for fever and pain:
days acetaminophen (A class drug), 500 mg, 1-2 tabs
doxycycline (A class drug) 100mg PO bid for 10 PO q4-6h prn
days
For relief of moderate to severe pain:
For clients with allergy to cephalosporins or acetaminophen with codeine 30mg (C class drug),
tetracycline: 1-2 tabs PO q4h prn
erythromycin (C class drug), Antibiotics as per physician order.
500 mg PO qid for 10 days
Monitoring, Follow-up and Referral
May also give: Medevac as soon as possible.
ceftriaxone (B class drug) 250mg IM (single dose)
Antibiotics for client with nonsexually transmitted

infection:
cotrimoxazole (C class drug), 800/160 mg PO bid
for 14 days
or
cephalexin (C class drug), 250 mg PO qid for 14
days

Prostatitis (Acute)
Acute infection of the prostate gland. • Benign prostatic hyperplasia with urinary tract
infection
Causes • Epididymitis
The same organisms that cause cystitis (E. coli, • Urethritis
Proteus, Klebsiella). • Cystitis
• Pyelonephritis
Risk Factors • Malignancy
• Prostatic calculi Complications
• Age > 50 years • Epididymitis
• Pyelonephritis
History • Acute urinary retention
• Abrupt onset of fever and chills • Sepsis
• Genital pain (midline and achy) • Abscess
• Pain in sacrum and low back may be present • Chronic prostatitis
• Dysuria, frequency, urgency (all symptoms of
cystitis), nocturia Diagnostic Tests
• Symptoms of bladder-neck obstruction may be • Urinalysis (routine and microscopy, culture and
present sensitivity)
• Flow and stream may be abnormal • Urethral swabs for culture (N. gonorrhea and
• Pain with bowel movements Chlamydia) if an STI is suspected (because of
• Post-ejaculation pain history) or a urethral discharge is detected
• Loss of libido • HIV testing
• RPR testing
Physical Findings
• Temperature may be elevated Management
• Heart rate may be elevated If the symptoms are mild to moderate, treat on an
• Client in moderate-to-severe distress, may outpatient basis. If the symptoms are severe and
appear acutely ill the client appears acutely ill, inpatient care is
• Client walks slowly, with legs apart required.
• Bladder may be visibly distended on abdominal
inspection Goals of Treatment
• Prostate gland enlarged, acutely tender, warm, • Relieve symptoms
with boggy consistency • Prevent complications
• Small amounts of pus may be expressed from
urethra Appropriate Consultation
• Urine may be cloudy or clear Consult a physician, especially if the symptoms
• Dipstick test: blood and protein may be present are severe or the client appears systemically
• Microscopic examination of urine: bacteria, unwell.
WBC and a few red blood cells (RBC) may be
present Nonpharmacologic Interventions
• Bed rest.
• Increase fluid for adequate hydration


Mild to Moderate Symptoms • Watch for distended bladder
Antibiotics: • If the client is unable to void and has a distended
cotrimoxazole (A class drug), 800/160 mg bid for bladder, have him sit in a tub filled with warm
21 days water and attempt to void into the water
or • Do not catheterize See "Acute Urinary
ciprofloxacin (B class drug) 500mg bid x 21 days. Retention," this chapter, if treatment as
If recurrent prostatitis may need 6 weeks. described here is not successful.
Severe Symptoms Referral

IV therapy as per physician order Medevac as soon as possible if symptoms are
Manage fever and pain: severe.
PO q4h prn

Balanitis
Inflammation of glans penis. Sample any discharge for culture and sensitivity.
Causes Management
• Allergic reaction (e.g. to condom latex, Goals of Treatment
contraceptive jelly) • Relieve symptoms
• Fungal (e.g. Candida albicans) or bacterial (e.g. • Prevent recurrence
Streptococcus) infection
• Risk factor: presence of foreskin/phimosis Nonpharmacologic Interventions
• Warm compresses or sitz baths
History • Local hygiene: ensure foreskin is easily
• Penile pain retractable
• Dysuria
• Drainage at site of infection Pharmacologic Interventions
• Erythema Start topical therapy. Choice depends on whether
• Swelling of prepuce you think it is a bacterial or a fungal infection or a
• Ulceration dermatitis.
• Plaques
Fungal
clotrimazole 1% (A class drug), bid on affected
Physical Findings area
• Redness, swelling of the glans penis or
• Discharge around glans nystatin (A class drug), bid to qid on affected area
Differential Diagnosis Bacterial

• Leukoplakia bacitracin ointment (A class drug), qid on affected
• Lichen planus area
• Psoriasis
• Reiter's syndrome Dermatitis
hydrocortisone 1% ointment (A class drug), qid on
Complications affected area
• Urinary meatal stenosis
• Premalignant changes resulting from chronic Follow up and Referral
irritation If rapid improvement does not occur with topical
• Urinary tract infection treatment, refer to physician.
If phimosis, refer immediately to physician.

Common Problems Of The Urinary System

Asymptomatic Bacteriuria
Definition Client Education
Presence of bacteria in urine without symptoms. • Recommend adequate fluid intake to flush
bacteria from the bladder and prevent stasis of
Causes urine (6-8 glasses of fluid per day)
• Anatomic structure (more common in women • Instruct client about proper hygiene (wiping
because the urethra is short and located close to from front to back)
the vagina) • Teach client the signs and symptoms of acute
• Hormonal changes (e.g. pregnancy, oral infection and advise client to return to the clinic
contraceptives) if these occur
• Relaxation of pelvic muscles (in elderly clients)
• Chronic prostatitis Pharmacologic Interventions
• Contamination of specimen Pregnant Women
• Indwelling catheters Treat all pregnant women with this condition to
ensure resolution of the bacteriuria:
History amoxicillin (C class drug), 250-500 mg PO tid for
7 days
• No urinary complaints
• Usually discovered on routine examination of If not sensitive to amoxicillin, consult physician
urine for alternate drug treatment.
• Common in women 20-50 years of age
• Chronic low-grade prostatitis often present in For clients with allergy to penicillin:
men > 50 years of age nitrofurantoin (C class drug), 100 mg PO bid for 7
• Common in elderly clients and those with an days
indwelling urinary catheter
Other Groups: Older Men with Benign
Physical Findings Prostatic Hyperplasia
Normal. Ask if there has been any change in symptoms,
however small. If symptoms have increased, treat
Laboratory Findings as for cystitis (see below); otherwise repeat
• Urine: clear urinalysis (routine and microscopy, culture and
• Dipstick test: normal sensitivity).
• Microscopic examination: bacteria evident
• Culture: positive in 24-48 hours Clients with Urinary Catheter
Consult with a physician, who may decide that
Ensure that the specimen is a properly collected condition may be left untreated. Antibiotic therapy
sample of midstream urine. would only encourage the growth of resistant
strains of bacteria.
Management
Goals of Treatment Elderly Clients
Antibiotic treatment is not needed. Simple
• Recognize the significance of asymptomatic
measures such as increasing fluid intake, proper
bacteriuria in the various subgroups (prenatal,
wiping, regular toileting and use of a commode
immunocompromised, elderly)
help to reduce the bacterial numbers.
• Eradicate bacteria from GU tract in pregnant
women

Healthy Non-Pregnant Women

If there have been no GU problems in the past and
there are currently no symptoms, the problem is
probably only contamination. Repeat the urinalysis
(routine and microscopy, culture and sensitivity).
Client education as above for nonpharmacologic
interventions.

Cystitis
Definition • Dipstick test: blood, protein and leucocytes in
Bacterial infection of the bladder. urine, nitrite positive
• Microscopic (spun urine): WBC, RBC and
Causes bacteria may be present
• E. coli (most common organism, in 80% to 0%
of cases) Differential Diagnosis
• Also Klebsiella, Pseudomonas, group B • Urethritis
Streptococcus and Proteus mirabilis, Chlamydia • Vulvovaginitis
• Urinary calculi
Risk Factors • Renal TB
• Female • STI
• Poor perineal hygiene • Benign prostatic hyperplasia
• Diabetes mellitus • Diabetes mellitus
• Urinary instrumentation (e.g. catheter) • Chronic prostatitis
• Neurogenic bladder (because of stroke or
multiple sclerosis) Complications
• Congenital abnormality of GU tract • Ascending infection (pyelonephritis)
• Renal calculi • Chronic cystitis
• Tumor
• Urethral stricture Diagnostic Tests
• Pregnancy • Urinalysis (routine and microscopy, culture and
• Increased sexual activity (in women) sensitivity) only if the client is known to have an
• Use of spermicides, diaphragm abnormality of the GU tract, if there is
• Prostatic hypertrophy diagnostic uncertainty or if the client is
• Immunocompromise (e.g. HIV infection) pregnant. Otherwise, empiric antibiotic therapy
is appropriate.
History • Urine for culture and sensitivity if there is
• Dysuria failure to respond to empiric therapy or a relapse
• Frequent urination, small amounts occurs less than a month after therapy.
• Urgency • Vaginal swab for analysis (routine and
microscopy, culture and sensitivity) prn.
• Suprapubic discomfort
• Rapid onset • Swabs for N. gonorrhoea and Chlamydia if an
STI is suspected.
In women, note presence of vaginal discharge, • Blood glucose level if symptoms suggest
menstrual flow and use of a diaphragm. diabetes mellitus.
In men, note presence of urethral discharge or
symptoms suggestive of benign prostatic Management
hyperplasia. Goals of Treatment
Physical Findings • Eradicate bacteria from the bladder
• Temperature may be elevated
• Mild-to-moderate suprapubic tenderness Client Education
• Prostate may be enlarged • Counsel client about appropriate use of
medications (dose, frequency, side effects, need
Laboratory Findings to complete entire course of medications)
• Urine: cloudy, concentrated • Recommend increasing fluid intake
(to 8-10 glasses per day)

• Instruct client in proper perineal hygiene amoxicillin (C class drug), 250-500 mg PO tid
(wiping from front to back) to prevent If not sensitive to amoxicillin, consult with
recurrence physician for alternate treatment.
• Recommend triple voiding (i.e. voiding before Nitrofurantoin is contraindicated near term and
and immediately after intercourse, then drinking during labor. Contact a physician for help in
a large glass of water and voiding again within choosing an antibiotic if the client is allergic to
1 hour) if client is a sexually active woman with penicillin or is near term.
recurrent cystitis. This process flushes out any
organisms that may enter the urethra during Monitoring and Follow-Up
intercourse. • If symptoms do not begin to resolve in 72 hours
or if symptoms progress despite treatment, client
Pharmacologic Interventions should return to the clinic for reassessment
Uncomplicated cystitis should be treated with a • Arrange follow-up after the completion of
10-day course of antibiotics: therapy and repeat the urinalysis and culture to
cotrimoxazole (C class drug) 800/160 mg PO bid ensure resolution of cystitis
or
nitrofurantoin (C class drug), 50 mg PO qid (or Referral
100mg bid) Clients with chronic or recurrent cystitis should be
or referred to a physician. Men > 50 years of age who
amoxicillin (C class drug), 250-500 mg PO tid present with a true (culture-positive) urinary tract
infection for the first time should also be referred
Cystitis in pregnancy should be treated with a to a physician for further evaluation.
7-day course of antibiotics:

Pyelonephritis
Bacterial infection of the collection system of the Early or mild infections may be treated on an
kidney. outpatient basis. Moderate or severe infections
usually require inpatient treatment.
Causes
• E. coli (most common) Goals of Treatment
• Also Enterobacter, Klebsiella, Pseudomonas • Eradicate bacterial infection
and Proteus (among others) • Prevent complications
• In unresolving pyelonephritis, suspect TB of the
kidney Appropriate Consultation
Moderate or Severe Infection
History • Consult a physician regarding IV antibiotics
• Flank pain • If unable to consult, start empiric IV antibiotic
• Fever, shaking chills therapy
• Dysuria, frequency, urgency Adjuvant Therapy
• Abdominal pain Moderate or Severe Infection
• Start IV therapy with normal saline
Physical Findings • Adjust IV rate according to age and other
• Temperature elevated medical problems (e.g. diabetes mellitus, heart
disease)
• Blood pressure may be mildly elevated
• Client appears moderately-to-acutely ill
Mild Infection
• Mild, generalized abdominal discomfort • Increase fluid intake (to 8-10 glasses of
• Marked or severe pain with deep abdominal fluid per day)
palpation of kidney
• Bed rest until symptoms improve
• Marked or severe costovertebral angle
tenderness with percussion over kidney
Client Education
Laboratory Findings medications (dose, frequency, completion of
• Urine: cloudy, dark or bloody entire course of antibiotics)
• Dipstick test: positive for WBC, blood and • Instruct client about proper hygiene to prevent
nitrates, possibly protein recurrence of infection
• Microscopic examination (spun urine): WBC,
RBC, bacteria Pharmacologic Interventions
Mild Infection
Differential Diagnosis Early or mild infections may be treated on an
• Pneumonia outpatient basis.
• Acute cholecystitis with fever Oral antibiotics--use one of the following for
• Appendicitis 10-14 days:
• Acute pancreatitis cotrimoxazole (C class drug) 800/160 mg PO bid
or
Diagnostic Tests ciprofloxacin (B class drug) 500mg PO bid for 14
• Obtain urine for urinalysis (routine and days
microscopy, culture and sensitivity) or

amoxicillin (C class drug), 1g PO stat then 500 Extra consideration is required in choosing drugs
mg PO tid for a pregnant woman. Consult a physician.
Empiric therapy with amoxicillin will be 20% less Monitoring and Follow-Up
effective than with cotrimoxazole because of Mild Infection
resistant strains of E. coli, but this is the best • Follow up in 2-3 days to determine clinical
choice if there is an allergy to sulfa drugs. response to therapy
• In 14 days, repeat the urinalysis and culture to
Analgesia and antipyretics: ensure resolution of the infection
PO q4-6h Moderate to Severe Infection
• Monitor response to therapy, vital signs and
Moderate to Severe Infection urinary output
Analgesia and antipyretics for fever and pain:
acetaminophen (A class drug), 325 or 500 mg, 1 Referral
or 2 tabs PO q4-6h prn
Moderate to Severe Infection
Medevac to hospital as soon as possible.
Antiemetics to control severe nausea and
vomiting: Young men who present with pyelonephritis for
dimenhydrinate (A class drug), 50-75 mg IM
the first time and clients with recurrent
pyelonephritis should be referred to physician for
Antibiotics: further investigation.
As ordered by physician.

Renal Colic (Calculi)

Definition Laboratory Findings
Pain produced by the presence and movement of a • Urine: may be normal or blood may be present
stone within the ureter or renal pelvis.
Causes • Acute pyelonephritis
• Familial predisposition to formation of calcium • Acute cholecystitis
stones • Acute abdomen (cholecystitis, appendicitis,
• Increased dietary intake of calcium gastroenteritis, diverticulitis)
• Dehydration • Peptic ulcer disease
• Hyperuricemia (may be associated with gout) • Salpingitis
• Recurrent urinary tract infections • Gastroenteritis
• Bone resorption • Peritonitis
• Prolonged immobilization • Pancreatitis
• Other genetic disorders (e.g. cystine stones, an • Ectopic pregnancy
inborn error of amino acid metabolism)
Complications
Risk Factors • Recurrent infection of the lower urinary tract
• Family history • Hydronephrosis
• Low fluid intake • Pyelonephritis
• Thiazide diuretics • Sepsis
• Bowel or kidney disease
• Malignant disease Diagnostic Tests
• Urinalysis (routine and microscopic).
History
• Sudden onset of severe colicky pain in the flank Management
• Pain may radiate to lower abdomen, groin, labia If symptoms are mild, client is afebrile and
or testicle diagnosis is clear, treat on outpatient basis. If
• Exact location of pain depends on location of symptoms are severe or the diagnosis is
stone, level of obstruction questionable, consult with a physician and
• Hematuria may be present inpatient treatment will be needed.
• Dysuria, urgency, frequency may develop
• Nausea and vomiting are often present Goals of treatment
Physical Findings • Identify complications
• Temperature elevated (if infection is also • Collect stone or stone fragments
present)
• Heart rate may be elevated Appropriate Consultation
• Blood pressure may be elevated Severe Condition or Questionable Diagnosis
• Appears in acute distress Consult a physician as soon as possible.
• Pale and sweaty
• Restless, tossing about, unable to find a Nonpharmacologic Interventions
comfortable position Mild Condition
• Abdomen may be distended • Encourage increase in fluid intake
• Costovertebral angle and abdominal tenderness • Strain urine to collect stones
• Bowel sounds may be decreased (because of
reactive ileus)

Severe Condition or Questionable Diagnosis Severe Condition or Questionable Diagnosis

• Bed rest Analgesia:
• Nothing by mouth if vomiting meperidine (D class drug), as ordered
Antiemetics for nausea and vomiting:
Adjuvant Therapy dimenhydrinate (A class drug), 50-75 mg IM q4-6
Severe Condition or Questionable Diagnosis hr prn
• Adjust rate according to severity of vomiting Monitoring and Follow-Up
and dehydration, client's age and underlying Severe Condition or Questionable Diagnosis
medical problems • Monitor urine output
• Generally, it is desirable to push the fluids to • Strain all urine for stones
help the stone pass, i.e. administer enough fluid • Send any stones for laboratory analysis
to produce urine output of 100-200 mL/h • Client may be discharged home once pain and
nausea are controlled
Pharmacologic Interventions • Instruct client to collect and strain all urine for
Mild Condition stones and save any stones that are passed
To control pain: • Follow up 12-24 hours after discharge
1-2 tabs PO q4h prn (maximum 15 tabs) Referral
If questionable diagnosis or if condition is severe,
if pain or fever persist, medevac to hospital.

Urinary Incontinence
Definition In women, incontinence is often associated with
Involuntary loss of urine. coughing, sneezing, laughing, climbing stairs,
exercising (stress incontinence).
Causes
Overflow Incontinence In men, dribbling and weak stream is usually
Leakage of urine due to overdistension of the associated with other symptoms of bladder-outlet
bladder, commonly caused by obstruction of the obstruction (see "Benign Prostatic Hyperplasia,"
bladder outlet (e.g. prostatic enlargement, fecal above, this chapter)
impaction) or neurologic disease (e.g. multiple
sclerosis). Previously "dry" elderly clients who suddenly
become incontinent may have an early urinary
Stress Incontinence tract infection or an intercurrent illness or
Leakage of urine due to an increase in intra- infection elsewhere.
abdominal pressure (e.g. with cough, exercise).
This form is more common in women. Poor pelvic If diabetes is suspected, ask about polyuria,
support (for example, because of multiple vaginal polydipsia, polyphagia, weight loss, recurrent
deliveries or postmenopausal estrogen deficiency) cystitis or vaginitis.
is the primary cause.
Physical Findings
Urge Incontinence The findings will depend upon the specific cause.
Leakage of urine due to inability to delay voiding A careful examination of the urinary and genital
when an urge is perceived. Causes include systems, the abdomen and rectum, and the
hyperactivity or instability of the bladder wall, neurologic system is required.
disorders of the central nervous system (e.g. • Distension of the bladder may be present
Parkinson's disease), and bladder irritability from • Assess prostate, anal-sphincter tone, rectal wall,
infection, stones, diverticula or tumor. amount of stool present in rectum
• Note atrophic urethral and vaginal changes,
Functional Incontinence relaxation of pelvic floor, pelvic masses
Leakage of urine due to inability to get to the • Assess deep tendon reflexes and perineal
toilet. Causes include age-related problems (e.g. sensation
decreased mobility, cognitive disability), alcohol
intoxication, medications (e.g. diuretics, sedatives) Differential Diagnosis
and diabetes mellitus (neurogenic bladder). See "Causes," above.
History Complications
• Loss of bladder control • Breakdown and ulceration of skin in the genital
• Amount of leakage varies with each person and area
with specific cause • Social embarrassment
• Qualify degree of difficulty in maintaining • Social and psychological problems
continence
• Determine when and how the urinary leakage Diagnostic Tests
occurs • Urinalysis (routine and microscopy, culture and
• Assess bowel habits, number of pregnancies and sensitivity) to identify cystitis
vaginal deliveries, postmenopausal symptoms, • Complete blood count, BUN, creatinine,
neurologic deficits electrolytes and calcium to check renal function
• Review medications • Blood sugar to rule out diabetes
• If infection is present, there will be related
symptoms of cystitis

Management • Suggest a bedside commode, if available, or a

Management is based on identifying and treating condom catheter
the underlying cause.
Chronic Day and Nighttime Incontinence
Goals of Treatment • Advise client to toilet regularly at a bedside
• Achieve relief of urinary symptoms commode
• Increase functional capacity of the bladder • Suggest adult diapers or a condom catheter to
help maintain dryness.
Nonpharmacologic Interventions • Instruct client and family members about good
The following simple measures should be tried. skin care to prevent skin breakdown and
infection
Stress Incontinence
• Demonstrate Kegel exercises to strengthen Medications are sometimes ordered by physician
pelvic floor and perineal muscles; advise client as an adjuvant therapeutic intervention to these
to do 10-15 repetitions of each exercise, three or nonpharmacologic measures.
four times a day
• Encourage weight loss, if appropriate, to reduce In the elderly client, assess life situation and any
symptoms recent life changes, mental status (to detect recent
• Encourage frequent toileting q3-4h, complete changes or confusion), general medical status (to
emptying, voiding before strenuous activities identify concurrent illness and whether client has
and use of sanitary napkins to maintain dryness physical difficulty getting to the toilet).
• Encourage client to establish a good bowel
routine to reduce straining at stool If client has a distended bladder, see "Acute
Urinary Retention," below, this chapter.
• Urinary stress incontinence of some small
Relieve fecal impaction with gentle disimpaction
degree may be physiological and may not be
or water enemas (see "Constipation," in chapter 5,
abnormal.
"Gastrointestinal System").
Nighttime Incontinence
Referral
• Advise client to reduce fluid intake in the Refer electively to a physician for evaluation if
evening 2 hours prior to bedtime
conservative measures fail to improve symptoms.
• Advise client to take diuretic drugs earlier in the
evening

Emergencies Of The Urinary And Male Genital

Systems
Testicular Torsion
Definition • Acute varicocele
Twisting of spermatic cord and testis, which • Testicular tumor
compromises blood supply to these structures and • Scrotal abscess
results in ischemic pain.
Complications
Causes • Testicular infarction
• Torsion usually spontaneous and idiopathic • Testicular atrophy
• Predisposing structural (genetic) defect • Abnormal spermatogenesis
• Occasionally caused by trauma to the groin • Infertility
History Diagnostic Tests

• Sudden onset of severe, constant, unilateral pain None.
in scrotum, groin or lower abdomen
• Pain may be made worse by elevation of Management
scrotum Goals of Treatment
• Pain not relieved by lying down • Relieve pain
• Nausea and vomiting may be present • Prevent complications
• Usually occurs in adolescents and young men
Physical Findings Consult a physician immediately. This is a surgical
• Temperature usually normal emergency.
• Blood pressure mildly elevated (because of pain) Nonpharmacologic Interventions
• Client in acute distress • Nothing by mouth
• Client bent over or unable to walk • Bed rest
• Unilateral scrotal swelling and redness
• Testis acutely tender, may be warm Adjuvant Therapy
• Testis swollen and found higher up (retracted) in • Start IV therapy with normal saline
the scrotal sac than expected • Adjust IV rate according to age and state of
• Absence of cremasteric reflex hydration
Differential Diagnosis Pharmacologic Interventions

• Epididymitis Analgesia, as per physician order
• Orchitis
Referral
• Trauma Medevac as soon as possible.
• Incarcerated or strangulated inguinal hernia
• Torsion appendix testis

Acute Urinary Retention

Definition • Tender, distended bladder may be felt above
Accumulation of urine in the bladder due to an symphysis, often reaching umbilicus
inability to empty the bladder. (neurogenic bladder is distended but non tender)
• Rectal examination: fecal impaction,
Causes enlargement of prostate, nodular or rocky hard
• Any process that causes increased bladder-outlet prostate, decreased anal tone or absent perineal
resistance or decreases bladder contractility sensation may be present
• Benign prostatic hyperplasia
• Side effects of drugs Differential Diagnosis
• Fecal impaction See "Causes," above.
• Prostatic cancer
• Acute prostatitis Complications
• Neurogenic bladder • Decreased renal function
• Urethral stricture or stone • Post-obstructive diuresis
• Impingement on sacral nerves by protruding • Renal failure
intervertebral disk • Infection of stagnant urine
• Spinal cord injury
Diagnostic Tests
History None.
• Strong urge to void but inability to do so
• Suprapubic fullness and pain Management
• Voiding habits before retention (hesitancy, Goals of Treatment
dribbling, daytime frequency, nocturia) • Identify underlying cause
• Bowel habits, last bowel movement and its • Relieve bladder distension
consistency
Review medications, noting any drugs that might Consult a physician.
predispose to acute urinary retention (excessive
alcohol intake, sedatives, decongestants in over- Nonpharmacologic Interventions
the-counter cold remedies, anticholinergics, • Encourage client to sit in a tub full of warm
antipsychotics and antidepressants). water and to try voiding into the water. If the
client is able to do so, reassess the bladder for
With a neurogenic bladder, symptoms of pain, residual distension.
fullness and urgency may be absent. However,
dribbling of small amounts of urine (overflow If the bladder is still distended, catheterization is
dribbling) may be present. required (unless there are contraindications). Use
the following technique:
Physical Findings • Use a Foley catheter (18 French in a male, 16
• Pulse may be elevated French in a female)
• Client may appear in moderate-to-acute distress • If the client is known to have benign prostatic
(but there may be no evidence of distress with a hyperplasia, a 16 French catheter may be tried if
neurogenic bladder) catheterization is unsuccessful with the larger
• Client may be restless and sweaty size of catheter
• Bladder distension may be noted on abdominal • Insert catheter and decompress the bladder
inspection slowly
• Remove 200 mL of urine, then clamp the
catheter for 30 minutes

• Continue to remove 50-75 mL of urine slowly Monitoring and Follow-Up

every 20 minutes until the bladder is empty Monitor hourly urine output carefully for the
• Leave catheter in place after decompression development of post-obstruction diuresis, a
• Do not insert catheter if retention is due to acute complication that occurs after the release of the
prostatitis obstruction, because of temporary impairment of
• Do not insert catheter if the pelvis is fractured renal function.
• Do not attempt catheterization more than three
consecutive times Diuresis is generally self-limiting and can be
managed with oral fluid intake based on thirst, but
client may require IV fluid therapy to prevent
dehydration.
Referral
Medevac to hospital.

Chapter 7- The Musculoskeletal System

Assessment Of The Musculoskeletal System................................................................................................... 1
Examination Of The Musculoskeletal System................................................................................................ 2
Differential Diagnosis Of Musculoskeletal Cardinal Symptoms.................................................................... 3
Common Problems Of The Musculoskeletal System ..................................................................................... 5

Neck Pain........................................................................................................................................................ 5
Adhesive Capsulitis (Frozen Shoulder), Tendinitis And Bursitis................................................................... 8
Rotator Cuff Syndrome................................................................................................................................. 10
Acromioclavicular Injuries ........................................................................................................................... 12
Glenohumeral Dislocations........................................................................................................................... 14
Lateral Epicondylitis (Tennis Elbow)........................................................................................................... 15
Carpal Tunnel Syndrome .............................................................................................................................. 17
Knee Injury ................................................................................................................................................... 18
Ankle Sprain ................................................................................................................................................. 20
Low-Back Pain ............................................................................................................................................. 22
Lumbosacral Strain And Sciatica.................................................................................................................. 23
Gout .............................................................................................................................................................. 26
Osteoarthritis (Degenerative Joint Disease).................................................................................................. 28
Rheumatoid Arthritis .................................................................................................................................... 30
Emergencies Of The Musculoskeletal System .............................................................................................. 32

Limb Fractures.............................................................................................................................................. 32
Clavicular Fracture ....................................................................................................................................... 35
Septic Arthritis.............................................................................................................................................. 37
Osteomyelitis ................................................................................................................................................ 39

Assessment Of The Musculoskeletal System

General Neurovascular Structures
The following characteristics of each symptom • Paresthesia
should be elicited and explored: • Paresis
• Onset (sudden or gradual) • Paralysis
• Chronology
• Current situation (improving or deteriorating) Functional Assessment
• Location Any self-care deficits in bathing, dressing,
• Radiation toileting, grooming, mobility, use of mobility aids.
• Quality
• Timing (frequency, duration) Medical History (Specific To
• Severity Musculoskeletal System)
• Precipitating and aggravating factors • Previous trauma (e.g. to bones, joints, ligaments)
• Relieving factors • Arthritis (rheumatoid or osteoarthritis)
• Associated symptoms • Diabetes mellitus (associated with greater risk of
• Effects on daily activities carpal tunnel syndrome)
• Previous diagnosis of similar episodes • Hypothyroidism (associated with greater risk of
• Previous treatments carpal tunnel syndrome)
• Efficacy of previous treatments • Recent immobilization of an extremity
• Medications (e.g. steroids)
Cardinal Symptoms • Allergies
In addition to the general characteristics outlined • Obesity
above, additional characteristics of specific • Osteoporosis
symptoms should be elicited as follows. • Cancer
• Menopause
Bones and Joints • Immune deficiency (recent infection)
• Pain, swelling, redness, heat, stiffness
• Time of day when these symptoms are most Family History (Specific To
bothersome Musculoskeletal System)
• Relation of symptoms to movement • Rheumatoid arthritis
• Limitation of movement • Diabetes mellitus
• Deformity • Hypothyroidism (associated with greater risk of
• Extra-articular findings: urethritis, pustular rash, carpal tunnel syndrome)
tophi, nodules • Osteoporosis
• Trauma: obtain accurate description of exact • Cancer (bone)
mechanism of injury
Personal And Social History (Specific
Muscles
To Musculoskeletal System)
• Pain
• Absenteeism from work or school
• Weakness (multiple days)
• Twitching • Occupational hazards (activity involving
• Wasting repetitive joint motion, e.g. kneeling, reaching
• History of previous injuries and treatment overhead, computer use)
received • Sports activities (especially contact sports)

• Risk behaviors for injuries (e.g. snowmobiling, • Exercise habits

skateboarding, injection drug use, alcohol abuse • Caffeine intake (decreases bone density)
[specifically drinking and driving])
• Calcium intake
• Smoking
Examination Of The Musculoskeletal System

The purpose of examining the musculoskeletal Palpation of Joints
system is to assess function and performance of Palpate each joint, including skin, muscles, bony
activities of daily living, as well as to check for articulations and area of joint capsule, for the
abnormalities. A screening exam is appropriate for following features:
most people. • Heat
• Swelling
Although the musculoskeletal and neurological • Tenderness
systems (see chapter 8, "Central Nervous System") • Nodules, masses
are discussed separately in this set of guidelines, • Crepitus
they are usually examined together.
• Ligament instability
General Range of Motion
• Apparent state of health Ask client to demonstrate range of active motion
• Appearance of comfort or distress while stabilizing the body area proximal to the
• Colour (e.g. flushed, pale) joint being moved. If you see a limitation, gently
• Nutritional status (obese or emaciated) attempt passive motion.
• Match between appearance and stated age The normal ranges of active and passive motion
should be the same.
Musculoskeletal Screening Exam
Observe client walking into examination room; Muscle Testing
assess gait, posture and use of aids. Determine • Test strength of prime muscle groups (i.e.
ability to perform activities of daily living (e.g. flexors and extensors) for each joint
sitting, standing, walking, dressing). • Muscle strength should be equal bilaterally and
Examine specific joints in the following order. should fully resist your opposing force
Compare corresponding paired joints. • There is wide variability in normal muscle
• Temporomandibular joint strength among different people
• Cervical spine
• Shoulders Ligament Stability Around Joints
• Elbows • Determine stability of collateral ligaments of
• Wrists, hands and fingers ankle
• Hips • Determine stability of collateral and cruciate
• Knees ligaments of knee
• Ankles, feet and toes
• Lumbar spine Neurovascular Status
Assess limbs for the following aspects and
Inspection of Joints conditions:
• Symmetry of structure and function • Sensation
• Note alignment, size (muscle bulk, bone • Pulses
enlargement) and contour of the joint • Paresis
• Inspect skin and tissues over joints for colour, • Paralysis
swelling, rash, masses or deformity

This part of the examination is particularly Table 1 presents the symptoms associated with
important if the client has experienced trauma. various types of musculoskeletal injury.
Table 1: Symptoms of Musculoskeletal Injury

Symptom Fracture Dislocation Sprain Strain
Pain Severe Moderate to severe Mild to moderate Mild to moderate
Swelling Moderate to severe Mild Mild to severe Mild to moderate
Bruising Mild to severe Mild to severe Mild to severe Mild to severe
Deformity Variable Marked None None
Function Loss of function Loss of function Limited Limited
Tenderness Severe Moderate to severe Moderate Moderate
Crepitus Present Absent Absent Absent
Differential Diagnosis Of Musculoskeletal Cardinal Symptoms

Table 2: Causes of joint pain
Inflammatory Non-inflammatory
• Tenosynovitis • Osteoarthritis
• Rheumatoid arthritis • Tendinitis
• Viral polyarthritis (e.g. hepatitis B, Epstein-Barr virus) • Systemic lupus erythematosus
• Septic arthritis (e.g. Staphylococcus aureus, streptococcal • Metabolic arthropathy
species) • Tumors
• Autoimmune disease (e.g. polymyalgia rheumatica) • Mechanical abnormalities (e.g. erosion
• Rheumatic fever of cartilage and bone)
• Immune complex arthritis (e.g. HIV) • Blood dyscrasias
• Polyarthritis associated with systemic diseases (e.g. • Sickle cell anemia
systemic lupus erythematosus, Lyme disease, syphilis, • Neuroarthropathy
bacterial endocarditis)
• Gouty arthritis
Table 3: Causes of neck pain and cervical spine disorders

Biomechanical Referred Rheumatologic Neoplastic
Neck strain Thoracic outlet syndrome Rheumatoid arthritis Osteoblastoma
Herniated disk Pancoast’s tumour Ankylosing spondylitis Osteochondroma
Spondylosis Esophagitis Psoriatic arthritis Giant cell tumour
Myelopathy Angina Reiter’s syndrome Hemangioma
Vascular dissection Myelopathy Metastases
Infectious Enteropathic arthritis Multiple myeloma
Osteomyelitis Neurologic Polymyalgia rheumatica Chondrosarcoma
Diskitis Brachial plexitis Fibromyalgia Chordoma
Meningitis Peripheral entrapment Myofascial pain Gliomas
Herpes zoster Neuropathies Diffuse idiopathic skeletal Syringomyelia
Lyme disease Reflex sympathetic hypertrophy Neurofibroma
dystrophy Microcrystalline disease
Miscellaneous
Paget’s disease
Sarcoidoisis

Table 4: Causes of shoulder pain
Intrinsic Disorders Extrinsic Disorders (Referred Pain)

• Glenohumeral osteoarthritis • Cervical spine disorders
• Acromioclavicular arthritis • Brachial plexus neuropathy
• Septic arthritis • Myofascial pain
• Rheumatoid arthritis • Thoracic outlet syndrome
• Gout • Diaphragmatic irritation
• Rotator cuff impingement • Neoplastic disease
• Rotator cuff tear • Myocardial ischemia
• Biceps tendinitis
• Biceps tendon rupture
• Calcific tendinitis
• Adhesive capsulitis
• Trauma to bony structures (e.g. clavicle,
acromioclavicular joint, glenohumeral joint)
Shoulder pain can arise from the bony structures of the shoulder or from the muscles, ligaments and tendons
that support the shoulder. Most shoulder problems are attributable to overuse and trauma.
Table 5: Causes of low-back pain
Mechanical Low-Back Disorders Non-mechanical Spine Disease Referred Pain of Visceral Disease
• Lumbar sacral strain • Neoplasia (e.g. multiple myeloma, • Prostatitis
• Degenerative disk disease lymphoma, spinal cord • Endometriosis
• Facet joint syndrome tumor,metastatic carcinoma) • Chronic pelvic inflammatory
• Spondylolisthesis • Infection (e.g. osteomyelitis, disease
septic disk, epidural abscess) • Kidney stones
• Herniated disk
• Spinal stenosis • Inflammatory arthritis • Pyelonephritis
• Osteoporosis • Ankylosing spondylitis • Aortic aneurysm
• Fracture • Psoriatic spondylitis • Pancreatitis
• Spondylolysis • Paget's disease (tuberculosis of • Cholecystitis
spine)
• Severe kyphosis • Penetrating peptic ulcer
• Severe scoliosis

Common Problems Of The Musculoskeletal System

Neck Pain
Definition Neuropathic pain is usually described as sharp,
Neck pain, acute and chronic, is commonly seen in burning or aching and often follows the
the primary care setting. Many disorders are distribution of the affected nerve segment. The
implicated in neck pain, but mechanical problems pain is worsened by movements that stretch the
of the cervical spine are the most common cause. involved nerve or nerve roots. It is frequently
Most patients improve with non-operative therapy accompanied by sensory and motor disturbances
within 3 months; only about 10% of patients such as hyperesthesia, paresthesia, hypalgesia and
require surgical intervention. a decrease in muscle strength. Disk herniation with
radicular pain is one example of neuropathic
Types disease.
Myofascial Pain
Myofascial pain is the most common type of acute Causes
and chronic neck pain. The upper trapezius and Mechanical Disorders
levator scapulae are the muscles most frequently Mechanical disorders that occur secondary to
involved in myofascial pain of the neck, head and overuse, trauma or deformity constitute the most
upper back. The pain is often described as dull, common cause of neck pain. Typically, these
aching or burning and is referred from active disorders are characterized by correlating
myofascial trigger points. A myofascial trigger exacerbation or alleviation of symptoms with
point is a hyper-irritable spot within a taut band of certain physical activities.
skeletal muscle or muscle fascia that is painful to
compression and gives rise to a characteristic Most mechanical disorders of the cervical spine
pattern of referred pain and tenderness and have a natural history of improvement. In 50% of
autonomic phenomena such as tingling, dizziness patients, the pain will decrease in 2-4 weeks, and
and gooseflesh. Each muscle with active trigger 80% of patients will be asymptomatic in 2-3
points gives rise to its own characteristic, months.
predictable and reproducible pattern of referred The causes of mechanical disorders include neck
pain and autonomic symptoms. strain, herniated disk, spondylosis and
myelopathy.
Neuropathic Pain
Disease and injury of the neck commonly involve Mechanical Neck Problems Without
nerves or nerve roots lying along the transverse Nerve Compression
processes or the paravertebral region of the spinal Clients with pain only in the cervical area, trapezii
cord. This produces neuropathic pain felt in the and shoulders may have one of many disorders, of
occipital region, the back, the posterior ear and ear which neck strain and cervical hyperextension
lobe, and the anterior neck. (whiplash) are the most common
A history of significant trauma, cervical arthritis,

prior herniated disk or herpes zoster infection,
along with typical neuralgic pain and sensory
disturbances, should suggest a neuropathic
process.

Table 6: History and physical examination for mechanical neck problems without nerve compression
Condition History Physical Examination
Neck strain Pain in middle or lower portion of the posterior Local tenderness in paracervical muscles,
neck decreased range of motion, loss of cervical
lordosis
Pain may be diffuse or localized to both sides of No abnormalities found on neurologic or
the spine shoulder examination
Spinal x-rays may be normal or reveal loss of
lordosis
Cervical Acceleration-deceleration injury to soft-tissue Soreness, paracervical muscle contraction and

hyperextension structures decreased range of motion
(whiplash) Common causes: rear-impact motor vehicle
crashes, falls, diving accidents, other sports Neurologic examination often unremarkable, but
injuries x-rays may reveal loss of cervical lordosis
Paracervical muscles stretched or torn, and
sympathetic ganglia may be damaged, resulting In severely injured clients, structural damage
in Horner’s syndrome, nausea, hoarseness or identified on x-rays mandates immediate
dizziness stabilization
Intervertebral disk injuries occur with severe
trauma
First symptoms occur 12-24 hours after trauma
Clients experience stiffness and pain with
motion; may also have difficulty swallowing or
chewing
Mechanical Neck Problems with Spinal Compression usually results from a combination
Compression of osteophyte growth and degenerative disk
The main type of mechanical neck problem with disease. Symptoms may involve all limbs and may
spinal compression is cervical myelopathy. This include difficulty in walking and urinary or fecal
condition occurs secondary to compression of the incontinence.
spinal cord or nerve roots in the spinal canal
(see Table 7). Only one-third of affected patients The most frequent presentation is arm pain and
report neck pain. Although cervical myelopathy is leg dysfunction. Older clients may describe leg
rare, one form, spondylitic myelopathy, is the most stiffness, foot shuffling and a fear of falling.
common cause of spinal cord dysfunction in Common findings include weakness of the limbs,
people over the age of 55 years. spasticity, fasciculations, hyperreflexia, clonus and
The location, duration and size of lesions influence Babinski's reflex in the lower extremities.
the severity and distribution of symptoms.
Table 7: Characteristics of radicular pain caused by compression of cervical nerve root

Location of Location of
Nerve root Area of pain Location of sensory loss
motor loss reflex loss
C5 Neck to outer shoulder, arm Shoulder Deltoid Biceps, supinator
C6 Outer arm to thumb, index Index finger and thumb Biceps Biceps, supinator
finger
C7 Outer arm to middle finger Index and middle fingers Triceps Triceps
C8 Inner arm to ring and little Ring and little fingers Hand muscles None
fingers

Differential Diagnosis Of Neck Pain

See Table 3 in "Differential Diagnosis of The use of a collar in clients with cervical
Musculoskeletal Cardinal Symptoms," above, this hyperextension should be severely limited except
chapter. in cases of disk herniation, which requires full-
time collar immobilization to limit radicular pain
Complications for longer periods.
• Permanent nerve damage with compression of
nerve root Pharmacologic Interventions
• Chronic neck pain Anti-inflammatory analgesics such as nonsteroidal
anti-inflammatory drugs (NSAIDs) can decrease
• Absenteeism from work
the pain and inflammation associated with
• Disability (long term) localized disease
Diagnostic Tests tid-qid
Discuss with a physician before ordering any tests. or
naproxen (C class drug), 250 mg PO bid-tid for
Management 2 weeks or longer prn
Goals of Treatment
• Relieve symptoms Do not use if there are contraindications to the use
• Regain or maintain full range of motion of NSAIDs (such as a history of peptic ulcer
• Prevent complications disease). Instead, use:
Appropriate Consultation PO tid-qid prn
Consult immediately if there is concern of serious
injury (e.g. trauma of significant force) or if there Monitoring and Follow-Up
is associated neuropathic pain and neurological • Arrange follow-up at 1-2 days, at 7 days and
changes. Treat all other injuries conservatively and then every 2 weeks to assess response to
follow up closely. treatment
• Start range-of-motion exercises within pain-free
Nonpharmacologic Interventions range in 2-3 days (in cases of minor injury)
• Clients without systemic disorders should be • Advise client to begin stretching and
treated with non-operative therapy for 3-6 weeks strengthening program when range of motion is
• Ice massage for 20 minutes qid provides regained
additional analgesia in some cases
• Heat may decrease muscle tightness and Referral
improve range of motion in others Most clients, including those with cervical
• Cervical collar and limiting motion are radiculopathy, improve and return to normal
suggested; short-term immobilization is useful, activity within 2 months. Clients who are still
particularly at night, when movement during symptomatic after 6 weeks of non-operative
sleep can cause pain treatment should be referred to a physician for
• A soft collar that supports but does not extend further evaluation.
the neck is an appropriate treatment; however,
its use should be decreased as neck pain Phone consultation or referral to physiotherapy.
diminishes

Adhesive Capsulitis (Frozen Shoulder), Tendinitis And Bursitis

Definition Nonpharmacologic Interventions
Adhesive capsulitis: Chronically stiff and painful Rest Injured Limb
shoulder, which begins without any significant • Avoid aggravating positions and activities
injury. • Type and period of rest varies according to
severity of symptoms and type of injury or
Tendinitis and bursitis: Inflammation of a tendon disorder
or a bursa within the shoulder. The supraspinatus • For upper limb: use sling in acute stage for brief
and long end of the biceps are especially period (2-3 days), then discontinue
susceptible.
Ice or Cold Pack Locally to Reduce Pain
Causes and Swelling
Adhesive capsulitis: Prolonged immobilization • Apply to area for 20 minutes qid
from either protracted use of a sling or disuse • If soft-tissue injury is severe, apply q2h
because of pain in the arm. • Use ice as long as swelling and pain are present
• Heat is contraindicated in acute soft-tissue injury
Tendinitis and bursitis: Overuse, repetitive strain
• Never use heat in acute or subacute phases of
from repeated motion.
recovery
• Heat may be used for chronic stiffness and
History And Physical Findings swelling
Adhesive capsulitis: Shoulder pain and limitation
of movement in one or more directions, with pain
occurring at the limits of motion. Other findings
Anti-inflammatory analgesics to reduce pain and
relatively unremarkable.
swelling:
ibuprofen (A class drug), 200 mg, 1-2 tabs PO tid-
Tendinitis and bursitis: Non-specific pain and
qid
aching of the shoulder. With supraspinatus
or
tendinitis, the pain is aggravated when the
naproxen (C class drug), 250 mg PO bid-tid for
shoulder is abducted and externally rotated against
2 weeks or longer prn
resistance. With bicipital tendinitis, the pain is
aggravated when the patient flexes forward against
Do not use if there are contraindications to the use
resistance.
of NSAIDs (such as a history of peptic ulcer
disease). Instead, use:
Management acetaminophen (A class drug), 500 mg, 1-2 tabs
Goals of Treatment PO tid-qid prn
• Relieve pain and inflammation
• Maintain function of shoulder Monitoring and Follow-Up
• Prevent complications • Arrange follow-up at 1-2 days and at 14 days
• Start range-of-motion exercises within pain-free
Most of the soft-tissue conditions about the range in 2-3 days (in cases of minor injury)
shoulder can be relieved by application of ice and • Advise client to begin stretching and
rest for 5-7 days (with short-term use of sling for strengthening program when range of motion is
2-3 days). regained
• Exercise progression: passive range of motion,
Physical therapy and rehabilitation are extremely
active assisted range of motion, isometrics,
important in regaining and maintaining range of
active stretching, and late stretching and
motion, flexibility and strength for optimal
strengthening exercises
shoulder functioning.
• Exercises are best done in multiple short
sessions, not long ones

• Exercise should be preceded by application of Referral

moist heat for 10-15 minutes and should be Refer to a physician if there is no improvement
followed by icing for 20 minutes with conservative therapy in 4-6 weeks.
• Any exercise that causes pain should be A physiotherapy consultation (if available) is
temporarily omitted especially important for adhesive capsulitis
• As range of motion, flexibility and strength because optimal treatment of this condition
improve, so will shoulder function involves extended, aggressive physical therapy.

Rotator Cuff Syndrome

Pain and diminished function of the shoulder Rest Injured Limb
secondary to inflammation and weakness of the Type and period of rest varies according to type
muscles of the rotator cuff. There are three stages, and severity of injury.
as outlined below.
Stages 1 and 2: Aggravating positions and
The rotator cuff muscles are the supraspinatus, activities should be avoided; a sling should be
infraspinatus, teres minor and subscapularis, all of used in acute injury stage for a brief period (2-3
which envelop the scapula. days)
Causes Stage 3: Place injured limb in sling for comfort

Stages 1 and 2: A rotator cuff tendinitis caused by
forceful or repetitive motion Ice or Cold Pack Locally to Reduce Pain and
Swelling
Stage 3: A complete traumatic tear of the Apply ice or cold pack as follows:
supraspinatus tendon • Apply to area for 20 minutes qid
• If soft-tissue injury is severe, apply q2h
History And Physical Findings • Use ice as long as swelling and pain are present
Stage 1: Occurs in people > 25 years of age; pain • Heat is contraindicated in acute soft-tissue injury
is noted over the anterior aspect of the shoulder • Never use heat in acute or subacute phases of
and is maximal when the arm is raised from 60° to recovery
120° elevation. • Heat may be used for chronic swelling
Stage 2: Usually occurs in people 25-40 years of Pharmacologic Interventions
age who have had multiple previous episodes; in Stages 1 and 2: Anti-inflammatory analgesics to
addition to pain from tendinitis inflammation of reduce pain and swelling:
the rotator cuff, some permanent fibrosis, ibuprofen (A class drug), 200 mg, 1-2 tabs PO tid-
thickening or scarring is present; x-rays may qid
reveal calcific deposits within the rotator cuff . or
naproxen (C class drug), 250 mg, PO q6h prn
Stage 3: Client usually > 40 years of age; may feel
a sudden pop in the shoulder and then suffer Do not use if there are contraindications to the use
severe pain; client notes increasing weakness of NSAIDs (such as a history of peptic ulcer
when trying to abduct and externally rotate the disease). Instead, use:
affected arm. acetaminophen (A class drug), 500 mg, 1-2 tabs
PO tid-qid prn
Management or
Goals of Treatment acetaminophen with codeine 30mg (C class drug),
• Relieve pain and inflammation 1-2 tabs q4h prn (maximum 15 tabs)
• Maintain function of shoulder
• Prevent complications Stage 2: In addition to the drugs given above,
corticosteroids (B class drugs) may be injected
Appropriate Consultation into the subacromial bursa.
Consult a physician immediately about all stage 3
injuries. Consult a physician if a stage 1 or 2
injury remains symptomatic for > 4-6 weeks.

Stage 3: Analgesics for pain: • Exercise should be preceded by application of

ibuprofen (A class drug), 200 mg, 1-2 tabs PO tid- moist heat for 10-15 minutes and should be
qid followed by icing for 20 minutes
or • Any exercise that causes pain should be
naproxen (C class drug), 250 mg, PO q6h prn temporarily omitted
or • As range of motion, flexibility and strength
acetaminophen with codeine 30mg (C class drug), improve, so will shoulder function
1-2 tabs q4h prn (maximum 15 tabs)
Referral
Monitoring and Follow-Up Physiotherapy consultation or referral should be
Stages 1 and 2: Clients with this type of injury considered if readily available.
should be monitored as follows:
• Arrange follow-up at 1-2 days and at 10 days Stage 2: If symptoms persist after 4-6 weeks of
• Start range-of-motion exercises within pain-free conservative therapy, consider referral to an
range in 2-3 days (in cases of minor injury) orthopedist for surgery consult.
• Advise client to begin stretching and
strengthening program when range of motion is Stage 3: Medevac urgently. Treatment is usually
regained surgical repair, depending on whether there is
• Exercise progression: passive range of motion, significant loss of function. Repair is more likely
active assisted range of motion, isometrics, in young clients than in elderly clients. Many
active stretching exercises, and late stretching elderly clients have progressive loss of the rotator
and strengthening exercises cuff as a result of aging.

Acromioclavicular Injuries
Grade 1 (sprain): Partial tear of the joint capsule. • X-ray may be advisable to determine extent of
Mild pain without joint deformity and minimal injury, especially in younger people with
ligamentous disruption and instability. significant symptoms
• Grade 1: Acromioclavicular joint films (with
Grade 2 (subluxation): Complete tear of the and without weights) yield normal findings
acromioclavicular ligaments. The • Grade 2: Stress x-ray of the acromioclavicular
acromioclavicular joint is locally tender and joint with the client holding a 4.5-kg (10-lb)
painful with motion. The distal end of the clavicle weight in both hands reveals widening of the
may protrude slightly upward. joint
• Grade 3: X-rays obtained with the client holding
Grade 3 (dislocation): Complete tear of the weights show superior displacement of the
acromioclavicular and coracoclavicular ligaments. clavicle and complete dislocation of the joint
Significant pain, especially on any attempt at
abduction; there is an obvious "step-off" deformity
Management
on physical examination.
Consult a physician for all grade 2 and 3 injuries
Causes as soon as possible.
Usually results from a direct blow to or fall on the
tip of the shoulder.
Rest Injured Limb
History Type and period of rest varies according to
• The history often involves a fall onto the apex of severity of injury.
the shoulder, usually with the arm in adduction. - Avoid aggravating positions and activities
Severe forces resulting from significant falls are - Grade 1: Sling in acute injury stage for very
often associated with grade 3 injuries. brief period (5-7 days), then discontinue
• Pain over injured area - Grade 2: Subluxation requires a longer period of
• Inability to use shoulder immobilization (7-14 days)
Physical Findings Ice or Cold Pack Locally to Reduce Pain and

• Pain at rest or elicited with movement Swelling
• Pain increases with severity of injury For all grades of acromioclavicular injuries, ice or
• Tenderness on palpation of the cold packs may be used:
acromioclavicular joint • Apply to area for 20 minutes qid
• There may be a "step-off" deformity of the • If soft-tissue injury is severe, apply q2h
acromioclavicular joint • Use ice as long as swelling and pain are present
• Note the position of the clavicle • Heat is contraindicated in acute soft-tissue injury
• Never use heat in acute or subacute phases of
Perform a careful neurovascular assessment of recovery
brachial-plexus motor and sensory function, • Heat may be used for chronic stiffness and
because associated injuries, though rare, can swelling
occur.
Complications
• Instability of the shoulder
• Loss of mobility

Pharmacologic Interventions • Advise client to begin stretching and

Anti-inflammatory analgesics to reduce pain and strengthening program when range of motion is
swelling: regained
ibuprofen (A class drug), 200 mg, 1-2 tabs PO tid- • Exercise progression: passive range of motion,
qid active assisted range of motion, isometrics,
or active stretching exercises, and late stretching
naproxen (C class drug), 250 mg, PO q6h prn and strengthening exercises
Do not use if there are contraindications to the use sessions, not long ones
of NSAIDs (such as a history of peptic ulcer • Exercise should be preceded by application of
disease). Instead, use: moist heat for 10-15 minutes and should be
acetaminophen (A class drug), 500 mg, 1-2 tabs followed by icing for 20 minutes
PO tid-qid prn • Any exercise that causes pain should be
or temporarily omitted
acetaminophen with codeine 30mg (C class drug), • As range of motion, flexibility and strength
1-2 tabs q4h prn (maximum 15 tabs) improve, so will shoulder function
• Arrange follow-up at 1-2 days and at 14 days Medevac urgently all clients with grade 3 injuries,
• Start range-of-motion exercises within pain-free as orthopedic consultation is required.
range in 2-3 days (in cases of minor injury)

Glenohumeral Dislocations
Dislocation of the humeral head from the X-ray (if available) is necessary before reduction;
glenohumeral joint socket. obtain images in two planes (anteroposterior [AP]
and lateral scapula) to confirm the dislocation and
Causes to rule out fracture, where possible, if mechanism
Trauma; usual mechanism is forced abduction and is suggestive.
external rotation (95% are anterior dislocations).
Management
• Severe pain • Relieve pain
• Client usually holds the arm tightly against the • Reduce dislocation
body • Prevent complications

• Shoulder appears flattened laterally and Consult a physician. The dislocation should be
prominent anteriorly reduced as soon as possible.
• The acromion process is prominent
• Shoulder appears to be "squared off" Nonpharmacologic Interventions
Immobilize the client's arm in a sling-and-swathe
Check for associated injuries: dressing.
• Proximal humeral fracture
• Avulsion of the rotator cuff Pharmacologic Interventions
• Injuries to the adjacent neurovascular structures; Analgesia is needed:
axillary nerve injury is most common and is meperidine (D class drug), 75-100 mg IM and use
of muscle relaxant
associated with decreased active contraction of
the deltoid muscle
Monitor pain and neurovascular status frequently
Differential Diagnosis until transfer.
• Soft-tissue injury
• Clavicle fracture Referral
• Acromioclavicular joint separation Medevac to hospital if unable to perform reduction
on site. Recurrent dislocation or subluxation is
Complications common and may require surgical repair, referral
• Neurovascular compromise to a physician may be necessary.

Lateral Epicondylitis (Tennis Elbow)

Definition • A constrictive band should be placed on the
An inflammatory process occurring at the extensor elbow (commercial "tennis elbow" bands are
origin of the lateral epicondyle. available)
• The joint should be rested (using a sling) for 2-3
Causes days
• Usually secondary to overuse or repetitive use
• Populations at risk: athletes and manual laborers Ice or Cold Pack Locally to Reduce Pain and
Swelling
History • Apply to elbow for 20 minutes qid
• Pain at the lateral epicondyle • Use ice as long as swelling and pain present
• Referred pain to the extensor surface of the • Heat may be used for chronic stiffness and
forearm swelling after the acute phase
• Pain exacerbated by resisted extension of the
wrist or fingers Pharmacologic Interventions
Physical Findings swelling:
ibuprofen (A class drug), 200 mg, 1-2 tabs PO tid-
• Swelling (mild)
qid
• Warmth or
• Redness (mild) naproxen (C class drug), 250 mg, PO q6h prn
• Tenderness over lateral elbow
Do not use if there are contraindications to the use
Differential Diagnosis of NSAIDs (such as a history of peptic ulcer
• Avulsion injury of the tendon disease). Instead, use:
• Bursitis acetaminophen (A class drug), 500 mg, 1-2 tabs
• Septic tenosynovitis PO tid-qid prn
• Arthritis or
Complications 1-2 tabs q4h prn (maximum 15 tabs)
• Recurrent episodes
• Tendon rupture Monitoring and Follow-Up
• Arrange follow-up at 1-2 days and at 14 days
Diagnostic Tests • Start gentle range-of-motion exercises within
None. pain-free range in 2-3 days
• Advise client to begin stretching and
strengthening program when range of motion is
Management
regained
Goals of Treatment
• Exercise progression: passive range of motion,
• Relieve pain active assisted range of motion, isometrics,
• Reduce inflammation active stretching exercises, and late stretching
• Strengthen the muscle and strengthening exercises
• Prevent complications • Exercises are best done in multiple short
Nonpharmacologic Interventions • Exercise should be preceded by application of
Rest the Limb moist heat for 10-15 minutes and should be
• Client should avoid exacerbating activities followed by icing for 20 minutes

Referral
In most clients, the problem subsides with
conservative treatment. Refer to a physician if
there is failure to respond to treatment.

Carpal Tunnel Syndrome

Definition • Peripheral neuropathy
The symptoms are a result of median nerve • Brachial plexus lesion
dysfunction because of compression within the
carpal tunnel. Tends to affect the dominant hand Complications
but may be bilateral. Without treatment, permanent injury to the nerve
Causes Management
• Overuse Goals of Treatment
• Ganglion cyst • Relieve symptoms
• Trauma: Colles' fracture • Prevent complications
• Predisposing factors: pregnancy, diabetes
mellitus, rheumatoid arthritis, hypothyroidism, Appropriate Consultation
systemic lupus erythematosus, Consult a physician if there is evidence of muscle
hypoparathyroidism, hypocalcemia weakness and wasting of the thenar eminence on
• Risk factors: jobs that involve repetitive flexion the initial visit. Otherwise, treat conservatively and
and extension of the wrist follow closely.
History Nonpharmacologic Interventions

Symptoms usually affect the thumb, index and • Avoid aggravating activities, especially
middle finger. repetitive motion activity
• Tingling or pricking sensation in the fingers • Splint with the wrist in neutral position of
• Burning pain in the fingers, especially at night extension
• Relief of symptoms afforded by shaking or
rubbing the hand Pharmacologic Interventions
• Arm pain Anti-inflammatory analgesics:
ibuprofen (A class drug), 200 mg, 1-2 tabs PO tid
Physical Findings or
• Sensory loss in the thumb, index and middle naproxen (C class drug), 250 mg, PO bid-tid
fingers
• Tinel's sign: painful sensation of the fingers Monitoring and Follow-Up
induced by percussion of the median nerve at the • Follow up in 2 weeks to see if there is response
level of the palmar wrist to treatment
• Phalen's sign: keeping both wrists in a palmar- • If improving, continue to see every 2 weeks until
flexed position may reproduce symptoms resolved or until 6 weeks has passed
• Weakness of the hand while performing tasks
(e.g. opening jars) Referral
Refer to a physician if the carpal tunnel symptoms
• Muscle wasting of the thenar eminence
do not improve in 6 weeks. If there is evidence of
(late sign)
thenar muscle weakness or atrophy, surgical
intervention is indicated.
• Cervical spine spondylosis

Knee Injury
Most knee injuries in adults involve the ligaments. • Posterior drawer test is used: knee is flexed 90°,
and posterior displacement of the tibia on the
Ligament Injuries femur is attempted
Collateral Ligament Injury
Grade 1 sprain: Microtear of the ligament; Meniscal Tears
increase in joint opening < 5 mm (0.2 inch); no • Medial meniscal injury is one of the most
instability. common causes of knee-joint pain; medial
meniscus is much more susceptible to tears than
Grade 2 sprain: Partial macrotear of the ligament lateral meniscus
accompanied by significant increase in joint • More than one-third of meniscal injuries are
opening (with an end point) and instability. associated with anterior cruciate ligament tear
and possibly medial collateral ligament injuries
Grade 3 sprain: Complete tear of the ligament, • Client reports pain at time of injury; pain
with no end point distinguishable on examination. persists and interferes with weight-bearing
activity
Collateral ligament injuries are usually caused by • Client often reports that the knee "locks," which
direct trauma to the contralateral side of the knee may be attributable to pain or a physical
or excessive indirect force to the knee in a varus or inability to extend the knee because the torn
valgus manner. meniscus prevents extension
• Most consistent physical finding is tenderness to
Pain and a sensation of tearing may have been palpation along the joint line
noted by the client at the time of injury. In case of • Clinical tests help identify meniscal injury
medial collateral ligament injury, there may be (e.g. McMurray's test and Apley's test)
tenderness along the distal femur extending to the
joint line.
Management
Medial collateral ligament injuries may be Goals of Treatment
associated with meniscal tears. • Relieve symptoms
• Restore or maintain knee function
Valgus and varus tests allow assessment of the • Prevent complications
collateral ligaments. With the knee in 30° of
flexion, the collateral ligaments can be isolated. Most knee injuries will respond well to
Increased laxity may be seen (in grade 2 or 3 conservative management.
sprain).
Anterior Cruciate Ligament Injury If there are any diagnostic doubts, consult a
• History of a twisting injury accompanied by a physician as soon as possible.
pop or a tearing feeling and subsequent effusion
• Hemarthrosis found in 75% of cases Nonpharmacologic Interventions
• Frequently associated with injury to a medial Conservative treatment of isolated grade 1 and 2
collateral ligament collateral ligament and minor meniscal injuries
involves nonpharmacologic interventions.
Posterior Cruciate Ligament Injury • Client should rest with an immobilizer splint or
• Most injuries result from direct trauma to bandage for 7-14 days
proximal tibia when the flexed knee is • Client should start using crutches with weight
decelerated rapidly, as in a dashboard injury bearing as tolerated as soon as ambulation
causes only minor pain
• Ice should be applied for 20 minutes qid

• Client should elevate knee for first 24-72 hours Referral

• Initiation of gentle range-of-motion exercises Collateral Ligament Injury
within the pain-free zone should begin as soon Grade 3 collateral ligament injuries can be treated
as pain and swelling subside enough to allow. non-operatively, but physician referral may be
Start with quadriceps extension. recommended to assess the need for surgical
intervention.
Anti-inflammatory analgesics: Anterior Cruciate Ligament Injury
ibuprofen (A class drug), 200 mg, 1-2 tabs PO tid Treatment should be supervised by an orthopedist.
or Treatment of acute injuries depends on the
naproxen (C class drug), 250 mg, PO bid-tid severity. Clients without associated meniscal,
collateral ligament or posterior cruciate ligament
Do not use if there are contraindications to the use injury should be treated by immobilizing the knee
of NSAIDs (such as a history of peptic ulcer for comfort; crutches should be used.
disease). Instead, use:
acetaminophen (A class drug), 500 mg, 1-2 tabs Clients with associated ligament injury or
PO q4h prn meniscal injury should be referred immediately to
an orthopedist, because surgery may be necessary.
If pain moderate to severe initially, use:
acetaminophen with codeine 30mg (C class drug), Posterior Cruciate Ligament Injury
1-2 tabs PO q4h prn to maximum of 15 tabs, then Isolated tears should be managed conservatively,
switch to plain acetaminophen but some posterior cruciate ligament injuries may
require surgical fixation.
Follow up in 1-2 days to reassess injury. If Meniscal Tears
swelling and pain are reduced, you may be able to If the knee remains locked or if symptoms of pain,
examine knee more thoroughly. giving way (a sense that the knee is going to
collapse) and swelling persist, client should be
referred to a physician to assess for the need for
surgical intervention.

Ankle Sprain
Inversion or eversion injury causing a tear of • Fracture
ligaments supporting the ankle, usually involving • Avulsion fracture
lateral ligaments. • Tendon rupture (e.g. Achilles', peroneal,
posterior tibial)
First-degree sprain: Ligament is stretched and
joint is stable. Complications
• Chronic laxity of ligaments and recurrent injury
Second-degree sprain: More severe; significant
to ankle
partial tearing of the ligament, joint is stable.
• Neurovascular compromise
Third-degree sprain: Complete tear of ligament(s),
joint is unstable. Diagnostic Tests
X-ray of ankle (according to Ottawa Ankle Rules,
below) to rule out a fracture if indicated.
Causes
• Trauma
Ottawa Ankle Rules
• Predisposing laxity of ligaments Perform radiography if there is pain near the
malleoli and inability to bear weight immediately
History at the time of injury and at the time of your
• Sudden twisting motion of foot and lateral ankle examination of the client or if there is point
• Most commonly results in forced inversion of tenderness over the bone at the posterior tip of
foot and ankle with injury to the lateral collateral either malleoli.
ligament
• Eversion-type injury to the deltoid ligament is Perform radiography if there is pain at the mid-
second most common type of sprain foot and inability to bear weight both immediately
• Depending upon extent of injury and degree of and at the time of your examination or there is
ligament injury, symptoms vary in severity bone tenderness at the navicular or at the base of
• Degree of pain depends on severity of injury the fifth metatarsal.
• Swelling
• Bruising Management
• Inability to walk (depending on degree of sprain) Goals of Treatment
• Reduce pain and swelling
Physical Findings • Rehabilitate ankle strength
• Affected limb may be unable to bear weight • Prevent further injury
• Swelling evident (extent depends on severity of
sprain) Appropriate Consultation
• Bruising present in moderate and severe sprains Consult a physician if joint instability is present at
• Anterolateral aspect of ankle joint tender initial examination. Also, consult a physician if
• Posterolateral aspect of ankle joint may be there is no improvement after 2 weeks of
tender conservative therapy.
• In severe sprains, anterior aspect of ankle also
tender Nonpharmacologic Interventions
• Lateral ligament may show laxity Rest the Joint
Type and period of rest varies according to
• Tenderness over either malleolus
severity of injury.
• Range of motion (dorsiflexion, plantar flexion,
• No weight bearing or partial weight bearing with
inversion) may be limited because of pain
crutches, limited weight-bearing activities

• For first- and second-degree sprains, a gradual • Balancing on one foot

increase in weight-bearing is recommended,
beginning as soon as pain and stability allow; Client Education
this promotes healing and proprioception • Counsel about the importance of rest, ice and
elevation
Ice or Cold Pack to Reduce Swelling and Pain • Teach to use crutches to prevent weight bearing
• Apply to lateral aspect of ankle for 20 minutes • Teach the proper application of tensor bandage
qid for 48 hours (longer if swelling continues) • Counsel about appropriate use of medications
• If sprain is severe, apply ice q2h (dose, frequency, side effects)
• Use ice as long as swelling and pain are present • Counsel about strategies to prevent further
• Heat is contraindicated for the acutely injured injuries to ankle (e.g. doing warm-up exercises
ankle before physical activities such as sports; wearing
• Never use heat in acute or subacute phases of high-top, lace-up shoes for walking and running)
recovery
• Heat may be used for chronic swelling Pharmacologic Interventions
Compression and Elevation to Reduce swelling:
Swelling and Pain ibuprofen (A class drug), 200 mg, 1-2 tabs PO tid-
• Tensor bandage should be worn during daytime qid prn
and removed at bedtime
• Ankle should not be wrapped too tightly If there are contraindications to acetylsalicylic acid
• When possible, ankle should be elevated above (ASA) or NSAIDs, use:
level of hip acetaminophen (A class drug), 500 mg, 1-2 tabs
PO q4h prn
Exercises
For moderate to severe pain, stronger analgesics
• Start gentle range-of-motion exercises for
may be needed in addition to anti-inflammatory
dorsiflexion within 24 hours
drugs in the first 24-48 hours; use:
• Encourage calf stretching as tolerated acetaminophen with codeine 30mg (C class drug),
• Instruct client to draw letters of alphabet with 1-2 tabs PO q4-6h prn (maximum 15 tabs)
ankle
Plantar flexion, inversion and eversion should be Follow up in clinic at 48 hours and again in 2
avoided in the very early stages of rehabilitation. weeks, or sooner if pain and swelling persist
Muscle-strengthening exercises should be started
Referral
when range of motion is regained. Instruct client
Arrange physiotherapy (if readily available) if
about the following exercises:
symptoms persist for more than 2-3 weeks.
• Toe and heel raises on inclined surface, holding Refer all grade 3 sprains to a physician. Consider
end position for 4-6 seconds (10-20 repetitions) consult with orthopedist for eversion-type injuries.
• Toe raises on flat surface, holding end position
for 4-6 seconds (10-20 repetitions)
• Heel and toe walking

Low-Back Pain
Acute low-back pain is one of the most common structures, but serious inflammatory, infectious
health problems. Almost everyone experiences it and neoplastic disorders also occur.
in his or her lifetime to some degree.
Back pain can also result from disorders of the
Back structures that can be a source of pain are visceral structures immediately anterior to the
ligaments, vertebral bones, facet joints, spine: aorta, kidneys, intestines, pancreas,
intervertebral disks, nerve roots and muscles. Pain stomach, gallbladder, prostate, uterus and ovaries.
usually results from strain or degeneration of these

Lumbosacral Strain And Sciatica

Definition • Interference with performance of job-related
Stretching or tearing of muscles, tendons, activities
ligaments or fascia of the lower back secondary to • Occupation involving bending or heavy lifting
trauma or chronic mechanical stress. May be • History of recent or previous trauma
accompanied by sciatica (pain in buttocks or legs, • Other underlying spinal disk, bone or joint
or both, along path of sciatic nerve, due to nerve disease (e.g. spinal stenosis, osteoarthritis)
root irritation). • Fever, chills
• Weight loss
Causes • Cancer
• Contusions
• Ligamentous strain Physical Findings
• Muscular strain • Client appears in mild-to-severe distress
• Muscular tension related to mechanical stress • Abnormal posture (tilting to one side)
• Osteoarthritis of spine • Difficulty with walking (ataxic gait)
• Protruding intervertebral disk • May be unable to stand or sit up straight
• Other disease process • Spinal deformities may be present
• Bruising or soft-tissue swelling may be present
Risk Factors • Spasm of para-spinal muscles may be present
• Aging • Intervertebral disk space may be tender in
• Prolonged periods of standing or sitting lumbar area and along paravertebral muscles
• Poor posture • Range-of-motion maneuver may be limited
• Pregnancy (especially forward flexion)
• Obesity • Straight leg raising may be limited because of
• Improper lifting techniques muscle tightness, muscle spasm or nerve root
• Family history irritation (sciatica)
• Osteoporosis • Reflexes normal in cases of soft-tissue injury,
• Past trauma but may be abnormal in cases of impingement
• Recent bacterial drug use on nerve root
• IV drug use • Weakness with heel or toe walking may be
• Immunosuppressed present (in cases of impingement on nerve root)
• Sensory deficits may be present (in cases of
History impingement on nerve root)
Obtain a detailed history, with a precise • Bowstring test may be positive (in cases of
description of the pain and events surrounding its impingement on nerve root)
onset (e.g. activity at the time). • Evaluate for "red flag" indicators for potentially
• Pain localized in low lumbar area serious conditions
• Pain may radiate into buttock or leg
(e.g. sciatica) Red Flag Indicators For Potentially
• Aching pain may be accompanied by intense, Serious Conditions
sharp muscle spasm Possible Fracture
• Sitting increases pain • Major trauma
• Supine posture decreases pain • Minor trauma in older clients or clients who may
• Rest decreases pain have osteoporosis
• Motion increases pain
• Interference with daily activities

Possible Cauda Equina Syndrome Appropriate Consultation

(Surgical Emergency) Consult physician for moderate-to-severe back
• Saddle-block anesthesia pain, especially if the client is > 50 years of age or
• Bladder dysfunction has neurologic abnormalities, or if you suspect an
• Severe or progressive neurologic dysfunction in underlying organic cause for the back pain.
the legs
• Laxity of anal sphincter Nonpharmacologic Interventions
• Major motor weakness in quadriceps (knee • Clients with sciatica may have a longer expected
extensors), ankle plantar flexors, evertors and recovery time than clients with non-specific
dorsiflexors (foot drop) back symptoms
• Bed rest is useful if pain and spasm preclude
Possible Tumor or Infection motion, but should not exceed 3 days; any
• Client age < 20 or > 50 years longer may actually increase pain and disability
• History of cancer • Heavy physical activity should be reduced for
• Constitutional symptoms such as fever, chills 1-2 weeks; otherwise activity as tolerated
and weight loss • No heavy lifting (> 11 kg [25 lb])
• Risk factors for spinal infection, recent bacterial • Client should sleep on a firm mattress support
infection, injection drug use or with pillow under knees when lying on back or
immunosuppression between knees when lying on side
• Pain that is worse in the supine position or • Ice packs can be used to reduce muscle spasm
severe nighttime pain (20 minutes q2-4h for 24-48 hours)
• Use a heating pad or hot water bottle to reduce
Differential Diagnosis muscle stiffness (if pain and spasm absent) after
See "Causes of Low-Back Pain," in "Differential the first 48 hours (20 minutes qid prn)
Diagnosis of Musculoskeletal Cardinal • Provide advice about nutrition and weight loss if
Symptoms," above, this chapter. client is overweight
• Time off should be brief; goal is to keep client
Complications active
• Chronic or recurrent back pain
Client Education
• Absenteeism from work
To Be Avoided
• Dependency on or abuse of analgesics
• Prolonged standing
• Occupational disability
• Prolonged sitting
• Lifting > 11 kg (25 lb)
Diagnostic Tests
• Lifting and twisting motion
In the absence of any red flag indicators, no
investigations are needed within the first 4 weeks • Slumping posture
of acute mechanical low-back pain from lumbar
strain. To Be Encouraged
• Lumbar support
Management • Frequent positional changes
Goals of Treatment • Maintenance of normal spine alignment when
• Relieve pain sitting or standing
• Prevent further injury • Proper lifting techniques
• Educate and reassure the client • Counsel client about appropriate use of
medications (dose, frequency, abuse, overuse)
• Maintain/improve activity level
• Teach the client back-strengthening and
conditioning exercises that can be done at home

• Advise client not to start exercises until acute acetaminophen with codeine 30mg (C class drug),
symptoms have subsided 1-2 tabs PO q4h prn (maximum 15 tabs) -- may be
used in addition to the anti-inflammatory drugs
Anti-inflammatory analgesics to reduce pain: For muscle spasm
ibuprofen (A class drug), 400 mg, PO tid-qid prn cyclobenzaprine (A class drug) 10mg PO tid for
or 3 days and reassess
naproxen (C class drug), 250 mg, PO bid
or Monitoring and Follow-Up
acetaminophen (A class drug), 500 mg, 1-2 tabs Arrange follow-up at 1-2 days, and then as needed
PO tid-qid prn
Referral
If pain is moderate to severe, or first-line agents • Refer to a physician if symptoms persist after
fail to control discomfort: 4 weeks, or sooner if symptoms are worsening
despite conservative treatment
• Arrange referral to a physiotherapist

Gout
Definition • Male or postmenopausal female
Inflammatory disease of peripheral joints related
to high concentrations of uric acid in the joints and Physical Findings
bones. Acute Attack
• Temperature usually normal
Causes • Heart rate may be elevated
• Primary gout: High levels of uric acid from • Client appears in acute distress
either increased production or decreased • Difficulty walking or unable to bear weight on
excretion of uric acid affected limb
• Secondary gout: Hyperuricemia from primary • Metatarsophalangeal or interphalangeal joint of
acquired diseases such as hypertension, renal great toe shows the following characteristics:
failure, hemolytic anemia, glycogen storage redness and swelling; overlying skin tense and
disease, psoriasis, renal insufficiency, shiny; range of motion reduced and
sarcoidosis, enzyme deficiencies accompanied by pain; joint acutely tender and
feels warm or hot
Risk Factors
• Obesity Chronic Disease
• Lead intoxication • Joint deformity may be present
• Medications such as salicylates, thiazide • Tophi (chalky deposits) may be present in
diuretics, corticosteroiods, cytotoxic drugs, pinnae of ear, olecranon bursa, dorsum of hands,
diazepam, ethambutol, nicotinic acid ulnar surface of forearms, Achilles' tendon and
• Alcohol abuse (especially binge drinking) joints of hands and feet
• Other risk factors: family history, diabetes
mellitus, hypertension, renal failure, Differential Diagnosis
hypothyroidism, hyper- or hypo-parathyroidism, • Septic arthritis
pernicious anemia • Pseudogout
• Bursitis
History • Cellulitis
• Sudden onset of pain in a joint • Osteomyelitis
• Great toe most commonly affected initially • Degenerative arthritis with acute inflammation
• Instep, ankle, knee, wrist and elbow may be • Rheumatoid arthritis
affected • Bunion
• Almost all attacks are monoarticular (involving
only one joint)
Complications
• Widespread joint involvement occurs rarely,
• Recurrent attacks
accompanied by fever, chills and general
• Joint deformity and reduced mobility
malaise
• Chronic pain
• Pain usually occurs spontaneously, is severe,
throbbing and continuous • Renal calculi
• First attack begins during the night or early • Nephropathy (may take 10 years to develop)
morning • Tophi (deposition of uric acid crystals in soft
• May be precipitated by trauma, alcohol binging, tissues)
recent infection, emotional stress or
administration of medications (diuretics, Diagnostic Tests
penicillin, insulin) • Serum uric acid (normal < 0.45 mmol/L
• Attacks are recurrent [7.5 mg/dL])
• Familial tendency

• White blood cell (WBC) count (elevated in acute • Advise client to avoid known precipitating
phase) factors
• Erythrocyte sedimentation rate (ESR) (elevated • Explain how to prevent irritation (e.g. proper-
in acute phase) fitting footwear, not going barefoot in the house)
• 24-hour urinary uric acid excretion (> 900 mg • Advise client to return to clinic at first sign of
suggests overproduction) recurrence
• Advise client to begin anti-inflammatory
Management medications at the first sign of an acute attack
Goals of Treatment
• Relieve symptoms Pharmacologic Interventions
• Prevent recurrence For acute gout, relieve pain and inflammation with
• Prevent complications NSAIDs:
ibuprofen (A class drug), 400 mg, PO tid until
Appropriate Consultation acute symptoms subside, then taper drug to
Consult a physician if the client is acutely ill or discontinue in another 72 hours
febrile on initial presentation. Consult a physician or
if no response to therapy in 24-48 hours. naproxen (C class drug), 250 mg PO bid for
7 days
ASA (Aspirin) is contraindicated for gout.
• No weight bearing
• Immobilize the joint until hyperacute symptoms If pain is severe, additional analgesia may be
are controlled
required until anti-inflammatory drugs start to
• Client should increase fluid intake during attack work:
(8 glasses daily) acetaminophen with codeine 30mg (C class drug),
• Client should discontinue alcohol consumption 1-2 tabs PO q4h prn (maximum 15 tabs)
• Low-fat diet (to reduce dietary purine, if
excessive) Monitoring and Follow-Up
• Weight reduction will help an obese client in the • Follow up in 24 hours to ensure response to
long term therapy
• Follow up in 1 month to evaluate status
Client Education • For client with chronic gout, measure uric acid
• Explain chronic nature and course of the disease levels annually and assess adherence to
• Counsel client about appropriate use of prophylaxis
medications (dose, frequency, side effects,
adherence to regimen between attacks to prevent Referral
future attacks) Refer to a physician regarding prophylactic
therapy for clients with recurrent episodes.

Osteoarthritis (Degenerative Joint Disease)

Definition • Muscle strength and joint stability (ligament)
Degenerative disease of the articular cartilage of may be affected
movable joints. Variable amounts of synovial • Osteophyte formation (bony enlargement)
inflammation result, new bone forms at joint • DIP joints may have osteophyte formation
surfaces (osteophytes). dorsally and marginally (Heberden's nodes)
• Redness or swelling not evident unless there has
Causes been an episode of secondary reactive synovitis
• Unknown. • Tenderness may be present in late disease
• Factors associated with osteoarthritis: aging, • Crepitations may be felt or heard with
previous joint trauma, chronic overuse of joint, movement of joint
altered biomechanics, obesity, metabolic
disorders (e.g. Wilson's disease), previous Differential Diagnosis
infection in a joint, endocrine disorders • Other forms of arthritis and articular disease
(e.g. diabetes mellitus), crystalline deposit • Trochanteric bursitis (in clients with hip
disease problems)
• Ligamentous or meniscal problems, local
History bursitis, loose bodies (in clients with knee
• Family history problems)
• Client usually > 50 years of age
• Joint pain (joints most affected are DIP [distal Complications
interphalangeal], PIP [proximal interphalangeal], • Chronic pain
MCP [metacarpophalangeal], knees, hips, • Progressive joint destruction with increasing loss
cervical spine, lumbar spine) of function and pain
• Pain is aching in character • Impingement of spinal nerves
• Pain often worsens with changes in weather
• Pain increases with activity Diagnostic Tests
• Pain relieved by rest None.
• Localized joint stiffness may be present in the
morning or after periods of inactivity Management
• Stiffness quickly relieved with movement (in Goals of Treatment
less than 30 minutes) • Relieve or modify symptoms
• Generalized joint stiffness absent • Preserve joint function
• Crepitus (a noisy joint) may be present • Prevent complications
• Joint enlargement with limited range of motion
may be present Appropriate Consultation
• Flare-ups of pain may occur after unaccustomed Consult a physician if client is < 50 years of age,
exercise joint involvement is atypical, or nerve dysfunction
is suspected.
Physical Findings
Extent and pattern of physical findings are Nonpharmacologic Interventions
variable. • Weight-reduction strategies if client is obese
• Difficulty with mobility may be present if spine, • Daily exercise program (walking is best)
hips or knees are affected • Range-of-motion exercises and muscle-
• Joints may appear enlarged and deformed strengthening exercises
• Range of motion limited according to extent of • Alternating application of heat and cold to
joint involvement reduce joint pain

Client Education Monitoring and Follow-Up

• Discourage bed rest or inactivity, as this will Follow up every 6-12 months. Clients receiving
cause further loss of function and increase daily doses of acetaminophen, ASA or other
immobility NSAIDs should undergo regular monitoring as
• Explain prognosis, process and expected course follows: complete blood count, creatinine level,
of the disease electrolyte level, liver function tests (LFTs) and
• Counsel client about appropriate use of stool examination (for occult blood).
medications (dose, frequency, side effects)
Referral
Pharmacologic Interventions Refer to a physician if symptoms are not
acetaminophen (A class drug), 500 mg, 1-2 tabs controlled with conservative treatment. Arrange
PO q4h prn for physiotherapy (if readily available).
If there is insufficient pain control, add low-dose

NSAID, if not contraindicated (e.g. heart failure,
hypertension, renal failure, peptic ulcer):
ibuprofen (A class drug), 200 mg, 1-2 tabs PO qid
prn
or
naproxen (C class drug), 250 mg bid prn

Rheumatoid Arthritis
Definition • Affected joints swollen (bilateral symmetric
A chronic systemic inflammatory disease that joint involvement common)
affects primarily the peripheral joints. Certain • Affected joints may be reddened
extra-articular manifestations are common, • Affected joints are warm and tender
including rheumatoid nodules, arteritis, peripheral • Range of motion reduced
neuropathy, keratoconjunctivitis, pericarditis and
splenomegaly. Chronic Progressive Disease
• Affected joints are enlarged
Causes • Joints become deformed: PIP joints take on
• Largely unknown fusiform shape; flexion contractures may occur
• Autoimmune disorder (e.g. Swan neck deformity); ulnar deviation of
• Viral infection MCP joints; deviation of wrists
• Subcutaneous rheumatoid nodules may be
Risk Factors present
• Usually occurs in women 30-60 years of age • Progressive weight loss may occur
• Family history
• Native ancestry Differential Diagnosis
• Degenerative osteoarthritis with inflammation
History • Septic arthritis
• Recent systemic illness or trauma may have • Polymyalgia rheumatica
occurred • Systemic lupus erythematosus
• Onset of symptoms generally insidious • Gout
• Hands, wrists, elbows, shoulders, ankles and feet • Psoriatic arthritis
are the joints most commonly affected; joints • Gonococcal arthritis
exhibit pain, swelling, stiffness, warmth, redness • Reiter's syndrome (in men)
• Pain and stiffness exacerbated by prolonged rest • Lyme disease
or strenuous activity • Polymyositis
• Joint stiffness for at least 1 hour upon rising in • Inflammatory bowel disease
morning, over a period of more than 6 weeks (e.g. Crohn's disease, ulcerative colitis)
• Fatigue, general malaise, anorexia and weight
loss present during acute exacerbations Complications
• Iritis • Chronic pain
• Progressive joint destruction
As disease progresses:
• Loss of mobility
• Morning and resting stiffness lasts for longer
periods of time (this increase over time is a good
• Anemia of chronic disease
indicator of disease progression) • Pulmonary and renal involvement
• Disease progresses to involve multiple other • Dermatitis
joints • Pericarditis
• Progressive joint destruction, deformity
Diagnostic Tests
Physical Findings Before medications are started, clients should
undergo some basic laboratory tests: complete
Acute Exacerbation
blood count, ESR, rheumatoid factor, anti-nuclear
• Client in moderate distress
antibody (ANA), creatinine and electrolyte levels,
• Temperature may be elevated LFTs. Urinalysis should also be performed before
• Heart rate may be elevated drug treatment starts.

Management • Assess family support systems and encourage

Goals of Treatment family members to become active in client's
• Control pain treatment program
• Reduce inflammation • Advise client to return to clinic if acute episode
• Preserve joint function occurs
• Prevent long-term disability
Appropriate Consultation Anti-inflammatory analgesics:
Consult physician for: ibuprofen (A class drug), 400 mg, PO tid
• Previously undiagnosed clients or
naproxen (C class drug), 250 mg, PO bid
• Clients whose disease is not controlled by
current therapy
• Clients whose disease is progressive
Acute Episode
• Clients in whom a complication is developing
• Follow up in 48-72 hours to assess response to
therapy
Client Education
• Adequate rest and nutrition Long-Term Surveillance
• Rest for affected joints • Follow up regularly as dictated by stage of
• Splint affected joint during acute phase prn disease
• Ice packs prn to reduce pain and swelling of • Assess weight, appetite, energy level, sense of
affected joints well-being
• Adequate, balanced, nutritious diet • Monitor symptoms for progression of disease
• Exercise program to maintain joint mobility and • Determine efficacy of therapy
muscle strength
• Encourage joint mobility through exercise
• Maintenance of ideal body weight program
• Explain process, course and prognosis of the • Identify acute exacerbations
disease
• Counsel client about appropriate use of Referral
medications (dose, frequency, side effects, Refer clients with persistent joint inflammation
compliance) (> 3 months) and any who present with severe
• Instruct client to take medications with meals to disease as soon as possible. Arrange physiotherapy
reduce gastrointestinal upset consult (if readily available).
• Stress importance of daily exercise in
maintaining function and mobility of joints

Emergencies Of The Musculoskeletal System

Note: For spine and pelvic fractures see Chapter 14: General Emergencies and Major Trauma
Limb Fractures
Definition • Radial fracture (wrist): In adults, the most
A break in the continuity of the bone. common radial fracture is the Colles' fracture,
which is extra-articular and occurs 2.5-3 cm
Causes (1-1.2 inch) proximal to the articular surface of
• Trauma the distal radius. This fracture occurs with the
• Pathological fracture secondary to underlying hand in dorsiflexion; the distal fracture segment
disease (e.g. osteoporosis) is angulated dorsally and causes a "dinner fork"
deformity.
Types of Fractures • Metacarpal fracture: Also known as "boxer's
• Closed (simple) fracture: fracture that does not fracture," this is a fracture of the distal neck of
communicate with the external environment the fifth metacarpal and is generally the result of
punching something with a closed fist (generally
• Open (compound) fracture: fracture that
a wall or refrigerator). Tenderness is localized to
communicates with the external environment
the injured metacarpal bone.
(through laceration of skin)
• Finger fracture: There are three types of finger
• Comminuted fracture: fracture involving three
fractures. (1) Distal tip fractures are usually
or more fragments
crush injuries to the tip of the finger. (2) Middle
• Avulsion fracture: fracture in which fragment of and proximal phalangeal fractures should be
bone is pulled from its normal position by examined for evidence of angulation (by x-ray)
muscular contraction or resistance of a ligament or rotation (by clinical examination), each of
• Greenstick fracture: incomplete angulated which requires reduction. (3) Small (< 25%)
fracture of a long bone, seen most often in avulsion fractures of the middle phalangeal base
children occur with a hyperextension injury.
• Undisplaced fracture: fractured bone stays in • Pelvic fracture: Often associated with major
alignment trauma and can lead to significant blood loss.
• Displaced fracture: fractured bone goes out of See "Pelvic Fracture," in chapter 14, "General
alignment Emergencies and Major Trauma."
• Hip fracture: Common in elderly clients. May
History not be very painful.
• Determine exact mechanism of injury • Femur fracture: Often associated with major
• Pain trauma and can lead to significant blood loss.
• Swelling • Tibia and fibula fracture
• Loss of function • Ankle fracture
• Numbness distal to fracture site (possible)
Physical Findings
Commonly Seen Fractures • Skin lacerations with protruding bones may be
• Fracture of the clavicle: See "Clavicle present if fracture is compound
Fracture," below, this chapter. • Bruising and swelling
• Fracture of radial head (elbow): Usually caused • Range of motion decreased
by a fall onto an outstretched hand. Client is • Affected part may be pale if blood flow to the
reluctant to pronate the hand or flex the elbow area is compromised
beyond 90°.

• Limb cool, pulses absent and sensation Management

decreased if blood supply has been Most bones join in 6-8 weeks; lower-limb bones
compromised may take longer and fractures in children may take
• Check temperature of area and presence of less time.
pulses distal to site of injury
• Test sensory function (to sharp and dull stimuli) Goals of Treatment
distal to site of injury • Stabilize fracture
• Affected area extremely tender • Relieve pain
• If bones are displaced, crepitations may be felt • Prevent or manage complications
• Identify and treat associated injuries
Table 8: Volumes of blood loss associated with Appropriate Consultation

some common fractures Consult physician for all suspected or confirmed
# tibia 350 - 650 mL fractures.
# femur 800 - 1200 mL
# humerus 200 - 500 mL Do not attempt to reduce a displaced fracture.
# ribs 100 - 150 mL • Immobilize and support involved area using
# pelvis 1500 - 2000+ mL splints, a back slab cast or sling (for upper
extremities) as appropriate
• For client with displaced fracture, give nothing
Differential Diagnosis by mouth because surgery may be needed
• Severe sprain
• Severe contusion Client Education
• Dislocation • Counsel client about appropriate use of
medications (dose and frequency)
Complications • Advise client to keep limb elevated as much as
• Hemorrhage possible during the first several days to reduce
• Damage to arteries, neurovascular bundle and swelling
surrounding soft tissues • Instruct the client about cast care: keep cast dry,
• Wound infection avoid poking objects down the cast, as this may
• Fat embolism result in damage to the skin
• Adult respiratory distress syndrome • Advise client to return to the clinic if pain
• Chest infection increases, if numbness or tingling develops, if
the limb becomes cool or if colour changes are
• Disseminated intravascular coagulopathy
noted in the distal limb
• Exacerbation of general illness
• Teach client how to care for limb after removal
• Compartment syndrome may result from casting of cast: skin should be kept clean and well
• Deformity hydrated with oil or petroleum jelly to prevent
• Osteoarthritis of adjacent or distant joints drying, cracking and infection; range-of-motion
• Aseptic necrosis exercises should be done to regain joint mobility
• Traumatic chondromalacia
• Reflex sympathetic dystrophy Adjuvant Therapy
If hypotension is present in a client with a major
Diagnostic Tests fracture (e.g. femur, pelvis, hip), treat for shock:
X-ray • Oxygen to keep oxygen saturation > 97%
• Start two large-bore IVs with normal saline or
Ringer's lactate

For management of hypovolemic shock, see traction, with local pressure over the prominent
"Shock," in chapter 14, "General Emergencies and proximal end of the distal metacarpal fracture.
Major Trauma" Follow-up x-ray within 7 days is necessary. If any
instability is noted after reduction or the fracture is
Pharmacologic Interventions comminuted, the client should be referred to an
Analgesia for pain as ordered by physician orthopedist for open reduction and internal
fixation.
Referral
Medevac to hospital. Distal Tip Fracture
Protective splinting of the tip for several weeks is
Management Of Specific Fractures Of usually satisfactory.
The Upper Extremity
Fracture of Radial Head Middle and Proximal Phalangeal
Management of undisplaced fracture includes a Fracture
sling and posterior elbow splint for 1-2 weeks with Nondisplaced extra-articular fractures can be
range-of-motion exercises initiated after 1 week. managed by 1-2 weeks of immobilization followed
Continue in sling for another week and do follow- by dynamic splinting with "buddy taping" to the
up x-ray to document that no displacement has adjacent finger.
occurred with mobilization.
Large intra-articular or displaced fractures are
Displaced fractures of the radial head should be usually unstable and require orthopedic referral.
referred to an orthopedist for operative repair.
Small (< 25%) Avulsion Fracture of
Radial Fracture Middle Phalangeal Base
Reduction by traction and manipulation is These injuries are managed by 2-3 weeks of
performed. After the fracture is reduced, a plaster immobilization with up to 15° of flexion at the PIP
short-arm cast is applied for 5-8 weeks. If the joint, followed by "buddy taping" for 3-6 weeks.
fracture is undisplaced, casting for 6 weeks
without reduction is indicated. Monitoring and Follow-Up
• Monitor vital signs, and watch for tachycardia
Metacarpal Fracture and hypotension; shock may occur with major
Undisplaced fractures of the base of the fractures of the pelvis and femur
metacarpals are treated by immobilization in a • Monitor neurovascular status of area distal to the
short-arm cast. Displaced fractures are reduced by fracture site

Clavicular Fracture
Definition • Rib pneumothorax (tension and traumatic)
Break in the continuity of the clavicle. • Rotator cuff injury
• Sternoclavicular joint injury
Eighty percent of clavicle fractures occur in the
middle third of the bone (class A), 15% involve Complications
the distal or lateral third (class B), and 5% involve • Brachial plexus compression may result from
the proximal or medial third (class C). hypertrophic callus formation and may cause
peripheral neuropathy
Class B fractures are further classified as: • Delayed union or non-union (especially with
• Type 1 (non-displaced): the supporting distal-third fractures)
ligaments remain intact and there is no • Poor cosmetic appearance
significant displacement of the fracture
• Post-traumatic arthritis
fragments
• Intrathoracic injury (as with fracture of the first
• Type 2 (displaced): the coracoclavicular rib, great force is necessary to cause proximal-
ligament ruptures, with resultant upward
third clavicle fractures, and it is imperative to
displacement of the proximal segment because
rule out underlying injuries)
of the sternocleidomastoid muscle
• Pneumothorax
• Type 3 (articular surface): fracture involves the
acromioclavicular joint
• Subclavian artery and vein injury
• Internal jugular vein injury
Causes • Axillary artery injury
• Fall onto shoulder or outstretched upper
extremity Diagnostic Tests
• Direct trauma to clavicle area • Routine clavicle x-ray (the fracture is usually
seen with an AP view)
History • Chest x-ray, if pneumothorax suspected
• Fall onto outstretched upper extremity, fall onto
the shoulder or direct clavicular trauma Management
• Pain (moderate to severe), especially with Goals of Treatment
movement of the upper extremity • Identify and treat associated life threatening
injuries
Physical Findings • Stabilize fracture site
• Tenderness • Relieve pain
• Swelling over fracture site • Identify and manage complications
• Deformity
• Ecchymosis, especially when severe
displacement causes tenting of skin • Employ the ABC approach (airway, breathing
and circulation) to evaluation and stabilization
• Bleeding due to open fracture (rare)
• Perform a careful secondary survey
• Non-use of arm on affected side
• Apply a cold pack to site of injury
Distal neurovascular examination and lung • Immobilize the upper extremity with a sling
auscultation (to clinically exclude pneumothorax)
must be performed. Class A (Middle-Third Fractures)
• Treat with sling immobilization (some prefer a
Differential Diagnosis figure-of-eight clavicular splint, especially for
• Dislocation displaced fractures)
• Shoulder fracture

Class B (Distal-Third Fractures) alignment; may be combined with a sling for

• Type 1 (non-displaced) and type 3 (articular added comfort
surface) fractures of the distal clavicle are • Counsel client about injury prevention: adequate
treated with sling immobilization protective gear for participation in certain sports,
• Type 2 (displaced) fractures should be use of seatbelts, drug and alcohol counseling (as
immobilized in a sling and swath and may needed), early physical therapy (e.g. range-of-
require orthopedic surgical fixation motion exercises) if indicated
Class C (Proximal-Third Fractures) Pharmacologic Interventions

• Treat non-displaced fractures with sling Control discomfort with NSAIDs. If pain
immobilization continues, add a narcotic analgesic:
• Displaced fractures may require orthopedic ibuprofen (A class drug), 400 mg PO tid, prn for
referral for surgical reduction 1-2 weeks
Client Education If pain is not controlled, add:

• Client should use a sling or shoulder acetaminophen with codeine 30mg (C class drug),
immobilizer 1-2 tabs PO q4h prn (maximum 15 tabs)
• Alternatively, client may use a figure-of-eight
bandage (clavicle strap); educate clients as to Monitoring and Follow-Up
proper placement and adjustment techniques; • Reassess injuries in 48 hours, then follow up
paresthesias or edema in the hands or fingers weekly until full shoulder mobility has returned
indicate that the strap is too tight and should be
removed; purpose of this bandage is to reduce Referral
pain by decreasing movement of the fracture • Medevac clients with open fractures
fragments, not necessarily to maintain perfect • Refer other clients if not improving

Septic Arthritis
Definition • Heart rate elevated
Bacterial infection of a joint. • Client appears ill and in acute distress
• Joint red
Causes • Joint swelling may be present
Common pathogens include Neisseria gonorrheae, • Range of motion severely limited
Staphylococcus aureus, Streptococcus • Client actively resists any movement of joint
pneumoniae, Mycobacterium tuberculosis, • Hemorrhagic skin lesions may be present
gram-negative bacilli and occasionally • Joint warmth may be present
Haemophilus; infection with viral and fungal • Joint tender
agents is rare but may occur in
• Regional lymphatic nodes enlarged and tender
immunocompromised clients.

• Trauma • Localized synovitis due to trauma
• Recent joint surgery • Bursitis
• Prosthetic joint • Cellulitis
• Contiguous spread from osteomyelitis • Rheumatic fever arthritis
• Extension of cellulitis • Active rheumatoid arthritis
• Hematogenous spread of bacteria • Active gout or pseudogout
• Pre-existing joint disease (e.g. rheumatoid • Reiter's syndrome
arthritis) • Psoriatic arthritis
• Injection drug use • Lyme disease arthritis
• Prior use of antibiotics, corticosteroids or
immunosuppressants Complications
• Serious chronic illness (e.g. diabetes mellitus, • Sepsis
liver disease, malignant disease) • Septic shock
• Primary immunodeficiency (e.g. HIV) • Osteomyelitis
• Joint destruction
History • Loss of limb
• Presence of one of the above risk factors
• Fever and chills Diagnostic Tests
• Sudden onset of acute monoarticular joint pain None.
• Heat
• Redness Management
• Swelling Goals of Treatment
• Large joint usually involved • Relieve pain and inflammation
• Client unable to bear weight on affected limb, • Prevent complications
unable to move joint
• Recent history of urethritis, salpingitis or Appropriate Consultation
hemorrhagic skin lesions (indicating gonococcal Consult a physician immediately.
infection) may be present
Physical Findings • Bed rest
The classic signs of acute inflammation may be • Splint limb, using pillows or a back slab, to
absent in elderly clients, chronically debilitated protect involved area from injury
people or clients receiving steroid therapy.
• Temperature elevated

Adjuvant Therapy Consider starting IV antibiotics in consultation

Start IV therapy to keep vein open. with physician if transfer to hospital will be
delayed more than an hour or two.
Analgesic or antipyretics for pain and fever: Monitoring and Follow-Up
acetaminophen (A class drug), 500 mg, 1-2 tabs Monitor vital signs frequently.
PO q4h prn
Referral

Osteomyelitis
Infection of the bone. • Infectious arthritis
• Active rheumatoid arthritis
Causes • Cellulitis
Bacterial infection (common pathogens are
Staphylococcus aureus, Streptococcus). Complications
• Chronic osteomyelitis
Risk Factors • Chronic bone pain
• Extension of existing soft-tissue infection • Loss of limb
• Trauma • Subcutaneous abscess
• Direct introduction of organism into the bone
• Hematogenous spread of pre-existing infection Diagnostic Tests
None.
People with diabetes, peripheral vascular disease
with chronic skin breakdown, and chronic skin
Management
infection are particularly prone to osteomyelitis.
Goals of Treatment
• Relieve infection
History
• Presence of one of the above risk factors
• Mild-to-moderate fever may be present Appropriate Consultation
• Infection of overlying skin and subcutaneous Consult a physician immediately.
tissues may be present
• Localized pain, increased by weight bearing or Nonpharmacologic Interventions
movement • Bed rest
• Heat, redness and swelling of affected area • Elevate and splint affected area
• Sinus may be draining
Adjuvant Therapy
Blood-Borne Osteomyelitis Start IV therapy with normal saline to keep vein
• Original site of infection frequently not apparent open.
• Most commonly occurs in vertebrae
• Presents as persistent back pain with minimal or Pharmacologic Interventions
absent fever Antipyretic or analgesic for pain and fever:
• May present as acute back pain with high fever, acetaminophen (A class drug), 500 mg, 1-2 tabs
paravertebral muscle spasm and guarding of PO q4h prn
movements (mimicking pyelonephritis)
Consult physician for choice of IV antibiotics
Physical Findings
• Temperature may be elevated Referral
• Heart rate moderately elevated Medevac as soon as possible.
• Client in moderate distress
• Distress with weight-bearing
• Involved area swollen, overlying skin red
• Range of motion reduced if adjacent joint is
involved
• Purulent drainage from sinus may be present
• Area warm and tender to touch

Chapter 8- The Central Nervous System

Assessment Of The Central Nervous System.................................................................................................. 1
Examination Of The Central Nervous System................................................................................................ 3
Common Problems Of The Central Nervous System .................................................................................... 5

Bell's Palsy...................................................................................................................................................... 5
Headaches ....................................................................................................................................................... 7
Muscle Tension Headache .............................................................................................................................. 8
Cluster Headache .......................................................................................................................................... 10
Migraine Headaches ..................................................................................................................................... 12
Temporal Arteritis (Giant Cell) .................................................................................................................... 15
Transient Ischemic Attack (TIA) .................................................................................................................. 16
Emergency Problems Of The Central Nervous System............................................................................... 18

Differential Diagnosis Of Acute Unconsciousness....................................................................................... 18
Meningitis ..................................................................................................................................................... 19
Seizure Disorder (Chronic) ........................................................................................................................... 21
Epilepticus (Acute Grand Mal Seizure)........................................................................................................ 23
Cerebrovascular Accident (Stroke)............................................................................................................... 24

Assessment Of The Central Nervous System

General • Precipitating factors, aggravating factors
The following characteristics of each symptom • Associated symptoms: nausea, vomiting, visual
should be elicited and explored: or sensory disturbances
• Onset (sudden or gradual) • Interference with daily activities
• Chronology
• Current situation (improving or deteriorating) Changes in Level of Consciousness
• Location • Dizziness
• Radiation • Fainting
• Quality • Convulsions
• Timing (frequency, duration) • History of head injury that produced any loss of
• Severity consciousness
• Precipitating and aggravating factors
• Relieving factors Motor Function
• Associated symptoms • Muscle weakness, paralysis, stiffness, spasm
• Effects on daily activities • Clumsiness, ataxia
• Previous diagnosis of similar episodes • Staggering gait with wide-base stance
• Previous treatments • Tremor
• Efficacy of previous treatments
Sensory Function
Cardinal Symptoms • Loss of or decrease in sensation
In addition to the general characteristics outlined • Sensation of "pins and needles," tingling
above, additional characteristics of specific • Burning sensation
Other Associated Symptoms
General Cerebral Function • Bowel or bladder dysfunction
• Changes in memory, especially recent • Impotence
• Changes in concentration • Pain
• Changes in mood
Medical History (Specific To Central
Cranial Nerve Function Nervous System)
• Changes in vision, drooping eyelids • Seizures
• Facial weakness • Head trauma
• Disturbance of speech production • Metabolic disorders (e.g. diabetes mellitus,
• Hearing loss, unusual noise in ears, difficulties thyroid problems)
with balance • Cardiac disorders (e.g. hypertension, heart
• Impairment of sense of smell or taste block)
• Transient ischemic attack
Headaches • Demyelinating disorders (e.g. multiple sclerosis,
• Onset, age at onset Parkinson's disease)
• Pattern, any changes in pattern, how it • Alcoholism
progresses • Migraine headaches
• Location, description, whether pulsating, degree • Psychiatric disorders (e.g. depression, bipolar
of pain disorder)
• Time of day, duration, frequency • Bell's palsy

Family History (Specific To Central Personal And Social History (Specific

Nervous System) To Central Nervous System)
• Seizures • Alcoholism and/or drug abuse
• Metabolic disorders (e.g. diabetes mellitus) • Occupational exposure to neurotoxins
• Cardiac disorders (e.g. hypertension, myocardial
infarction, stroke)
• Demyelinating disorders (e.g. multiple sclerosis,
Parkinson's disease)
• Headaches (including types)
• Psychiatric disorders

Examination Of The Central Nervous System

General Appearance
• Apparent state of health To Be Assessed During History-Taking
• Appearance of comfort or distress • Level of consciousness
• Colour (e.g. flushed, pale, cyanotic) • Mental status
• Nutritional status (emaciated or obese) • Speech (clarity, content, volume, rate)
• Match between appearance and stated age
Cranial Nerves
Screening Examination See Table 1.
The following screening examination will reveal
areas of difficulties. If deficits are discovered, a
more in-depth examination is required.
Table 1: Screening tests for cranial nerves

Cranial Nerve Test
I Olfactory Smell (test only if there is a specific complaint)
II Optic Visual acuity, visual fields, funduscopic examination
III Oculomotor Pupillary response (direct or consensual)
IV Trochlear Extraocular eye movements
VI Abducent
V Trigeminal Motor function: clench teeth, open jaw.
Sensory function: pain (sharp stimulus); light touch (cotton wisp); sensation on
forehead, cheek, chin.
Corneal reflex (omit if client is conscious)
VII Facial Facial symmetry; raise eyebrows, frown, close eyes tightly against resistance,
show teeth, puff cheeks, smile
VIII Acoustic Hearing (watch ticking, whisper), Rinne and Weber tests
(Vestibulocochlear)
IX Glossopharyngeal Movement of palate, uvula, pharyngeal wall. Gag reflex and swallowing.
X Vagus Hoarseness
XI Spinal accessory Shoulder shrug against resistance. Head turn against resistance
XII Hypoglossal Stick out tongue, push tongue against each cheek
Motor Function, Sensory Function and

Reflexes
Assess motor function, sensory function and
reflexes together, as follows.

Table 2: Glasgow Coma Score

Glasgow Coma Score
Eye Opening (E) Verbal Response (V) Motor Response (M)

4=Spontaneous 5=Normal conversation 6=Normal
3=To voice 4=Disoriented conversation 5=Localizes to pain
2=To pain 3=Words, but not coherent 4=Withdraws to pain
1=None 2=No words...only sounds 3=Decorticate posture
1=None 2=Decerebrate
1=None
Total = E+V+M
Note that the phrase 'GCS of 11' is essentially

meaningless, and it is important to break the figure Legs
down into its components, such as E3V3M5 = • Straight-leg raising
GCS 11. • Bowstring test
• Quadriceps test
A Coma Score of 13 or higher correlates with a • Heel-to-toe walk
mild brain injury, 9 to 12 is a moderate injury and • Heel-shin test
8 or less a severe brain injury.
• Romberg test
Source: Teasdale G., Jennett B., LANCET (ii) 81- • Blunt and sharp pin prick
83, 1974. • Reflexes (Achilles' tendon, patellar, plantar)
Arms and Hands Meningeal Irritation

• Grip strength Test for meningeal irritation if indicated:
• Raise both arms and hold (assess for palmar • Neck stiffness
drift) • Brudzinski's sign
• Finger-nose test (assess for eye-hand • Kernig's sign
coordination)
• Blunt and sharp pin prick
• Reflexes (biceps, triceps, brachioradialis
[supinator])

Common Problems Of The Central Nervous System

Bell's Palsy
Sudden, painless, unilateral paralysis of facial • Stroke (brain stem)
muscles due to inflammation and swelling of the • Cerebral tumor
seventh cranial nerve (the facial nerve). The • Parotid gland tumor
condition usually resolves spontaneously. • Middle ear or mastoid infection
• Meningitis
Causes • Head or facial trauma with fracture
• Largely unknown • Lyme disease
• Possibly viral infection of facial nerve • Herpes zoster oticus
• May be related to Lyme disease and HIV • Guillain-Barré syndrome
infection • Multiple sclerosis
• Hereditary and vascular factors may be
contributory
Complications
• Corneal abrasion
Risk Factors
• Corneal ulceration
• Pregnancy (third trimester)
• Keratitis
• Positive family history
• Chronic facial weakness
• Hypertension
• Facial muscle contracture
• Diabetes mellitus
Diagnostic Tests
History
None.
• Sudden onset of unilateral facial weakness
• Progression to complete paralysis within a few
Management
hours
Goals of Treatment
• Inability to close eye on affected side
• Protect the eye from injury
• Excessive tearing of affected eye may be present
• Taste sensation may be altered
• Hypersensitivity to sound Management is directed toward the symptoms and
• Pain in or behind ear may occur on affected side depends on the time and severity of presentation.
just before onset of facial weakness
Physical Findings Consult a physician immediately. If within 72
• Client appears anxious hours of onset and the client is at high risk for
• Flat nasolabial fold denervation (e.g. full unilateral facial paralysis,
• Client unable to close eye, raise eyebrow or > 50 years of age, diabetic), drug therapy may be
smile on affected side indicated (see "Pharmacologic Interventions,"
• Widened palpebral fissure below)
• Eyeball rolls upward when client attempts to
close eyelid Nonpharmacologic Interventions
• Drooling may be present Reassure client that full recovery can be expected
• Sensation to light touch and pin prick may be in 6-8 weeks.
reduced
• Loss of forehead wrinkles

Client Education Prevention of drying of eye: eye drops

• Counsel client about appropriate use of hydroxypropyl ethyl cellulose (Isopto Tears®,
medications (dose, frequency, side effects) q1-2h during the day;
• Recommend adequate nutritional intake and lubricant ophthalmic eye ointment (Lacri-Lube®)
suggest that client direct food and liquids to and eye patch hs
unaffected side of mouth to prevent drooling and
to promote proper mastication Monitoring and Follow-Up
• Recommend adequate oral hygiene after meals • Arrange daily follow-up for several days
to prevent collection of food and liquids within • Assess progression of palsy
affected cheek • Monitor for symptoms of corneal abrasion: stain
• Suggest protection of affected eye to prevent corneal surface with fluorescein prn and
corneal abrasions (e.g. wearing sunglasses examine to identify development of corneal
during the day to prevent dust particles from abrasion; if corneal abrasion suspected or
entering eye, taping the eye closed at night) detected, see "Corneal Abrasion" in chapter 1,
• Recommend facial exercises and massage, to be "The Eyes"
performed 2 or 3 times daily to prevent muscle
atrophy (wrinkle forehead, blow out cheeks, Referral
purse lips, close eyes) Refer to a physician for initial management if
complications are suspected or detected or if
Pharmacologic Interventions condition does not resolve.
Antiviral or anti-inflammatory drugs as prescribed
by the physician.

Headaches
General • Temporomandibular joint syndrome
Most headaches (90%) are benign. • Closed-angle glaucoma
There is a wide variety of causes of headaches, • Trigeminal neuralgia
ranging from abnormalities of the head and neck • Herpes zoster infection
to systemic illness. Other causes include use or • Retro-orbital disease process
abuse of drugs, alcohol or chemicals.
Metabolic Causes
Differential Diagnosis Of Headache • Food additives or toxins (e.g. nitrites,
Primary monosodium glutamate, alcohol)
• Migraine • Side effect of medication (e.g. nitrates, oral
• Tension (muscle contracture) contraceptives, calcium-channel blockers)
• Cluster • Related to fever
• Other • Related to hypercapnia (increased carbon
o Cold stimulus (e.g. ice cream) dioxide levels)
o Benign
o Post-traumatic Vascular Causes
• Hypertension
Secondary • Vasculitis
Disorders of the Cerebral Parenchyma • Embolic or thrombotic events
• Brain tumor
• Brain abscess Features Suggestive Of A Serious
• Intracranial hemorrhage Cause Of Headache
• Cerebral trauma • Advanced age
• Hydrocephalus • Worst headache ever experienced
• Hypertension • Onset with exertion
• Decreased alertness or cognition
Disorders Involving the Meninges • Radiation of pain between the shoulder blades
• Meningitis (which suggests spinal arachnoid irritation)
• Subarachnoid bleeding • Association with nuchal rigidity
• Any history or physical finding suggestive of
Disorders Involving the Extracranial infection (e.g. fever)
Structures • Headache worsening under observation
• Dental abscess
• Paranasal sinusitis

Muscle Tension Headache

Definition • Dull, tight sensation
Diffuse pain in the head. • Occasionally throbbing
• Present on rising in the morning
Episodic: usually associated with some stressful • Wax and wane during the day
event, of moderate intensity, self-limited and • Prevent client from falling asleep, but never
responds to nonprescription preparations awaken client from sleep
• Medication affords only minimal or no relief
Chronic: often occurs daily (must be present for
at least 15 days per month for 6 months to be
Associated Symptoms
considered chronic); pain often bilateral, usually
occipito-frontal and associated with contraction
• Nausea
of muscles of the neck and scalp • Anorexia
• Fatigue
Causes • Concentration impaired
• Stress or anxiety
• Poor posture Physical Findings
• Cervical osteoarthritis • Client in no distress, although may complain of
headache at time of presentation
• Intramuscular vasoconstriction of scalp muscles
• Depression (found in 70% of those with daily • Results of neurologic examination completely
normal
headache)
• Life-time prevalence: 88% in females, 69% in • Muscular tightness in the neck, upper trapezius,
occipital and frontal scalp muscles
males, common in children 8-12 years of age

• Excess caffeine intake Although most chronic headaches are benign, it is
important to rule out other more serious problems:
• Medications (e.g. long-term use of
acetaminophen) • Caffeine dependency
• Obstructive sleep apnea • Nonprescription drug dependency (e.g.
acetaminophen with or without codeine)
• Family history
• Dental disease including temporomandibular
joint dysfunction
History
• Post-traumatic headache
• History vague
• Depression
• No obvious relieving or precipitating factors
identified • Chronic sinusitis
• Document medication use: type, frequency,
• Temporal arteritis
amount, effect • Migraine headache
• Often associated with abuse or overuse of • Eye problem
medications, especially analgesics • Middle ear disease
• 40% of patients have positive family history • Hypertension
• 60% of patients > 20 years of age at onset • Intracranial infection (meningitis)
• Pain becomes more constant and severe over
time Complications
• Stressful events aggravate symptoms • Dependence on analgesic medication
• Depression
Features Of Headaches
• Generalized Diagnostic Tests
• Constant None.

Management Client Education

Goals of Treatment • Counsel client about appropriate use of
• Identify symptoms suggestive of serious medications (dose, frequency, avoidance of
pathology overuse)
• Relieve symptoms • Suggest stress-management strategies (e.g.
relaxation techniques)
Consult physician if symptoms suggest serious Pharmacologic Interventions
pathology (e.g. neurologic deficit). Otherwise, Analgesics:
treat conservatively and follow. acetaminophen (A class drug), 500 mg, 1-2 tabs
PO q4h prn
Nonpharmacologic Interventions or
• Provide supportive environment ibuprofen (A class drug), 200 mg, 1-2 tabs PO
• It is important for success of therapy that q4h prn
caregiver be nonjudgmental
• Explore current life situation: encourage client Monitoring and Follow-Up
to talk about worries, concerns, fears Follow up in 1-2 weeks to assess response to
interventions.
• Discover areas of difficulty that could contribute
to headaches
• Evaluate stress level
Referral
Refer to a physician if there is failure to respond to
• Ice packs may help therapy or if there is concern about an underlying
• Massage therapy may help disorder, or if recurrent.
• Rest in dark, quiet room may help
• Recommend decrease in use of caffeinated
products

Cluster Headache
Definition During Attacks
Recurrent attacks of severe unilateral headaches • Acute distress
around the eye and temple. Attacks last • Pale
approximately 30-120 minutes and occur one to • Diaphoretic
three times per day, at the same time of day, for up • Restless
to 12 weeks; this pattern is typically followed by • Ipsilateral nasal rhinorrhea
1-24 months without an attack. • Ptosis of affected eyelid
• Conjunctival redness and excessive tearing of
Causes affected eye
Unknown. • Occasionally vomiting
Risk factors Between Attacks
• Male > 30 years of age • Client feels well (i.e. completely asymptomatic)
• Possible relationship to previous head injury • Results of neurologic examination normal
• May be triggered by alcohol, nitroglycerine,
disturbance in sleep cycle, emotion (anger),
excessive physical activity
• Temporal arteritis
• Subarachnoid hemorrhage (initial presentation)
History
• Episodic, long-lasting tension headaches
• Client usually male, older than mid-20s
• Trigeminal neuralgia
• Cyclic or seasonal pattern to attacks
• Acute glaucoma
• Sudden onset of unilateral pain
• Sinusitis
• Headache usually begins without warning, often
during sleep
• Pheochromocytoma
• Begins as dull ache, which quickly increases to
severe pain Complications
• Peaks in 15 minutes • Inadequate nutrition during "cluster"
• Pain steady, boring, piercing and centered about • Depression
one eye (retro-orbital) • Potential for drug abuse (e.g. analgesics)
• No aggravating or relieving factors
• Pain extends into adjacent cheek, temple, Diagnostic Tests
forehead None.
• Usually resolves within 30-120 minutes, leaving
client fatigued Management
• Pain recurs later the same day or at same time Goals of Treatment
next day • Relieve pain
• Cycle repeats itself until "cluster" ends • Prevent recurrence
Associated Symptoms during Attack Appropriate Consultation

• Nausea Consult a physician for acute attack.
If symptoms are significant during an initial
Physical Findings attack, serious pathology must be ruled out.
• Heart rate elevated during attack
Client Education
• Bradycardia may be present in 43% of cases
• Explain expected course of disease and
prognosis and how to avoid precipitants

• Counsel client about appropriate use of Monitoring and Follow-Up

medications (dose, frequency, compliance, • Monitor medication compliance
avoidance of overuse or abuse of analgesics) • Assess effectiveness of prophylaxis
• Counsel client about appropriate use of • Assess for depression
prophylactic medication • Assess for analgesic abuse or dependence
• Recommend avoidance of alcohol, bright light,
anger, stressful activity or undue excitement Referral
during a cluster • Refer all previously undiagnosed clients as soon
• Recommend that client decrease smoking during as possible to a physician during an acute attack
a cluster, as smoking reduces response to drug • Clients with chronic recurrence of cluster
treatment headaches should be evaluated by a physician if
• Counsel client about smoking cessation symptoms are not controlled by prophylaxis
Do not give analgesics in a previously
undiagnosed client until you have consulted a
physician, as these drugs may mask the
progression of neurologic symptoms.
A physician may prescribe a trial of

dihydroergotamine (B class drug) or similar drug.

Migraine Headaches
Recurrent headaches due to vascular disturbances. During Attack
• Moderate distress
Causes • Pale
• Unknown • Diaphoretic
• Individual attacks may be triggered by specific • Scalp arteries may be distended
foods (e.g. chocolate, cheese, smoked meats, • Photophobia
alcohol, caffeine, other food additives and • Scalp tenderness
preservatives), missing meals, menstrual cycle, • Results of neurologic exam usually normal
oral contraceptives, fatigue, excessive sleep, during and between attacks
stress or relief of stress, excessive or flickering
light Criteria for Diagnosing Migraine without
Aura
Risk Factors 1. At least 5 attacks fulfilling criteria 2, 3, 4 and 5
• Female
• Young age (10-30 years) 2. Each attack, untreated or treated unsuccessfully,
• Family history of migraine lasts 72 hours
History 3. Each attack has at least 2 of the following

• Regular or near regular perimenstrual or characteristics:
periovulatory timing • Unilateral most often, but 30% to 40% have
• Abatement of headache with sleep bilateral pain
• Prodrome may be present: irritability, mood • Pulsating quality (occurring at any time during
swings, changes in energy level, food cravings, the attack); 50% of those with migraines report
fluid retention non-throbbing pain; headache quality may vary
• Aura (including visual defects and sensory over the course of the attack
losses) may be present: precedes headache, lasts • Moderate or severe intensity, enough to interfere
approximately 5-30 minutes, recedes with onset with daily activities
of headache (although sometimes aura and • Pain aggravated by physical activity such as
headache may overlap) walking up or down stairs
Pain of Headache 4. During an attack at least one of the following

• Unilateral or diffuse symptoms is present:
• Moderate to severe intensity • Nausea and vomiting
• Peaks within 1 hour • Photophobia, phonophobia and osmophobia
• Pulsating in nature (at onset or any time during
attack) 5. There is no evidence from the client's history or
• Rest in dark, quiet room helps physical examination of any other disease that
• Bending forward or moving head increases pain might cause headaches
Associated Symptoms Criteria for Diagnosing Migraine with

• Photophobia (aversion to light) Aura
The criteria are the same as for migraine without
• Phonophobia (aversion to noise)
aura, but also include symptoms of neurologic
• Osmophobia (aversion to odors) dysfunction (including visual disturbances) before
• Nausea and vomiting or during attack.
• Diarrhea, constipation
• Chills, tremor, sweating

Differential Diagnosis Client Education

• Disorders or infections of head and neck • Explain expected disease course and prognosis
• Systemic illness • Counsel client about appropriate use of
• Toxic effects of drugs, alcohol, chemicals medications (dose, frequency, avoidance of
• Intracranial lesion overuse or abuse)
• Stroke • Recommend regular rest and activities,
• Drug-seeking behavior appropriate diet
• Attention-seeking behaviour • Help client to identify trigger factors and then to
attempt to reduce or eliminate them
(e.g. caffeine, alcohol, certain foods, oral
Complications
contraceptives, nuts, cheese)
• Family and marital dysfunction if headaches
• Prophylactic medications are ineffective if the
frequent
person is concurrently taking analgesics on a
• Depression regular basis. Instruct client not to take headache
• Drug addiction (e.g. to prescription analgesics) medications other than those prescribed.
• The client should be prepared to experience
Diagnostic Tests some side effects, to take the medication daily
None. and to recognize that the drug therapy will need
to be adjusted or changed until efficacious
Management drug(s) and doses are identified.
Goals of Treatment • The client should also expect to have some
• Identify and modify trigger factors migraine attacks, although these will probably
• Relieve symptoms be less severe or less frequent than before.
• Prevent recurrences • Explain that prophylaxis is designed to be used
for a number of months and then weaned. Some
Appropriate Consultation clients may need long-term therapy.
Consult physician if an acute attack is moderate to • Instruct any female client to report if she
severe and is unresponsive to first-line drug becomes pregnant or is contemplating
therapy, or if attacks recur and are not controlled pregnancy, as some prophylactic drug therapies
with current prophylactic regimen. will have to be stopped.
Severe Attack Adjuvant Therapy

Consult physician for medication orders. Severe Attack
For severe attack only, start IV therapy with
Nonpharmacologic Interventions normal saline; adjust rate according to state of
Mild or Moderate Attack hydration.
• Rest in dark, quiet room
• Ice packs Pharmacologic Interventions
• Pressure massage of the scalp Symptomatic Therapy, Mild or Moderate
• Relaxation therapy Attack
• Cognitive-behavioral therapy (e.g. stress Analgesia:
management training) enteric-coated acetylsalicylic acid (ASA)
(A class drug), 325 mg, 1-2 tabs PO q4h prn
Severe Attack or
• Bed rest in dark, quiet room ibuprofen (A class drug), 200 mg, 1-2 tabs PO
• Nothing by mouth temporarily if vomiting is q4h prn
significant or
*acetaminophen with codeine 30mg
(C class drug), 1-2 tabs PO q4h prn

*Combination medications can be used if clients Monitoring and Follow-Up

do not respond to initial therapy with non-steroidal Mild or Moderate Attack
anti-inflammatory drugs (NSAIDs). They are to be Encourage regular follow-up until headaches are
used for short periods only. Overuse of such effectively controlled; frequency of follow-up
combination medications is one of the most should be individualized to each person's unique
prominent causes of rebound headache (a leading circumstances.
form of chronic daily headaches).
Severe Attack
Antiemetics for vomiting if necessary: Monitor response to therapy and vital signs.
dimenhydrinate (A class drug), 50 mg PO q4-6h
prn Referral
Mild or Moderate Attack
If headache does not resolve refer to physician for • Arrange follow-up with physician to discuss
prescription for pain control. prophylactic therapy if headaches are frequent or
severe enough to interfere with daily activities
Avoid use of meperidine, if at all possible. This • Referral for a neurologic examination may be
drug should be used as a last resort only. needed if optimum first-line therapy and
prophylaxis fail to control attacks
Prophylactic Therapy
As ordered by physician Severe Attack
Medevac may be required if attack is prolonged
and unresponsive to therapy (a condition known as
status migrainous).

Temporal Arteritis (Giant Cell)

Definition • Temporal artery may be firm, nodular, non-
Inflammation of temporal arteries. compressible, tender
• Temporal artery may be pulseless
Causes
• Largely unknown Differential Diagnosis
• Possibly autoimmune reaction • Other disorders of head and neck
• Systemic illness
History
• Age > 50 years Complications
• Client may initially complain of flu-like • Blindness on affected side
symptoms • Progression to blindness of other eye
• Headache unilateral or bilateral • Stroke
• Headache located in temporal or periorbital area • Coronary occlusion
• Onset gradual or sudden • Arterial insufficiency of upper extremities
• Pain slight and transient initially
• Pain becomes more severe (throbbing or boring) Diagnostic Tests
and constant over several days • Determine erythrocyte sedimentation rate (if test
• Not relieved by over-the-counter medications available) (will be elevated)
Associated Symptoms Management

• Malaise Goals of Treatment
• Night sweats • Diagnose the problem
• Fever • Prevent complications
• Shoulder and back pain
• Reduced vision of eye on affected side Appropriate Consultation
Consult a physician immediately if this diagnosis
Physical Findings is suspected.
• Temperature may be mildly elevated
• Client appears mildly-to-moderately ill Pharmacologic Interventions
• Visual acuity may be reduced on affected side Oral prednisone may be initiated by the physician
• Problem with visual acuity may progress to if transfer to hospital will be delayed.
other eye
• Range of motion of shoulder(s) may be reduced; Referral
shoulder movement may be painful Arrange transfer to hospital for further
investigation (e.g. CT scan) and treatment as soon
• Shoulder joint may be tender
as possible (biopsy of temporal artery is needed to
confirm diagnosis).

Transient Ischemic Attack (TIA)

Acute episode of temporary, focal loss of cerebral Because TIA may be brief, the results of a
function that is vascular in origin. Onset is rapid, physical examination may be entirely normal.
and symptoms are of variable duration, typically Careful examination of the neurologic and
lasting 2-15 minutes but rarely as long as 24 hours. cardiovascular systems is required. Look for
Most TIAs last less than 1 hour. evidence of atherosclerosis (e.g. peripheral
vascular disease, heart disease).
TIA is an important omen of impending stroke;
one-third of all patients with TIA have a stroke • Blood pressure and heart rate often normal
within 5 years of the first event. • Pulse may be irregular (because of underlying
atrial fibrillation)
Causes • Hypertension may be present
• Temporary reduction or cessation of cerebral • Client usually looks well
blood flow • Muscular weakness of affected side may be
• Underlying problem: atherosclerosis of carotid obvious or subtle
or vertebrobasilar arteries • Visual acuity may be reduced
• Balance may be slightly affected
Risk Factors • Confusion may be evident
• Advancing age • Look for old surgical scars from previous heart
• Hypertension surgery
• Diabetes mellitus • Carotid artery thrill may be present
• Heart disease • Focal sensory deficits
• Cardiac arrhythmias (atrial fibrillation) • Focal motor deficits
• Smoking • Deep tendon reflexes may be increased or
• Family history decreased for first 24 hours after attack
• Carotid bruit(s) may be present
History • Other peripheral arterial bruits may be present
• Usually one of above risk factors is present (e.g. aortic, iliac)
• Attacks may occur several times a day or once • Heart murmur may be present
or twice a year
• Symptoms generally similar for repeat attacks Differential Diagnosis
• Identify previous symptoms of peripheral Differential diagnosis includes anything that can
vascular disease, coronary artery disease cause decreased cerebral blood flow with cerebral
• Symptoms acute at onset ischemia or transient impairment of cerebral
• Symptoms resolve completely in 24 hours function.
• Client remains conscious throughout attack
• Symptoms depend on affected blood vessel • Hypotensive episode
• Carotid artery: unilateral symptoms, ipsilateral • Bell's palsy
blindness, contralateral weakness or paresthesia, • Dissecting aortic aneurysm
aphasia, headache (may follow attack) • Heart disease
• Vertebrobasilar arteries: confusion, vertigo, • Focal seizure
binocular blindness or diplopia, weakness or • Cerebrovascular accident
paresthesia of extremities, drop attacks in which • Hypoglycemia
client remains conscious but suddenly collapses • Anemia
• Slurred speech may be present

Complications • Recommend that clients receiving anticoagulant

• Future cerebrovascular accident or myocardial therapy avoid foods high in vitamin K (e.g.
infarction. yellow and green vegetables)
• Injury • For clients receiving anticoagulant therapy,
stress importance of avoiding injury
Diagnostic Tests • Offer lifestyle counseling on ways to reduce risk
• Electrocardiography may be helpful factors such as control of hypertension, smoking
• Look for evidence of atrial fibrillation cessation, weight reduction, reduction of dietary
fat, regular exercise
• Bloodwork (CBC, electrolytes)
Management ASA therapy (for antiplatelet effects) as per
Goals of Treatment physician order.
• Modify risk factors
• Prevent future TIA or stroke Monitoring and Follow-Up
Follow up regularly to monitor symptoms and
Appropriate Consultation track progress in reducing risk factors; frequency
Consult a physician as soon as possible. of follow-up will depend on severity of symptoms
and number of risk factors.
Client Education
• Explain disease course and expected outcome Referral
• Counsel client about appropriate use of • Manage as a stroke in progress (see
medications (dose, frequency, total amount, "Cerebrovascular Accident (Stroke)," in next
long-term use, side effects, precautions if also section, "Emergency Problems of the Central
receiving anticoagulant therapy) Nervous System").
• Medevac to hospital as soon as possible
• For investigation of underlying pathology

Emergency Problems Of The Central Nervous System

Differential Diagnosis Of Acute Unconsciousness
Metabolic disturbances (mnemonic "AEIOU and sometimes S")
A for anoxia
E for ethanol intoxication
I for insulin excess (hypoglycemia)
O for overdoses (drugs)
U for uremia
S for seizure
Hypoperfusion of the brain

• Stroke
• Hypotension
• Hypovolemia
• Arrhythmias
• Head trauma
• Coma
For detailed information on coma, see "Coma (Not Yet Diagnosed)," in chapter 14, "General Emergencies
and Major Trauma"
For detailed information on head trauma, see "Head Trauma" in chapter 14, "General Emergencies and
Major Trauma".

Meningitis
Definition • Focal neurologic signs
Infection of meninges. • Photophobia
• Petechiae may be present
Causes • Cervical nodes may be enlarged
• Viral or bacterial infection • Brudzinski's sign
• Most common bacterial causes in adults: • Kernig's sign
Hemophilus influenzae, Neisseria meningitides,
Streptococcus pneumoniae Differential Diagnosis
• Bacteremia
Risk factors • Sepsis
• Alcoholism • Brain abscess
• Chronic otitis media • Seizure
• Sinusitis
• Mastoiditis Complications
• Closed head injury • Seizure
• Pneumococcal pneumonia • Coma
• Recurrent meningitis • Blindness
• Immunocompromised • Deafness
• Palsies of cranial nerves III, VI, VII, VIII
History • Death
• Usually preceded by infection of upper
respiratory tract Diagnostic Tests
• High fever • Complete blood count
• Headache, which becomes increasingly severe • Blood cultures
• Headache made worse with movement, • Urinalysis (routine and microscopy, culture and
especially bending forward sensitivity)
• Sudden vomiting, often without preceding • Throat swab for culture and sensitivity
nausea • WBC
• Photophobia • Consider ECG and chest X-ray
• Changes in level of consciousness that progress
from irritability, through confusion, drowsiness
Management
and stupor to coma
Goals of Treatment
• Seizures may develop
• Control infection
• Stiff neck and/or neck pain
Perform a full head and neck examination to
Consult a physician immediately.
identify a possible source of infection.
• Temperature elevated Nonpharmacologic Interventions
• Heart rate elevated or bradycardia with raised • Bed rest
intracranial and intraocular pressure
• Blood pressure normal (low if client is in septic
• Insert indwelling urinary catheter (optional if
shock)
client is conscious)
• Client in moderate-to-acute distress
• Client flushed
• Altered level of consciousness

Adjuvant Therapy Monitoring and Follow-Up

Start IV therapy with normal saline; adjust rate • Monitor ABC (airway, breathing, circulation)
according to state of hydration. and vital signs q30-60min or more frequently as
required
Do not overload with fluids, as this could cause • Monitor carefully for development of neurologic
brain edema. symptoms
• Monitor intake and hourly urine output
Antipyretics to control fever: Referral
acetaminophen (A class drug), 325 or 500 mg, Medevac as soon as possible.
1-2 tabs PO or PR q4h prn
IV antibiotics as ordered by physician

Seizure Disorder (Chronic)

Definition • History of stroke, head trauma, hypoxia,
Sudden, temporary brain dysfunction due to neurologic infection, exposure to toxins,
abnormal electrical activity in the brain. developmental problems
Types Physical Findings

• Generalized tonic, clonic (grand mal) After Acute Seizure
• Focal • Temperature normal unless infection is present
• Absence (petit mal) • Heart rate elevated
• Complex partial • Blood pressure variable
• Partial • Postictal state if seizure has occurred recently
• Myoclonic (e.g. drowsiness, confusion, behavioral changes)
• Infantile spasm • Evidence of trauma
• Unclassified (characterized by eye movements • Results of neurologic examination and
or chewing) examination of other systems depend on specific
• Status epilepticus cause of seizure
Causes When Not in Active Seizure State

• Epilepsy The results of neurologic examination are usually
• Drug-related causes (non-compliance with normal.
prescribed regimen, withdrawal syndromes,
overdose, multiple drug abuse) Differential Diagnosis
• Hypoxia • Epilepsy
• Brain tumor • Drug-related problem (non-compliance with
• Cerebral infection (e.g. meningitis) prescribed regimen, withdrawal syndromes,
• Metabolic disturbance (e.g. hypoglycemia, overdose, multiple drug abuse)
uremia, liver failure, electrolyte disturbance) • Hypoxia
• Alcohol withdrawal • Brain tumor
• Head injury • Cerebral infection
• Stroke • Metabolic disturbance (e.g. hypoglycemia,
uremia, liver failure, electrolyte disturbance)
History • Alcohol withdrawal
• One of causes listed above usually present • Head injury
• Family history of seizure disorder • Stroke
• Age at onset, frequency of seizure activity
• Sudden loss of consciousness or loss of motor Complications
control (or both) • Injuries during seizure (e.g. a fall)
• Description of seizure activity variable (depends • Hypoxia during seizure
on type) • Status epilepticus
• Loss of bowel and bladder control during active • Interference with normal lifestyle (e.g. work,
seizure (e.g. grand mal) driving, social interactions)
• History of aura before onset of seizure may be
present Diagnostic Tests
• Precipitating factors: alcohol use, street drug • Blood sugar, electrolytes
use, illness such as infection, poor compliance • Drug screen and levels
with seizure medications • ECG if questioning a stroke


Management depends on underlying cause and As per physician order.
severity of symptoms.
Anticonvulsants are tailored to the specific type of
Goals of Treatment seizure. Monotherapy is ideal, but 10% to 15% of
• Control seizures patients need two or more medications. Poor
• Prevent recurrence compliance is the major cause of seizure
• Achieve good adherence to treatment regimen recurrence.
over the long term
• Discontinue medications eventually with Commonly Used Anticonvulsants (B class
continued control of seizures drugs)
• carbamazepine
Appropriate Consultation • clonazepam
• If client is in active seizure on arrival, see • gabapentin
"Status Epilepticus (Acute Grand Mal Seizure)," • lamotrigine
this chapter • phenobarbital
• If client is not in active seizure on arrival: • phenytoin
consult physician immediately for any case of • primidone
previously undiagnosed seizure and for anyone • valproic acid
with history of breakthrough seizures • vigabatrin

• Assist client to identify and reduce or avoid • Follow up every 6 months if seizures are well
trigger factors, alcohol controlled, more frequently if client is having
• Alcohol withdrawal counseling and support breakthrough seizures
• Recommend regular meals and balanced • Assess adherence to medication regimen
nutrition • Monitor serum drug levels every 6 months if
• Encourage stress reduction stable, more frequently if necessary
• Recommend avoidance of fatigue
• Suggest relaxation therapy Referral
• Refer urgently if client is having breakthrough
Client Education seizures
• Importance of following medication regime • Refer electively for review by a physician at
• Regular laboratory follow-up least annually if seizures are well controlled
• Side effects of medication • Consider neurologic follow-up if symptoms are
• Importance of routine exercise and diet not controlled on current medications
• Be aware of triggers
• Alcohol counseling if needed

Epilepticus (Acute Grand Mal Seizure)

Definition • Random blood glucose
State of epileptic seizure lasting > 15 minutes or • Urinalysis (routine and microscopy, culture and
occurrence of repeated seizures without the patient sensitivity)
regaining consciousness. If the seizure lasts > 60 • Drug screen and levels
minutes and is untreated, status epilepticus is • Electrolytes
associated with significant morbidity and
mortality. Management
Goals of Treatment
Cause • Protect airway
• Unknown • Stabilize cardiorespiratory function
• Inadequate absorption of anticonvulsants • Stop seizures
• Noncompliance with medications
• Dosage of anticonvulsants reduced too rapidly Nonpharmacologic Interventions
• Ensure airway is clear and patent
History • Suction as necessary
• Attack begins as seizure • Insert oral pharyngeal airway
• Episodes of tonic and clonic movements occur • Assist ventilation as needed with Ambu bag
repeatedly without client regaining • Monitor neuro vital signs
consciousness
• May go on for hours or days Adjuvant Therapy
• Oxygen to keep oxygen saturation > 97%
Physical Findings • Start IV therapy with normal saline; adjust rate
• Temperature normal unless underlying infection according to state of hydration
is present • Monitor closely for respiratory depression
• Heart rate elevated, may be irregular
• Respirations irregular (absent during seizure, Pharmacologic Interventions
present between seizures) Anticonvulsive therapy by physician order.
• Blood pressure elevated or low diazepam (D class drug), may be given IV.
• Oxygen saturation may be decreased Note: diazepam is not effective IM
• Client unconscious Administer diazepam with caution to clients who
• Client pale or cyanotic have received barbiturates, as the side effects of
• Evidence of loss of bowel and bladder control respiratory depression are additive.
• Repeated episodes of tonic and clonic
movements Appropriate Consultation
• Foaming at mouth may be present Consult a physician as soon as possible.
• Evidence of trauma
Complications • Identify focal neurologic deficits
• Hypoxia • Observe for return to normal level of
consciousness
• Cardiac arrhythmia
• Monitor vital signs
• Brain damage
• Monitor for continued seizure activity
• Death
Referral
Diagnostic Tests Medevac as soon as possible.
• Electrocardiogram (ECG) (if available) if client
> 50 years of age

Cerebrovascular Accident (Stroke)

Definition Progressing Stroke
Sudden onset of a focal neurologic deficit • Neurologic dysfunction evolving painlessly over
resulting from either infarction or hemorrhage several hours or days
within brain tissue. Eighty percent of strokes are • Headache absent
ischemic, and about 25% are caused by cerebral • Involves progressively more of the body
emboli. • Progression stepwise, with periods of stability;
may be continuous
Causes • Consciousness may be reduced or altered
Infarction from Thrombus or Emboli
• Progressing stroke: unstable, progressing Completed Stroke
neurologic deficits • Abrupt onset
• Completed stroke: stable, non-progressing • Symptoms maximal in a few minutes
neurologic deficit • One-sided neurologic deficits
• Consciousness may be reduced or altered
Risk Factors
• Atrial fibrillation Intracranial Hemorrhage
• Valvular heart disease (especially mitral stenosis • Suggested by coma, vomiting, severe headache,
and mitral prolapse) history of anticoagulant therapy, history of
• Coronary artery disease vascular anomaly (e.g. aneurysm, angioma),
• Recent myocardial infarction systolic blood pressure > 220 mm Hg, blood
• Ventricular aneurysm glucose > 9.43 mmol/L in nondiabetic client
• Carotid stenosis • Subarachnoid hemorrhage suggested by new-
• Peripheral vascular disease onset, severe headache that may be followed by
• Smoking nausea and vomiting and loss of consciousness
• Hyperlipidemia (transient or coma); however, client may have
• Diabetes mellitus only headache and normal results on physical
• History of injection drug abuse (e.g. cocaine, exam
amphetamines)
Physical Findings
Intracranial Hemorrhage • Heart rate may be elevated, pulse irregular
• Intracerebral hemorrhage: hemorrhage in or • Blood pressure may be normal
around brain • Client may be in moderate-to-acute distress
• Subarachnoid hemorrhage: accounts for 5% to • Client may be unconscious
10% of strokes • Mental confusion may be present
• One-sided weakness may be present
Risk Factors • Aphasia may be present
• Hypertension • Bladder and bowel incontinence may be present
• Arteriovenous malformations • Sensation may be reduced on affected side
• Muscle weakness on affected side
History • Reflexes on affected side may be reduced or
• Presence of one of the risk factors listed above hyperactive
• Abrupt onset is suggestive of infarction, but • Clonus may be present
must rule out brain abscess, tumor and subdural • Carotid bruits may be present
hematoma • Heart murmur may be present

Differential Diagnosis Adjuvant Therapy

• Seizure disorder • Oxygen to keep oxygen saturation > 97%
• Subdural hematoma • Start IV therapy with normal saline; adjust rate
• Head injury according to age, pre-existing medical problems,
• Tumor state of hydration and client's ability to take
• Alcohol consumption fluids
• Do not overload with volume, especially if
Complications cerebral hemorrhage is suspected.
• Inadequate ventilation
• Aspiration
• Seizures
• Disturbances in communication Pharmacologic Interventions
• Acute urinary retention or urinary incontinence • As ordered by physician
• Bowel incontinence • Do not attempt to reduce blood pressure, as
• Deep vein thrombosis elevated blood pressure is often compensatory,
• Death and a sudden drop in blood pressure could
increase severity of stroke
Diagnostic Tests
• ECG may be helpful. Look for atrial fibrillation Monitoring and Follow-Up
• Blood sugar • Monitor vital signs, fluid intake and hourly urine
output
Management • Monitor level of consciousness, changes in
Goals of Treatment neurologic status
• Protect airway • Monitor for complications
• Ensure adequate ventilation • Monitor for decompensation of pre-existing
• Decrease deficit medical problems

• Insert oral pharyngeal airway (if unconscious) Medevac as soon as possible.
• Suction secretions prn
• Ventilate with Ambu bag at 12 bpm prn
• Nothing by mouth if stroke affects level of
consciousness or impairs swallowing
mechanism
• Insert urinary catheter if level of consciousness
impaired

Chapter 9- The Integumentary System

Assessment Of The Integumentary System..................................................................................................... 1
Physical Examination ..................................................................................................................................... 2
Common Problems Of The Skin ...................................................................................................................... 3

Abscess (Subcutaneous) ................................................................................................................................. 3
Cellulitis.......................................................................................................................................................... 4
Furuncle And Carbuncle................................................................................................................................. 6
Impetigo .......................................................................................................................................................... 8
Eczema (Atopic Dermatitis) ......................................................................................................................... 10
Pediculosis (Lice Infestation) ....................................................................................................................... 12
Scabies .......................................................................................................................................................... 13
Ringworm (Tinea)......................................................................................................................................... 15
Stasis Dermatitis ........................................................................................................................................... 17
Urticaria (Hives) ........................................................................................................................................... 18
Warts (Verrucae)........................................................................................................................................... 20
Dermatological Emergencies.......................................................................................................................... 21
Skin Wounds................................................................................................................................................. 21
Burns............................................................................................................................................................. 25
Frostbite ........................................................................................................................................................ 31

Assessment Of The Integumentary System

General • Influence of environmental or occupational
The following characteristics of each symptom factors
• Onset (sudden or gradual) Medical History (Specific To
• Chronology Integumentary System)
• Current situation (improving or deteriorating) • Allergic manifestation (e.g. asthma, hay fever,
• Location urticaria)
• Quality • Recent or current viral illness
• Timing (frequency, duration) • Recent or current bacterial illness
• Severity • Fever
• Precipitating and aggravating factors • Allergies to drugs, foods, other chemical
• Relieving factors substances
• Associated symptoms • Medications (e.g. steroids, OCPs [oral
• Effects on daily activities contraceptive pills], antibiotics, OTCs
• Previous diagnosis of similar episodes [over-the-counter drugs])
• Previous treatments • Immunosuppression (e.g. HIV/AIDS)
• Efficacy of previous treatments • Seborrheic dermatitis
• Psoriasis
Cardinal Symptoms • Diabetes mellitus
above, additional characteristics of specific Family History (Specific To
symptoms should be elicited, as follows. Integumentary System)
• Allergies (e.g. seasonal, to food)
Skin • Seborrheic dermatitis
• Changes in texture or colour • Others at home with similar symptoms
• Unusual dryness or moisture (e.g. rash)
• Itching • Psoriasis
• Rash
• Bruises, petechiae Personal And Social History (Specific
• Changes in pigmentation To Integumentary System)
• Lesions • Obesity
• Changes in moles or birthmarks • Poor hygiene
• Hot or humid environment, poor environmental
Hair sanitation
• Changes in amount, texture, distribution • Stress (may precipitate flares of chronic skin
problem such as psoriasis)
Nails • Exposure to new chemicals (e.g. soaps), foods,
• Changes in texture, structure pets, plants
• Emotional disturbance
Other Associated Symptoms • History of sensitive skin
• Site of onset • Others at home, work or school with similar
• Date(s) and site(s) of recurrence(s) symptoms
• Intermittent or continuous • Recent travel

• Apparent state of health • Vascularity (erythema, abnormal veins)
• Appearance of comfort or distress • Bruises, petechiae
• Colour (e.g. flushed, pale) • Edema (dependent, facial)
• Nutritional status (obese or emaciated) • Induration
• State of hydration • Individual lesions (colour, type, texture, general
• Match between appearance and stated age pattern of distribution, character of edge,
• Vital signs (temperature may be elevated) whether raised or flat)
• Hair (amount, texture, distribution)
Inspection And Palpation Of The Skin • Nails (shape, texture, discoloration, grooving)
• Colour • Mucous membranes
• Temperature, texture, turgor • Flexural folds or skin creases
• Dryness or moisture • Examine lymph nodes
• Scaling • Examine area distal to enlarged lymph nodes
• Pigmentation
Table 1: Major Types of Skin Lesions

Type of Lesion Characteristics
Atrophy Skin thin and wrinkled
Crust (scab) Dried serum, blood or pus
Erosion Loss of part or all of the epidermis
Excoriation Linear or hollowed-out crusted area, caused by scratching, rubbing or picking
Lichenification Skin thickened, skin markings accentuated (e.g. atopic dermatitis)
Macule Flat, circumscribed, discoloured spot; size and shape variable (e.g. freckle, mole, port-wine stain)
Nodule Palpable, solid lesion that may or may not be elevated (keratinous cyst, small lipoma, fibroma)
Papule Solid elevated lesion (e.g. wart, psoriasis, syphilitic lesion, pigmented mole)
Pustule Superficial elevated lesion containing pus (impetigo, acne, furuncle, carbuncle)
Scales Heaping-up of the horny epithelium (e.g. psoriasis, seborrheic dermatitis, fungal infection,
chronic dermatitis)
Telangiectasia Fine, often irregular red line produced by dilatation of a normally invisible capillary
Vesicle Circumscribed, elevated lesion <5 mm in diameter containing clear fluid; larger vesicles are
classified as bullae or blisters (e.g. insect bite, allergic contact dermatitis, sunburn)
Ulcer Loss of epidermis and at least part of the dermis
Wheal Transient, irregularly shaped, elevated, indurated, changeable lesion caused by local edema (e.g.
allergic reaction to a drug, a bite, sunlight)

Common Problems Of The Skin

Abscess (Subcutaneous)
A collection of pus in subcutaneous tissues. Consult a physician if client is febrile or appears
acutely ill; if extensive cellulitis, lymphangitis or
Causes adenopathy is present; or if an abscess is suspected
• Infection with bacteria, e.g. Staphylococcus or detected in a critical region (e.g. head or neck,
aureus, anaerobes, other microorganisms hands, feet, perirectal area) or in an
• Predisposing factors: folliculitis, cellulitis, immunocompromised client (e.g. diabetic person).
trauma, incision
• Soak abscess with warm saline compresses four
History times a day
• Pain, swelling, redness at infected site • Cover any open areas with a sterile, non-
• Fever may be present adherent dressing (e.g. Telfa®)
• Injury or trauma • Rest, elevate and gently splint infected limb
• Temperature may be elevated • Medication instruction
• Heart rate may be elevated • Dressing changes as directed
• Client may look ill • Cleansing of wound
• Localized redness, swelling
• Lesion may be draining Adjuvant Therapy
• Localized induration As per physician consultation if indicated
• Tenderness
• Fluctuance (may be difficult to palpate if abscess Start IV therapy with normal saline; adjust rate
is deep) according to state of hydration and age
• Regional lymph nodes may be enlarged and
tender Pharmacologic Interventions
• Size of abscess often difficult to estimate; Small, Uncomplicated Abscess
abscess usually larger than suspected Antibiotics:
cloxacillin (A class drug), 250-500 mg PO qid for
10 days
or
Cellulitis.
cephalexin (C class drug), 250 mg PO qid for
10 days
Complications
Sepsis. For clients with allergy to penicillin:
erythromycin (A class drug), 250-500 mg PO qid
Diagnostic Tests
Swab discharge for culture and sensitivity. Antipyretics and analgesia:
Management 1-2 tabs PO q4-6h prn
Goals of Treatment IV antibiotics may be started before transfer if
• Control infection ordered by a physician:
Refer if not resolving or if complications occur.

Cellulitis
Acute, diffuse, spreading infection of the skin, • Extension of infection
involving the deeper layers of the skin and the • Abscess
subcutaneous tissue. • Sepsis
Causes Diagnostic Tests

• Bacteria: most commonly Staphylococcus or • Swab any wound discharge for culture and
Streptococcus sensitivity.
• Predisposing factors: local trauma, furuncle, • WBC
underlying skin ulcer, type 2 diabetes, poor
circulation Management
Goals of Treatment
If a bite was the original trauma, different
organisms are involved. See "Skin Wounds," in
"Dermatological Emergencies," below, this • Identify formation of abscess
chapter. • Prevent complications

Consult physician if any of the following
• Localized pain
conditions pertain:
• Redness
• cellulitis is moderate to severe (e.g. large area is
• Swelling involved)
• Area increasingly red, warm to touch, painful • cellulitis is progressing rapidly, which may
• Area around skin lesion also tender indicate an invasive streptococcal infection
• Mild fever and headache may be present • cellulitis involves hands, feet, face or a joint
• client is immunocompromised (e.g. has diabetes
Physical Findings mellitus)
• Temperature may be elevated • client is febrile, appears acutely ill or shows
• Heart rate may be elevated signs of sepsis
• Redness, swelling
• Advancing edge of lesion diffuse, not sharply Nonpharmacologic Interventions
demarcated • Apply warm saline compresses to affected areas
• Small amount of purulent discharge may be qid
present • Elevate, rest and gently splint the affected limb
• Skin surrounding lesion red and swollen, may be
tense Client Education
• Edema • Counsel client about appropriate use of
• Tenderness medications (dose, frequency, compliance)
• Induration (firm to touch) • Encourage proper hygiene of all skin wounds to
• Regional lymph nodes may be enlarged, tender prevent future infection
• Stress importance of close follow-up
• Folliculitis Adjuvant Therapy
• Foreign body • If original lesion caused by trauma, check for
• Abscess tetanus vaccination; if not up to date, administer
• Necrotizing fasciitis tetanus vaccine.

• Start IV therapy with normal saline to keep vein Antipyretics and analgesia:
open; adjust rate according to state of hydration acetaminophen (A class drug), 500 mg, 1-2 tabs
and age PO q4-6h prn
Pharmacologic Interventions Administer IV antibiotics only as directed by a

Oral antibiotics: physician.
cloxacillin (A class drug), 250-500 mg PO qid for
10 days Monitoring and Follow-Up
or • Follow up daily to ensure that infection is
erythromycin (A class drug), 250 mg PO qid for controlled
10 days • Instruct client to return for reassessment
or immediately if lesion becomes fluctuant, if pain
cephalexin (Keflex) (C class drug), 250-500 mg increases or if fever develops
PO qid for 10 days
Monitor affected area frequently for progression.
Referral
Refer to physician if no improvement.

Furuncle And Carbuncle

Furuncle or boil: an acute, tender perifollicular • Scarring
inflammatory nodule • Spread of infection (e.g. lymphangitis,
lymphadenitis)
Carbuncle: a cluster of furuncles, generally larger • Abscess
and deeper • Recurrence
• Staphylococcal infection of several hair follicles • Swab discharge for culture and sensitivity
• Predisposing factors: obesity, diabetes mellitus, • Determine blood glucose level if infection is
poor hygiene, excessive friction or perspiration, recurrent or if symptoms suggestive of diabetes
seborrhea, local trauma (e.g. from plucking mellitus are present
hairs), use of systemic steroids
Management
• Usually found on the neck, axilla, breasts, face • Control infection
and buttocks • Prevent recurrence
• Local redness, swelling, pain, tenderness
• Identify predisposing underlying conditions
• Begins as a small nodule, quickly becomes a (e.g. diabetes mellitus)
large pustule
• If poked, purulent, sanguineous material drains Appropriate Consultation
• May occur singly or in groups Consult physician if a large furuncle or carbuncle
• May be recurrent is present, as surgical drainage may be needed.
• Fever absent
Physical Findings • Apply warm saline compresses to area at least
• Nodule or pustule 5-30 mm in diameter qid. This may lead to resolution or spontaneous
• Deep red in colour drainage if the lesion or lesions are mild.
• Central area may spontaneously drain pus • Cover area with a sterile, non-adherent dressing
• Carbuncle may present as red mass with • If area is fluctuant and pointing, incise lesion
multiple draining sinuses in area of thick, with a single stab wound and allow pus to drain.
inelastic tissue (e.g. posterior neck, back, thigh)
• Lesion(s) warm, tender to touch Client Education
• May be fluctuant • Counsel client about appropriate use of
• Regional lymph nodes usually not enlarged or medications (dose, frequency)
tender • Encourage proper hygiene of the area
• Stress importance of regular skin cleansing to
Differential Diagnosis prevent future infection
• Cellulitis • Recommend that client avoid picking or
• Abscess squeezing the lesions
• Impetigo • Instruct clients with recurrent disease to bathe
• Insect bites area bid with a mild antiseptic soap to help
prevent recurrences


Antibiotics if infection is moderate or severe: • Follow up in 2 days and at 7-10 days
cloxacillin (A class drug), 250 mg PO qid for • Instruct client to return immediately for
7-10 days reassessment if lesion becomes fluctuant, if pain
increases or if fever develops
For clients with allergy to penicillin:
erythromycin (A class drug), 250 mg PO qid for Referral
7-10 days Arrange elective follow-up with physician if
infections recur.

Impetigo
Highly contagious superficial bacterial infection of • Localized or widespread cellulitis
skin. • Post-streptococcal glomerulonephritis
(uncommon in adults)
Causes
• Streptococcus, Staphylococcus or a mixture of Diagnostic Tests
both None.
• Predisposing factors: local trauma, insect bites,
skin lesions from other disorders (e.g. eczema, Management
scabies, pediculosis) Goals of Treatment
History • Prevent auto-innoculation
• More common on face, scalp and hands, but • Prevent spread to other household members
may occur anywhere
• Involved area is usually exposed Appropriate Consultation
• New lesions usually due to auto-innoculation Consult a physician if there is failure to respond to
• Rash begins as red spots, which may be itchy therapy.
• Lesions become small blisters and pustules,
which rupture and drain Nonpharmacologic Interventions
• Discharge dries to form characteristic golden • Apply warm saline compresses to soften and
yellow crusts soak away crusts qid and prn
• Lesions painless • Cleanse with antiseptic antimicrobial agent to
• Fever and systemic symptoms rare decrease bacterial growth
• Mild fever may be present in more generalized
infections Client Education
Physical Findings medications (dose, frequency, compliance)
• Thick, golden yellow, crusted lesion on a red • Recommend proper hygiene (i.e. daily washing
base with prescribed soap)
• Numerous skin lesions at various stages present • Counsel client about prevention of future
(vesicles, pustules, crusts, serous or pustular episodes
drainage, healing lesions) • Suggest strategies to prevent spread to other
• Bullae may be present household members (e.g. proper hand-washing,
• Lesions and surrounding skin may feel warm to use of separate towels)
touch
• Regional lymph nodes may be enlarged, tender Pharmacologic Interventions
Apply topical antibiotic preparation after each
soaking:
mupirocin ointment (A class drug), qid
• Infected eczema, contact dermatitis, scabies
• Herpes simplex infection with blisters or crusts Oral antibiotics may be necessary if there are
• Chickenpox infection with blisters or crusts multiple lesions that appear infected:
• Shingles (herpes zoster) with blisters or crusts cloxacillin (A class drug), 500 mg PO qid for 10
• Bullous insect bites days
or
erythromycin (A class drug), 250 mg PO qid for
10 days

or • Instruct client to return for reassessment if fever

cephalexin (C class drug), 500 mg PO qid for 10 develops or infection spreads despite therapy
days
Referral
Monitoring and Follow-Up Not usually necessary unless complications
• Follow up in 2-3 days to assess response to develop.
treatment

Eczema (Atopic Dermatitis)

Chronic, itchy, inflammatory condition of the skin • Secondary bacterial infection
• Chronic irritation of skin
Causes • Side effects of medication (e.g. steroid
• Largely unknown preparations)
• Inherited skin sensitivity
• Allergy Diagnostic Tests
None.
History
• Pattern in adulthood differs from that in infancy Management
and childhood Goals of Treatment
• Periods of remission and exacerbation • Relieve symptoms
• Family history of eczema, allergies and asthma • Prevent secondary infection
common
• Characterized chiefly by itching and scaling Appropriate Consultation
• Eruptions of small groups of vesicles may occur Consult a physician if no response to therapy after
• Scratching leads to rupture of vesicles 1 week.
• Clear serous fluid oozes from vesicles, leading
to development of rash Nonpharmacologic Interventions
• Vicious cycle of itch, scratch, rash, itch • Offer support to client, as it can be difficult to
• Usually affects face, neck, upper arms and back, live with this irritating and cosmetically
flexural folds, feet unattractive condition
• May be more generalized • Advise client to stop using steroid preparations
• Secondary bacterial infection common once acute lesions have healed, since steroids do
• Specific irritating agents can be identified not have any preventive benefit and may further
• Wool, solvents, perfumed creams, lotions, soaps irritate and damage skin
bothersome • Assist client to identify precipitating and
• Allergies, asthma, contact dermatitis often aggravating factors, and encourage avoidance
present • If lesions are dry, promote lubrication with
Glaxal® base, Nivea® cream or petroleum jelly
Physical Findings (Vaseline® bid, after bathing and prn
• Skin scaly, dry, thickened (lichenified)
• Fissures may be present Client Education
• Excoriations • Counsel client about appropriate use of
• Mild redness and edema often present medications (dose, frequency, application)
• Vesicles may be present in some areas • Encourage proper hygiene to prevent secondary
• Lesions may be weeping bacterial infection
• Pustular or crusted lesions may be present • Recommend loose-fitting cotton clothing
• Some areas of skin usually show chronic • Recommend avoidance of coarse materials and
changes (thin skin, scarring, lichenification) wool
• Recommend avoidance of overheating
Differential Diagnosis • Recommend avoidance of irritants at work and
• Seborrheic dermatitis at home
• Dry skin (winter itch) • Recommend use of a soap substitute (e.g.
• Allergic contact dermatitis Aveeno® and avoidance of soaps)
• Psoriasis • Suggest that cotton gloves be worn inside rubber
• Scabies gloves when client works with liquids

• Suggest that greasy lubricants be applied within Monitoring and Follow-up

minutes of leaving shower or bath to "lock in" Follow up in 1-2 weeks to assess response. Advise
moisture client to return sooner if there are signs of
infection developing.
Reduce inflammation if itch moderate or severe: Referral
hydrocortisone 0.5% cream or ointment Arrange elective follow-up with a physician if
(A class drug), tid for 1-2 weeks there is no response to treatment.
Gels and creams are used for acute, weeping

eruptions. Ointments are used for dry or
lichenified lesions. Lotions are used for hairy
areas.
Relieve itch with oral antihistamines:

diphenhydramine (A class drug) 25-50mg
PO tid-qid
or
hydroxyzine (A class drug), 10-25 mg PO hs and
bid prn
Start with 10 mg if client is small, elderly or

taking anxiolytics. Sedative effect of hydroxyzine
is useful to break the itch-scratch cycle.

Pediculosis (Lice Infestation)

Infestation with lice. Goals of Treatment
• Eradicate infestation
Causes • Prevent recurrences
There are 3 types: head lice, body lice and pubic • Prevent spread to close contacts
lice.
Risk Factors • Remove dead lice and nits with tweezers or nit
• Crowded housing (e.g. shared beds), crowded comb. Soaking the head with white vinegar and
schools waiting 10 mins before combing may loosen nits
• High pediatric population • Avoid irritation of eyes and mucous membranes
• Failure to recognize an infestation • Remove nits on eyelashes with petroleum jelly
• Faulty application of treatments (nits become coated, and ova die from
• Failure to treat close contacts simultaneously suffocation)
• Failure to eradicate lice from linens and clothing • Instruct client to place small amount of
at time of treatment petroleum jelly on tips of fingers, then close
• Lack of running water, which can predispose to eyes and rub petroleum jelly into lids and brows;
poor hygiene and secondary skin infection repeat bid or tid for 4 or 5 days
• Examine all family members and close personal
History contacts, including schoolmates and daycare
• Head lice: involve scalp contacts, and treat if infested
• Body lice: involve body • Recommend that combs, brushes, hats, coats,
• Pubic lice: involve pubic area and may be found bedding and clothing of all household members
in hairs of abdomen, thighs, axilla, eyebrows, be washed in warm soapy water
eyelashes
• Severe itching of involved area Client Education
• Excoriation of skin • Counsel client about proper use of medication
• Secondary bacterial infection may occur and side effects
• Client may find lice or nits on bedclothes, in • Recommend avoidance of sharing of combs,
seams of clothing brushes, hats, etc.
• Suggest that mattresses (which can harbor lice)
be taken outside for the day
Physical Findings
• Things that cannot be washed should be dry-
• Small gray-white nits cemented to base of hair
cleaned or put in clothes dryer
shafts
• May return to school post-treatment
• Lice may be visualized
• Excoriation of skin
Antiparasitic shampoo agent for head lice (apply
Differential Diagnosis topically and massage in thoroughly for 10
• Dandruff minutes, then rinse):
permethrin cream rinse (A class drug)
Complications
• Recurrent infestation Monitoring and Follow-Up
• Skin infection Follow up in 7 days. Shampoo treatment may be
repeated 7-10 days after original application.
Diagnostic Tests
None. Referral
Usually not necessary.

Scabies
Infestation of the skin with a mite parasite. • Pediculosis
• Impetigo
Cause • Eczema
Sarcoptes scabiei. • Contact and irritant dermatitis
Risk Factors Complications

• Failure to recognize an infestation • Secondary bacterial infection
• Faulty application of treatment regimens
• Failure to treat close contacts Diagnostic Tests
• Failure to eradicate mites from clothing and bed None.
linen
• Crowded housing, shared beds, crowded schools Management
and daycare centers Goals of Treatment
• High pediatric population • Eradicate infestation
• Lack of running water, which may predispose to • Control secondary infection
poor hygiene and secondary skin infection • Relieve symptoms
• Severe itching Consult physician if unsure of diagnosis.
• Itching generally worse at night
• Rash of hands, feet, flexural folds Nonpharmacologic Interventions
• Transmitted by intimate contact with infected • Prophylactic therapy essential for all household
person members, since signs of scabies may not appear
• Transmitted by clothes for 1-2 months after the infection is acquired
• Symptoms may take 2-3 weeks to develop after • Treat all household members at the same time to
contact with mite prevent re-infection
• Symptoms are due to hypersensitivity to mite • All bed linen (sheets, pillowslips) and clothing
and its products worn next to the skin (underwear, T-shirts,
socks, jeans) should be laundered in a hot soapy
Physical Findings wash and dried with a hot drying cycle
• Usually affects interdigital web spaces, flexures • If hot water is not available, place all bed linen
of wrists and arms, axilla, belt line, lower folds and clothing into plastic bags and store away
of buttocks, genitalia, areolae of nipple from family for 5-7 days, as the parasite cannot
• Diffuse red rash survive beyond 4 days without skin contact
• Primary lesions: papules, vesicles, pustules, • Placing bedding outside in the cold or in
burrows ultraviolet light will also help
• Secondary lesions: scabs, excoriations, crusts, • Children may return to daycare or school the day
nodules, secondary infection after treatment is completed
• Lesions in various stages present at the same • Healthcare workers who have had close contact
time with clients with scabies may require treatment
• Secondary lesions may predominate • Community education, aimed at early
• Burrows (gray or flesh-coloured ridges 5-15 mm recognition and awareness of scabies, is
long) may be few or many important
• Burrows commonly seen on anterior wrist or • In widespread scabies epidemics, prophylactic
hand and in interdigital web spaces treatment of a whole community may be optimal
management

• Vacuum upholstered furniture Topical antiparasitic agents can cause dermatitis if

used incorrectly (i.e. if overused).
Client Education
• Counsel client about proper use and side effects Pruritus may be a problem particularly at night.
of medication. Instruct client that itch will persist for up to
• Hygiene 2 weeks. To manage itching:
diphenhydramine (A class drug) 25-50mg PO tid-
Pharmacologic Interventions qid
Scabicide cream or lotion, to be applied to entire or
body, from chin to toes (emphasize that scabicide hydroxyzine (A class drug), 10-25 mg PO bid and
must be applied in skin creases, between fingers hs prn
and toes, between buttocks, under breasts and to
external genitalia): Monitoring and Follow-Up
permethrin 5% dermal cream (A class drug), • Follow up in 1 week to assess response to
(drug of choice) treatment
• Advise client to return immediately if signs of
Use as per product monograph. Treatment may be secondary infection develop
repeated in one week if necessary.
The safety of permethrin in pregnant and lactating Referral
women has not been established. Refer if no response to treatment.

Ringworm (Tinea)
Definition Causes
Superficial infection of skin. Fungi that invade dead tissues such as the stratum
• On feet: tinea pedis (athlete's foot) corneum, nails and hair (dermatophytes). More
• In groin: tinea cruris (jock itch) common in diabetics.
• On body: tinea corporis
History And Physical Findings
See Table 2 below
Table 2: History and physical findings for various forms of tinea

Type History Physical findings
Tinea pedis Affects feet. Itch severe. Scaling and redness, Scaling of lateral interdigital areas. Moist,
mainly between toes. Foul odour may be whitened, macerated, cracked skin may be
present. Area may be moist, whitened, present. Skin peels off easily with red, raw,
macerated, cracked. Skin peels off easily, with tender area underneath. One or several small
red, tender area underneath. One or several blisters may be present. Sole of foot may be
small vesicles may be present. Vesicles rupture involved, with marked scaling. Fissures may
leaving a “collarette” of scales. May involve become secondarily infected (cellulitis)
sole of foot with marked scaling (itch minimal)
Tinea cruris Affects groin. Common in men. Itch mild to Involves crural areas and upper inner thigh.
severe. Begins as erythema of crural fold. Scaly reddish brown lesion. Sharply defined
Spreads outward. May spread on to thighs or margin. Central clearing absent. Groin, thigh,
buttocks. Scrotum and penis not usually buttock may be involved. May be bilateral or
affected. Often spread by infected towel. Often unilateral. Scrotum and penis not usually
associated with tinea pedis. Predisposing affected.
factors: excessive sweating, diabetes mellitus,
friction
Tinea Affects any smooth, non-hairy part of body. Lesions variable in size. Typically a well-
corporis Scaly, circular or oval skin lesions. Frequently circumscribed circular or oval patch. Reddish
itchy. May be asymptomatic. pink and scaly. Central clearing. Accentuation
of redness at outer border. Margins scaly,
vesicular or pustular.
Differential Diagnosis Diagnostic Tests

• Soft corn Take skin scrapings for mycologic investigation
• Wart (fungal culture).
• Seborrheic dermatitis Management
• Candidal infection of foot or groin Goals of Treatment
• Local chafing or irritation of groin • Relieve symptoms
• Contact or allergic dermatitis • Eradicate infection
• Psoriasis
Complications Consult a physician if there is failure to respond to
Secondary bacterial infection (particularly with an adequate trial of antifungal therapy.
tinea pedis).
Client Education
• Recommend elimination of moisture and heat

• Suggest that client modify socks and footwear tolnaftate cream or powder (A class drug), bid or
e.g. avoid wearing rubber shoes tid
• Recommend avoidance of restrictive clothing,
nylon underwear, prolonged wearing of wet Tolnaftate powder has additional drying benefits.
bathing suit or work clothes
• Counsel client about appropriate use of For tinea corporis, apply one of these topical
medications (dose, frequency, compliance) antifungal agents for 2-4 weeks.
• Recommend proper hygiene e.g. client should
change socks frequently Monitoring and Follow-Up
Follow up in 2 weeks to ensure resolution.
For tinea pedis and tinea cruris, topical antifungal Referral
agent for at least 2 weeks; continue until 1 week Refer to physician if fungal infections are
after resolution of lesions: recurrent, if they develop in an immunosuppressed
miconazole skin cream (A class drug), bid or tid or diabetic client, if there is no response to
or therapy, or if the nails become involved.
clotrimazole skin cream (A class drug), bid or tid
or

Stasis Dermatitis
Inflammation of skin caused by pooling of venous Goals of Treatment
blood in lower limb. • Control edema
• Prevent formation of ulcers
Causes • Prevent infection
• Improper venous drainage
• Predisposing factors: varicose veins, previous Appropriate Consultation
deep vein thrombosis, arterial disease, smoking, Consult physician if no resolution or if condition
CHF, diabetes progresses.

• Itchiness • Encourage client to elevate legs
• Itch worsens with use of soaps, drying, bathing • Application of compression with support hose or
• Swelling of ankles tensor bandages when ambulatory
• Initially, swelling is relieved by elevation • Application of cool normal-saline soaks or wet
• Later, swelling may become constant normal-saline dressings in acute phase
• Lubrication of area twice daily with emollient
Physical Findings cream
• Usually begins on medial ankle, may spread to • Avoidance of irritants (soap, hot water, rough
lower third of leg clothes, rubbing)
• Localized swelling
• Tiny petechiae Pharmacologic Interventions
Antibiotics as ordered by physician if
• Excoriations, redness, scales
superinfection apparent.
• Diffuse red-brown pigmentation develops
• Entire circumference of lower leg may become
involved
• Follow up in 1 week to determine if there is a
response to conservative therapy
Differential Diagnosis • Monitor for signs of skin breakdown, infection
• Contact dermatitis • Advise client of the signs of infection and
• Cellulitis instruct him or her to return to clinic
immediately if they occur
Complications
• Skin breakdown, ulceration Referral
• Infection Arrange follow-up with physician if condition
• Deep venous thrombosis deteriorates.
Diagnostic Tests
None.

Urticaria (Hives)
Local wheal and erythema of skin None.
Causes Management
• Often unknown Goals of Treatment
• Chronic idiopathic • Relieve symptoms
• Hypersensitivity to foods, drugs, inhaled • Identify precipitating factor
allergens, insect bite or sting • Prevent recurrence
• Emotional upset
• Physical agents (e.g. heat, cold, sun) Appropriate Consultation
• Systemic disease (e.g. systemic lupus Contact physician if any of the following pertain:
erythematosus) • Symptoms are severe
• Infection (e.g. hepatitis, mononucleosis or other • Complications are present
viral illness) • If shortness of breath, wheezing or swelling of
tongue or mouth occurs
History • Client is pregnant or lactating
• Recent exposure to one of above causes possible
• Itchy white-to-pink patches Nonpharmacologic Interventions
• Client may feel unwell • Application of cool compresses to reduce itching
• Avoidance of overheating
Physical Findings • Temporary avoidance of hot, spicy food
• May occur anywhere on body • Colloidal oatmeal baths
• May be localized or generalized
• Lesions multiple, irregular in shape and size Client Education
• Raised white or light rose-pink patches, usually • Counsel client about appropriate use of
surrounded by red halo medications (dose, frequency, side effects)
• Peripheral extension and coalescence of patches • Recommend proper skin hygiene to prevent
may occur infection
• Patches may wax and wane • Recommend avoidance of scratching; client
• Individual wheals rarely persist for > 12-24 should keep fingernails short and clean
hours • Assist client in identifying causative agent
• Signs of scratching may be evident (including any recent changes in food or brands,
as different food companies put different
additives into their products)
• Vasculitis
• Insect bites Apply topical antipruritic agents:
• Erythema multiforme calamine lotion qid prn
• Systemic lupus erythematosus
Oral antihistamine to relieve itch and suppress
Complications formation of new lesions:
• Recurrence cetirizine (A class drug) 10mg PO od for 2-7 days
• Severe itching or
• Systemic allergic response with bronchospasm diphenhydramine (A class drug), 25-50 mg PO
• Anaphylaxis q6-8h for 2-7 days
or

hydroxyzine (A class drug), 25-50 mg PO q6-8h tongue or mouth occurs; in this situation, refer
for 2-7 days to "Anaphylaxis," in chapter 14, "General
Emergencies and Major Trauma"
Monitoring and Follow-up
• Follow up in 2-7 days Referral
• Instruct client to return for reassessment if Refer to a physician for evaluation if lesions are
lesions progress despite therapy recurrent or persistent.
• Instruct client to return to clinic immediately if
shortness of breath, wheezing or swelling of

Warts (Verrucae)
Common, contagious, benign epithelial Goals of Treatment
hyperkeratotic tumors • Eradication of lesion
• Control of spread
Causes
Human papillomavirus Appropriate Consultation
Arrange consultation with physician if warts are
History on face or genitals, or if client is pregnant.
• Occur most commonly in children
• May persist for many years and disappear Nonpharmacologic Interventions
spontaneously • Give the client lots of support and
• Single or multiple lesions encouragement to persevere, as the treatment is
long and tedious
Physical Findings • Before each application of medication: soak
• Usually occur on hands, fingers, feet and face affected area in warm water to soften wart; use a
• May be small or large pumice stone to remove dead tissue, or pare
away dead skin with scalpel
• May be single or in clusters
• Raised tumors with thickened, rough surface
Client Education
• White, gray, yellow or brown
• Black dots (thrombosed capillaries) may be seen medications - dose, frequency, application
within wart
• Protect normal surrounding skin with Vaseline®
• Well-defined round or irregular margin
petroleum jelly
• Surface may be flat (flat wart)
• Suggest strategies to avoid spread to other areas
• Firm, rough of body and to other persons
• Lesions bleed from central capillaries when
pared Pharmacologic Interventions
Apply topical treatment to warts:
Differential Diagnosis salicylic and lactic acid liquid (A class drug), od
• Corns for up to 3 months
• Molloscum contagiosum
• Melanoma Monitoring and Follow-Up
Follow up every week to assess response and
Complications adherence to treatment regime.
• Unacceptable cosmetic appearance
• Enlargement or spread of warts Referral
Refer electively to a physician if no response after
Diagnostic Tests 12 weeks of therapy.
None.

Dermatological Emergencies
Skin Wounds • Discharge
• Fever
Definition • Local lymphadenopathy
Breach in the integrity of the skin (external surface
of the body) Assess integrity of underlying structures (nerves,
ligaments, tendons, blood vessels):
Causes • Vascular injury: Capillary refill should be
Blunt trauma: split- or crush-type injuries will checked distally.
swell more and tend to have more devitalized • Neurologic injury: Check distal muscle strength,
tissue and a higher risk of infection movement distal to wound and sensation.
Always check sensation before administering
Sharp trauma: clean edges, low cellular injury and anesthesia. For hand and finger lacerations
low risk of infection check two-point discrimination, which should be
< 1 cm at the fingertips.
Bite injury: animal or human • Tendons: Can be evaluated by inspection, but
individual muscles must also be tested for full
History range of motion and full strength.
• Mechanism of injury
• Contaminants: wound contact with manure, rust, Assess range of motion of all body parts
dirt, etc. will increase risk of infection surrounding the wound site.
• Time of injury (after 3 hours, the bacterial count • Bones: Check for open fracture or associated
in a wound increases dramatically) fractures.
• Amount of blood lost • Foreign bodies: Inspect the area.
• Loss of function in nearby tendons, ligaments,
nerves (sensation) Complications
• Medical illnesses, conditions, treatments: • Infection
diabetes mellitus, chemotherapy, steroids, • Poor healing
peripheral vascular disease and malnutrition may • Laceration of nerve
delay wound-healing and increase the risk of • Compartment syndrome: loss of sensation may
infection be the first sign; pain severe, out of proportion to
• Allergies (to drugs, dressings, local anesthetics) injury
• Medications currently used (especially steroids, • Crush injury may decrease two-point
anticoagulants) discrimination, and it may take several months
• Status of tetanus vaccination to recover
• Status of rabies vaccination • Injury to major vascular structures (e.g. artery)
• Injury to tendon
• Temperature Diagnostic Tests
• Heart rate, blood pressure (if significant blood • Usually none
loss from wound) • If there is strong clinical suspicion of foreign
• Dimensions of wound, including depth body or fracture, x-ray or ultrasound may be
necessary
Assess for infection:
• Redness Management
• Heat Goals of Treatment
• Tenderness • Restore function

• Minimize risk of infection • High-pressure irrigation is the most effective

• Repair injured tissue with a minimum of means of cleansing a wound. Use normal saline
cosmetic deformity in a 60-mL syringe with a 19-gauge needle.
Appropriate Consultation Scrubbing does not cleanse the wound as well, and
Consult a physician if any of the following pertain: using any disinfectant in the wound damages
• Wound is extensive, deep or infected healthy cells needed for healing.
• Muscle, tendon, nerve or vascular compromise • Skin disinfection: Can be performed with
is present or suspected povidone-iodine solution. Avoid getting the
• Significant tissue deficit is present solution in the wound, because it will impede
• Wound is more than 12 hours old healing.
• Hair can be clipped in the area if necessary.
Wound Repair: General Principles Shaving hair is not recommended.
• Most wounds may be closed with sutures up to • Never shave eyebrows. They are needed for
12 hours after the injury; clean well and use alignment of the wound and may not grow back.
clinical judgment when choosing which wounds • Flush well with normal saline after disinfection.
to close.
• Do not suture wounds that are infected or Open Wound Care
inflamed, dirty wounds, human or animal bites, • To keep the wound open, pack it with bulky, wet
puncture wounds, neglected wounds or severe saline gauze dressings daily. This will keep the
crush wounds. tissue moist and help debride.
• Wounds on the face that are up to 24 hours old • Avoid iodine dressings because they damage
may be closed after thorough cleaning. The healthy tissue and slow granulation.
blood supply in this area is much better and the • When clean granulation tissue is apparent,
risk of infection therefore much lower. secondary closure may be considered;
• Do not clamp vascular structures until it is alternatively, the dressing can be changed to dry,
determined if the vessel is a significant one sterile, packing material.
needing repair.
Wound Closure
Nonpharmacologic Interventions • Steri-Strips: If the wound is small and shallow
Homeostasis and falls together naturally along lines of
Direct pressure is the first choice for controlling tension, it may only need to be reinforced with
bleeding. If a fracture is involved, immobilization steri-strips. Dress the wound with dry sterile
will help control bleeding gauze. Instruct client to keep wound clean and
dry for 48 hours.
Skin Preparation • Suturing: Larger wounds need suturing (Table
• Debridement: Using aseptic technique, remove 3). Close in layers as necessary using simple
devitalized tissue; avoid taking healthy tissue. interrupted sutures.
Table 3: Types of suture material for particular sites

Type of suture Size Body area
Nonabsorbable Silk or Nylon coated with polypropylene #3-0. 4-0 Scalp

glycol (Prolene) #5-0, 6-0 Face
#5-0 Forehead
Absorbable Chromic (catgut) #3-0, 4-0, 5-0 Subcutaneous tissue

Monofilament (Monocryl) Muscle

Local Anesthetic for Suturing with a contaminated foot wound, or other clients
Lidocaine (1% to 2%) is the most frequently used with peripheral vascular disease:
local anesthetic (onset 2-5 minutes, duration 60 cloxacillin (A class drug), 250-500 mg PO qid for
minutes): 10 days
lidocaine 1% with or without epinephrine
(maximum 30 mL) For clients with allergy to penicillin:
or erythromycin (A class drug), 250 mg PO qid or
lidocaine 2% with or without epinephrine 500 mg bid for 10 days
(maximum 10 mL)
Topical Antibiotics
Nurses should use 1% lidocaine without Consider topical antibiotic ointment for wounds on
epinephrine as first choice when suturing a wound. face and torso:
bacitracin ointment (A class drug), qid for 5 days
For adults, the maximum dose of 1% lidocaine
(without epinephrine) is 4.5 mg/kg (maximum Antibiotic ointment should not be left on wounds
30 mL). of the distal extremities for more than 24-48 hours,
because it may lead to maceration and could delay
Never use lidocaine with epinephrine on the wound healing.
ears, nose, fingers, toes or penis.
Antibiotics for Bites
• Use a 22- or 25-gauge needle Human Bites
• Infiltrate the anesthetic slowly through the open Antibiotics should be given prophylactically for all
wound edge, avoiding the intact skin human bites:
• Always pull back on plunger to ensure the amoxicillin/clavulanate (B class drug),
needle is not in a blood vessel 20-40 mg/kg daily, divided tid, PO for 7 days
• Administer subsequent injections into an area
that has already been anesthetized Cefixime is an acceptable alternative.
• It may be of value to dribble a small amount of
lidocaine on to the wound before infiltration to Consider IV antibiotics if infection has already
provide some initial anesthesia occurred, especially for a bite on the hand.
• Give anesthetic at least 5 minutes to be effective
• If extensive suturing is required, it may be Cat Bites
necessary to anesthetize and suture a small area Antibiotics are routinely given for cat bites.
at a time to prevent anesthetic from wearing off
before suturing is complete The drug of choice is:
amoxicillin/clavulanate (B class drug),
• Toxic effects of lidocaine: Observed if anesthetic
20-40 mg/kg daily, divided tid, PO for 7 days
is injected into a blood vessel inadvertently;
symptoms include dizziness, tinnitus,
Vibramycin is an alternative.
nystagmus, seizures, coma, respiratory
depression, arrhythmias and seizures
(all symptoms are usually self limiting) Dog Bites
Only 5% of dog bites become infected, and routine
prophylaxis is not recommended. If there is a need
to treat, amoxicillin/clavulanate is the drug of
Antibiotic Prophylaxis choice (as for other types of bites).
There is no medical indication for prophylactic
antibiotics in routine, uncontaminated skin
wounds. However, consider prophylactic antibiotic
Tetanus Prophylaxis
For recommendations concerning tetanus
use for clients prone to endocarditis, clients with
prophylaxis, refer to Canadian Immunization
hip prostheses or lymphedema, diabetic clients
Guide, 6th ed. (Health Canada, 2002; page 210).

Client Education Table 4: Timing of removal of sutures

• Keep wound covered for 24 hours Timing of suture
Site of wound
removal
Monitoring and Follow-up
Face 3-5 days; steri-strip
• Instruct client to return for reassessment if reinforcement after
redness, swelling, discharge, pain or fever suture removal
develops Scalp 7-10 days
General Guidelines for Removing Trunk 7-10 days

Sutures
• Wound appears clean and healed Arms 7-10 days
• Wound appears dry; no drainage evident
Legs 10-14 days
• For larger wounds it is advisable to initially
remove alternate sutures to ensure that wound Joints (dorsal surface) 14-21 days (splint
edges stay approximated recommended)
• Sutures should be removed according to the
recommendations in Table 4 Referral
• Consider surgical consult if there is suspicion of
Increase time before removal of sutures in diabetic injury to major structures
or steroid-dependent clients in whom healing may • Open fracture is an indication for surgical
take several weeks. debridement and repair (except in the case of
fracture of a distal phalanx, where copious
irrigation and oral antibiotics are acceptable
treatment if the injury can be monitored
carefully for infection)

Burns
Definition • Flame; tends to cause full-thickness burn,
Tissue injury caused by thermal contact. especially if clothing burns
• Molten metal, tars or melted synthetics lead to
Types of Burns prolonged skin contact
First-Degree
Affects epidermis only; painful and erythematous. Electrical
• Similar to crush injuries: muscle necrosis,
Second-Degree rhabdomyolysis, myoglobinuria occur
• Superficial: Affects epidermis and outer half of • Require special consideration as these burns are
dermis; hairs are spared often more serious than they appear; always
• Deep: Affects epidermis, with destruction of assume that an electrical burn is severe
reticular dermis; can easily convert to full-
thickness burn if secondary infection, Chemical
mechanical trauma or progressive thrombosis • Strong acids are quickly neutralized or quickly
occurs absorbed
• Alkalis cause liquefaction necrosis and can
Third-Degree penetrate deeply, leading to progressive necrosis
Tissue is dry, pearly white, charred, leathery. up to several hours after contact
Heals by epithelial migration from the periphery
and by contracture. May involve adipose, fascia, Radiation
muscle or bone. • Initially appear hyperemic; may later resemble
third-degree burns
Causes • Changes can extend deep into the tissue
Thermal • Sunburns are of this type and involve moderate
• Due to external heat source superficial pain
Table 5: Assessing depth of a burn

Characteristic First degree Second degree Third degree
Blisters None Present None
Colour Red Red White, charred
Moisture Dry Wet Dry
Sensation Present Present Absent
Pain Moderate Severe Absent
History Physical Findings

• Obtain accurate description of exact mechanism • Assess ABC
of injury • Temperature may be elevated if wounds infected
• Inquire about any treatment given at home (e.g. • Heart rate may be elevated because of pain
cooling, application of oils) • Blood pressure may be low if client is in shock
• Medical history (but only when time permits) • Determine depth (Table 5) and extent (Figure 1)
• Medications currently being taken (but only of the burn
when time permits)
• Allergies (but only when time permits)
• Tetanus vaccination status (but only when time
permits)

Figure 1: Assessing extent of a burn (Wallace's • Secondary infection

Rule of Nines) • Renal failure
• Carbon monoxide poisoning
Diagnostic Tests
None.
Management
Table 6: Criteria for transfer of burn patient
• Burns covering 10% or more of body surface
(if age >50 years)
• Second and third degree burns covering 20% or

more of body surface (any age)
• Burns of face, hands, feet, perianal or genital

area, over major joints
• Smoke inhalation, electrical burns, chemical

burns
• Burns associated with major injuries or

fractures
• Circumferential chest or extremity burns
• Lesser burns in a client with underlying disease

(e.g. diabetes mellitus)
Goals of Treatment
• Promote healing and restoration of tissue
Assessing The Severity Of The Burn
The severity of a burn depends on the: Nonpharmacologic Interventions
• depth of the burn The first step is general first aid, cleansing and
• amount of surface area involved cooling the affected area.
• location of the burn • Thermal burn: Cool if area is still warm to
• accompanying complications touch. Burns caused by liquid should be cooled
rapidly, and any clothing in contact with the area
• age of the patient
should be removed rapidly to decrease contact
time. Immerse in cool water to reduce heat and
Differential Diagnosis prevent extension of burn. Do not immerse or
• Scalded skin syndrome apply cold water if burns involve > 10% of
• Systemic reaction (e.g. drug reaction) body.
• Yeast infection
Complications
• Increasing depth of burn
• Shock

• Chemical burn: Irrigate. If dry powder is still • Suggest that analgesics be taken 1 hour before
visible on the skin, brush it away before dressing changes
irrigating the skin with water. Irrigate with • Recommend that dressing be kept clean and dry
copious amounts of water for at least 15 until area healed
(preferably 30) minutes after powders have been
removed. This process should be started at the Adjuvant Therapy
accident scene if possible. Alkali burns should Give tetanus vaccination if needed (refer to the
be irrigated for 1-2 hours after injury. Call Canadian Immunization Guide, 6th ed., 2002).
poison control center for specific instructions.
• Tar burn: Cool, clean gently, and apply a Pharmacologic Interventions
petrolatum-based antibacterial ointment (e.g. Analgesia:
Polysporin®) or other petroleum-based product. ibuprofen (A class drug), 200 mg, 1-2 tabs PO
Do not attempt to scrape tar off the skin surface, q6h prn
as this can cause further damage. Avoid or
chemical solvents, which may cause additional acetaminophen (A class drug), 500 mg, 1-2 tabs,
burns. After 24 hours the tar can be washed q4h prn
away and the injury treated as a thermal burn. or
• Electrical burn: Be cautious and observe the acetaminophen with codeine 30mg (C class drug),
client closely. Watch for cardiac arrhythmias. 1-2 tabs q4-6h prn (maximum 15 tabs)
Cardiac monitoring for 24 hours is essential if
there was significant exposure to electrical Consult a physician if additional analgesia needed
current. Apply a cervical collar. Look for long- for debridement, etc.
bone fractures secondary to muscle contraction.
An electrical burn may cause thrombosis of any Larger, more severe deep second-degree burns
vessel in the body. Clean and dress as for a require topical antibiotic ointment or impregnated
thermal burn (see below). dressings (ointments can make evaluation of
drainage difficult). Apply:
Treatment Of Minor Burns silver sulfadiazine (C class drug), od
Nonpharmacologic Interventions or
First degree burns bacitracin ointment (A class drug), od
• Cleanse with normal saline or sterile water or
• Dressings: Cover area lightly with sterile, dry chlorhexidine dressing (A class drug), 0.5%, od
gauze dressing
• Absolute contraindication to silver sulfadiazine:
Second degree burns term pregnancy
• Remove any attached clothing and debris • Relative contraindication to silver sulfadiazine:
• Cleanse with normal saline or sterile water possible cross-sensitivity to other sulfonamides,
pregnancy
• Gently debride using sterile technique
• Small blisters may be left intact Prophylactic antibiotics should rarely be required
• Debride open blisters but may be considered for:
• Dressings: Small, less severe second-degree • immunocompromised clients
burns do not require antimicrobial ointment or • clients at high risk of endocarditis
impregnated dressings; instead, apply non-
• clients with artificial joints
adherent porous mesh gauze dressing
(e.g. Jelenet®)
Discuss choice with a physician.
Client Education
• Follow up in 24 hours and daily until the burn is
medications (dose, frequency)
healed

• Re-evaluate depth and extent of injury • Absolute sterility is not mandatory during
• Monitor for healing and development of dressing changes; however, cleanliness and
infection thorough cleaning of hands, sinks, tubs and any
• Cleanse and debride prn; tub soaks can help instruments used is emphasized. Acetic acid
loosen coagulum and speed separation of (0.25%) can be applied for pseudomonal
necrotic debris prophylaxis.
• Reapply bacitracin or silver sulfadiazine and dry
sterile dressing

Figure 2: Treatment of Major Burns
Stop the burning process
Perform primary survey
Provide airway and breathing

assistance
- oxygen therapy
- positioning
Consult with physician
Apply wet normal saline dressings to cool the burn
Perform secondary survey
Assess severity of the burn (use rule of nines)
Initiate IV normal saline
Provide analgesia for pain

-morphine 2.5 mg IV
titrated to effect
Calculate IV fluid requirements and administer fluids

according to formula:
wt (kg) x % burn= mL/hr
4
Insert Foley catheter and monitor urine output
Provide further wound care
Transport according to criteria for hospitalization
Source: the Canadian Red Cross Society

and Outpost Hospitals Program (January
2000)

Figure 3: Treatment of Chemical burns
Perform primary
survey
Provide airway and breathing assistance

- oxygen therapy
- positioning
Consult with physician
Manage the chemical

- flush/irrigate burns
- remove clothing
- protect yourself
Perform secondary survey
Assess severity of the burn
Initiate IV normal saline
Provide analgesia for pain

- morphine 2.5 mg IV
titrated to effect
Administer fluids according to formula
Monitor vital signs and systemic signs
Transport according to criteria for hospitalization
Source: The Canadian Red Cross

Society and Outpost Hospital
Program (January 2000)

Frostbite
Thermal injury to tissue caused by cold. Injury • Infection
may occur without (Table 7) or with (Table 8) • Hypothermia
freezing of the tissue. Freezing of the tissue is • Tissue loss
defined by the formation of ice crystals. • Hypersensitivity to cold in affected area may last
several years or be permanent
Cause • Gangrene
Exposure to cold.
Management
Most commonly affects hands and feet. • Identify associated hypothermia
• Rewarm parts
Frostnip • Control pain
• Initially cold, burning pain
• Prevent infection
• Area becomes blanched
• With rewarming, area becomes reddened Nonpharmacologic Interventions
• Rapidly rewarm affected part by immersion in
Frostbite 42°C water for 20-30 minutes; slow rewarming
• Cold burning pain progresses to tingling is not good.
• Later, numbness or heavy sensation • Do not rub and do not use hot water bottles
• Area becomes pale or white • Rest affected limb; avoid irritation to skin
• Rewarming causes pain • Continue rewarming once process has started
until skin is warm, soft, pliable and flushed red
Physical Findings (See also Tables 7 • Prevent refreezing; if in the field, do not thaw
and 8) extremity until assured it will not refreeze
• Variable • Elevate limb once it is rewarmed; leave exposed
• Temperature may be reduced if there is if possible
associated hypothermia or elevated if there is • Do not break blisters
infection • Separate toes and fingers with dry cotton wool
• Client in mild-to-acute distress • Wrap client loosely in bulky soft material and
• Affected area may be reddened or white protect from injury and exposure during
• Edema may be present transport
• Blisters may be present • Give warm fluids to drink
• Infection may be evident if client presents later • Forbid smoking
• Area is initially cold and hard to touch
• Sensation reduced (feels like a piece of wood) Client Education
• If rewarming has occurred, area will be warm • Dress in layers with appropriate cold-weather
and tender gear
• Cover all exposed skin areas
Differential Diagnosis • Prepare properly for trips in cold climates
• Superficial versus deep frostbite • Avoidance of smoking, as nicotine constricts
small vessels

Table 7: Types of cold injury without frostbite

Type of injury Cause Clinical observations Treatment
Chilblain (peripheral Prolonged dry exposure Affected areas are pruritic, reddish Rewarm as for frostbite
cold injury without at temperatures above blue; may be swollen; may have (see text); pain
freezing of tissue) freezing blisters or superficial ulcerations; medication should be
areas may be more temperature provided
sensitive in future; no permanent
injury
Trench foot and Prolonged wet exposure May have tissue destruction Rewarm as for frostbite
immersion injury at temperatures above resembling second degree burns, (see text)
freezing including blisters, pain,
hypersensitivity to cold; temperature
sensitivity may be permanent
Pharmacologic Interventions Monitoring and Follow-up

Mild Frostbite Mild Frostbite
Analgesia for pain: Reassess and re-dress wound daily for 4-7 days,
acetaminophen (A class drug), 325 or 500 mg, until the wound is healing well. Watch for signs of
1-2 tabs PO q4h prn infection.
or
ibuprofen (A class drug), 400 mg, 1-2 tabs PO Appropriate Consultation
q4h prn Consult a physician for all but mild frostnip.
Moderate to Severe Frostbite Referral

Analgesia for pain, which may be severe during Moderate-to-Severe Frostbite
rewarming: Medevac anyone with moderate-to-severe frostbite
meperidine (D class drug), 50-100 mg IM q3-4h to hospital as soon as possible.
Table 8: Classification of frostbite

Frostnip Superficial frostbite Deep frostbite
Superficial, skin changes Tissue below skin pliable, soft Tissue feels woody under skin; affects
reversible muscles, tendons, etc.
Blisters appear in 24-48 hours;
Skin blanched, numb; loss of fluid reabsorbs; hard, blackened Extremity cool, deep purple or red, with dark,
sensation eschar develops; generally hemorrhagic blisters and loss of distal
superficial, remains sensitive to function; may take several months to
Comparable to first degree hot heat and cold determine extent of injury
thermal burn
Treat conservatively; generally Frozen tissue will eventually slough
resolves without surgical
intervention in 3-4 weeks

Chapter 10- Hematology, Metabolism, and

Endocrinology
Common Hematologic Problems ..................................................................................................................... 1
Anemia............................................................................................................................................................ 1
Iron Deficiency Anemia.................................................................................................................................. 2
Megaloblastic Anemia .................................................................................................................................... 4
Common Endocrine And Metabolic Problems............................................................................................... 6

Diabetes Mellitus ............................................................................................................................................ 6
Hyperthyroidism ........................................................................................................................................... 13
Hypothyroidism ............................................................................................................................................ 15
Osteoporosis.................................................................................................................................................. 17
Metabolic Emergencies................................................................................................................................... 19
Diabetic Ketoacidosis ................................................................................................................................... 19
Hypoglycemia............................................................................................................................................... 21
Explanatory Note
For this chapter, history and examination of the system are not discussed as such, because hematologic,
metabolic and endocrine disorders often manifest symptoms and signs in more than one body system. The
cardiovascular, gastrointestinal, neurologic, endocrine and integumentary systems in particular should be
evaluated, as problems or symptoms of hematologic, metabolic and endocrine disorders commonly manifest
in these systems.
See individual chapters for information on history and physical examination relevant to each of these systems.

Common Hematologic Problems

Anemia • Dyspnea on exertion
• Easy fatigability
Definition • Fainting, lightheadedness
Anemia can be generally defined as a reduction in • Tinnitus, roaring in the ears
hemoglobin level. In determining the seriousness
• Headache
of the anemia, the level of hemoglobin is less
• Palpitations
important than the underlying cause. However,
there are more than 200 types of anemia, which • Exacerbation of pre-existing cardiovascular
makes determining the cause difficult. conditions
Angina pectoris, intermittent claudication and

Classification nighttime muscle cramps are some of the effects of
There are three main ways of classifying anemias.
anemia on already-compromised perfusion.
Cytometric types: depend on cell size and
hemoglobin-content parameters, such as mean Physical Findings
corpuscular volume (MCV) and mean corpuscular For slowly developing anemia:
hemoglobin concentration (MCHC) • Pallor
• Tachycardia
Erythrokinetic types: take into account the rates of • Systolic ejection murmur
red blood cell (RBC) production and destruction
In rapidly developing anemia (as from hemorrhage
Biochemical/molecular types: consider the cause and certain catastrophic hemolytic anemias),
of the anemia at the molecular level additional symptoms and signs are noted:
• Syncope on rising from bed
For example, sickle cell anemia is classified as • Orthostatic hypotension (i.e. the blood pressure
normocytic, normochromic in the cytometric falls when the patient is raised from a supine to a
classification, as hemolytic in the erythrokinetic sitting or standing position)
classification, and as resulting from a DNA • Orthostatic tachycardia
mutation producing amino acid substitution in the
hemoglobin chain according to the Keep in mind that if anemia develops through
biochemical/molecular classification. rapid bleeding, the hematocrit and hemoglobin
will be normal (because in hemorrhage the loss of
History RBCs and plasma is proportional). Therefore, your
When symptoms do develop, they are related to appreciation of the clinical signs will be of more
the precarious state of oxygen delivery to the value in diagnosing this type of anemia than will
tissues: the results of laboratory tests.

Iron Deficiency Anemia

Definition standard deviations (SD) below the mean should
Subnormal quantity of hemoglobin, number of be considered anemic, and investigation is needed.
RBCs or volume of packed cells in the blood. In The anemia is often accompanied by depletion of
general, clients with hemoglobin more than two iron stores.
Table 1: Reference value for blood components

Component Measurement Age (years) Females Males
Hemoglobin (g/L) 1-4 111-145 111-145

5-9 114-145 114-151
10-14 124-145 124-158
≥15 121-164 140-179
Red blood cells (x 10 12/L) 1-4 4.0 – 5.2 4.0 – 5.2

5-9 4.2 – 5.3 4.2 – 5.3
10-14 4.5 – 5.7 4.5 – 5.7
15-49 4.0 – 5.4 4.6 – 6.0
≥50 4.0 – 5.6 4.4 – 5.8
Hematocrit (proportion) 1-4 0.35 – 0.45 0.35 – 0.45

5-9 0.36 – 0.47 0.36 – 0.47
10-14 0.38 – 0.47 0.38 – 0.49
≥15 0.38 – 0.50 0.42 – 0.54
White blood cells (x 109/L) 1-4 5.0 – 12.0 5.0 – 12.0

5-49 4.0 – 10.5 4.0 – 10.5
≥50 4.0 – 10.0 4.0 – 11.0
Platelets (x 109/L) 1-4 175 – 500 175 – 500

5-9 175 – 420 175 – 420
10-14 175 – 375 175 – 375
≥15 170 – 375 160 – 350
Causes History
• Inadequate dietary intake of iron (common in • Iron deficiency anemia is not a disease, but a
children, adolescents and elderly people) sign of an underlying disorder
• Increased requirements for iron without • A complete history and physical examination are
concomitant increase in intake (during growth required
spurts in infants, young children, adolescents • Symptoms vary according to severity of the
and pregnant women) anemia, underlying cause, rapidity with which
• Blood loss due to excessive menstruation, the underlying condition developed, and
disease of the gastrointestinal tract (e.g. peptic presence of pre-existing heart and lung disease
ulcer, hiatus hernia), malignant disease,
telangiectasia, previous acute blood loss (e.g. Mild Condition
trauma, surgery) • Often asymptomatic
• Impaired absorption of iron because of partial • Fatigue
gastrectomy, malabsorption syndromes • Dyspnea
• Palpitations after exertion

Moderate or Severe Condition Diagnostic Tests

• Symptomatic at rest • Complete blood count, differential blood count,
• Exercise intolerance reticulocyte count, blood smear film for RBC
• Symptoms of heart failure, syncope may be morphology
present • Serum iron level, total iron-binding capacity
• Palpitations, dizziness, headache, tinnitus (TIBC), serum ferritin level
• Irritability, insomnia, inability to concentrate • Test three separate samples of stool for occult
• Hypersensitivity to cold and malaise blood
• Menstrual disturbances
• Medications such as anticonvulsants Management
(e.g. phenytoin, primidone, triamterene, Goals of Treatment
sulfamethoxazole/trimethoprim (long-term use • Increase hemoglobin concentration
only), oral contraceptives • Replenish body stores of iron
• HIV medications (e.g. zidovudine [AZT] and • Identify underlying cause
antineoplastic drugs [for chemotherapy])
• Alcohol intake Appropriate Consultation
• Dietary history (e.g. strict vegetarianism) Consult a physician immediately if hemoglobin
• Gastric or small-bowel surgery < 90 g/L, stool is positive for occult blood or client
• Chronic inflammatory disease such as appears acutely ill.
rheumatoid arthritis, Crohn's disease
• Malignant disease Client Education
• Diminished renal, hepatic or thyroid function • Explain disease process, course and prognosis
Physical Findings medications (dose, frequency, side effects)
• Heart rate increased • Suggest dietary modifications to increase intake
• Postural blood pressure drop may be present of iron (e.g. organ meats, egg yolk, prunes,
grapes, raisins, cream of wheat)
• General pallor
• Appears tired and lethargic • Recommend frequent periods of rest to reduce
fatigue
• Conjunctival and palmar pallor
• Recommend avoidance of alcohol and
• Glossitis may occur in severe anemia acetylsalicylic acid (ASA) products
• Cracking at corners of mouth • Counsel client about prevention of constipation
• Nail changes (e.g. encourage a high-roughage diet)
• Liver or spleen may be enlarged
• Skin and hair may feel dry Pharmacologic Interventions
• Functional systolic murmur may be present Oral iron therapy:
ferrous sulfate (A class drug), 300 mg PO tid
Rule out other causes of anemia. See general Monitoring and Follow-Up
section "Anemia," above, this chapter. Follow up in 1 month: hemoglobin level should
rise by at least 1 g/L while client is receiving
Complications therapy. Continue iron for 3 months after initial
• Frequent infections follow-up to replenish iron stores.
• Side effects of iron therapy
• Decompensation of pre-existing medical Referral
problems Any client in whom there is no response after 1
month of oral therapy should be referred to a
physician for further investigation.

Megaloblastic Anemia
Production of abnormally large, oval RBCs with • Complete blood count
elevated MCV (>100 fL [femtoliters]). • Differential blood count
• Blood smear
Causes • Iron level
Vitamin B12 deficiency (pernicious anemia), • Total iron-binding capacity (TIBC)
resulting from: • Ferritin level
• Inadequate dietary intake (e.g. strict • Vitamin B12 level
vegetarianism) • Serum level of RBC folate
• Impaired absorption (e.g. after gastrectomy or
surgery to the ileum)
Management
• Increased requirements (e.g. in pregnancy) Goals of Treatment
• Faulty utilization • Determine the cause of the anemia
• Replace identified deficiencies
Folic acid deficiency, resulting from:
• Inadequate intake (e.g. in elderly, alcoholic or
chronically ill clients)
Consult a physician immediately if the symptoms
• Malabsorption syndromes of anemia are significant or if complications are
• Increased demand (e.g. in pregnancy, terminal present, and to obtain medication orders.
illness)
• Use of drugs that are folate antagonists such as Client Education
methotrexate, phenytoin, • Explain disease process, course and prognosis
sulfamethoxazole/trimethoprim
• HIV disease (and associated drug therapy) medications (dose, frequency, side effects)
• Other chemotherapy agents • Provide dietary counseling on foods rich in folic
acid: green leafy vegetables, grains, wheat bran,
History liver
• Insidious onset • Stress importance of returning for follow-up
• Occurs in the fifth to sixth decades of life
• Fatigue, lethargy Pharmacologic Interventions
• Indigestion, constipation or diarrhea For vitamin B12 deficiency (pernicious) anemia
• Sore tongue and folic acid deficiency anemia: medications as
• Neurological symptoms (such as peripheral per physician order.
neuropathy, weakness, unsteadiness, spasticity
and changes in emotional affect) occur with Monitoring and Follow-Up
vitamin B12 deficiency • Follow up 2 weeks after treatment is started to
• Neurological symptoms are absent in folic acid determine response to therapy; recheck blood
deficiency work at that time
• With both types of deficiency anemia there is
Differential Diagnosis usually a rapid response: within 1 week,
Other types of anemia (see general section • hematocrit levels begin to rise
"Anemia," above, this chapter). • Continue to follow up monthly, and repeat blood
work until stabilized
Complications • Physician referral if no improvement
• Infections
• Falls or other trauma
• Heart failure

Serum potassium level should be monitored As hemoglobin rises in response to vitamin B12
closely in clients with severe pernicious anemia administration, the MCV gradually decreases and
complicated by heart failure. (A rapid rise in the client may become microcytic, with the
reticulocytes and use of diuretics combine to cause hemoglobin plateauing at a level below normal. If
hypokalemia. Supplementary potassium should be this occurs, oral iron therapy should be added to
administered). Consult a physician for the achieve maximum hemoglobin response.
medication order.

Common Endocrine And Metabolic Problems

Diabetes Mellitus
Definition Impaired Glucose Tolerance
Diabetes mellitus is a metabolic disorder People with a fasting blood glucose level > 6.1 -
characterized by hyperglycemia, which is due to 7.0 mmol/L and a 2-hour pc blood glucose level
reduced insulin secretion, increased tissue between 7.8 and 11.1 mmol/L are considered to
resistance to insulin action or both. have impaired glucose tolerance.
Classification Both of these groups have a higher risk of diabetes

Type 1 mellitus and cardiovascular disease than the
Type 1 diabetes mellitus is primarily the result of general population. Preventive interventions
pancreatic ß-cell destruction, which leads to involving lifestyle changes and more frequent
absolute insulin deficiency and tendency to screening for diabetes should be a priority for
ketoacidosis. Onset is usually at younger age these people.
(<30 years).
Causes
Type 2 • Genetic
Type 2 diabetes mellitus occurs as a result of some • Autoimmune
degree of defect in insulin secretion and an • Related to pancreatitis
increase in resistance to insulin in the tissues. Age
at onset is usually middle age or older. People with Risk Factors
type 2 diabetes are much less prone to • Family history
ketoacidosis. • Hypertension
• Hyperlipidemia
The prevalence of type 2 diabetes is reaching • Central obesity
epidemic proportions among First Nations people.
• Smoking
Age-adjusted prevalence rates are 19% to 26%,
among the highest in the world. The condition is
• High-fat diet
also occurring atypically in children and young • Previous gestational diabetes
adults in this population.
History
Gestational Diabetes • Polyuria, polydipsia, polyphagia
Gestational diabetes is a transient disorder, starting • Nocturia
in pregnancy and ending with delivery. Women • Weight history (especially any weight loss)
with gestational diabetes often go on to have type • Fatigue, irritability
2 diabetes later in life. Gestational diabetes is • Obesity (particularly in the central trunk)
defined as fasting blood glucose > 5.3 mmol/L and • Blurred vision, changes in vision, frequent
1-hour pc blood glucose > 10.6 mmol/L or 2-hour changes in optical prescription
pc blood glucose > 8.9 mmol/L. These pc glucose • Nausea and vomiting
levels are based on a 75-g glucose load. • Unresolving "flu-like" illness (ketoacidosis)
• Reversible paresthesia of fingers or toes
Impaired Glucose Tolerance (Pre-
Diabetes) Past History
Impaired Fasting Glucose Tolerance • Obstetric: gestational diabetes, large babies
People with a fasting blood glucose level between (>4.5 kg at delivery)
6.1 and 7.0 mmol/L, which is below the diagnostic
• Endocrine disorders
threshold for diabetes, are considered to have
impaired fasting glucose tolerance.
• Cardiovascular disease

• Hypertension • Cardiac system: signs of heart failure, bruits,

• Hyperlipidemia peripheral pulses
• Recurrent or unresolving vaginal infections • Abdomen: enlargement of organs
(yeast), urinary tract infections, skin infections • Genitourinary system: signs of nephropathy
(especially of feet) (e.g. proteinuria)
• Surgery (e.g. on pancreas) • Musculoskeletal system: signs of limited joint
mobility, arthropathy of hands
Family History • Skin: infection (e.g. feet or nails), colour,
• Diabetes mellitus temperature, poor healing
• Hyperlipidemia • Signs of neuropathy: neurological effects;
• Hypertension changes in vibrational sense (e.g. in feet),
• Renal disease proprioception, response to light touch (with
• Infertility monofilament), reflexes
• Hirsutism
• Autoimmune diseases Differential Diagnosis
• Pancreatitis • Impaired fasting glucose tolerance (fasting blood
• Blindness glucose 6.1-7.0 mmol/L)
• Impaired glucose tolerance (2-hour pc blood
Current Health glucose level with 75-g glucose tolerance test
• Eating habits (food choices, meal patterns, [GTT] 7.8-11.1 mmol/L)
cultural influences concerning food) • Nondiabetic glycosuria
• Physical activity level, factors limiting physical • Drug side effects (e.g. oral contraceptives,
activity corticosteroids, thiazide diuretics)
• Medications (e.g. thiazides, sugar-containing • Diabetes insipidus
medications, corticosteroids) • Pheochromocytoma
• Allergies • Cushing's syndrome
• Smoking habits
• Alcohol use Complications
• Social factors: family dynamics, education, • Ketoacidosis (type 1); see "Diabetic
employment, lifestyle, coping skills Ketoacidosis," under "Metabolic Emergencies,"
below, this chapter
Physical Findings • Hyperosmolar nonketotic coma
A complete review and examination of all body • Coronary artery disease, peripheral vascular
systems must be done to detect the presence of any disease
damage secondary to the diabetes. • Nephropathy, urinary infections
• Client appears ill if diabetes is of acute onset • Retinopathy, cataracts (early onset), blindness
• Client appears wasted if there has been weight • Peripheral neuropathy
loss • Recurrent skin (yeast) infections
• Vital signs: changes depend on initial presenting • Premature death from complications
complaint and presence of underlying damage to
target organs Diagnostic Tests
• Blood pressure may be elevated Diagnostic Blood Glucose Levels
• Eyes: funduscopic signs of retinopathy Random blood glucose level > 11.1 mmol/L in
• Oral cavity: poor dental health (client at risk for presence of symptoms (if random result < 11.1
infection) mmol/L, have client return within a day or two for
• Neck: thyroid assessment a fasting glucose test to ascertain definitive
• Chest: routine respiratory exam diagnosis)
or

Fasting blood glucose level > 7.0 mmol/L on two • Counsel client about appropriate use of
or more occasions medications (dose, frequency, route of
or administration, side effects)
Blood glucose level 2 hours after oral GTT (with • If client is taking insulin, monitor ability to self-
75-g load) = 11.1 mmol/L administer
• Provide dietary counseling
Other Tests • Have client maintain a dietary intake journal,
• Lipid levels, complete blood count, creatinine and review the journal regularly
level and TSH • Home glucose monitoring is essential; have
• Urinalysis (routine and microscopy) client demonstrate ability to perform these tests
• Urine dipstick test for glucose, ketones and accurately, provide instruction as necessary, and
protein, microalbuminuria encourage maintenance of daily diary of results
• Discuss with client the procedure to follow in
Management the event of an illness
Goals of Treatment • Educate client about signs and symptoms of
• Attain optimum glycemic control hyperglycemia and hypoglycemia, and tell client
• Educate the client for self-care what to do if these conditions develop
• Prevent complications • Discuss foot care with client: keep feet clean;
• Attain optimum control of concomitant avoid dry skin (apply moisturizer daily); wear
hypertension and hyperlipidemia and other appropriate shoes or boots (not tight); avoid
cardiovascular risk factors going barefoot; avoid open-toe shoes; do not cut
• Prioritize for alcohol and drug rehabilitation nails too short; give prompt attention to cuts and
sores
Appropriate Consultation • Exercise will help with weight control and will
Consult a physician immediately if diabetes reduce blood glucose levels
mellitus is suspected. All drug therapy for clients
with diabetes is initiated by a physician. Involve the entire family in diabetic teaching to
give them an understanding of diabetes and to
Nonpharmacologic Interventions enlist their support and assistance in the client's
Lifestyle Modifications management of the condition.
• Nutrition therapy: consultation with dietician is
recommended Pharmacologic Interventions
• Nutritional recommendations: choose well- Type 1
balanced diet from the four food groups; Insulin therapy as ordered by physician (Table 2).
decrease saturated fats to < 10% of total Type 2
calories; ensure adequate intake of Physician-initiated drug therapy:
carbohydrates, protein, vitamins and minerals
• Useful starting point is to plan meals with 55% Monitoring and Follow-Up
carbohydrates and 30% fat content Follow up every 4-6 weeks initially or more often
• Exercise program: regular activity (e.g. walking as needed. Once stabilized, follow up three or four
for 20 minutes three times weekly) times a year. Monitoring should involve the
following components.
• Weight control to maintain healthy body weight
• Smoking and alcohol cessation At each visit:
• Education in diabetes self-care 1. Assess compliance with medications, diet and
exercise
Client Education
• Explain nature, course and prognosis of disease, 2. Review dietary journal with client and tailor
as well as possible complications: condition can diet plan to client's preferences and food
be controlled, but it cannot be cured availability

3. Measure blood pressure and weight each visit Annually:

10. Electrocardiography (ECG) (if > 35 years of
4. Perform foot examination at least twice yearly age)
5. Encourage weight loss if appropriate: aim to 11. Fasting lipid profile

reduce excess body weight by about 0.5 kg/week
(in most cases this can be achieved by reducing 12. Eye (dilated funduscopic) exam by eye team
caloric intake by about 500 calories/day)
(see Flow Sheet)
6. Encourage client to exercise regularly (a daily
walk is the best form of exercise for the general (Reference: Practical Diabetes Management:
population) Clinical Support for Primary Care Physicians. Fall
2000. Intramed Health Services, Mississauga,
7. Measure fasting blood glucose; measure HbA1C ON) (www.amda.ab.ca)
every 3-4 months if client is not stable and every
6 months if client is stable Referral
• Refer all newly diagnosed clients to a physician
8. Urinalysis for gross protein (q 6-12 months) as soon as possible for complete evaluation and
referral to diabetic clinic.
9. If nephropathy is diagnosed, refer to physician. • Arrange follow-up with a physician twice yearly
Follow-up monitoring as directed by physician if stable or more frequently as necessary
Table 2: Types of insulin

Type Time to onset of action Peak action Duration of action
Lispro 5-10 minutes 45 minutes 3-4 hours
Regular 30-45 minutes 2-5 hours 5-8 hours
NPH 1-3 hours 4-12 hours 18-24 hours
70/30 30-45 minutes 2-12 hours 18-24 hours
50/50 30-45 minutes 2-12 hours 18-24 hours
Lente 2-5 hours 7-15 hours 18-22 hours
Ultra-Lente 4-6 hours 8-20 hours 24-28 hours
Prevention Strategies Screening Strategies

Primary Prevention, Type 1 Diabetes Screening for Diabetes Mellitus
Mellitus High-risk groups require aggressive screening for
There are no known proven strategies to prevent diabetes.
type 1 diabetes mellitus.
The 2003 Clinical Practice Guidelines for the
Primary Prevention, Type 2 Diabetes Management of Diabetes in Canada (Meltzer et al.
Mellitus 2003) recommended the following screening
• The major focus of any diabetes strategy should principles.
be primary prevention
• Programs should be targeted to school children People > 45 years of age should be screened every
and their parents (to prevent diabetes in future 3 years. Screening should be annual for anyone
generations) and to individuals who are at with any of the following risk factors:
increased risk • Obesity (body mass index > 27 kg/m2)
• Primary prevention is aimed at weight control • First-degree relative with diabetes mellitus
through a program of diet and exercise • Member of a high-risk population (e.g.
Aboriginal Canadian)

• Low level of high-density lipoprotein • Coronary artery disease

(HDL)(<0.90 mmol/L) or elevated fasting level • Presence of complications associated with
of triglyceride (>2.8 mmol/L) diabetes
• History of gestational diabetes
• History of impaired fasting glucose tolerance
(fasting blood glucose 6.1-6.9 mmol/L)
• History of impaired glucose tolerance (fasting
blood glucose < 7.0 mmol/L, 2-hour pc blood
glucose level [2 hours after oral GTT] 7.8-11.0
mmol/L)
• Hypertension



Hyperthyroidism
Definition Special considerations in the elderly client:
One form of thyrotoxicosis in which an excess of • Classic presentation may be absent
thyroid hormone is secreted. • Usually only three clinical signs: fatigue, weight
loss, tachycardia
Causes • Goiter is much less common in this age group
• Graves' disease
• Toxic multinodular goiter (which develops in Special considerations in the pregnant client:
response to some bodily need, e.g. pregnancy) • Radioactive iodine is contraindicated in
• Thyroid cancer pregnancy
• Postpartum thyroiditis (onset 2-6 months • Propylthiouracil can induce hypothyroidism or
postpartum) is a mild, short-term form cretinism in the fetus
• Thyrotoxicosis may improve during pregnancy
Risk Factors but will relapse in the postpartum period
• For Graves' disease: positive family history,
female 20-40 years of age, other autoimmune Physical Findings
disorders • Heart rate increased, may be irregular (client
• For toxic multinodular goiter: older age; recent may present with atrial fibrillation)
exposure to iodine-containing medication (e.g. • Blood pressure: systolic hypertension may be
amiodarone or radiocontrast dye); long-standing present
simple goiter; conditions such as puberty or • Weight decreased
pregnancy; immunologic, viral or genetic • Skin warm, moist and velvety; palms may be
disorders sweaty
• Hair thin and silky
History • Eyes prominent or protruding, staring; lid lag
• Usually woman between 20 and 40 years of age present (exophthalmos)
• Symptoms (as listed below) variable in severity • Only 50% of patients have enlargement of the
• Fatigue, weakness thyroid gland
• Insomnia • Thyroid diffusely enlarged, smooth, possibly
• Weight loss with no change in diet or appetite asymmetrical and nodular; a thrill may be felt or
• Heat intolerance a bruit may be heard directly over the gland
• Excessive sweating • Heart: point of maximal impulse (PMI)
• Alterations in bowel habits displaced if enlargement has occurred; thrills or
• Menstrual changes (e.g. decreased menses) systolic murmur may be present
• Restlessness, nervousness, irritability • Lungs normal
• Inability to concentrate • Liver and spleen enlarged
• Mood swings (from depression to extreme • Hands: fine resting tremor may be present
euphoria) • Legs: bilateral non-pitting edema
• Visual changes (e.g. diplopia, photophobia, eye • Hyperactive reflexes
irritation, bulging eyes, decreased blinking)
• Difficulty swallowing, hoarse voice Differential Diagnosis
• Palpitations • Transient thyroiditis
• Exertional dyspnea, fatigue, chest pain • Thyroid cancer
• Edema (e.g. periorbital, in feet and ankles) • Pheochromocytoma
• Loss of hair, change in hair texture (hair • Menopause
becomes fine and silky) • Anxiety

Complications • Protection of the eyes to prevent irritation and

• Exophthalmos abrasions: sunglasses, patches at night, use of
• Loss of vision artificial tears to prevent drying
• Corneal abrasions
• Atrial fibrillation Client Education
• Angina • Explain disease course and expected outcome
• Heart failure • Counsel client about appropriate use of
• Hypertension medications (dose, frequency, side effects,
avoidance of abrupt discontinuation)
• Thyrotoxic storm (rare)
• Osteoporosis (in elderly women)
Drug therapy as ordered by physician.
Diagnostic Tests
Progressive TSH. TSH (will be decreased) and Radioactive iodine therapy as ordered by specialist
thyroxine (T4) level (may be elevated).
Management • Clients treated with radioactive iodine should be
Goals of Treatment seen monthly until a euthyroid state achieved;
• Relieve symptoms thereafter, follow up every 6 months
• Return to euthyroid state • Monitor TSH level for hypothyroidism
• Prevent complications • Elderly women with hyperthyroidism are at
increased risk for accelerated bone loss; consider
Appropriate Consultation monitoring bone density annually in these
Consult a physician. clients

• Dietary modifications: high-calorie diet, Refer all newly diagnosed clients
frequent nutritious snacks, caffeine restriction
• Frequent rest periods to avoid fatigue

Hypothyroidism
Definition Late Symptoms
A clinical state resulting from decreased secretion • Slowing of intellectual and motor activity
of thyroid hormones or from resistance to • Absence of sweating
hormone action; this leads to a progressive • Modest weight gain
slowing of all body functions. • Constipation
• Periorbital and peripheral edema
Myxedema is the severest form of • Pallor
hypothyroidism.
• Hoarseness
• Decreased sense of taste and smell
Causes • Muscle aches and stiffness
Primary Hypothyroidism
• Dyspnea
• Idiopathic decrease in production of hormone
• Deafness
• Autoimmune thyroiditis (Hashimoto's disease)
• Cessation of menses
• Endemic iodine deficiency
• Night blindness
• Congenital defects
• Depression
• Infertility
Secondary Hypothyroidism
• Radioactive iodine therapy
Physical Findings
• Thyroidectomy
• Heart rate decreased
• Insufficient dose of thyroid replacement therapy
• Blood pressure normal (diastolic hypertension
• Subacute thyroiditis (after a viral illness)
may be present)
• Common in the postpartum period as subacute
• Postural hypotension (with pituitary or
granulomatous thyroiditis
hypothalamic failure)
• Insufficient stimulation from the pituitary or
• Facial pallor
hypothalamus axis (pituitary or adrenal disease)
• Jaundice may be present
Risk Factors • Puffiness of face and eyelids (myxedema)
• Woman > 40 years of age (at highest risk) • Thin, brittle nails
• Presence of another autoimmune disorder • Coarse, thin hair
• Recent acute viral or bacterial infection • Occasional purpura
• Treatment with radioactive iodine • Thickening of nose and lips in more advanced
• Thyroidectomy cases
• Evidence of pituitary or hypothalamic disease • Poor skin turgor
• Postpartum period • Dry, rough, thickened skin
• Thyroid gland may be enlarged
History • Pleural effusion may be present
Symptoms may be subtle, insidious. • Displaced apical beat (if enlargement of left
ventricle has occurred)
Early Symptoms • Heart sounds may seem distant
• Weakness • Delayed return of deep tendon reflexes
• Fatigue (Achilles)
• Cold intolerance
• Lethargy Differential Diagnosis
• Dry, flaky skin • Thyroid cancer
• Headache • Euthyroid sick syndrome
• Menorrhagia • Nephrotic syndrome
• Anorexia • Nephritis

• Depression • Emphasize the need for lifelong treatment and

• Dementia from other causes the dangers of not taking medications
• Heart failure • Teach client about signs and symptoms of
hyperthyroidism (indicating medication
Complications overdose) and hypothyroidism (indicating
• Coronary artery disease, congestive heart failure medication underdose)
• Constipation, megacolon • Provide dietary advice (e.g. increase fiber and
• Increased susceptibility to infection fluids to prevent constipation)
• Mental disturbances including depression, • Drugs should be taken on an empty stomach, as
organic psychosis dietary fiber can interfere with absorption.
• Myxedema coma
• Infertility
As ordered by physician
• Hypersensitivity to opiates
• Adrenal crisis Monitoring and Follow-Up
• Bone demineralization • Follow up as needed until stabilized
• Monitor weight, blood pressure and energy level
Diagnostic Tests • Assess compliance with medications
• TSH and T4 • Monitor TSH and T4 levels as ordered until
• Complete blood count euthyroid state is attained
• Cholesterol and triglycerides • Follow up every 6-12 months after TSH level is
• Liver function tests (LFTs) normalized
Management Referral
Goals of Treatment Refer to physician for diagnosis
• Return to euthyroid state
• Prevent complications Arrange follow-up with a physician as required:
• During initial replacement phase
Appropriate Consultation • Whenever symptoms are not controlled by
Consult with a physician therapy
• If there is evidence of complications
Client Education • Once yearly when maintenance dose is
• Explain nature, course and prognosis of disease established
medications, including side effects

Osteoporosis
Definition History
Generalized, progressive disorder of bone • Postmenopausal female (90% of cases)
metabolism characterized by reduction of bone • Generalized aching in bones, particularly lower
tissue mass, resulting in bone fragility. back
• Non-traumatic fractures, often of weight-bearing
Causes bones of spine
Rarely due to a single factor. • Progressive structural changes of spine (e.g.
kyphosis and lordosis)
Primary Osteoporosis • Loss of height
• Type 1 results from postmenopausal endocrine • Minimal trauma may cause hip and Colles'
changes and occurs between 51 and 75 years of fractures
age • Diet - calcium poor
• Type 2 occurs in people > 70 years of age and
probably results from age-related reduction in Physical Findings
vitamin D synthesis or resistance to vitamin D • Usually thin, frail elderly woman
effects
• Various degrees of bony deformity, often of
spine (kyphosis)
Secondary Osteoporosis
• Height decreased (compared with known
• Endocrine basis: glucocorticoid excess, previous height)
hyperthyroidism, hyperparathyroidism, diabetes
• Bone tenderness to deep palpation may be
mellitus
present (particularly over tibia)
• Drug-induced: corticosteroids, barbiturates,
• Difficulty with mobility
heparin, thyroid hormones, alcohol, tobacco,
caffeine
• Other causes: chronic renal failure, liver disease, Differential Diagnosis
chronic obstructive pulmonary disease (COPD), • In premenopausal women and in men, rule out
rheumatoid arthritis, malignant disease, organic disease (see "Causes, Secondary
Cushing's syndrome, multiple myeloma Osteoporosis," above)
• Osteoarthritis
Risk Factors • Renal or collagen disease
• Family history • Metastatic bone disease
• Age • Multiple myeloma
• Female • Hyperthyroidism
• Low initial bone mass (slender body frame)
• Menopause (estrogen deficiency) Complications
• Deficient calcium and vitamin D intake or • Vertebral crush fractures
absorption • Physiological fractures
• Smoking • Chronic pain and disability
• Excessive alcohol consumption
• Excessive caffeine Diagnostic Tests
• Sedentary lifestyle (with reduced stress on • Complete blood count and erythrocyte
bones) sedimentation rate (ESR); levels of glucose,
• Osteoarthritis TSH, parathyroid hormone, estrogen, alkaline
phosphatase, calcium, vitamin D
• Bone densitometry test as ordered by a physician

Management • Importance of calcium rich foods (dietary

Goals of Treatment sources of calcium include salmon, sardines,
• Primary prevention green vegetables, cheeses, skim milk)
• Reduce further bone loss in elderly clients • Discuss risk factors
• Detect and manage fractures • Make changes to exercise pattern
• Preventative supplement options available over
Nonpharmacologic Interventions the counter
• Ensure adequate calcium and vitamin D intake
in diet (1200-1500 mg per day) Pharmacologic Interventions
• Recommend an exercise program (walking 50- Hormone Replacement Therapy as ordered by
60 minutes three times a week provides physician. Women with symptomatic osteoporosis
optimum benefit) who are unable or unwilling to use estrogen may
• Smoking cessation counseling benefit from bisphosphonate drug therapy, e.g.
• Encourage elimination of alcohol and caffeine etidronate (B class drug).
from diet
• Assess home environment for hazards to Monitoring and Follow-Up
mobility; modify or provide aids as required • Women should undergo Pap smear testing when
HRT is started
Client Education • Bone densitometry as ordered by physician
• Explain disease course and outcome: this is a • Follow-up as discussed with physician
chronic condition that can be controlled but not • People taking calcium supplements may be at
cured; pain is often chronic risk for kidney stones.
medications (dose, frequency, side effects, Referral
importance of compliance) Refer the following clients to a physician for
• Advise client to return to clinic for assessment if assessment:
character of pain changes or if pain becomes • Persons with high risk for or clinical evidence of
more severe osteoporosis
• Women in menopause (for prophylactic
hormone replacement)
• Suspected osteoporosis

Metabolic Emergencies
Diabetic Ketoacidosis
A condition due to insulin deficiency that is • Severe dehydration
characterized by hyperglycemia, ketonemia, • Electrolyte imbalance (e.g. hyponatremia,
ketonuria, acidosis and dehydration. hypokalemia, hyperkalemia, decreased serum
bicarbonate)
Causes • Cerebral edema related to overaggressive
• Type 1 diabetes mellitus. rehydration
• Noncompliance with diet • Hypoglycemia related to overcorrection of
• Failure to take insulin properly hyperglycemia
• Concurrent illness or infection or failure to • Gastric dilatation
adjust diabetic regimen when ill • Paralytic ileus
• Inadequate insulin (dose, type)
Diagnostic Tests
History • Concentration of ketones in urine
• Insidious onset • Random blood glucose level with glucometer
• Malaise, weakness, marked fatigue • Blood for baseline creatinine and electrolyte
• Thirst levels and complete blood count
• Polyuria, polydipsia, polyphagia • ECG may be helpful: look for the tall T-wave of
• Anorexia hyperkalemia and watch for signs of silent
• Nausea and vomiting myocardial infarction in the older diabetic client
• Abdominal pain
• Muscle aches Management
• Headache The reversal of diabetic ketoacidosis should be
• Blurred vision gradual to prevent overcorrection.
• Reversible paresthesia in fingertips
Goals of Treatment
• Assess and stabilize airway, breathing and
Physical Findings
circulation (ABC)
• Client appears ill
• Rehydrate
• Temperature normal
• Identify precipitating factors
• Heart rate rapid
• Treat any underlying cause (e.g. infection)
• Respirations deep and rapid (Kussmaul
• Reduce blood glucose to about 13.8 mmol/L
respiration)
• Blood pressure usually normal
• Postural blood pressure drop Consult a physician immediately
• Reduced level of consciousness may be present
• Fruity odor on breath Adjuvant Therapy
• Mucous membranes dry Oxygen as needed; keep oxygen saturation > 97%
• Skin warm and dry, loss of turgor
Intravenous Therapy
Differential Diagnosis Reversing the dehydration will assist in reducing
• Hypoglycemia the blood glucose level.
• Other causes of stupor or coma (e.g. stroke, head • Start IV therapy with 0.9% normal saline
injury, alcohol or drug overdose)

• Run at 500-1000 mL/h (10-20 mL/kg per hour) Monitoring and Follow-Up
as per physician orders • Check blood glucose hourly and before insulin
• After this, adjust IV infusion rate according to administration: avoid falls in glucose
clinical response, state of hydration and ongoing > 5.5 mmol per hour
urinary losses • Monitor heart rate, blood pressure, postural
blood pressure changes and mental status
Nonpharmacologic Interventions frequently
• Insert indwelling urinary catheter • Cardiac monitoring
• Insert nasogastric tube if client is comatose • Measure intake and output hourly; test urine for
ketones hourly (hyperglycemia will resolve
Pharmacologic Interventions before ketonuria) and report results to physician
Consult a physician to start insulin therapy. • Clients may take fluids orally when they can be
tolerated
Referral

Hypoglycemia
Subnormal blood glucose level. Blood glucose level with glucometer
(< 3.3 mmol/L is the autonomic warning level; if
Causes 2.8 mmol/L, client will have symptoms of
• Delayed meal neuroglycemia).
• Inadequate total caloric intake
• Unusual physical exertion Management
• Insulin measurement error Goals of Treatment
• Insulin overdose • Increase blood glucose level quickly
• "Brittle" diabetic • Identify concurrent illness or associated injury

• Sudden onset • Assess and stabilize ABC
• Hunger • Give the conscious client 12 oz (360 mL)
sweetened orange juice or some other form of
• Sweating
rapidly absorbed sugar
• Shakiness, tremor
• Anxiety, restlessness Adjuvant Therapy
• Faintness, weakness Adjuvant therapy should be undertaken if client is
• Nausea nauseated, stuporous or unconscious or is unable
• Palpitations to take oral therapy.
• Progression to mental confusion, bizarre • Oxygen to keep oxygen saturations >97%
behavior, personality changes, reduced • Start IV therapy with 5% dextrose in water
consciousness or loss of consciousness, seizures (D5W) at 100-150 mL/h
Physical Findings Pharmacologic Interventions

• Heart rate rapid dextrose (D class drug), 50% solution, preloaded
syringe, 25-50 mL IV stat over 1-3 minutes
• Blood pressure elevated
or
• Pale
glucagon (D class drug), 0.5-1.0 mg SC, IM or IV
• Diaphoretic
• Anxious, restless Monitoring and Follow-Up
• Tremor • Observe response to treatment
• Confusion • Recheck serum glucose level immediately
• Bizarre or aggressive behavior • When client regains consciousness or recovers,
• Staggering gait, may appear intoxicated obtain an accurate history and do a thorough
• Unconscious or experiencing seizure examination
• Cold, clammy skin • Identify any associated illness, previous
episodes of hypoglycemia, head trauma or other
Differential Diagnosis injuries
• Alcohol intoxication • Give client a balanced meal
• Alcohol-induced hypoglycemia • Monitor glucose hourly with glucometer for
• Drug-induced hypoglycemia (e.g. overdose) recurring hypoglycemia
Complications Appropriate Consultation

• Injury due to a fall Consult a physician as soon as possible.
• Hypoxia of brain Referral
• Seizures Medevac client if you are unable to stabilize blood
• Death glucose or if underlying cause is not clear.

Chapter 11- Communicable Diseases

Common Communicable Diseases................................................................................................................... 1
Sexually Transmitted Infections ..................................................................................................................... 1
Hepatitis.......................................................................................................................................................... 5
Mononucleosis (Infectious) ............................................................................................................................ 9
Bacterial Gastroenteritis................................................................................................................................ 11
Giardiasis Gastroenteritis.............................................................................................................................. 12
Tuberculosis.................................................................................................................................................. 14
Invasive Group A Streptococcal Infection.................................................................................................... 18
Communicable Diseases
Refer to:
Communicable Disease Manual (GNWT, DHSS, February 2000)
Available on GNWT DHSS infoweb (http://infoweb.hlthss.gov.nt.ca/) under "Internal Resources" - "Internal
Forms and Manuals"
Human Immunodeficiency Virus

For information about HIV infection and AIDS, refer to:
HIV Infection and AIDS: Information for Health Professionals (GNWT, DHSS, August 1999)
Sexually transmitted infections

Refer to Canadian STD guidelines 1998
(http://www.hc-sc.gc.ca/pphb-dgspsp/publicat/std-mts98/index.html)
New Canadian STD guidelines are due to be published in 2003
Refer also to American STD guidelines 2002 (http://www.cdc.gov/std/treatment/rr5106.pdf) and
Communicable Disease Manual above
Immunization
For information about and guidelines for vaccination and immunization, refer to:
Canadian Immunization Guide, 6th ed. (Health Canada, 2002).
(http://www.hc-sc.gc.ca/pphb-dgspsp/publicat/cig-gci/index.html)

Common Communicable Diseases

Sexually Transmitted Infections
Note: The term Sexually Transmitted Disease Specific History
(STD) is now being replaced with Sexually Men
Transmitted Infection (STI). The term STI has • Urethral discharge (amount, colour and time of
been used throughout this document, except when day it is most noticeable [in urethritis the
referring to documents where the term STD was discharge is most prominent after a long period
originally used. Nurses are encouraged to use the without voiding])
term sexually transmitted infection and the • Dysuria
abbreviation STI. Health Canada now uses STI • Itch or irritation in distal urethra or meatus
but many of their older publications and web • Pain or swelling in the scrotum or inguinal
pages still use the term STD. region
• Genital rash or lesions
History Of Present Illness And • Rectal discharge, itch or pain
Review Of System • Changes in oral mucosa
When investigating any possible sexually
transmitted infection (STI) the practitioner must Women
obtain the following information in a • Vaginal discharge (amount and colour, odor and
nonjudgmental, factual manner. consistency, presence of vaginal itch)
• Painful intercourse on penetration or deep
General History dyspareunia
A detailed, comprehensive sexual history is • Burning sensation with urination (as urine
mandatory. passes over the external genitalia)
• Site(s) of sexual contact (vaginal, oral, anal) • Genital rashes or lesions
• Sexual orientation (homosexual, bisexual, • Lower abdominal pain
heterosexual) • Postcoital, midcycle or excessive menstrual
• Use of condoms bleeding
• Use of other birth control methods • Dysuria, frequency, urgency, nocturia,
• Number of sexual partners in recent past (For hematuria
length of time to trace contacts see • Last menstrual period and any possibility of
Communicable Disease Manual, page STDs-2) pregnancy
• History of sex with injection drug users • Rectal discharge, itch or pain
• Exchange of sex for money, drugs or other • Changes in oral mucosa
benefit (e.g. housing)
• Period since last sexual intercourse with most Examination Of The System
recent partner When an STI is suspected, the practitioner is
• Previous history of STIs advised to perform a detailed, comprehensive
• Present symptoms of STIs in client and in examination of the entire genitourinary region, as
partner(s) well as a full extragenital examination to detect
• Injection drug use, needle-sharing, tattoo, other manifestations of the possible STI.
piercing Remember to inspect the pubic hair for lice and
• Enlargement of lymph nodes nits and the perianal region for abnormalities.
• Fever or chills
• Joint pain, arthritis, conjunctivitis, rash at other Pay special attention to the pharynx, the
body sites conjunctiva, the lymph nodes, the joints and the
skin on the lower abdomen, thighs, palms,
forearms and soles.

Physical Examination Women

Men • Obtain urine or samples from the endocervix,
• Inspect and palpate the penis and glans for rectum and pharynx to be cultured for
lesions Chlamydia, N. gonorrheae and other bacteria
• Retract foreskin if required • Hanging drop (saline wet mount) to test for
• Examine meatus for urethral discharge candida, trichomonas and bacterial vaginosis
• Milk urethra from base of penis to glans three or • Observe for clue cells on saline wet mount
four times to detect small amounts of discharge • Perform "whiff test" of vaginal secretions
• Inspect and palpate scrotum for heat, tenderness, • Offer HIV counseling and testing if client has
swelling and lesions apparent risk factors
• Examine perianal area for discharge, tenderness, • Test for HPV
swelling, lesions and tears • Test for Herpes
Women Clinical Presentation And

• Genital examination must also include a Management
speculum examination with adequate For a complete discussion of the clinical
visualization of the cervical os presentation and treatment of STIs, refer to and
• Inspect and palpate the external genitalia, follow the Canadian STD Guidelines (Health
including the labia, to detect lesions, swelling, Canada, 1998).
erythema, discharge
• Inspect colour of vaginal walls Contact Tracing
• Observe the amount and colour of vaginal and General Principles
endocervical discharge • A client who presents with symptoms suggestive
• Wipe off secretions overlying the cervix, and of an STI should be considered an index case
inspect for erythema and edema until proven otherwise.
• Monitor for bleeding induced by taking • Investigate this symptomatic client by obtaining
endocervical swabs appropriate swab and blood samples, and treat
• Examine perianal area for discharge, tenderness, with appropriate medications as if the test results
swelling, lesions and tears were positive.
• Obtain a list of all sexual contacts in the past 2-
Differential Diagnosis of STIs 12 months (see Communicable Disease Manual,
The client's symptoms and signs may suggest the page STDs - 2). Fill out the appropriate
specific STI (Table 1). reporting forms and send to the Public Health
Department.
Diagnostic Tests • If the test results are negative for an STI, further
Men steps are not necessary.
• Obtain urine or samples from urethra, rectum • If the test results are positive for an STI, call in
and pharynx to be cultured for Chlamydia and the contacts of the index case.
Neisseria gonorrheae • Treat each contact as if he or she were a new
• Obtain sample for syphilis testing (RPR, VDRL) index case.
• Obtain samples for viral culture (e.g. herpes; • Obtain the appropriate swab and blood samples
dark-field smear for syphilis), which may be from each contact.
warranted if there are genital lesions • Treat each new index case with appropriate
• Offer HIV, Hepatitis B and Hepatitis C medications as if the test results were positive.
counseling and testing if client has apparent risk • Index cases should be treated with the
factors appropriate antibiotic(s) at the time of
presentation because of the length of time
required to receive test results.

• Be alert to the fact that notifiable diseases may your province or territory and report
differ from one province or territory to another. accordingly.
Become familiar with the notifiable diseases in
Table 1: Symptom and signs of some sexually transmitted infections

Symptoms and signs Possible STI syndrome
In men
Urethral discharge, burning on urination, urethral or Urethritis
meatal itch
Painful genital ulcers or lesions, painful inguinal Genital ulcer disease (e.g. genital herpes, syphilis,
lymphadenopathy chancroid)
Painless genital lesions with or without inguinal Genital ulcer disease, genital warts (condyloma
lymphadenopathy accuminata or human papillomavirus infection)
Acute onset of unilateral scrotal pain or swelling Epididymitis
Rectal discharge, rectal bleeding, tenesmus constipation Proctitis
In women
Vaginal discharge, odor, genital itch, introital Vulvovaginitis (e.g. trichomonas vaginalis infection)
dyspareunia, external dysuria
Recent onset of abdominal pain, unusual vaginal Cervicitis or pelvic inflammatory disease
bleeding, deep dyspareunia, with or without genital
discharge
Painful genital ulcers or lesions, painful inguinal Genital ulcer disease (e.g. genital herpes, syphilis,
lymphadenopathy chancroid)
Painless genital lesions with or without inguinal Genital ulcer disease, genital warts (e.g. condyloma
lymphadenopathy accuminata or human papillomavirus infection)
Rectal discharge, rectal bleeding, tenesmus constipation Proctitis

Table 2: NWT Notifiable Diseases Schedule
SCHEDULE A - Item I
SCHEDULE A - Item II
Reportable to Chief Medical Health Officer by
Reportable to Office of the Chief Medical Health Officer
telephone as soon as suspected and followed within 24
(OCMHO) in writing within 7 days.
hours by a written report.
1. Amebiasis 1. Acquired Immunodeficiency Syndrome

2. Anthrax (AIDS) and any Human
3. Botulism Immunodeficiency Virus (HIV)
4. Campylobacteriosis Infection
5. Cholera 2. Brucellosis
6. Diphtheria 3. Chancroid
7. Escherichia coli (verotoxigenic) 4. Chicken Pox (Varicella)
8. Food Poisoning (including communicable 5. Chlamydial Infections
enteric infections) 6. Congenital Cytomegalovirus infection
9. Gastroenteritis, epidemic (including institutional 7. Congenital or Neonatal Herpes simplex infections
outbreaks) 8. Creutzfeldt-Jacob Disease
10. Hantaviral disease (including Hantavirus 9. Cryptosporidiosis
Pulmonary Syndrome) 10. Cyclospora
11. Hemorrhagic Fevers 11. Giardiasis (symptomatic cases only)
12. Hepatitis (all forms) 12. Gonococcal infections
13. Influenza 13. Hemolytic Uremic Syndrome
14. Invasive Group A Streptococcal infections 14. Human T-cell Lymphotropic Virus infections
(including Toxic Shock Syndrome, Necrotizing 15. Leprosy
Fasciitis, Myositis and Pneumonitis) 16. Listeriosis
15. Invasive Haemophilus influenzae type B (Hib) 17. Lyme Disease
infections 18. Methicillin-Resistant Staphylococcus
16. Invasive Neisseria meningitidis infections Aureus (MRSA)
17. Legionellosis 19. Mumps
18. Malaria 20. Psittacosis/Ornithosis
19. Measles 21. Q fever
20. Meningitis/Encephalitis 22. Respiratory Syncytial Virus (RSV)
21. Neonatal Group B Streptococcal infections 23. Tapeworm infestations (including
22. Pertussis (whooping cough) Echinococcal disease)
23. Plague 24. Trichinosis
24. Poliomyelitis 25. Toxoplasmosis (symptomatic only)
25. Rabies (or exposure to rabies) 26. Tularemia
26. Rubella and congenital rubella syndrome 27. Vancomycin-Resistant Enterococci
27. Salmonellosis (VRE)
28. Shigellosis
29. Syphilis
30. Tetanus
31. Tuberculosis
32. Typhoid and paratyphoid fevers
33. Yellow fever
34. Epidemic forms of other diseases
35. Unusual clinical manifestations of disease

Hepatitis
Definition Causes
Inflammation of liver cells resulting in necrosis Five distinct viruses: hepatitis A virus, hepatitis B
and bile stasis. virus, hepatitis C virus, hepatitis D virus and
hepatitis E virus (not seen in Canada).
Table 3: Comparison of five forms of viral hepatitis

Form Transmission Incubation time Chronicity
A Fecal – oral 15 – 50 days No
B Parenteral, sexual, perinatal 45 – 160 days Yes (1% of cases)
C Parenteral 14 – 140 days Yes (70% of cases)
D Parenteral; may coexist with hepatitis B Unknown Yes
E Fecal – oral 14 – 60 days No

The five types of hepatitis are similar in clinical • Hepatic cancer
presentation and therefore cannot be readily • Cirrhosis
distinguished by clinical features. Serologic testing • Infectious mononucleosis
is needed for accurate diagnosis. The severity of • Alcohol-induced hepatitis
symptoms depends on the infective agent, and • Drug-induced hepatitis
many of those infected are asymptomatic.
• Obstructive jaundice
• Fever (unusual with hepatitis B or C, occurs in
60% of those with hepatitis A)
Complications
• Malaise
• Fulminant hepatitis (occurs in 0.1% of cases, but
• Nausea and vomiting prevalence is higher among pregnant women)
• Anorexia • Spread to close contacts or community
• Dark, tea-coloured urine • Increased incidence of liver cancer
• Abdominal pain, especially in right upper
quadrant
Diagnostic Tests
• Jaundice (in 60% of affected adults)
• Urinalysis: urine dark, tea-coloured; dipstick test
• Headache positive for bilirubin
• Liver function tests (LFTs): increased AST
Physical Findings (aspartate aminotransferase) and ALT (alanine
Findings depend on stage of disease. aminotransferase) (ALT in particular shows
• Temperature may be elevated in pre-icteric marked elevation)
phase • Alkaline phosphatase (mild-to-moderate
• Client appears mildly-to-moderately ill increase)
• Lethargy • Bilirubin (normal to markedly elevated)
• Sclera jaundiced • Hepatitis serology screening (see Table 4 for
• Skin jaundiced details of findings)
• Liver may be tender and enlarged; edge of liver
smooth and soft It is impossible to distinguish a flare-up of chronic
• Bowel sounds normal hepatitis B or C from acute cases; only over time
• Bruising (a sign of severe disease) will it be possible to identify a carrier of the virus.

Table 4: Serologic features of viral hepatitis

Form Serologic marker Interpretation
A IgM anti-HAV Acute disease
IgG anti-HAV Remote infection and immunity
B HBsAg Acute or chronic disease

HBeAg Active replication
IgM anti-HBcAg Acute disease
IgG anti-HBcAg Acute disease
• HBsAg positive Chronic disease
• HBsAg negative Prior exposure
C Anti-HCV Acute, chronic or unresolved disease;

co-infection with HIV
D HBsAg and anti-HDV Acute disease

• IgM anti-HBcAg positive Co-infection with HBV
• IgG anti-HBcAg positive Superinfection
E None
HAV - hepatitis A virus HBV - hepatitis B virus HBsAg - hepatitis B surface antigen
HBeAg - hepatitis B e antigen HBcAg - hepatitis B core antigen HCV - hepatitis C virus
HDV - hepatitis D virus
Management • Client should be symptom-free before returning

Hepatitis is a reportable communicable disease. In to school/work and usual routines
most cases no specific therapy is indicated, and it
usually resolves spontaneously in 4-8 weeks Community Outbreaks of Hepatitis A
without complications or sequelae. During community outbreaks of hepatitis A,
advise community members about the following
Clients are most infective before the onset of preventive measures:
jaundice. Virus may be shed for up to 1 week after • Water purification (boiling of water for 20
jaundice appears. minutes) before drinking
• Impeccable hand washing to reduce fecal-oral
Goals of Treatment spread
• Prevent disease • Sanitary disposal of fecal material
• Minimize liver damage • Use of separate linens and dishes may be helpful
• Reduce spread of infection but proper cleansing of these items is more
• Symptom control and treatment important

Consult a physician for all cases (except those that • For symptomatic relief (e.g. fever, nausea and
are clearly mild hepatitis A) and for any client vomiting, pruritus, abdominal pain) consult
who is acutely ill at the time of presentation. physician
• Any hepatotoxic drugs should be identified and
Nonpharmacologic Interventions discontinued until recovery is complete
• Increase hydration (8-10 glasses of fluid daily) • Stop oral contraceptives to avoid cholestatic
• Adequate, well-balanced diet symptoms, and counsel client about alternative
• Abstention from alcohol for 3-4 months contraceptive method
• Activity as tolerated

Monitoring and Follow-Up Control measures: Community teaching about and

• Follow up all acute cases of hepatitis A in 24-48 impeccable hand-washing to prevent fecal-oral
hours to re-evaluate condition. After that, see spread is the key. Sanitary disposal of feces is also
client weekly for 2-4 weeks and again at 6 important.
weeks to verify resolution of symptoms.
• Repeat LFTs at 6 weeks (in acute hepatitis B and Children and adults with hepatitis A should be
C, elevation of liver enzymes may be prolonged, excluded from school, daycare and work places
so LFTs should be repeated every 3 months until until at least 1 week after onset of illness (until
normal). jaundice disappears).
• Clients with chronic hepatitis B and C should be Schoolroom exposure does not generally pose a
seen every 3-4 months for symptoms and signs, risk to others, and mass vaccination with immune
and liver function should be monitored. globulin is not indicated.
Referral Hepatitis B
• Referral to a physician is required for further Immunoprophylaxis with hepatitis B vaccine is
assessment, diagnosis and investigation for all indicated for all persons at risk, and is a routine
but hepatitis A, (hepatitis B, C and D can part of the childhood vaccination program in the
become chronic). NWT.
• Medevac anyone who is acutely ill at time of
presentation Groups at risk: healthcare workers, dialysis
patients, recipients of blood or blood products,
injection drug users, sexually active homosexual
Prevention Of Spread And males, people in household or sexual contact with
Management Of Contacts an infected person, people with needlestick injury,
Management of contacts depends on the people engaging in high-risk sexual behavior,
underlying cause of disease. newborns of infected mothers.
Hepatitis A In AdultsGive:
Immune serum globulin is effective in preventing hepatitis B vaccine, 1.0 mL IM at 0, 1 and 6
or modifying hepatitis A in household contacts: months (3 doses) (where time zero is the time of
immune globulin (A class drug), 0.02 mL/kg the first dose)
Use of immune globulin more than 2 weeks after hepatitis B human immune globulin 0.06 mg/kg IM
last exposure is not indicated. can be given within 24 hours of percutaneous or
permucosal exposure (e.g. needlestick injury) in a
Routine prophylaxis with hepatitis A vaccine is previously un-immunized person. Follow with
not indicated but is advisable for people traveling three doses of hepatitis B vaccine as outlined
to areas of high prevalence, for people living in above.
areas where disease is endemic and there are
recurrent outbreaks, for immunocompromised Hepatitis C
people (e.g. HIV-positive clients) and for There are no specific prevention strategies other
homosexual men. than avoidance of contact with the blood of an
infected person through universal blood and body
This vaccine is not yet one of those routinely fluid precautions. Safe sex practices are
supplied by provincial government programs. recommended. Once infected, minimal alcohol use
Check with the Communicable Disease Consultant (< 4 drinks/week) is important to prevent liver
at the Department of Health and Social Services damage. Teach client about hepatotoxic
for information on how to obtain this vaccine for a medications.
client who might benefit from prophylaxis.

Hepatitis D Hepatitis E
Hepatitis D cannot be transmitted except in the Immunoprophylaxis for hepatitis E (which is not
presence of hepatitis B virus. Prevention of seen yet in Canada) does not exist. Prevention
hepatitis B is therefore key in preventing hepatitis through good sanitation and hygiene is key.
D. Universal precautions for blood and body fluids
should be observed.

Mononucleosis (Infectious)
Acute viral infection with classic triad of • Pneumonia
symptoms: fever, pharyngitis and enlarged lymph • Guillain-Barré syndrome
glands. • Hepatitis
• Aseptic meningitis
Causes • Encephalitis
• Epstein-Barr virus • Hemolytic anemia
• Spread from person to person by the • Thrombocytopenia
oropharyngeal route (via saliva), and only rarely • Agranulocytosis
by blood transfusion • Myocarditis
• Incubation period 4-6 weeks • Splenic rupture
• Polyneuritis
History • Orchitis
Adolescents and young adults are most often
affected.
Diagnostic Tests
• Fever
• Serum sample for mononucleosis spot test
• Sore throat
• Complete blood count (lymphocytosis is
• Fatigue, malaise characteristic)
• Headache
• Throat swab to rule out group A streptococcal
• Eyelid and orbital swelling (GAS) pharyngitis
• Lymph glands swollen (especially posterior
cervical glands)
Management
• Period of communicability is prolonged, and Goals of Treatment
pharyngeal excretion of virus may persist for a
• Provide supportive care until recovery
year or more after illness
Physical Findings
• Temperature may be mildly elevated
• Warm salt water gargles for sore throat
• Client appears tired
• Eyelid and periorbital edema Client Education
• Pharynx red, swollen; may have tonsillar • Advise client to eat foods as tolerated, but
exudate recommend well-balanced nutrition
• Petechiae on the palate • Advise client to undertake activity as tolerated;
• Enlargement of lymph nodes of the neck help client to plan a realistic schedule of rest,
(especially posterior cervical nodes) with modification of school or work
• Splenomegaly responsibilities as needed
• Hepatomegaly, with or without jaundice • Suggest increasing fluid intake, which may be
beneficial
Differential Diagnosis • Teach client good hand-washing technique to
• Group A streptococcal (GAS) pharyngitis prevent spread, but client does not need to be
• Hepatitis isolated from others
• Viral pharyngitis • Suggest that client decrease stress if possible
• Cytomegalovirus infection • Recommend that client avoid contact sports for
• Toxoplasmosis at least 1 month or until full resolution of
• Secondary syphilis enlarged spleen because of the increased risk of
• Rubella splenic rupture

• Advise client the duration of the illness is Monitoring and Follow-Up

variable, with the typical, uncomplicated illness Follow up once weekly until symptoms resolve.
lasting 3-4 weeks
Pharmacologic Interventions Consult a physician if symptoms persist for more
Mild analgesic: than 3 weeks or if there are any complications,
ibuprofen (A class drug), 200 mg, 1-2 tabs PO such as jaundice or neurological symptoms.
q4h prn
or Referral
acetaminophen (A class drug), 325 or 500 mg, Not usually required.
1-2 tabs PO q4h prn

Bacterial Gastroenteritis
Refer to Communicable Disease Manual • Teach client how to avoid spreading bacteria to
(February 2000), Enteric Diseases (Bacterial) other household and community members
(impeccable hand washing after toileting is the
Management most useful intervention)
Goals of Treatment • Teach client the signs of dehydration and advise
• Prevent complications client to return to clinic if these occur
• Prevent spread of infection to others • Enteric precautions are required during acute
• Identify asymptomatic household carriers of illness, because Shigella infection is highly
Salmonella contagious
• Clients should not handle food or provide child
Infection with Salmonella and Shigella are or patient care until follow-up stool cultures are
notifiable communicable diseases. negative

Consult a physician for treatment of clients who Control nausea and vomiting:
are immunocompromised or debilitated and those dimenhydrinate (A class drug), 25-50 mg IM prn
who have severe symptoms or are dehydrated. stat, then 50 mg PO q4-6h prn
Nonpharmacologic Interventions Do not use anti-diarrheal medications

Refer to "Diarrhea," in chapter 5, (e.g. loperamide or diphenoxylate-atropine), as
"Gastrointestinal System," for details of general these slow the clearance of bacteria from the
management of diarrhea. bowel.
Rehydrate with small amounts of fluids, given Consult with a physician before giving antibiotics,
frequently; use oral rehydration fluids if necessary as they may prolong the carrier state and
or IV therapy if serious dehydration is present (see encourage development of resistant strains.
"Dehydration" in chapter 5, "Gastrointestinal
System"). Monitoring and Follow-Up
• Instruct client to return for follow-up in
Client Education 24-48 hours if symptoms are not diminishing
• Recommend increased rest during acute phase • Isolation not necessary
• Recommend water purification (boiling all water • Household contacts or contacts involved in
used in the house for 20 minutes) direct client care must be investigated (obtain
• Counsel client about appropriate personal three stool samples for culture)
hygiene (hand-washing after touching soiled
material and after using the washroom; separate Referral
utensils) Usually not necessary unless there is significant
dehydration or failure to improve with therapy.

Giardiasis Gastroenteritis
Refer to Communicable Disease Manual • Early satiety
(February 2000), Enteric Diseases (Parasitic) • Bloating
• Sulfurous belching
Definition • Substernal burning and acid indigestion
Parasitic intestinal infection. • Anorexia
• Fatigue, malaise
Causes • Weight loss (occurs in > 50% of patients,
• Giardia lamblia, one of the most commonly average weight loss is 4.5 kg [10 lb])
identified intestinal parasites • Chronic illness (adults present with long-
• Infection caused by ingestion of infective cysts standing malabsorption syndrome and children
• Person-to-person transmission (fecal-oral) and with failure-to-thrive syndrome)
poor hygiene are the primary means of infection
• Giardiasis may also be contracted through the Unusual presentations include:
ingestion of contaminated water, a mechanism •Allergic manifestations, such as urticaria
responsible for a significant number of •Erythema multiforme
waterborne outbreaks •Bronchospasm
• Venereal transmission occurs through direct •Reactive arthritis
fecal-oral transmission •Biliary tract disease
History Physical Findings

A broad spectrum of clinical syndromes may • Physical examination generally unremarkable
occur. Most symptoms are gastrointestinal.
• Abdominal examination may reveal nonspecific
A small number of people have the following
tenderness without evidence of peritoneal
symptoms:
irritation
• Abrupt onset of explosive, watery diarrhea
• Rectal examination should reveal heme-negative
• Abdominal cramps stool
• Foul flatus • In severe cases, evidence of dehydration or
• Vomiting wasting may be present
• Fever and malaise
These symptoms last 3-4 days before transition
• Gastroenteritis (viral, bacterial)
into the more common subacute syndrome.
• Amebiasis
Most patients experience a more insidious onset of • Bacterial overgrowth syndromes
symptoms, which are recurrent or resistant: • Crohn's ileitis
• Stool malodorous, mushy and greasy • Cryptosporidium enteritis
• Watery diarrhea may alternate with soft stools or • Irritable bowel syndrome
even constipation • Sprue (celiac [nontropical] or tropical)
• Stools do not contain blood or pus, since • Lactose intolerance
dysenteric symptoms are not a feature of
giardiasis Complications
• Dehydration
Upper GI symptoms, often exacerbated by eating, • Malabsorption and weight loss
accompany stool changes or may be present in the
absence of soft stools: Diagnostic Tests
• Upper and mid-abdominal cramping Stool samples (three) taken at 2-day intervals
• Nausea should be examined for ova and parasites.


Goals of Treatment Antibacterial, antiprotozoan to treat infection:
• Relieve symptoms metronidazole (A class drug), 250 mg PO tid for
• Prevent complications 5-7 days
• Prevent spread to others
High-dose, short-course regimens are less
efficacious and should be avoided. The most
common side effects include a metallic taste in the
Emergency care consists of restoration of volume
mouth, nausea, dizziness and headache.
status through oral rehydration or IV
administration of crystalloid solution if client is
Do not give to pregnant women, especially those
dehydrated on presentation. For details, see
in the first trimester. Consult a physician for
"Dehydration" in chapter 5, "Gastrointestinal
alternative treatment for a pregnant woman.
System."
• Advise client to eat foods as tolerated; low-
lactose and low-fat diet may be helpful until
symptoms diminish • Follow up closely (e.g. daily) if dehydrated on
presentation: monitor hydration status, weight
• Advise client to undertake activity as tolerated
and symptoms
• Frequent, impeccable hand washing, especially
• Obtain repeat stool samples in 1-2 weeks to
after toileting, is essential
ensure resolution of infection
• Drinking water should be purified by boiling for
20 minutes
• Ensure that close contacts of the client are also Consultation is generally not necessary for
examined for giardiasis and treated, if giardiasis unless there is no improvement with
appropriate treatment.
Referral
Refer to a physician as soon as possible if
symptoms persist or worsen despite treatment.

Tuberculosis
Refer to NWT Tuberculosis Manual (March • Institutional living (e.g. in a correctional facility
2003) or nursing home)
• Immunocompromise (e.g. HIV/AIDS)
Definition • Medications that suppress immunity
Acute granulomatous infection with a (e.g. high-dose steroids)
mycobacterium. Organism is initially inhaled into • Diabetes mellitus
the body through the pulmonary system. After • Chronic renal failure
pulmonary inoculation, the organism can spread to • Malnutrition
other areas of the body, including the middle ear, • Alcoholism
bones, joints, meninges, kidney and skin.
• Close contact with an infected person
Spread is contiguous or via the lymph or blood.
Approximately 85% of patients present with History

pulmonary disease. Most active cases are TB should always be considered if the classic
confirmed by culture of Mycobacterium symptoms are present in a client from a high-risk
tuberculosis. group, if unexplained cough and constitutional
symptoms persist for more than a few weeks or if
Extrapulmonary disease may be diagnosed on the pneumonia fails to resolve in any client.
basis of characteristic pathological findings and • Cough
clinical presentation. • Hemoptysis
• Fever
Extrapulmonary disease is more common in • Night sweats
clients with HIV infection and those from certain • Anorexia
ethnic groups, including Asians and Aboriginal • Weight loss
Canadians, than in other clients. • Fatigue
• Exposure to TB
Stages Of Disease • History of active TB and adequacy of previous
Latent Infection treatment
The person has a primary infection with the • History of positive Mantoux test and adequacy
organism and has low numbers of tubercle bacilli of prophylaxis
in the body but does not have active disease. The
risk of active infection is high in certain groups of Be alert to the diseases, drugs and conditions that
people with latent disease. (See "Risk Factors," predispose an infected client to active TB
below.)
Physical Findings
Active Tuberculosis Perform a complete physical examination.
The person has active infection and high numbers • Client may appear chronically ill, cachectic
of tubercle bacilli, and the condition is contagious.
• Weight loss
The risk of active disease is highest in the first 2
years after exposure.
• Signs of pleural effusion on chest examination
• Enlargement of liver or spleen
Causes • Enlargement of lymph nodes
Mycobacterium tuberculosis
Risk Factors • Pneumonia
• Aboriginal Canadian ancestry • Bronchiectasis
• Single men > 65 years of age • Lymphoma
• Urban homelessness • Fungal infection

Complications It is insufficient to describe the test result as

• Lung abscess simply "positive" or "negative." These
• Empyema designations are arbitrary and have different
• Spread of infection to extrapulmonary structures meanings in different people.
• Spread of infection to others
Consult the NWT Tuberculosis Manual (March
• Drug resistance
2003) for guidelines for significant and
• Death insignificant Mantoux test results.
Diagnostic Tests (Section 5, page 4)
Mantoux Test (Tuberculin Skin Test)
The Mantoux test has three indications: diagnosis Other Diagnostic Tests
of infection, diagnosis of active disease and • Complete blood count
epidemiological tool. • Chest x-ray
• Three sputum samples for acid-fast bacilli and
The test should not be performed in the following M. tuberculosis culture
situations: • Three urine samples for acid-fast bacilli culture
• client who has had previous severe blistering
reactions to the Mantoux test Management
• client with documented active TB Goals of Treatment
• client with extensive burns or eczema • Prevent latent infection from progressing to
• client who has had a viral infection (such as active disease
measles or mumps) in the past month or who has • Ensure adequate treatment of active disease
received vaccination with a live-virus vaccine in • Prevent spread of disease to others
the past month (e.g. MMR)
False-negative results may occur in seriously ill, Appropriate Consultation
anergic people (e.g. those with HIV/AIDS or Consult a physician immediately for all cases of
active TB). suspected active TB and for any client who has a
newly positive Mantoux test result.
Reaction to tuberculin antigen may wane to non-
reactivity with age, whereas repeat skin testing Nonpharmacologic Interventions
may boost reactivity. Thus, it is important to • Notify the NWT Department of Health and
perform a two-step Mantoux test in populations Social Services of clients whose Mantoux tests
who are likely to undergo serial testing (e.g. have recently converted to positive, as well as all
nursing home residents and healthcare workers). new cases of active TB
This will identify those whose response has waned • Complete TB assessment form
over time.
• Carry out contact tracing: all close family,
BCG (bacille Calmette-Guérin) vaccination may friends and job contacts should undergo
trigger a positive Mantoux result. This response screening Mantoux test, repeated 3 months later
wanes over time, usually disappearing in if the initial result is negative
10-15 years. In general, a positive Mantoux result • Check with the Communicable Disease
> 10 years after BCG vaccination should not be Consultant at the Department of Health and
attributed to the BCG. Social Services for additional information
• Adequate balanced nutrition, which aids healing
The standard dose of the purified protein and may help prevent active TB in those with
derivative (PPD) used in the Mantoux test is latent infection
5 tuberculin units. The result is determined • Adequate rest, especially in active disease
48-72 hours after injection by measurement (in
millimeters) of the transverse diameter of
induration (the surrounding erythema should be
ignored).

Client Education If drug resistance is a possibility, a four-drug

• Explain disease process, course and prognosis regimen should be considered.
• Stress importance of strict adherence to
medication regimen In addition to the antituberculous drugs, the client
• Explain risks, benefits and side effects of drugs may also be given vitamin B6 (especially in the
• Stress importance of close follow-up presence of alcoholism, diabetes mellitus or
pregnancy, or if there is a concern about
Pharmacologic Interventions nutritional status), although this is optional:
pyridoxine (vitamin B6) (B class drug),
Latent Disease
25 mg PO od
Therapy with a single drug, isoniazid (INH), can
greatly reduce the risk of active TB in those with
After 2 months of therapy, pyrazinamide is usually
latent infection. Therefore, for those with a
discontinued if culture results indicate the
positive Mantoux test result, INH prophylaxis may
presence of a fully sensitive organism. Then, INH
be considered. The risk of adverse effects from
and rifampin can be given twice weekly.
INH must be weighed against its benefit in
reducing the risk of active disease.
A twice-weekly schedule lends itself to fully
supervised directly observed therapy (DOT). This
isoniazid (INH) (B class drug), 300 mg PO od for
optimal regimen should last at least 6 months in
6-9 months
total.
and
pyridoxine (vitamin B6) (B class drug), 25 mg PO
A total of 9 months or more may be needed if
od
clinical, radiologic or bacteriologic findings show
a slow response. If second-line regimens are
Active Infection
required, and particularly if there is a concern
Treatment is always with multiple drugs for 6-12
about drug resistance, much longer courses of
months on average and only initiated by a
treatment (15-18 months) are required. Regimens
physician.
of 18 months or longer are needed if neither INH
or rifampin is used in the drug regimen.
The optimal initial regimen is three or four drugs,
TB medications are prescribed by TB specialists.
including INH, rifampin, pyrazinamide,
Consult the Communicable Disease Consultant at
ethambutol and streptomycin.
the Department of Health and Social Services
before TB drugs are prescribed.
Table 5: Doses of and common adverse reactions to first-line antituberculous drugs

Drug Usual daily dose Adverse reactions*
Isoniazid (INH) 300 mg Hepatitis, paresthesia
Rifampin 600 mg Hepatitis, flu-like illness
Pyrazinamide 1500-2500 mg in divided doses Hepatitis, elevated serum level of

uric acid, arthralgia
Ethambutol 2400 mg in divided doses Retrobulbar neuritis
Streptomycin 1000mg Vertigo, tinnitus, renal failure
* All of these drugs may cause rash, nausea and fever


• Follow client closely while on therapy (at least All clients with suspected active TB should be
monthly) admitted to hospital for investigation and
• Monitor adherence to medication regimen, for treatment. If transport is in a public vehicle
symptoms of disease and for drug side effects (e.g. aircraft), the client should wear an
• Liver enzyme levels should be checked regularly appropriate mask (one that can filter particles of
• Clients receiving ethambutol should have colour 1 µm in diameter and that provides a tight facial
vision screened every 6 months seal) to protect others.
• Clients with active TB need repeat chest x-ray
monthly for the first 3 months
• Have a physician review client at every
opportunity during therapy

Invasive Group A Streptococcal Infection

Definition Early signs and symptoms of necrotizing fasciitis:
Invasive group A streptococcal (GAS) disease is a • Severe pain, swelling and redness at the wound
severe and sometimes life-threatening infection in site
which the bacteria have invaded various parts of • Fever
the body, such as the blood, the cerebrospinal
fluid, deep muscle and fat tissue, or the lungs. Early signs and symptoms of STSS:
•Fever
Invasive GAS infections may manifest as any of •Dizziness
several clinical syndromes, including pneumonia, •Confusion
bacteremia in association with cutaneous infection •Rash and abdominal pain
(e.g. cellulitis, erysipelas or infection of a surgical •Severe pain, swelling and redness at the wound
or non-surgical wound), deep soft-tissue infection site
(e.g. myositis or necrotizing fasciitis), meningitis,
peritonitis, osteomyelitis, septic arthritis,
Streptococcal Toxic Shock Syndrome
postpartum sepsis (i.e. puerperal fever), neonatal
STSS is an illness with the following clinical
sepsis or non-focal bacteremia.
manifestations occurring within the first 48 hours
of illness:
Two of the most severe, but least common, forms
of invasive GAS disease are:
• hypotension (defined by systolic blood pressure
< 90 mm Hg for adults or less than the fifth
• necrotizing fasciitis (infection of muscle and fat percentile by age for children < 16 years of age)
tissue) and
• multiorgan involvement characterized by two or
• streptococcal toxic shock syndrome (STSS). more of the following:
Approximately 20% of patients with necrotizing
• renal impairment
fasciitis and 60% with STSS die.
• coagulopathy
Only about 10% to 15% of patients with other • liver involvement
forms of invasive GAS disease die. • acute respiratory distress syndrome (defined
by acute onset of diffuse pulmonary infiltrates
Cause and hypoxemia in the absence of cardiac
Group A Streptococcus. failure or by evidence of diffuse capillary leak
manifested as acute onset of generalized
edema or pleural or peritoneal effusion with
Risk factors
Although anyone can get GAS disease (including hypoalbuminemia)
STSS), people with underlying health problems • generalized erythematous macular rash that
such as diabetes mellitus, chronic heart, lung or may show desquamation
kidney problems, cancer or HIV infection are at • soft-tissue necrosis, including necrotizing
greater risk for invasive GAS disease. fasciitis or myositis, or gangrene
A break in the skin, such as a cut or surgical Differential Diagnosis

wound, or chickenpox may increase a person's • Cellulitis
risk. Close contacts of a case (family or household • Sepsis
members, healthcare providers, nursing home • Septic shock
staff) may be at increased risk for infection
because of direct contact with secretions from the Complications
infected person. • Sepsis
• Septic shock
History And Physical Findings • Amputation
Presence of risk factors. • Death

Diagnostic Tests • In addition to antibiotics, supportive care in an

None. intensive care unit and sometimes surgery are
necessary with these diseases
Management
Prevention of Invasive GAS Infection Adjuvant Therapy
• Spread of all types of GAS infections may be • Oxygen prn to keep saturation > 97%
reduced by proper hand washing, especially after • Start IV therapy with normal saline to keep vein
coughing and sneezing, before preparing foods open
and before eating
• For anyone with a significant sore throat, a If client presents with signs of sepsis or septic
throat swab should be taken for culture and shock, aggressive fluid resuscitation is necessary,
sensitivity if clinically indicated (see Appendix as follows:
1, "Sore Throat Score," in chapter 2, "Ears,
Nose and Throat") to determine whether it is a Start two large-bore IV lines with normal saline
streptococcal infection; if so, the person should (for details, see "Shock," in chapter 14, "General
stay home from work, school or daycare until 4 Emergencies and Major Trauma")
hours or more after antibiotic therapy has been
initiated If client's symptoms are suspicious for GAS
• All wounds should be kept clean and should be disease or he or she would be at higher risk of
monitored for possible signs of infection (e.g. invasive disease (e.g. if he or she has diabetes
increasing redness, swelling and pain at the mellitus, cancer, chronic heart disease,
wound site); clients should be advised to seek alcoholism), antibiotic therapy may be started
medical help immediately if any of these signs while waiting for transfer. Choice of antibiotics
occur, especially if fever is also present should be determined in consultation with a
physician.
Consult a physician immediately if there is Monitoring and Follow-Up
suspicion of invasive GAS infection. Monitor ABC and symptoms frequently.

• Protect airway and ensure adequate ventilation Medevac.
• Bed rest
• Protect infected area from further injury

Chapter 12 - Obstetrics
Assessment of the Prenatal Client 3
Prenatal Care: Initial Visit and Subsequent Visits 3
Common Obstetric Problems and Emergencies 9

Bleeding in Pregnancy 9
Ectopic Pregnancy 13
Hydatidiform Mole 15
Hyperemesis Gravidarum 17
Multiple Gestation 20
Polyhydramnios 22
Gestational Diabetes 23
Hypertension in Pregnancy (formerly toxemia) 27
Hypertensive Crises (Eclampsia) 31
Intrauterine Growth Retardation 34
Antepartum Hemorrhage (late) 36
Group B Streptococcal Infection 38
Preterm Labou 39
Premature Rupture of Membranes 42
Postpartum Hemorrhage 44
Unplanned Delivery of a Term Pregnancy in the Health Centre 46
August 2007 Adult

Acknowledge
Anna Bergen Sonja Boucher Elizabeth Cook

Dr. Bing Guthrie Rachel Munday Lesley Paulette
Faye Stark Judy Wilson
References
The references for these topics are not meant to be inclusive. It is expected that the Community
Health Nurse would consult with her nurse-in-charge, the visiting settlement physician, the various
hospitals’ emergency physicians, and/or the Northern Women’s Health Program.
12-2 Adult August 2007

Assessment of the Prenatal Client

Prenatal Care: Initial And Subsequent Visits
Refer to NWT Prenatal Record and Reference Guide for completion of the NWT Prenatal Record
(September 2005) and check references at the end of this topic.
Initial Visit
• Psychiatric problem
History • Other
Health History
• Cardiovascular Obstetrical History
• Hypertension • Number of pregnancies including abortions
• Genitourinary • Dates and locations of previous pregnancies
• Renal • Perinatal complications – including antepartum,
• Thrombosis/Phlebitis intrapartum, delivery, and postpartum
• Asthma • Delivery history
• Diabetes • Infant sex, birth weight, condition
• Epilepsy • Present health of children
• Thyroid disease
• Bleeding disorder
Clinical Dating
• Transfusions –including the year
• Surgeries • LNMP - Start and end dates of most recent
• Psychiatric/Depression normal menstrual period
• TB exposure • Was most recent period like others in duration
• Infections and amount of flow? (if not, determine dates of
previous period)
• Was there any bleeding after most recent normal
Social History
menstrual period?
• Nutrition- recall chart to ID women at risk for • Amenorrhea for how long. One or two periods
deficiencies. Can use Canada Food Guide.
missed (however, may be amenorrheic because
• Special diet
of Depo Provera effect)
• Alcohol –T-ACE tool • Contraceptives: type, when last used
• Drugs –includes marijuana
• EDD –by LNMP
• Substance abuse e.g. glue, hairspray
• Ultrasound - Dating Ultrasound if dates are
• Smoking-includes smokeless tobacco uncertain - do prior to 16 weeks gestation.
• Second hand smoke
• Domestic violence: use SAFE or ALPHA tools Present Pregnancy
• Support systems –outside the Health Centre • Bleeding -determine amount, any associated
pain
Family/Genetic History • Nausea and vomiting in the morning
• Congenital Anomaly • Vaginal discharge or fluid leakage (colour, odor,
• Neural tube defect amount)
• Genetic disease • Infections or fever -urinary symptoms
• Diabetes- including gestational • Depression
• Hypertension • Other
• Bleeding Disorder
• Twins- and multiple births
• Anesthesia problem
August 2007 Adult 12-3

Allergies/Medications Pelvis
• Type, dosage, period of use • Perineal varicosities
• Prescription, traditional, OTC • Previous tears, episiotomy
• Type of reaction to medications • Hemorrhoids
• Vaginal bleeding, discharge (colour, odor,
Physical Examination consistency, amount)
Perform a complete examination of all systems on • Cervix and vaginal walls have bluish color (8
first visit. weeks+)
• Uterus: palpable only on pelvic examination in
General first trimester and in obese women.
• Apparent state of health • Describe uterine size (e.g. average size, orange,
grapefruit)
• Appearance of comfort or distress
• Colour (e.g. flushed, pale) • Position of uterus (e.g. retroverted)
• Nutritional status (obese or emaciated) • Cervical assessment (position, appearance)
• Muscular support in the pelvic floor
• Facial edema
(e.g. cystocele, rectocele)
• Tender/nontender thyroid enlargement may be
• Evidence of infections (e.g. warts, herpes)
present
• Body piercing
Vital Signs
• Temperature Laboratory Tests
• Heart rate: elevated (by 10%) in second half of Blood Work follow NWT Guidelines
pregnancy because of increased blood volume • Complete blood count
• Respiratory rate • ABO grouping and Rhesus (Rh) type
• Blood pressure (sitting) • Antibody screening
• Fetal heart rate: 110-160 bpm (heard at • Rubella titre
12-18 weeks gestational age) • Syphilis testing
• Hepatitis Band C screening
Breasts • HIV test (opt out program in the NWT, required
• Enlarged; areolae and nipples darker and prior to infant BCG)
enlarged • Varicella antibody titre if no history of varicella
• Signs of infection infection or contact with infection
• Masses, tenderness
Urine Testing
• Nipples: shape (e.g. inverted), erosion, discharge
• At initial visit: urinalysis, routine and
• Body piercing
microscopy, culture and sensitivity
• Augmentation surgeries
Cervical and Vaginal Examination
Abdomen • PAP smear unless the client is being followed in
• Striae an abnormal pap schedule already.
• Scars • HSSA approved testing for Neisseria
• Measurement of fundal height, shape of fundus gonorrhoea, and Chlamydia. A cervical swab
• Agreement between fundal height and expected for culture and sensitivity or the first urine is
date of delivery used for this test.
• Fetal lie, presentation and movements • Vaginal swab for culture for trichomonas,
• Engagement bacterial vaginosis.
• Uterine tenderness or hardness
• Contractions (e.g. Braxton-Hicks)

Subsequent visits • Timing variable in multigravida

• Fetal head engages in maternal pelvis
• May produce urinary and musculoskeletal
History disturbances e.g. ligamentus pain
• Identified risk factors from history each visit
• Headaches, edema
Laboratory tests
• Abdominal pain
Swabs and Cultures
• Vaginal bleeding or discharge
• Group B streptococcus (GBS) screening at
• Urinary complaints
35-37 weeks –recto/vaginal. (If multiple
• GI disturbances gestation consider at 32 weeks).
• New stressors • Repeat Neisseria gonorrhoeae and Chlamydia
• Sings of premature labour culture at 35-37 weeks gestational age
Physical Urine testing

• SFH –Client lying down. Measure fundal height • Urinalysis at each visit (dipstick)
from top of symphysis to top of fundus with tape • Microscopic examination and culture and
measure and record (in centimetres [cm]) sensitivity as required
• As a general rule, measurement in centimetres • There is increased risk of asymptomatic
equals number of weeks of gestation after 20 bacteriuria in pregnancy that could cause
weeks until 36-38 weeks (Table 1) premature labour).
• Vital signs:
-BP: a physiological drop usually occurs in Maternal serum screening (MSS)
second trimester • Offered to all women with sufficient information
-Heart Rate/Heart sounds: soft systolic and appropriate discussion to allow informed
ejection flow murmur may be present (because consent. At 15-20 weeks, optimally at 16 weeks
of expanded vascular volume) gestational if at risk, and if requested by mother
• Weight: ideal 10-12 kg (2 kg in first trimester, • Based on identified risk and individual clinic
about 4-5 kg in second trimester and 4-5 kg in situations.
third trimester)
• Assess: fetal lie, presentation and movements. Amniocentesis
At 34 weeks, if the fetal lie is not cephalic, • Offered to clients over the age of 40 (singleton)
consider referral to visiting physician. or 32 (twins) at the time of delivery, and/or
• Assess fetal head for engagement in maternal clients with first degree relatives with neural
pelvis later in pregnancy tube defects/spina bifida.
• Fetal heart: rate and rhythm of heartbeat, • Offer to clients if MSS is positive.
location of heart tones (e.g. above umbilicus at • All women should receive appropriate
term may mean breech) counseling first, and offered genetic counseling.
Quickening ABO+Rh
• Advise client to record date of first perceived • If Rh-negative, repeat antibody screen per Blood
fetal movement (usually occurs at 20 weeks Services recommendation
gestational age in primigravida and at 18 weeks
in multigravida). Hemoglobin:
• Screen once during each trimester (a drop in
Lightening hemoglobin is expected in the second trimester
• Occurs when the fetal head engages in maternal because of increased blood volume)
pelvis. • If low, closer monitoring each trimester
• Usually occurs by 37 weeks gestational age in • Consider pharmacological/nutrition intervention.
primigravida.

Diabetes Screening f/u by oral GTT of 75G for proper diagnosis and
GCT – refers to oral 50-g glucose challenge test treatment.
• If the oral GCT is greater than or equal to
GTT –refers to oral 75-g glucose tolerance test. If 10.3mmol/L, the patient is diagnosed with GDM
woman is not at high risk, perform 50-g glucose and does not need further testing
challenge test (GCT) at 24-28 weeks gestational • If the oral GCT was given at 16-20 weeks, and if
age. negative, then f/u by a second one at 24-28
If woman is at high risk (morbid obesity, strong weeks. May consider oral GTT on consult with
family history, previous stillbirth), give the initial physician.
oral GCT at 16-20 weeks. May consider oral GTT
on consultation with physician.
• Oral GCT value of greater than or equal to
7.8mmo/L at 1 hour is considered positive and
Table 1: Approximate measurements of fundal height ***SFH is equal to the GA after

20 weeks plus or minus 2 cm If there is no change in SFH over 3 weeks, then refer to
MD or referral centre for follow-up.
Fundal height as measured
Weeks of gestation Fundal height
with fingers
8 Not palpable in abdomen (still in Size of an orange (bimanual
pelvis examination)
12 Variable At symphysis
16 Variable Halfway between symphysis and

umbilicus
20 20 At umbilicus
24 24 3 or 4 fingers above umbilicus
28 28 Halfway between umbilicus and

xyphoid process
32 32 3 or 4 fingers below xyphoid
36 36 At xyphoid process
38-40 Variable 2 fingers below xyphoid
* Measurements differ between primigravida and multigravida
Screening (Anatomical) Ultrasound follow-up ultrasound is recommended at 18 weeks

• Recommend ultrasound between 16-20 weeks gestation.
(optimal time 18 weeks) for anatomy and
confirmation of dates (if not already done). Management: Antenatal Care
• Follow-up screens are not routine, and are at the
Goals
discretion of the referral midwife, nurse
• Identify problems and complications early and
practitioner or physician. May need to consult
seek appropriate interventions to contribute to
one if soft markers are present or abnormalities
healthy pregnancy
are identified.
• Ensure maternal and fetal well being
• If the dates are uncertain, then a first trimester
ultrasound is recommended. In this case a • Provide reassurance and education

NWT Clinical Practice Guidelines for Primary Care Nursing (Adult)

Arrange a consultation with the physician once per Prenatal vitamins (A class drug), 1 tab PO daily
trimester if possible and as necessary if an throughout pregnancy
abnormality is identified or suspected.
If hemoglobin < 100 g/L, start iron:
Client Education ferrous sulfate (C class drug), 300 mg PO 1-3
• Encourage adequate dietary intake of protein times per day throughout pregnancy
and fiber
• Recommend avoidance of overeating and Rhogam (B class drug) should be given to Rh-
excessive weight gain negative women at 28 weeks gestational age. If
• Recommend smoking cessation if appropriate given earlier, another course should be given 12-
• Encourage abstinence from alcohol and any drug 13 weeks after the first course.
substances Remember to give Rhogam if pregnancy is
terminated spontaneously or therapeutically.
• Advise client to avoid use of over-the-counter
(OTC) drugs
• Counsel client on initial visit re expected Usual Schedule for Monitoring and
laboratory/radiology tests Follow-Up
• Recommend daily exercise to maintain physical • Up to 28 weeks gestational age: every 4weeks
and mental health. • 28-36 weeks gestational age: every 2 weeks
• Recommend proper daily personal hygiene • 36 weeks until delivery or evacuation: weekly
• Teach client about signs of preterm labour • If clinical situations require it, schedule visits
• Recommend loose fitting, comfortable clothing more frequently.
and avoidance of restrictive clothing around legs • Additional visits at 34 and 35 weeks are
(e.g. knee socks, "knee highs") recommended in communities from where the
• Counsel client about infant nutrition options patient will eventually need to be transported.
early in pregnancy, promote breastfeeding
• Teach proper breast care: cleaning, proper Referral
support for breast-feeding • Refer to physician as soon as possible if high
• Advise client that sexual intercourse may be risk identified
continued if she feels comfortable and there are • In client’s third trimester, consult with NIC and
no specific contraindications (bleeding) receiving centre to determine appropriate
• Encourage attendance at prenatal classes if elective travel date for client.
offered in the community • Consult the HSSA’s Policy for elective travel for
confinement.
Instruct client to return to clinic if any of the
following develop: References
• Severe continuous headaches or visual National Institute on Alcohol Abuse and
disturbances Alcoholism, October 2004
• Edema of face and hands
• Recurrent vomiting Midmer et al. (1996). The “ALPHA” tool. LAMP
• Abdominal pain and Women’s Habitat, Ontario: The SAFE Tool.
• Bleeding -vaginal
SOGC Fetal Health Surveillance 2002
• Rupture of membranes
• Decrease in or lack of fetal movement Meltzer, Donna (November 2005). Complications
• Fever, chills or infection in any area of Body Piercing, American Family Physician.

Dynacare Kasper Medical Laboratories. (February

2004). Memorandum on Testing available for GC SOGC. Screening for Gestational Diabetes
and Chlamydia. Mellitis. (November 2002). #121
SOGC. Healthy Beginnings: Guide for Care SOGC. CPG. The Use of First Trimester
during the Pregnancy and Childbirth (December Ultrasound (October 2003). #135.
1998) #71.
Martin, E. Jean (2002) Intrapartum Management
SOGC. CPG The Prevention of Early Onset Modules. Lippincott Williams, Philadelphia.
Neonatal Group B Streptococcal Disease. (2004)
#149. SOGC. CPG Exercise in Pregnancy and the
Postpartum Period. (June 2003). #129.
BC Reproductive Care Program (June 2003)
Antenatal Screening and Diagnostic Tests
Guideline #17.

Common Obstetric Problems and Emergencies

Bleeding In Pregnancy
A variety of conditions or problems may cause these are obstetric emergencies and are discussed
bleeding during pregnancy (Table 4). Many of in detail below.
Table 4: Differential diagnosis of bleeding in pregnancy

Gestational age < 20 weeks Gestational age ≥20 weeks
Implantation bleeding Placenta previa
Delayed normal menses Abruptio placentae
Cervical lesions (erosion, polyp, dysplasia) Premature labour
Ectopic pregnancy Hydatidiform mole
Spontaneous abortion Intrauterine death
(threatened, inevitable, incomplete) Cervical lesions
Missed abortion “Show”
Spontaneous Abortion
Definition the uterus (where blood clots may be mistaken
Loss or impending loss of pregnancy before 20 for tissue) or cervical canal, a situation that
weeks gestation. causes ongoing cramping and excessive bleeding
• Speculum examination reveals dilated internal
Threatened Abortion os and tissue within the endocervical canal or
• Early symptoms of pregnancy may be present vagina.
• Mild cramps with bleeding • Bleeding may be heavy.
• Cervix long and closed
• Uterus appropriate for gestational age Missed Abortion
• Progresses to inevitable abortion in • Products of conception retained 3 or more weeks
approximately 50% of cases after fetal death
• Signs and symptoms of pregnancy abate;
Inevitable Abortion pregnancy test becomes negative
• Persistent cramps and moderate free bleeding • Brownish vaginal discharge (rarely frank
• Cervical os is open bleeding) occurs
• Should not be confused with incompetent cervix, • Cramping rare
which is not associated with cramping and is • Uterus soft, irregular and smaller than
potentially treatable; incompetent cervix is gestational age
associated with painless cervical dilatation • Ultrasonography rules out live fetus
Complete Abortion Septic Abortion

• Entire conceptus expelled, followed by decrease • Any of the above scenarios and temperature >
or cessation of cramps and bleeding 38°C without other source of fever
• On examination, uterus is firm and smaller than • Associated with intrauterine device or
would be expected for gestational length of instrumentation during therapeutic abortion
pregnancy procedure
• Abdominal and uterine tenderness are present, as
Incomplete Abortion well as purulent discharge and possibly shock
• Symptoms the same as for inevitable abortion
but some products of conception are retained in

Causes • Incomplete abortion: cervical os open, bleeding

Spontaneous abortion occurs in 15% to 25% of from os can be seen, mild suprapubic tenderness
clinically recognized pregnancies and perhaps present, uterus may be small for dates
closer to 50% of all conceptions.
• Fetal abnormalities incompatible with life Differential Diagnosis
(chromosomal and other) • Ectopic pregnancy
• Defective implantation • Hydatidiform mole
• Maternal infection • Other common causes of vaginal bleeding (e.g.
• Uterine and cervical anomalies cervical erosion, polyp, cervicitis, local trauma)
History For other entities, see Table 4, above, this chapter.

• Symptoms and signs suggestive of pregnancy
(missed period or periods, nausea, vomiting, Complications
breast tenderness) • Severe hemorrhage
• Cramping pain • Hypovolemic shock
• Vaginal bleeding often with passage of tissue • Retention of products with or without
endometritis
All clients with bleeding sufficient to soak one pad
• Cervical shock (vasovagal hypotension due to
per hour or symptoms of orthostatic drop in blood dilatation of cervix by tissue)
pressure (dizziness upon standing, faintness) need
• An infection
to be examined.
Physical Findings Diagnostic Tests

• Pregnancy test positive in 75% of cases, so
Examination should include stability of vital signs,
orthostatic vital signs, pelvic examination to look negative result does not rule out spontaneous
for open or closed cervical os, presence of tissue abortion.
and other causes of vaginal bleeding (such as • Measure hemoglobin level
cervical erosion, polyp, infection, vaginal lesion or • Urinalysis
ectopic fetus). The uterus should be measured.
Fetal heart tones should be checked carefully with Management
Doppler scanning. Goals of Treatment
• Heart rate may be elevated • Prevent complications
• Blood pressure may be low • Control blood loss
• Postural blood pressure drop may be present • Maintain blood volume
• Oxygen saturation may be abnormal if in shock
• Client appears anxious In an outpatient setting it is often difficult to
determine if a spontaneous abortion is complete or
Pelvic Examination incomplete. It is probably prudent to manage all
• Keep to a minimum spontaneous abortions as incomplete abortions if
• Only use gentle speculum exam on advice of there is significant, active vaginal bleeding
physician associated with abdominal pain.
• Threatened abortion: cervical os closed,
bleeding from os may be seen Threatened, Incomplete or Inevitable
• Inevitable abortion: cervical os open, some Abortion without Hemodynamic
products of conception bulging through os, Compromise
bleeding from os can be seen If there is no hemodynamic compromise,
threatened, incomplete or inevitable abortion
should be managed as outlined in Table 5.

Inevitable or Incomplete Abortion in If you cannot start IV therapy and bleeding is

Hemodynamically Unstable Client significant:
oxytocin (D class drug), 5-10 mg IM and consult
Appropriate Consultation physician.
Consult a physician as soon as client is stabilized.
Verify Rh status and give Rh immune globulin
Nonpharmacologic Interventions (RhIG) within 48 hours, if indicated (available
• Nothing by mouth from the Laboratory Department of Regional
Hospitals).
• Bed rest
• Trendelenburg position (prn) to aid venous
return
• Monitor vaginal bleeding, cramps, passage of
• Insert urinary catheter if client is in shock tissue or clots, vital signs, intake and output
• Monitor intake and output hourly • Save all products of conception passed and send
• Aim for urine output of 50 mL/h to hospital with client
Initial aggressive fluid resuscitation is needed if Medevac as soon as possible.
client is in hypovolemic shock:
• Start IV therapy with normal saline References
• Start two large-bore IV lines if client is websites and references: (last accessed 18
hypotensive September 2006)
• Give 20 mL/kg normal saline as a bolus over 15 http://www.emedicine.com/med/topic3241.htm
minutes Early Pregnancy Loss; Petrozza, J.C. et al
• Reassess for signs of shock http://www.emedicine.com/EMERG/topic3.htm
• Repeat 20 mL/kg boluses until systolic blood Abortion, Complete; Valley, V.T., et al
pressure stabilizes at >90 mm Hg, then adjust http://www.emedicine.com/EMERG/topic5.htm
rate according to severity of vaginal bleeding Abortion, Incomplete; Valley, V.T., et al
and vital signs http://www.emedicine.com/emerg/topic6.htm
• Oxygen to keep saturation > 97% Abortion, Inevitable; Valley, V.T., et al
Refer to protocol for managing hypovolemic http://www.emedicine.com/emerg/topic7.htm
shock, under "Shock," in chapter 14, "General Abortion, Missed; Valley, V.T., et al
Emergencies and Major Trauma." http://www.emedicine.com/EMERG/topic11.ht
m Abortion, Threatened; Gaufberg, S.V.
Pharmacologic Interventions http://www.emedicine.com/EMERG/topic10.ht
oxytocin drip (D class drug), 20 units in 1 L m Abortion, Septic; Gaufberg, S.V.
normal saline or Ringer's lactate, 50-100 mL/h

Table 5: Management of threatened, incomplete or inevitable abortion without

hemodynamic compromise
Threatened abortion Incomplete or inevitable abortion
• Rest has traditionally been advised however, • Rest is not indicated as it is not expected to save
there is not enough evidence to suggest that this pregnancy
increased rest has any effect on the outcome. • acetaminophen (A class drug) 500mg 1-2 tabs
www.cochrane.org/reviews/en/ab003576.html PO q4h prn for discomfort
accessed 18 Sept 2006 • Nothing in the vagina (no tampons, douches,
• acetaminophen (A class drug) 500mg 1-2 tabs intercourse)
PO q4h prn for discomfort • Tissue visible in os should be gently removed
• Nothing in the vagina (no tampons, douches, with ring forceps to allow contraction of uterus;
intercourse) minimize manipulation to minimize risk of infection
• Consider ultrasonography to visualize gestational • Consider pharmacologic interventions as above
sac and cardiac activity or to rule out ectopic • Clients with incomplete abortion (tissue passed
pregnancy and multiple pregnancy. (Cardiac with continued bleeding) often require suction
activity predictive of continued pregnancy in >90% curettage or dilatation and curettage
of cases) • Provide emotional support
• Consider monitoring quantitative ß-HCG (human
chorionic gonadotropin) for prognosis (increase of
<66% in 48 hours predictive of abortion or ectopic
pregnancy)
• Provide emotional support

Ectopic Pregnancy
Definition • Pain may be severe enough to cause fainting

Implantation and growth of fertilized ovum
outside of uterus. Commonly occurs in a fallopian • Pain may become generalized or remain
tube, but may also occur in the abdominal cavity, localized in one quadrant
on an ovary or in the cervix. The following • Pain may radiate to shoulder tip (in cases of
applies to tubal ectopic pregnancies. massive hemorrhage). This is usually noted in a
supine position and/or on inspiration
* Any woman of reproductive age who presents • Nausea and vomiting frequently present
with abdominal pain, cramping and/or vaginal • Backache may be present
bleeding – ectopic pregnancy should be
considered. This is a medical emergency* Chronic (Unruptured) Ectopic Pregnancy
• Accounts for 60% of cases
Causes • Slight, persistent vaginal spotting over several
Unknown but accounts for 2% of all pregnancies. days
• Lower abdominal discomfort (often mild)
Risk factors • Attacks of sharp pain and faintness occasionally
• Previous STI and/or pelvic inflammatory disease present
• Current use of intrauterine device • Distension may be present
• Previous tubal or abdominal surgery
• Previous ectopic pregnancy Physical Findings
• Relative infertility • Hemodynamically unstable if ruptured (elevated
• Use of fertility drugs or assisted reproductive heart rate, hypotensive)
technology • Postural blood pressure drop may be present as
• Increasing age – most common in women aged an early sign of blood loss
35-44 • Client in moderate-to-acute distress
• Smoking (may alter tubal/uterine motility, or • Pale, sweating
altered immunity) • Client walks carefully, bent slightly forward,
holding lower abdomen (guarding)
History • Abdominal distension may be present
• Amenorrhea of 6-8 weeks • Bowel sounds may be decreased
• If amenorrhea not present most recent period • Lower abdominal tenderness
may have been lighter and represent an • Rebound, guarding, rigidity may be present and
implantation bleed are suggestive of rupture
• Symptoms of pregnancy, followed by abnormal
vaginal bleeding, may be only scanty spotting Pelvic Examination
(Vaginal bleeding is present in ~ 50% of cases) • Caution –pelvic exam should be gentle so as not
• Lower abdominal pain: crampy, may be to rupture an unruptured ectopic.
unilateral • Unilateral adnexal tenderness
• May have had previous positive pregnancy test • Tender adnexal mass or fullness may be present
• Cervical os closed
Acute (Ruptured) Ectopic Pregnancy • Bleeding from os, but no tissue present
• Accounts for 40% of cases • Pain on movement of cervix
• May be hemodynamically unstable • Uterus may be soft, enlarged, nontender
• Sudden onset of unilateral lower abdominal pain
• Pain usually severe
• Pain may be constant or intermittent

• Acute appendicitis Nonpharmacologic Interventions
• Acute pelvic inflammatory disease • Bed rest
• Ruptured ovarian cyst or torsion of ovarian cyst • Trendelenburg position (prn) to aid venous
• Other acute abdominal pathology return if client is in shock
• Spontaneous abortion • Nothing by mouth
• Monitor vital signs
Complications • Insert urinary catheter
• Shock
• Future ectopic pregnancy Adjuvant Therapy
• Risk of maternal mortality if not treated • Oxygen to keep saturation > 97%
• Start 2 large-bore (14 or 16-gauge) IV lines with
normal saline or Ringer's lactate
Diagnostic Tests
• Reassess for signs of shock
• Pregnancy test: result may be positive or
negative
See protocol for managing hypovolemic
• Hemoglobin
shock, under "Shock," in chapter 14,
• Chronic ectopic: increased WBC
"General Emergencies and Major
• Ultrasound is the definitive test to rule out
Trauma."
ectopic.
Management • Monitor vital signs closely q5-15min
Maintain a high index of suspicion for this
• Monitor intake and urine output hourly
diagnosis in a sexually active female who has pain
and vaginal bleeding.
References
Goals of Treatment Sepilian, Vicken & Wood, Ellen. E-Medicine
• Manage complications Ectopic Pregnancy last updated Oct. 2005.
Accessed Oct. 9, 2006
• Rule out differential diagnoses and treat
http://www.emedicine.com/med/topic3212.htm
appropriately (Secondary level assessment may
be needed to differentiate – i.e. ultrasound) Murray, H; Baakdah, H.; Bardell, T. and Tulandi,
T. Diagnosis & treatment of ectopic pregnancy
Appropriate Consultation & Referral Canadian Medical Association Journal, Oct 11,
**Consult a physician as soon as possible for 2005. Accessed Oct. 9, 2006
Medevac as urgent surgical intervention may be http://www.cmaj.ca/cgi/content/full/173/8/905
required.**
Tenore, J.L. Ectopic Pregnancy, American
If Pain Severe or Client Hemodynamically Family Physician. Feb. 2000. Accessed Oct. 9,
Compromised 2006.http://www.aafp.org/afp/20000215/1080.ht
Severe pain or hemodynamic compromise ml
suggests possible rupture.

Hydatidiform Mole
• Pregnancy-induced hypertension during first
Definition half of pregnancy
Mass of vessels resulting from cystic proliferation
• Hyperthyroidism
of chorionic epithelium. May be benign or
malignant. Forms part of the spectrum of tumours • Bleeding during pregnancy, accompanied by no
termed Gestational Trophoblastic Disease detectable fetal heartbeat and uterine
enlargement after 12 weeks gestation by dates
Causes
Most complete hydatidiform moles are 46XX and
• Threatened or inevitable abortion
all the chromosomes come from the male; 10-15%
are 46XY, (2 sperm, 1 carrying an X and the other
a Y fertilize an empty egg). Partial hydatidiform For differential diagnosis of bleeding in
moles are 69 XXY and 2 sets of chromosomes are pregnancy, see "Bleeding in Pregnancy," above,
of paternal origin. this chapter.
Complications
History
• Bleeding during late first trimester, early second • Hemorrhage
trimester • Sepsis
• Vaginal blood dark brown to bright red • Choriocarcinoma (typically occurs later)
• Spotting or profuse bleeding
• Passage of cysts (in grape-like clusters) Diagnostic Tests
• Absence of quickening • Urine pregnancy test
• Pre-eclampsia may be present • Urinalysis: routine and microscopic
• Exaggerated signs of pregnancy • Measure hemoglobin level if client is bleeding
• Excessive nausea and vomiting (may present as • Quantitative serum HCG. Any level
hyperemesis gravidarum) >100,00mIU/ml should arouse suspicion of
molar pregnancy.
Physical Findings • CBC, RFTs, LFTs, Thyroxin
• Blood pressure may be elevated • Ultrasound to rule out hydatidiform mole.
• Fundal height may be greater than expected for
dates Management
• Examine all material passed per vagina for Goals of Treatment
presence of cysts • Identify condition early
• Uterus larger than expected for dates • Prevent complications
• Mild uterine tenderness may be present because
of over-distension Appropriate Consultation
• Fetal parts not felt Consult a physician if this diagnosis is suspected.
• Fetal heart not heard
Client Education
Most clients are symptomatic before 17th week of • Because of the small but real potential for
pregnancy. development of malignant disease, and because
these malignancies are absolutely curable, the
Suspect this diagnosis in clients with the following importance of consistent follow-up care (after
signs and symptoms: uterine evacuation) must be emphasized.
• The patient must avoid pregnancy until HCG
levels have remained normal for 6 months
• Effective contraception should be used. If a
pregnancy was to occur, the elevation in beta-

HCG levels could not be differentiated from the • Serial measurement of HCG (weekly) until three
disease process. consecutive negative results, then monthly for 6-
• Future pregnancies should undergo early months
sonographic evaluation because of the increased • Regular pelvic examinations
risk of recurrence of a molar gestation. • CXR indicated if serum HCG rises.
• The risk of recurrence is 1-2%. • Emotional support
• Regular pelvic examinations
• CXR is indicated if HCG levels rise References
www.sogc.org SOGC. Gestational Trophoblastic
Referral Disease. (May 2002). #114
Refer for definitive assessment, which requires
ultrasonography and measurement of serum http://www.emedicine.com/med/topic1047.htm
human chorionic gonadotropin (HCG) as soon as Hydatidiform Mole; Moore, L., et al
possible. Definitive treatment is surgical
evacuation. http://www.emedicine.com/med/topic866.htm
Gestational Trophoblastic Neoplasia; Hernandez,
Long-Term Follow-up E.
Follow up after surgery is critical.

Hyperemesis Gravidarum
(HG)
Definition • Various degrees of dehydration may be present:

HG is defined as excessive vomiting that leads to skin may be pale, eyes may appear sunken,
weight loss >5% of prepregnancy weight , with mucous membranes may be dry, skin turgor may
associated electrolyte imbalances and ketonuria be poor
(Occurs in about 1% of pregnancies). Will need a
physician consult if this severe. Laboratory Findings
• Urinalysis: urine concentrated; ketones may be
Causes present
Largely unknown. Can involve many contributing • Oliguria
factors. • Anemia
• Electrolyte imbalances.
History
• Persistent and excessive nausea and vomiting Differential Diagnosis (complete
throughout the day history taking and physical exam
• Client unable to keep down any solids or liquids must be done)
• Hydatidiform mole
If the condition is prolonged, client may also • Multiple gestation
report:
• Other medical causes of vomiting (e.g.
• Fatigue gastroenteritis, pancreatitis)
• Lethargy • Mood disorders
• Headache • Thyroid disorder
• Faintness • Renal disorder
• Weight loss • Helicobacter pylori
• Anxiety
• Depression Complications
• Signs of hypokalemia • Dehydration
• Electrolyte disturbances
Physical Findings • Nutritional deficiencies
• Heart rate may be elevated and weak (due to • Intrauterine growth retardation (IUGR)
fluid loss)
• Fetal death
• Blood pressure normal, but may be low if
• Maternal anxiety and depression
dehydrated
• Postural blood pressure drop may be present if
dehydrated Diagnostic Tests
• Weight may be reduced from previous • Urinalysis: routine and microscopic
measurement • CBC, electrolytes
• Client appears in mild-to-moderate distress (The • Consider ultrasound for growth and to rule out
nausea and vomiting in pregnancy (NVP) may multiple pregnancy, and molar pregnancy.
be mild, moderate or severe but may not
accurately reflect the distress it causes). The Management
negative impact of NVP on relationships has Goals of Treatment
major consequences on women’s working • Recognize condition early to prevent
abilities- 47% feel job efficiency is reduced, progression and hospitalizations.
35% lose work time, and 25% lose time from • Prevent complications
home life.

• Exclude organic causes (e.g. urinary infection, inner aspect of the wrists, just proximal to the
hepatitis, disorders of the gastrointestinal tract, flexor crease. (e.g. Seabands®)
gallbladder or pancreas)
Table 3: Foods that may appeal to pregnant
Appropriate Consultation women
• Consult a physician if nonpharmacologic Taste or texture Food suggestions
interventions fail to control symptoms in milder Salty Chips, pretzels
cases Tart, sour Pickles, lemonade
• Consult a physician immediately if the woman Earthy Brown rice
shows signs of dehydration Crunchy Celery sticks, apples
Bland Mashed potatoes
Nonpharmacologic Interventions Soft Bread, noodles
• Ginger supplementation Sweet Sugary cereal
Fruity Juicy, fruity popsicles
• Reassure client that condition improves with Wet Juices, seltzer drinks
time, usually by end of first trimester Dry Crackers
• Advise client to arise slowly and to keep soda
crackers at the bedside (to be eaten before
rising) Pharmacologic Interventions
• Suggest that client eat small amounts, at Consult with physician for drug(s) of choice and
frequent intervals, of whatever food and fluids dosage routine if medication needed to control
appeal vomiting. Patient prescription may be required.
• Emphasis is on intake, not on content, while
client is symptomatic; see Table 3 for gravol (A class drug) can be used for short term
suggestions of foods that appeal to pregnant relief.
women because of their taste and texture. There
is no evidence to prove that dietary changes diclectin as per physicians order
relieve the NVP. SOGC recommends dietary
and lifestyle changes should be liberally Consider Esophageal reflux therapies (antacids
encouraged and women should be counseled to and ranitidine)
eat whatever appeals to them
• Suggest that someone else do the cooking at Monitoring and Follow-Up
home, as food odors may initiate nausea Follow up weekly until symptoms resolve:
• Omit iron and vitamin supplementation until • Measure fundal height and compare with
nausea resolves (the use of B6 complex is previous values
encouraged in pregnancy. • Monitor fetal heart rate
• Ask client to monitor intake and urine output at • Monitor vital signs, urine output and ketones
home • CBC and electrolytes
• Recommend increased rest, as fatigue seems to • Ultrasound for growth if needed
exacerbate symptoms; client may need help with • Observe dental enamel for damage and
other children in the home encourage dental hygiene.
• Arranging for leaves of absence from work early
in the pregnancy may reduce the overall time Adjuvant Therapy
lost from outside employment If client is significantly dehydrated:
• Psychotherapeutic measures (e.g. stimulus • Initially maintain nothing by mouth
control, biofeedback, relaxation techniques and • Bed rest
imagery) may be helpful • Start IV therapy with normal saline
• Acupressure at the P6 (Neiguan) point has been • Adjust rate according to state of hydration
demonstrated to be helpful. This point is on the
• Transfer or medevac

If hypovolemia is present, see protocol References

for managing hypovolemic shock, under
"Shock," in chapter 14, "General Emergencies SOGC The Management of Nausea and Vomiting
and Major Treatment of Pregnancy. (October 2002) #120.
The Motherisk Nausa and Vomiting of

Pregnancy (NVP) Forum.
http://www.motherisk.org/women/forum.jsp

Multiple Gestation
Definition • Polyhydramnios
Presence of more than one fetus in a single • Hyperemesis gravidarum
pregnancy. While there are important • Post-partum haemorrhage
considerations, this is a normal variation.
Fetal Complications
Causes • Intrauterine growth retardation (IUGR)
• Fertilization of more than one ovum • Congenital anomalies (twice the risk)
• Splitting of one fertilized ovum into two • Intrauterine death
separate fetuses • Prematurity
• Predisposing factors: familial history of multiple • Twin to twin transfusion
gestation, treatment of infertility with ovulatory
drugs Diagnostic Tests
• Older >30 • Ultrasonography is needed for definitive
• High parity or history of previous multiple birth diagnosis and to confirm chorionicity.
• Serial Ultrasounds (i.e. every 2 weeks)
History beginning at 24 weeks gestational age to assess
Suspect multiple gestation in clients with family the growth of each fetus, rule out discordancy,
history of multiple gestation and in those receiving anomalies and feto-fetal transfusion syndromes,
drug treatment for infertility. and are also used to measure cervical length.
• Discomforts of pregnancy may present earlier • GBS swab and STI screen at 32 weeks as
and are more pronounced delivery prior to 40 weeks gestation is common
• Morning sickness, nausea and heartburn may • CBC – once a trimester at least, and more
present earlier and are more persistent frequently if hemoglobin is below 10, nutrition
• Later in pregnancy, dyspnea and indigestion are is not adequate, or other concerns such as poor
more pronounced weight gain. There is an increased demand for
iron in all pregnancies and this is intensified in a
multiple gestation.
Physical Findings
• Fundal height greater than expected for dates • MSS – at 15-20 weeks, optimally at 16 weeks.
• Fetal movements may be seen over wide area • Amniocentesis – offered at maternal age of 32
years or more at time of delivery or if MSS is
• Excessive number of fetal parts may be felt positive.
• Two distinct fetal hearts may be heard
• Weight gain above the expected, especially early Management
in pregnancy Goals of Treatment
• Elevated hCG and alpha-fetoprotein above • Identify multiple gestation early
expected levels.
• Identify complications early
Differential Diagnosis Appropriate Consultation
• Polyhydramnios • Consult a physician if this diagnosis is suspected
• Large single baby (macrosomia) as regular physician follow up will be required,
and a referral to an Obstetrician/Gynecologist
Complications may be required for delivery. Thereafter, consult
Maternal Complications physician if complications are suspected or
• Preeclampsia (can develop sooner and be more detected.
severe) • Consult a nutritionist, or a dietician as
• Anemia nutritional demands are increased in a multi-
• Premature labour and delivery

fetal pregnancy. This consult may be done as a

teleconference. Monitoring and Follow-up
• Follow up in clinic biweekly from time of
Nonpharmacologic Interventions diagnosis
• Assess family support and readiness for multiple • Regular visits as determined by physician
birth and possible prematurity. This should also
include possible transfer of the client and/or Referral
infants to Yellowknife or Edmonton. As discussed refer to physician and
• Arrange earlier transfer (i.e. 34 weeks) to dietician/nutritionist
tertiary setting to await delivery as with most
multi-fetal pregnancies delivery occurs at about References
36 weeks of gestation SOGC. Management of Twin Pregnancies (Part
• Notify expected place of delivery of twin 1). # 91. (July 2000). Accessed Oct. 9, 2006
pregnancy. Due to staffing levels and gestation http://www.sogc.org/guidelines/public/91E-
at birth the woman and infants may need to be CONS1-July2000.pdf
transferred out of NT.
SOGC. Management of twin pregnancies (Part 2)
Client Education #92 (August 2000). Accessed Oct. 9, 2006
• Symptoms of preterm labour http://www.sogc.org/guidelines/public/93E-
• Prepare family for possible Cesarean section. CONS2-August2000.pdf
Most twins if vertex can be delivered vaginally. Marchiano, D. and Ural, S.H. e-Medicine Prenatal
Cesarean section is indicated under certain Nutrition Accessed Oct. 9, 2006
conditions determined by physician
http://www.emedicine.com/med/topic3234.htm
• Instruct client about proper nutrition (including Last updated Aug. 6, 2005
vitamin and iron supplementation): nutritional
demands in a multi-fetal pregnancy differ from Zack, T; Pramanik, A. and Ford, S. Multiple
those of a singleton pregnancy, and an increase Births Accessed Oct. 9, 2006
of 300 kcal daily over intake for a singleton http://www.emedicine.com/ped/topic2599.htm
pregnancy is recommended. Last updated May 2
None for multi-fetal pregnancy – as per all other
pregnancies, and pregnancy related
complications.

Polyhydramnios
Accumulation of excessive amounts of amniotic • Premature labour
fluid (>1500 mL). • Malpresentation
• Prolapse of umbilical cord with rupture of
Causes membranes
• In ~65% of cases of polyhydramnios the cause is • Postpartum hemorrhage
unknown • Preeclampsia
• Gestational diabetes • Placental abruption
• Multiple gestation • Renal Dysfunction (maternal & fetal)
• Fetal anomalies (e.g. neural tube defect)
• Fetal infection (CMV, Toxoplasmosis, Rubella, Diagnostic Tests
Syphilis) • Anatomical Ultrasonography needed to confirm
• Isoimmunization diagnosis and for detailed anatomy to rule out
congenital anomalies.
History
• Develops after 28-32 weeks of gestation Management
• Presence of predisposing maternal conditions Goals of Treatment
(diabetes) Identify condition early.
• Abdominal discomfort due to overstretching of
uterus and abdominal wall Appropriate Consultation
• Dyspnea and heartburn due to excessive Consult a physician if this diagnosis is suspected.
elevation of diaphragm
• Leg and vulvar edema Nonpharmacologic Interventions
Provide support and counseling as necessary to
• Excessive weight gain
client and family.
Education re symptoms of preterm labour
Physical Findings
• Weight increased by 2-4 kg in 4 weeks above Pharmacologic Interventions
weight gain expected for gestation without None.
explanation
• Uterus larger than expected for dates Referral
• Shape of abdomen is globular Arrange referral for investigation
• Skin over abdomen shiny, with prominent veins
and marked striae
References
• Fundal height greater than expected for dates Boyd, R.L. and Carter, B.S. E-Medicine:
• Fetal parts difficult to feel Polyhydramnios and Oligohydramnios
• Uterus tense
Accessed Oct. 9, 2006.
• Fetal heart beat muffled or distant or may be
http://www.emedicine.com/ped/topic1854.htm
inaudible
Last updated May 19, 2006
Perinatal Institute: Fundal Height
• Multiple pregnancy
Measurement, Example 4: Excessive Growth
Accessed Oct. 9, 2006
http://www.perinatal.nhs.uk/growth/example.h
tm Last updated Oct. 9, 2006

Gestational Diabetes
NOTE: If client has pre-existing diabetes, it is an automatic referral to a

physician for guiding care.
Definition History
Gestational diabetes consists of both insulin Most clients with gestational diabetes are
resistance and diminished insulin secretion that asymptomatic.
develops during pregnancy. The mother has • Polydipsia
increased risks for gestational hypertension, • Polyuria
polyhydramnios, UTI’s, and operative delivery • Polyphagia
secondary to macrosomia and sequela. After the • Weight loss
birth, blood sugars usually return to normal levels; • Failure to gain weight
however, research shows that the occurrence of
• Recurrent urinary tract infections or vaginal
gestational diabetes increases the future risk for
candidiasis
progression of type 2 diabetes mellitus.
• Blurred vision
• Headaches
Causes • Drowsiness
• Genetic predisposition
• Hyperpnea (deep respirations)
• Increased tissue resistance to insulin during
pregnancy, due to increased levels of estrogen • Nausea
and progesterone • Signs of hypoglycemia
• Preexisting diabetes
Physical Findings
Current Risk Factors 2 • Fundal height may be greater than expected for
• Maternal obesity (BMI >40) gestational dates as per rule of plus or minus 2
• Previous diagnosis of GDM or glucose cm after 20 weeks gestation.
intolerance • Polyhydramnios on ultrasound
• Excessive weight gain during pregnancy
• Hyperlipidemia Laboratory Findings
• Hypertension • Urine: glucose or ketones may be indicated by
• Repeated glycosuria (> +1) dipstick test
• 24-28 week GCT > 7.8 mmol (see NWT
• Maternal age > 35 years
Guidelines and Diabetes algorithm)
• Member of high-risk population (e.g. Aboriginal
people, Hispanic, Asian or African descent)
Complications
• First degree relative with diabetes
• Past history of glucose intolerance Maternal
• Past adverse obstetrical history whose outcomes • Ketoacidosis
usually related to gestational diabetes (large • Postpartum hypoglycemia
baby > 4500 gm, shoulder dystocia) • Polyhydramnios
• Recurrent miscarriages • Premature labour and delivery
• History of congenital anomalies (if poor glucose • Complication in labor and delivery related fetal
control during fetal organ formation) size (macrosomia is defined as > 4500 grams)
• Polycystic ovary syndrome and / hirsutism • Post partum hemorrhage
• Corticosteroid use
Fetal
• Intrauterine death
• IUGR

• Prematurity and Sequalea • If the oral GCT is greater than or equal to

• Neonatal hypoglycemia 10.3mmol/L, the patient is diagnosed with GDM
• Congenital malformations and does not need further testing
• Neonatal death • If the oral GCT was given at 16-20 weeks, and if
negative, then f/u by a second one at 24-28
Diagnostic Tests weeks. May consider oral GTT on consult with
Gestational Diabetes Screening physician.
If woman is not at high risk, perform 50-g glucose
challenge test (GCT) at 24-28 weeks gestational Two hour 75g Oral Glucose Tolerance
age. Test (OGTT) PROCEEDURE
If woman is at high risk (morbid obesity, strong • Determine fasting blood glucose level (draw
family history, previous stillbirth) or has venous sample)
symptoms suggestive of gestational diabetes, give • Give 75g oral glucose load
the initial oral GCT at 16-20 weeks. May consider • Determine blood glucose levels at 1 and 2 hours
oral GTT on consult with physician. after administration of glucose load (diagnostic
• Oral GCT value of greater than or equal to levels given in Table 2) (draw venous samples)
7.8mmo/L at 1 hour is considered positive and • If any two values are met or exceeded, client has
f/u by oral GTT of 75G for proper diagnosis and gestational diabetes (GDM)
treatment. • If only one value is met or exceeded, client has
impaired glucose tolerance (IGT)
.
Table 2: Diagnostic glucose levels in 2-hour glucose tolerance test

Time after glucose load Diagnostic glucose level
Fasting AC> 5.3 mmol

1 hour > 10.6 mmol
2 hours > 8.9 mmol
Source: guidelines screening for gestational diabetes (2003 clinical practice guidelines for management of diabetes in
Canada)
**Referral to physician needed if the results fall within these values. (Done
through regular referral procedure if no access to an MD in community)
Management
Goals of Treatment No pharmacologic Interventions
• Identify condition early Dietary adjustment is the mainstay of therapy
• Optimize control of blood sugar Referral to diabetic clinic.
• Prevent maternal and fetal complications • Caloric intake should be 30-35 kcal/kg daily
• Recommend glucose levels pre-prandial < 5.3 • “Going on a diet” not encouraged.
• Client should avoid cakes, candy and other fast-
Appropriate Consultation acting carbohydrate foods
Consult a physician as soon as abnormal glucose • Dietary composition should be 50% to 60%
tolerance is diagnosed in a pregnant woman. carbohydrate, 20% to 25% protein and 20% fat,
Internal Medicine specialist may be consulted by with high fiber content
the GP. Thereafter, consult a physician if client • Three meals and three snacks, one at bedtime, is
fails to gain weight or loses weight, has recommended. Keep it simple. “NO powdered
discrepancies in fundal heights and if she is juice” diet
symptomatic. • Complex carbohydrates are recommended (e.g.
bread, pasta, beans, potatoes). Portion size of fist

• Discourage excessive salt use travel to see an MD. Plan for early referral for
• Encourage exercise, which has been shown to be delivery.
especially beneficial when used in combination
with dietary therapy Ultrasonography
• Encourage home glucose monitoring as per the • Ultrasonography should be done early in the
diabetic clinic’s recommendations pregnancy for accurate gestational dating.
• Encourage use of a diabetic log, and review • Follow up ultrasounds will be determined by the
home monitoring at each visit physician in consultation with OB/GYN.
• Prevention of excessive weight gain is important Growth may be monitored more frequently due
• Provide support and reassurance during to the diabetes.
pregnancy
• Follow diabetic clinic’s recommendations on a Other Follow-Up
patient specific basis. • After 40 weeks of gestation, fetal surveillance is
initiated, and delivery is recommended if there is
Pharmacologic Interventions any evidence of fetal compromise.
If fasting glucose remains >10.3. mmol/L, insulin • Women with gestational diabetes should have a
therapy is indicated and will be prescribed by the 75-g oral glucose tolerance test (OGTT) 6-12
physician. weeks postpartum to rule out persistent
carbohydrate intolerance.
Insulin requirement tends to rise as pregnancy
progresses, so frequent dose adjustments may be Counsel the client that her risk of frank diabetes at
needed. Woman may need to travel to see MD some point later in her life is approximately 35%.
more often.
Referral
Monitoring and Follow-Up (unless • Referral to settlement physician to internal
ordered otherwise) medicine for complex care is usually needed for
Follow up every 2 weeks until 36 weeks all but the mildest cases
gestational age and then weekly. Assess the • Follow-up should be by a physician whenever
following: possible
• Dietary compliance • Client would benefit from assessment and
• Weight gain or loss counseling by a dietician if this service is readily
• Peripheral edema available
• Blood pressure Consult with settlement physician about optimum
• Uterine size time for transfer out of community for delivery.
• Fetal growth
• Home glucose monitoring results References
Intrapartum Management Modules. A Prenatal
Check patient’s blood sugar log at each visit. Do Education Program, Enjoin Martin, 2002
finger poke with each prenatal visit.
Recommended preprandial level < 5.3 mmol. Diabetes in Pregnancy Module 21. Canadian
Follow diabetic clinic and physician’s Diabetes Association (Available in the Health
recommendations. Consult with a physician if Centers) 2005
evidence of poorly controlled glucose levels or
changes needed to treatment regime. May need to

Gestational Diabetes
Screening for Gestational Diabetes
Assess risk and screen early if multiple risk factors. All pregnant women should be screened for
glucose abnormalities between 24 and 28 weeks gestation
Assess Risk
If multiple risk factors present, screen in the first
trimester and repeat as needed.
All pregnant women between 24 – 28

weeks gestation
Glucose challenge test (GCT) = plasma
glucose drawn 1 hour post 50 g glucose
drink
Plasma glucose <7.8 Plasma glucose 7.8 –

mmol/l 10.2 mmol/l
Plasma glucose
>10.3 mmol/L
No gestational Administer 75 g
diabetes. OGTT
Retest if risk
factors warrant
AC > 5.3 mmol/L
1 hr > 10.6 mmol/L
2 hr. > 8.9 mmol/L
If 1 value met or exceeded If 2 values met or

exceeded
Gestational
IGT of pregnancy Diabetes
Initiate diet + testing Initiate diet, testing and
And re-evaluate lab /or insulin as required
glucose in 2 – 4 wks. for treatment

Hypertension in Pregnancy
Definition • If father of this pregnancy is different than the

Hypertension in Pregnancy is found in 10% of
previous pregnancy
cases and is classified in four categories:
1. Chronic or Pre-existing hypertension: Begins History

prior to pregnancy, or prior to 20 wks • History of pregnancies – often found in
gestation, and BP >140/90 mmHg. Is not primigravida, or first pregnancy with new
associated with proteinuria, end-organ partner
damage, and persists after delivery. • Age of client
• Thorough family history to rule out possible
2. Gestational hypertension with proteinuria, presence of one of predisposing factors listed
edema & sustained hypertension (a.k.a. above
Preeclampsia) • Excessive weight gain may be first warning
▪Mild: BP >140/90 mmHg <160/110 mmHg signal
(or an increase of 30/15 mmHg respectively), • Symptoms that range from minimal to severe
▪Proteinuria 1+ - 2+ (<300mg/24hr, on 24 hr (see physical findings)
urine), no end organ damage, no pathological
edema, Severe: BP >160/110 mmHg, Physical Findings
▪Proteinuria 3+ - 4+ (>500mg/24hr on 24 hr • Physical findings depends on severity of disease
urine), end organ damage present (HELLP *, (Edema is not a diagnostic criteria for
oliguria, IUGR), may have unexpected wt. Gestational Hypertension)
gain (>1kg/week) • Severity of the disease is determined by relative
increase in blood pressure above client's normal
3. Pre-existing hypertension with superimposed readings, and presence of signs and symptoms.
gestational hypertension with proteinuria.
• Hypertension in pregnancy requires
(Patient’s with pre-existing hypertension may
preeclampsia to be ruled out (proteinuria, end
develop significant proteinuria, end organ
organ damage), therefore the symptoms are
damage, pathological edema {preeclampsia})
related to end organ damage and are listed by
system and from mild to severe:
4. Gestational Hypertension without proteinuria. CNS:
Usually diagnosed in the latter half of the
Headache, visual disturbances (mobile spots),
pregnancy, is transient in nature, no
hyper-reflexes, stupurous, unconscious, clonus,
proteinuria, no end organ damage, may
seizures (eclampsia – see following page on
develop within 24 hours postpartum, but
eclampsia), stroke, coma
resolves approximately 2 weeks post partum.
CVS:
Hypertension that is diagnosed antenatally, but
Increasing severe blood pressure, HELLP
final classification to be made 6 weeks after
syndrome (hemolysis, elevated liver enzymes,
delivery
low platelets)
* Resp:
HELLP syndrome – hemolysis, elevated liver
Dyspnea related to pulmonary edema
enzymes, low platelets) Abd:
Nausea and vomiting, RUG / epigastric pain
Causes secondary to liver damage, abruptio placentae,
• Unknown GU:
• Predisposing factors: hypertension, Proteinuria (see definitions), oliguria,
primigravida, <20 years or >35 years of age, Fetal:
diabetes mellitus, chronic renal disease, multiple Tachycardia >160bpm, IUGR secondary to
gestation, polyhydramnios, hydatidiform mole placental insufficiency, fetal acidosis

Recommendations On Criteria For Management

Diagnosis Goals of Treatment
• See Definitions for clarity • Identify the condition early to prevent
• Except for very high diastolic readings progression
(> 110 mm Hg or more), all diastolic readings • Prevent maternal and fetal complications (See
> 90 mm Hg should be confirmed/repeated after ‘physical findings’)
4 hours. • Prevent eclampsia
• A rest period of 10 minutes should be allowed
before the blood pressure is measured. The Appropriate Consultation
woman should be sitting upright and a correctly • Consult a physician if hypertension in
sized cuff should be positioned at the level of pregnancy is present.
the heart. • Do not delay consultation if proteinuria, or
If any proteinuria present: symptoms present. May require medevac if
• Rule out other causes (UTI, vaginal discharge, signs and symptoms present or progress.
etc.) • Urgent consultation with physician in referral
• See client again soon and reassess urine, BP and centre if BP is 160/110 or more.
check for signs and symptoms
• If proteinuria present on consecutive visit with Client Education
no other causes, or with elevated BP, or other • Explain disease course and expected outcome.
symptoms, do a 24 hour urine collection • Stress the necessity of frequently monitoring
• Edema and weight gain should not be used as condition for early detection of disease
diagnostic criteria. progression.
• Instruct client to return to clinic immediately if
Laboratory Findings signs and symptoms occur and/or progress.
• Proteinuria on dipstick (consider 24 hour urine) • Possibility of referral out with a prolonged stay
• May find low platelets (HELLP syndrome) in Community of Delivery.
• Monitor for elevated liver enzymes
Non-pharmacologic Interventions
Complications • Non-pharmacologic management should be
• Preterm delivery (as definitive treatment for considered for any pregnant woman with a
gestational hypertension with proteinuria is systolic blood pressure of 140-150 mm Hg or a
delivery) diastolic pressure of 90-99 mm Hg, or both, as
• Abruptio placentae measured in a clinical setting.
• Baby small for gestational age (e.g. intrauterine • A short-term stay in hospital may be required
growth retardation [IUGR]) for definitive diagnosis (serial blood pressure,
• HELLP syndrome (Hemolysis, elevated liver ultrasonography, lab tests)
enzymes, low platelet count) • Management, dependent on blood pressure,
• Disseminated intravascular coagulation (DIC) gestational age, and presence of associated
• Aspiration or injury during seizure maternal and fetal risk factors, includes close
• Maternal and fetal morbidity and mortality supervision, limitation of activities and some
bed rest.
• A normal diet without salt restriction is advised.
Diagnostic Tests
• Pre-existing hypertension should be managed
• CBC, PT, PTT the same way as before pregnancy. However,
• Urinalysis and 24 hour urine, BUN & Cr additional concerns are the effects on fetal well-
• Liver Function Tests being and the worsening of hypertension during
the second half of pregnancy.

• There is, as yet, no treatment that will prevent Magnesium sulfate is a cerebral depressant that
exacerbation of the condition. reduces neuromuscular irritability. It can cause
If severity increases: vasodilation and reduction in blood pressure.
• Bedrest in a quiet, dark room
• Position client on her left side Symptoms of magnesium sulfate toxicity:
• Be prepared for possibility of eclampsia – oral respiration rate of less than 8, respiratory
airway, NPO, suction/ambubag, record seizure depression or arrest, maternal sedation, reduced or
time, length, and type. absent deep tendon reflexes, cardiac arrest, coma.
• Foley catheter and maintain urine output The antidote is
>25mL/hr, check protienuria hourly.
calcium gluconate (B class drug).
For mild gestational hypertension with Keep preloaded syringe of 10% calcium
or without proteinuria: gluconate at bedside.
• Antihypertensives – if patient was on
antihypertensive treatment prenatally, continue After the loading dose of magnesium sulfate:
with this after consultation with physician. solution of 20 g magnesium sulfate in 1 L normal
methyldopa (B class drug), as per physician saline or Ringer's lactate, 1-2 g/h (50-100 mL/h)
prescription
Transport may be commenced once the loading
Monitoring and Follow-Up dose is complete and the maintenance dose has
been started.
• Monitor vital signs and general condition for
progression of symptoms
• Monitor symptoms related to complications
(headaches, abdominal pain, reflexes, etc.) • Monitor state of consciousness and respiratory
rate constantly; monitor deep tendon reflexes
• Assess fetal heart, fetal movement and fetal
(patellar) and blood pressure q15min; monitor
growth
fetal heart rate q30min.
• Provide symptomatic support • If respiratory rate 8-12/min, reflexes reduced or
• May require weekly prenatal assessments urine output < 100 mL in previous 4 hours,
reduce infusion of magnesium sulfate by 50%.
Referral • If respiratory rate < 8/min or reflexes absent,
Medevac to hospital for evaluation may be
stop infusion of magnesium sulfate, then
advisable if there are significant symptoms and unclamp main line of Ringer's lactate and run at
risk. 100 mL/h. Consult a physician and then give
antidote:
For severe gestational hypertension
with proteinuria: 10% calcium gluconate (B class drug), 10 mL(1 g)
Refer to your HSSA protocol. IV over 5-10 minutes
Infuse over 15 minutes: If a seizure occurs:
magnesium sulfate (B class drug), 2-4 g in 100 mL • Suction nasopharynx prn
of normal saline via a drip chamber
• Administer oxygen
• Position the client on her side and cushion
Then reassess respiratory rate and reflexes.
appropriately
• Record length and type of seizure
Piggyback administration of this drug via a main
line is required. • After seizure, assess uterine contractions,
vaginal bleeding, uterine tenderness, abdominal
pain and fetal heart rate
• Discuss the use of additional seizure
medications with physician

• In case of prolonged seizure activity, Referral

consideration should be given to tracheal Medevac as soon as possible.
intubation
Immediate Medevac required if progression of
Antihypertensive therapy is added if maternal signs and symptoms, or risk for eclampsia
diastolic blood pressure is > 105 mm Hg: (seizures).
hydralazine (B class drug), 5 mg IM stat or 1 mg
IV as test dose, then 5-25 mg IV over 2-4 minutes; References
Canadian Hypertension Society (2006)
May need to be repeated in 20-30 minutes (5-10
mg IV) if the blood pressure is not reduced ALARM (Advances in Labour and Risk
effectively with the first dose. With severe Management), (SOGC, 2003)
hypertension (diastolic pressure > 110 mm Hg), http://www.bchealthguide.org/kbase/topic/major/h
the administration of an antihypertensive agent w2834/descrip.htlm
should be considered as follows:
hydralazine (B class drug), 5-10 mg via Michael B Brooks, MD, Consulting Staff,
intermittent IV bolus administration Department of Emergency Medicine, St. Mary-
Corwin Medical Center, (emedicine 2005).
Check blood pressure every 5 minutes.
Do not decrease the diastolic pressure to < 90 mm Paul Gibson, MD, Assistant Professor,
Hg as this would reduce the placental perfusion Departments of Medicine and Obstetrics and
and be detrimental to the fetus. Abruptio placentae Gynecology, Division of General Internal
is a possible complication of acute changes in Medicine, University of Calgary, (emedicine,
blood pressure. 2006)
Therapeutic approach to hypertension during
Precautions with Hydralazine pregnancy: Extrapolation of findings from
• Antihypertensive effects start within reproductive studies in animals to humans
30-60 minutes and last for about 4-6 hours
Arieh Lalkin, MD; Ronen Loebstein, MD;
• Contraindication: heart disease
Antonio Addis, PHARMD; Gideon Koren, MD,
• Side effects: tachycardia, palpitations, faintness, FRCPC, 1998 (www.motherrisk.org)
headache, hypotension

NWT Clinical Practice Guidelines for Primary Community Care Nursing (Adult)
Hypertensive Crisis (Eclampsia)
Definitions • Preterm labour and delivery

• Eclampsia: Convulsions or coma in pregnant or • Abruptio placentae
postpartum woman. Convulsion may occur in a
• HELLP syndrome (hemolysis, elevated liver
stable client with mildly elevated blood pressure
enzymes, low platelet count)
in absence of excessive weight gain and/or
edema. • Disseminated intravascular coagulopathy -
• HELLP syndrome: hemolysis, elevated liver hemorrhage
enzymes, low platelet count. • Stroke (CVA)
• Maternal death
History • Fetal death
A complete history and physical should be
Diagnostic Tests
completed and include but not limited to:
• Grand mal seizure may have occurred before • Vital signs including oxygen saturation
presentation • Urinalysis (for proteinuria, 24hr urine if
• Facial twitching may rapidly progresses to body positive)
rigidity • Measure blood glucose level
• Generalized contraction and relaxation of body • Measure hemoglobin level
muscles follows
Management
• Typically lasts for 60-75 seconds
Goals of Treatment
• Coma follows the convulsion
• Prevent end organ disease/damage, including
• Client usually does not remember anything of
brain injury
the event
• Prevent convulsions
• Respiration absent during seizure
• Prevent maternal injury during convulsion
• Rapid and deep respiration usually begins after
convulsion ends • Prevent fetal injury
One-third of seizures occur prenatally, one-third Appropriate Consultation

occur during labour, and one-third occur within Consult a physician as soon as possible, and
the first 24 hours postpartum. recommend medevac.
The stabilization of the client should be discussed

Physical Findings
with the referral center to determine what drug
• Physical findings in eclampsia are extremely therapy should be initiated before transfer and
variable
whether the therapy should be continued in transit.
• Client in acute distress (respiratory, CNS, end If intravenous magnesium sulfate or hydralazine
organ damage – e.g. renal, liver, lungs) hydrochloride is used during transport, a physician
• May be stuporous, unconscious or in convulsion should accompany the client. Tracheal intubation
• Vomiting or retching may be present and ventilation might become necessary if there is
• Deep tendon reflexes hyperreactive respiratory depression.
• Clonus may be present
• Urine: proteinuria present Adjuvant Therapy
• Oxygen 6-10 L/min
Complications • Start IV therapy with normal saline to keep vein
• Maternal injury during seizure/s open
• End organ disease and/or damage • Adjust IV rate if there is unusual fluid loss
• Aspiration (vomiting, diarrhea, other)
• IUGR - Fetal distress

Do not overhydrate with IV fluids as this may Transport may be commenced once the loading
increase risk of iatrogenic pulmonary edema. dose is complete and the maintenance dose has
been started.
• Bed rest in a quiet, darkened room Monitoring and Follow-Up
• Position client on her left side • Monitor state of consciousness and respiratory
• Stay with client at all times; do not leave her rate constantly; monitor deep tendon reflexes
alone (one to one nursing care) (patellar) and blood pressure q15min; monitor
• Nothing by mouth fetal heart rate q30min.
• Protect airway • If respiratory rate 8-12/min, reflexes reduced or
• Place artificial airway in client's mouth prn urine output < 100 mL in previous 4 hours,
reduce infusion of magnesium sulfate by 50%.
• Ensure that breathing and ventilation are
adequate • If respiratory rate < 8/min or reflexes absent,
stop infusion of magnesium sulfate, then
• Have oral airway and Ambu bag at bedside
unclamp main line of Ringer's lactate and run at
• Wipe away and suction oral secretions 100 mL/h. Consult a physician and then give
• Document time, duration and type of seizure antidote:
• Insert Foley catheter attached to a closed
drainage bag to monitor urine output closely 10% calcium gluconate (B class drug), 10 mL
(recommended); urinary output should be (1 g) IV over 5-10 minutes
greater than 25 mL/h
• Check urine for protein hourly If a seizure occurs:
• Suction nasopharynx prn
Pharmacologic Interventions • Administer oxygen
Infuse over 15 minutes: • Position the client on her side and cushion
magnesium sulfate (B class drug), 2-4 g in 100 mL appropriately
of normal saline via a drip chamber
• Record length and type of seizure
• After seizure, assess uterine contractions,
Then reassess respiratory rate and reflexes.
vaginal bleeding, uterine tenderness, abdominal
pain and fetal heart rate
Piggyback administration of this drug via a main
line. • Discuss the use of additional seizure
medications with physician
Magnesium sulfate is a cerebral depressant that • In case of prolonged seizure activity,
reduces neuromuscular irritability. It can cause consideration should be given to intubation
vasodilation and reduction in blood pressure.
Antihypertensive therapy is added if maternal
Symptoms of magnesium sulfate toxicity: diastolic blood pressure is > 105 mm Hg:
respiratory depression or arrest, reduced or absent hydralazine (B class drug), 5 mg IM stat or 1 mg
deep tendon reflexes, cardiac arrest, coma. The IV as test dose, then 5-25 mg IV over 2-4 minutes;
antidote is May need to be repeated in 20-30 minutes
(5-10 mg IV) if the blood pressure is not reduced
calcium gluconate (B class drug). effectively with the first dose. With severe
hypertension (diastolic pressure > 110 mm Hg),
Keep preloaded syringe of 10% calcium the administration of an antihypertensive agent
should be considered as follows:
gluconate at bedside.
hydralazine (B class drug), 5-10 mg via
intermittent IV bolus administration
After the loading dose of magnesium sulfate:
solution of 20 g magnesium sulfate in 1 L normal
Check blood pressure every 5 minutes.
saline or Ringer's lactate, 1-2 g/h (50-100 mL/h)

Do not decrease the diastolic pressure to Referral

< 90 mm Hg as this would reduce the placental Medevac as soon as possible.
perfusion and be detrimental to the fetus. Abruptio
placentae is a possible complication of acute References
changes in blood pressure. Dr.Turnell, Lecture Reproductive-Urology,
Obstetric Review, University of Alberta, 2004
Precautions with Hydralazine Webpage: BC Health Guide
• Antihypertensive effects start within (www.bchealthguide.org - search eclampsia)
30-60 minutes and last for about 4-6 hours Webpage: www.familydoctor.org (search
• Contraindication: heart disease hypertension and eclampsia)
• Side effects: tachycardia, palpitations, faintness,
headache, hypotension

Intrauterine Growth Restriction

(IUGR)
Definition • Poor weight gain (doesn’t ‘look’ pregnant)

• Slow fetal growth within uterus
• Fetus small for gestational age Physical Findings
• Symmetrical vs. Asymmetrical • Weight unchanged or decreased from previous
visit
Asymmetrical occurs in most of the cases of • Fundal height unchanged or less than expected
IUGR and occurs due to placental insufficiency. from previous visit
The abdomen is small, but the head and limbs are
within acceptable percentile. Suspicion should be raised if fundal height does
Symmetrical usually occurs due to anomaly, the not exhibit the predicted growth: at 20wks = 20cm
head and limbs are generally below the 10th +/- 2cm or no increase over a 3 week period.
percentile. Actual fundal height is not reliable until the
second trimester, however measurements still need
Causes to be done throughout pregnancy for trending.
Maternal Factors:
• Age A lag in fundal height by 4 cm warrants ultrasound
• Environmental / Social factors – smoking, drug evaluation.
use, alcohol use, obesity
• Poor obstetrical history – past IUGR, stillbirth,
• Miscalculation of dates (Use LMP if woman is
or birth defect babies
sure of dates, or use earliest U/S for EDD
• History of maternal disease – hypertension etc. calculations. If discrepancy is <10days and
woman is sure of her dates, use her LMP dates
Fetal Factors: for EDD)
• Chromosomal abnormalities • Improper measurement on previous assessment
• Structural abnormalities • Intrauterine death
• Multiple gestation
• Prematurity Complications
• Infections – CMV, toxoplasmosis, rubella, Antepartum Complications
herpes, HIV, Hepatitis A or B, Syphilis • Oligohydramnios (insufficient liquor)
• Intrapartum fetal acidosis (due to insufficient
Placental Factors: placental circulation)
• Inadequate placenta – r/t maternal medications, • Intrauterine death
maternal disease processes, maternal elevated • Risk of preterm labour
AFP
• Impaired umbilical blood exchange – previa, Neonatal Complications
hypertension • Persistent fetal circulation
• Meconium aspiration syndrome
History • Hypoxic ischemic encephalopathy
• Usually occurs in second trimester • Hypoglycemia
• Client may be aware of lack of growth • Hypocalcemia
• Altered fetal movements (increased or • Hyperviscosity
decreased) • Defective temperature regulation
• Gestational hypertension and gestational
diabetes may be present
Diagnostic Tests
• Other illnesses may be present • Urinalysis

• Blood sugar measurement Pharmacologic Interventions

• Ultrasonography (18 week Anatomical U/S) None.
• Maternal workup to rule out underlying
pathology Monitoring and Follow-Up
• Once this diagnosis is made, more frequent
Ultrasonography, preferably serial, is needed for prenatal visits are essential for monitoring.
definitive diagnosis. • This may include serial ultrasounds and stress
tests. The frequency of visits will depend on
Management establishing the underlying cause of the growth
Goals of Treatment retardation.
• Prevent condition through education about • More frequent visits to referral centre may be
nutrition, avoidance of substance use, especially needed throughout pregnancy for serial growth
smoking ultrasounds.
• Identify associated disorders early (e.g. diabetes
mellitus, hypertension) Referral
• Genetic screening – Maternal Serum Screening • Refer to physician and/or NWHP (Northern
if warranted and consent received* Woman’s Health Program) as soon as possible
• Maintain a healthy fetus and hopefully a health for further assessment.
newborn. • Close antenatal surveillance is required, and the
decision as to when to deliver the infant is
MSS – refer to handout from the NWHP at the complex.
Stanton Territorial Hospital • Consideration must be given to have this
woman’s prenatal care delivered in a secondary
Appropriate Consultation or tertiary care centre.
Consult a physician immediately if this diagnosis
is detected or suspected. References
Consider consult to nutritionist if this is identified ALARM and SOGC. (2002) Gestational
as a contributing factor. Hypertension.
Martin, E. Jean. (2002). Intrapartum Management
• Provide support to client and family. Modules. A Perinatal Education Program.
• Attempt to treat underlying cause. Lippincott Williams, Philadelphia.

Antepartum Hemorrhage (Late)
Definition
Vaginal bleeding that occurs after 20 weeks of • Give 20 mL/kg normal saline as a bolus over 15
gestation. minutes
• Reassess for signs of shock
Causes • Repeat 20 mL/kg boluses until systolic blood
The two most common causes are placenta previa pressure stabilizes at >90 mm Hg
and abruptio placentae, described in Table 6. • Ongoing IV therapy is based on response to
initial fluid resuscitation, continuing losses and
Diagnostic Tests underlying cause, treat to achieve a good
• Measure hemoglobin level hemodynamic response
• Urinalysis • Adjust IV rate accordingly, to maintain urine
output of 50 mL/h
Management • Oxygen to keep saturation > 97%
Goals of Treatment
• Identify condition early Pharmacologic Intervention
Verify Rh status and give Rh immune globulin
• Resuscitate and stabilize if client is in shock (RhIG) within 48 hours, if indicated (available
• Prevent complications from the Laboratory Department of Regional
Hospitals).
• Monitor vital signs q10-15min if hypotension is
Nonpharmacologic Interventions present or vaginal bleeding continues
• Nothing by mouth • Monitor fetal heart rate q15min
• Bed rest • Monitor for signs of onset of labour
• Trendelenburg position (prn) to aid venous • Assess stability of pre-existing medical
return if client is in shock problems
• Insert urinary catheter if client is in shock
• Monitor intake and output hourly Referral
• Aim for urine output of 50 mL/h Medevac as soon as possible.
Adjuvant Therapy References

Initial aggressive fluid resuscitation is needed if http://www.emedicine.com/med/topic6.htm
client is in hypovolemic shock: Abruptio Placentae; Gaufberg, S.V
• Start two large bore IV14g-18g
• Start IV therapy with normal saline http://www.emedicine.com/MED/topic3271.htm
Placenta Previa; Ko, P

Table 6: Description and classification of placenta previa and abruption placentae

Placenta previa Abruptio placentae
Definition
Aberrant implantation of placenta in lower uterine segment Separation of the placenta from the uterine wall after 20
weeks gestation; may be partial, rarely complete
Classification
Marginal: low-lying implantation, near the cervical os but Mild: slight vaginal bleeding (< 100 mL); no fetal heart rate
not covering it abnormalities; no evidence of shock or coagulopathy
Partial: partly covering cervical os Moderate: moderate vaginal bleeding (100-500 mL) and
uterine hypersensitivity with or without elevated tone; mild
Complete: completely covering cervical os shock and fetal distress may be present
Severe: extensive vaginal bleeding (>500 mL), tetanic uterus

and moderate to profound maternal shock; fetal death and
maternal coagulopathy are characteristic
Prevalence
1 in 200 deliveries often misdiagnosed in 2nd trimester on 10% of all deliveries (severe form rare)
ultrasound, before lower segment has formed.
Risk Factors
Increasing maternal age, multiparity, prior uterine scar; Prior history of abruption, maternal hypertension, cigarette
associated with breech and transverse presentations, prior or cocaine use, increasing maternal age, multiparity; sudden
placenta previa decompression of uterus (rupture of membranes, after
delivery of first twin), trauma to abdomen
Clinical Presentation
• Vaginal bleeding is typically painless, with bright red • Vaginal bleeding in 80% of cases, but may be
blood concealed in the remainder (i.e. retroplacental bleeding);
• Blood loss is usually not massive with initial bleed, but therefore maternal hemodynamic situation may not be
bleeding tends to recur and become heavier as the pregnancy explained by observed blood loss
progresses • Pain and increased uterine tone typical
• Verify Rh status • Pain increased in severity
• Verify Rh status
Physical Findings
• Heart rate may be normal or elevated • Depend on degree of detachment, amount of blood loss
• Blood pressure normal, low or hypotensive • With mild abruption, signs may be minimal
• Postural blood pressure drop may be present • Heart rate mildly to severely elevated
• Fetal heart rate usually normal, initially • Blood pressure normal, low or hypotensive
• Fetal heart rate depends on amount of bleeding • Fetal heart rate elevated, reduced or absent
• Mild distress to frank shock • Client appears in acute distress
• Bright red bleeding per vagina • Client may be pale or unconscious (if in shock)
• Fundal height consistent with dates • Vaginal bleeding moderate, profuse or absent
• Uterus soft, normal tone, nontender • If membranes ruptured, amniotic fluid may be bloody
• Uterine size consistent with dates • Uterus may be larger than expected for dates
• Transverse, oblique or breech lies common • Uterus tender
• Should be suspected in client with persistent breech • Increased uterine tone (tense or hard)
presentation • Uterine contractions may be present and prolonged
• Advisability of speculum examination debatable • Uterus may fail to relax completely between
• Digital examination contraindicated in Health Centres contractions
.

Group B Streptococcal
Infection
Definition • Any woman with documented GBS bacteriuria

Group B streptococci (GBS) is a bacterial in this pregnancy.1
infection that involves the pregnant woman and • Women in preterm labour at <37 weeks
her newborn infant, causing maternal infections of gestational age unless there has been negative
the uterus, placenta, and urinary traction and GBS vaginal/rectal swab culture within 5 weeks.
infections in the infant that can be localized or • If GBS culture result is unknown and the
involving the infant’s entire life. woman has ruptured membranes at term for
greater than 18 hours.
Estimates of GBS colonization rates among
pregnant women range from 15% to 40%. GBS Pharmacologic Interventions
infection is transmitted in 40% to 70% of cases, Antibiotic regimen of choice for intrapartum
but sepsis develops in only 1% to 2% of affected prophylaxis:
newborns.
penicillin G 5 million units (B class drug) IV load
GBS sepsis presents in the early neonatal period followed by 2.5 million units every 4 hours until
(<7 days of age) or somewhat later (7 days to 3 delivery
months of age). Early onset is more common and or
is associated with a higher mortality rate. ampicillin (C class drug), 2 g IV at least 4h prior
to delivery, followed by
Diagnostic Tests 1-2 g IV q4-6h until delivery or until labour is
• Universal screening of all pregnant women at stopped1
35-37 weeks of gestation with a vaginal/rectal
swab. For clients with allergy to penicillin:
clindamycin (B class drug), 900 mg IV q8h until
Management delivery or until labour is stopped
• Consult a physician or nurse practitioner when References
risk factors are indicated. SOGC .The Prevention of Early-Onset Neonatal
Group B Streptococcal Disease. (September
Risk Factors for which Intrapartum 2004). # 149. pages 826-832.
Chemoprophylaxis is recommended
Blondel-Hill, Edith and Fryters, Susan (2006).
• Treat with IV antibiotics in the following cases: Bugs & Drugs. Antimicrobial Reference. Capital
• Intrapartum (at time of labour) or with rupture of Health Alberta. Page 414.
membranes if:
• Positive GBS culture screening done at 35 Martin, E .Jean (2002) Intrapartum Management
weeks, Modules. Lippincott Williams, Philadelphia
• Any woman with an infant previously infected
with GBS,

Preterm Labour

Onset between age of viability and 37 weeks • In early gestation, subtle signs with general
gestational age of regular contractions with discomfort and lower back pain.
progressive cervical dilatation and/or effacement. • Moderate distress
• "Bloody show" may be present.
Discrimination from "false labour" is difficult, • Contractions (strength, frequency, duration)
unless there is cervical dilatation, which indicates • If contractions moderate to strong, uterine
true labour; however, postponement of treatment changes seen on abdomen
until such dilatation occurs may lower the chances • Fetal heart rate: identify changes with
of treatment success. contractions.
• Uterine tenderness or hardness
Causes • Assess position and presentation of fetus,
Frequently unknown. Several factors have been
engagement of head
associated with preterm labor.
• Cervical dilatation, effacement, descent and
presentation of fetal parts
Maternal Factors
• Infection (systemic, vaginal, urinary tract,
• Avoid digital exam in presence of suspected
ROM unless ordered by consulting physician
amnionitis)
• Uterine anomalies
prior to transport.
• Fibroids
• Retained intrauterine device Differential Diagnosis
• Cervical incompetence • Braxton-Hicks contractions in later pregnancy
• Overdistended uterus (polyhydramnios, multiple • False labour in later pregnancy
gestation) • Urinary Tract Infection
• Rupture of membranes • Pelvic/vaginal infection
• Physical and situational stress
• Poor nutrition/underweight Complications
• Smoking • Progression to active labour
• Gestational hypertension • Progression to preterm delivery
Fetal Factors Diagnostic tests

• Congenital anomalies • Fern test of amniotic fluid
• Intrauterine death • Amnioswab test
• Urinalysis: evidence of infection may be present
History • Cervical and vaginal swabs for STI, BV
• Presence of one or more risk factors • Consider Point of Care Testing dipstick, if
• Onset of contractions available, to estimate the cervical ripeness and
• Contractions regular, becoming stronger and the risk of preterm delivery for e.g Actim Partus
closer together or Fetal Fibronectin
• Rupture of membranes and passage of bloody
mucus may have occurred Management
• Clients at risk should be identified during Goals of Treatment
routine prenatal visits • Slow or halt labor
• Cramping, general discomfort, lower back pain • Deliver preterm infant safely, if delivery
necessary in most appropriate setting whenever
possible.

Appropriate Consultation ampicillin (C class drug), 2 g IV at least 4h prior

Consult a physician. Discuss care plan based on to delivery, followed by
most accurate gestational age, membrane status, 1 g IV q4-6h until delivery or until labour is
cervical dilation. stopped1
Nonpharmacologic Intervention For clients with allergy to penicillin:

Bed rest in left lateral decubitus position. clindamycin (B class drug), 900 mg IV q8h until
delivery or until labour is stopped
Adjuvant Therapy
Start IV therapy with normal saline to keep vein • Consider antibiotics for all women with ruptured
open membranes with risk factors such as:
• Increased temperature > 38°C or fetal/maternal
Pharmacologic Interventions tachycardia or uterine tenderness
Tocolytic agent • Consider antepartum antibiotics for all women
Discuss with a physician possible use of tocolytic with ruptured membranes prior to 34 weeks,
agent to attempt to halt contractions and to permit regardless of clinical presentation
timely transport to referral centre.
indomethacin (A class drug) only if <32 weeks • Monitor uterine contractions, vital signs and
gestational age, 100mg PR prior to transfer. fetal heart rate
Consult with physician for subsequent doses if
transport is delayed Assess probability of imminent delivery on the
basis of the following factors:
Steroids • Cervical effacement and dilatation
Discuss with physician the use of steroids to • Frequency of uterine contractions
accelerate fetal lung maturation only in fetuses • Parity
less than 34 weeks gestational age: • Previous obstetric history
• Woman states is ready to push.
Preferred drug of choice-
betamethasone (B class drug) 12 mg IM q24 Prepare for delivery as necessary.
hours x 2 doses Refer to "Unplanned Delivery in the Health
Centre," at the end of this chapter.
Or alternately
Referral
dexamethasone (B class drug), 6 mg IM q12h, 4 Medevac as soon as possible
doses only
Antibiotics References
ALARM 13th edition 2006.
• Discuss with physician for antibiotic use
depending on clinical picture.
• Ensure Group B strep prophylaxis for all women
SOGC. Women’s Health Information, Pregnancy,
with confirmed positive GBS or unknown GBS Preterm Labour. (October 2006).
status.
Give: Sosa, C., et al. (2004) Bed rest in singleton
penicillin G (B class drug) 5 million units IV load Pregnancies for preventing preterm birth
followed by 2.5 million units every 4 hours until (Cochrane Review). In: the Cochrane Library,
delivery or labor has stopped Issue 1, Cichester UK: John Wiley & Sons Ltd.
or

Table 7: Quick reference guide for procedures prior to and during medevac of pregnant women with suspected /
confirmed premature labour or premature rupture of membranes
Always consult with the receiving physician. The care plan will be based on many factors including,
but not limited to, the most accurate gestational age, membrane status, labour status and cervical
dilation, parity, and obstetrical history.
Establish IV line; consider need for second line

Avoid unnecessary digital exam in presence of suspected or confirmed rupture of membranes.
Tocolysis
Discuss with physician the possible use of a tocolytic agent to attempt to halt contractions in order to facilitate
timely transport to referral centre.
indomethacin (only if < 32 weeks) 100 mg PR prior to transport

Consult with physician for subsequent doses if transport is delayed.
Steroids
Discuss with physician the possible use of steroids to accelerate fetal lung maturation, only if <34 weeks.
Preferred Drug:
betamethasone 12 mg IM q 24 hrs x 2 doses
or alternately,
dexamethasone 6 mg IM q12h x 4 doses
Antibiotics
Ensure Group B Strep antibiotic prophylaxis for all women with unknown or confirmed positive GBS status,
regardless of gestational age or membrane status.
Preferred Drug:
penicillin G 5 million units IV loading dose at least 4 hours prior to delivery, then 2.5 million units IV q4h until
delivery
or alternately,
ampicillin 2g IV loading dose, then 1 g IV q4h until delivery
If client allergic to penicillin:
clindamycin 900mg IV q8h until delivery
Consider antibiotics appropriate for chorioamnionitis for all women with ruptured membranes who present with
fever, maternal or fetal tachycardia, uterine tenderness or irritability, or WBC changes.
Consult physician for choice of antibiotics.
Consider antepartum antibiotics for all women with ruptured membranes prior to 34 weeks, regardless of clinical
presentation.

Premature Rupture of Membranes
Definition
Rupture of membranes is considered premature if • Vital signs
it occurs more than 1 hour before onset of labour. • Assess fundal height for consistency with dates
"Preterm premature" is premature rupture of • Assess fetal engagement through abdominal wall
membranes is rupture that occurs before 37 weeks • Evaluate for uterine contractions
of gestation. • Assess fluid leaking from vagina (color, odor,
amount)
• Assess for bleeding from vagina
Causes
• Check for cord prolapse.
• Unknown
• Abdominal trauma
• Incompetence of cervix If rupture of membranes has been documented,
• Uterine abnormality a sterile vaginal examination should be
• Hydramnios performed with the following goal:
• Assess cervix for changes and signs of onset of
• Multiple gestation
• Abnormal lie of fetus labor
• Placenta previa
• Viral or bacterial intrauterine infection Differential Diagnosis
• Bacterial vaginal infection • Loss of bladder control
• Previous cervical surgery • Premature labour
• Following amniocentesis • Term labour
• Smoking and other lifestyle habits
Complications
History • Intrauterine infection
• Sudden gush of fluid or continuous trickle from • Preterm delivery
vagina • Cord prolapse/compression
• Fluid may be clear or colored as pale green,
brownish, stained with blood Diagnostic Tests
• Sometimes described as loss of control of • Amniotest –using sterile swab
bladder or wet panties • Urinalysis (routine, microscopic and culture)
• Using pads for leakage • CBC and differential early on
• No uterine contractions felt • Ferning testing
Prenatal History Management

• Assess (from history or from records) for Goals of Treatment
vaginal group B streptococcus (GBS) status • Identify presence of amniotic fluid
during pregnancy • Prevent infection
• Develop appropriate care plan for medevac/
Physical Findings possible delivery
• Cervical digital examination with ruptured
membranes increases risk of chorioamnionitis. Appropriate Consultation
Therefore, evaluate cervix visually with sterile Consult a physician as soon as possible if you
speculum. Avoid digital examination if possible, suspect this diagnosis.
unless client is in labour and delivery is
inevitable Nonpharmacologic Interventions
• Fetal heart rate – evidence of bradycardia • Bed rest
suspect cord prolapse. • Diet as tolerated
• Encourage ample fluid intake po
• Change sanitary pad at least q2h

• Shower rather than bath. Steroids

• Pericare appropriate If transport is delayed and gestational age is less
• Change maternal position (left lateral or right than 34 weeks, discuss with a physician the role of
lateral recumbent) that optimizes FHR. corticosteroids in fostering fetal lung maturation.
• Knee chest position. If cord prolapse is Refer to “Preterm Labour” in this chapter.
confirmed, maintain knee-chest position and
apply digital pressure on presenting part, holding Monitoring and Follow-Up
it away from the cord, up and out of the pelvis, • Monitor for development of labour or infection
normally until the client reaches the OR. • Monitor vital signs, including temperature, q2h
(Consult with a physician and medevac team re • Monitor fetal heart rate q2h if not in labour
assignment of responsibility during transport) (q15min if in labor)
Or • Monitor quantity of fluid loss pv
• Knee chest position: alternate method – using an • Monitor vaginal loss for foul-smelling discharge
indwelling Foley catheter, fill the bladder with • Monitor fundus for development of tenderness
500 ml normal saline. This will keep the
presenting part away from the cord. Referral
Antibiotics Reference
Discuss with a physician the need for prophylactic th
ALARM –13 Edition 2006.
antibiotics depending on vaginal GBS status and
clinical presentation (i.e. febrile or not, in labor or
not)

Postpartum Hemorrhage
Definition • Massage fundus manually to stimulate uterine
Postpartum hemorrhage (PPH) is typically contraction. Be cautious not to over-massage.
classified as primary or secondary (Table 8). • Insert Foley catheter (bladder distension can
Blood loss > 500 mL after spontaneous vaginal prevent effective contraction of uterus)
delivery and >1000 mL after instrumental or • Bimanual compression may be necessary if
operative delivery. Therefore, clinical experience bleeding uncontrolled with all other
is necessary to determine when bleeding is interventions: capture uterus between both hands
occurring too rapidly or at the wrong time or is (one hand in vagina, one hand on fundus) and
unresponsive to appropriate treatment. Any post exert firm pressure
partum blood loss that leads to homodynamic
instability is to be treated as hemorrhage. Blood Adjuvant Therapy
loss will be less well tolerated if the client has low • Oxygen to keep oxygen saturation > 97%
hemoglobin (anemia) or has not had the normal • Start at least 2 large-bore (14- or 16-gauge) IV
expansion of blood volume during pregnancy, as lines with normal saline
in cases of hypertension with proteinuria. • Aggressive fluid resuscitation as necessary for
hemodynamic stabilization
Complications • Give 20 mL/kg IV fluids as a bolus over 15
• Anemia minutes
• Hypotension • Reassess for signs of shock
• Hypovolemic shock • Repeat 20 mL/kg boluses of IV fluids until
• Secondary infection systolic blood pressure stabilizes at >90 mm Hg
• Sepsis • Treat to achieve a good hemodynamic response
• Maternal death
Diagnostic Tests Assist uterine contraction:
Serial or follow up CBC oxytocin (D class drug), 10 units IM or 5 units IV
push stat
Management then:
Goals of Treatment oxytocin (D class drug), 20 units in 1 L normal
• Replace blood losses saline IV fluid infused rapidly
• Stimulate uterus to contract Bolus oxytocin can cause transient hypotension
• Prevent hypovolemic shock then hypertension.
See protocol for managing hypovolemic shock, Consult physician for further management.
under "Shock," in chapter 14, "General
Emergencies and Major Trauma." Monitoring and Follow-up
• Monitor vital signs and general condition
Appropriate Consultation frequently until stable
Consult a physician as soon as possible. • Monitor intake and hourly urine output
• Aim for urine output of about 50 mL/h
• Nothing by mouth Referral
• Bed rest, warmth, supportive measures Medevac as soon as possible. Surgical intervention
• Trendelenburg position if client is in may be required.
hypovolemic shock (this may cause pooling of
blood in uterus, but it is helpful) Reference
ALARM – PPH Chapter 2005

Table 8: Definition, causes, history and physical findings for primary and secondary postpartum
hemorrhage
Primary Secondary
Definition
Blood loss > 500 mL immediately after or within 24 Blood loss > 500 mL per vagina 24 hours to 6 weeks
th th
hours of delivery postpartum (usually occurs between 10 and 14 day)
Causes
• TONE: Atonic uterus • Retained placental fragments
• TISSUE: Laceration of cervix, vagina, perineum, • Endometritis
• TRAUMA: laceration, rupture, inversion
• THROMBIN: coagulopathy
• Predisposing factors; prolonged labour, rapid labour,
high parity, bladder distension, multiple gestation,
partial separation of placenta, retained fragments,
retained blood clots, antepartum hemorrhage, uterine
inversion
History
• Presence of one of the above causes • Persistent bright red lochia or large or small amount
• Vaginal bleeding • Lochia may have returned to normal
• Restlessness, anxiousness • Client presents with sudden, severe, bright red
• Nausea and vomiting may develop bleeding
• Note Rh status • Passage of clots and tissue
• Fatigue and dizziness may be present (if bleeding is
slow, continuous)
• Symptoms of shock may be present (if bleeding is
sudden, acute)
• Foul discharge and fever may be present (if there is a
secondary infection)
Physical Findings
• Heart rate rapid • Temperature may be elevated
• Blood pressure low or hypotensive • Heart rate rapid; may be weak, thready (if client is in
• Postural blood pressure drop may be present shock)
• Acute distress possible (agitation from shock) • Blood pressure low to hypotensive (if client is in
• Client pale, possibly diaphoretic shock)
• Continued profuse bleeding after delivery • Postural blood pressure drop may be present (early
sign of impending shock)
• Placenta or membranes may be incomplete
• Client in moderate to severe distress
• Fundus above level of umbilicus
• Uterus soft, boggy • Bright red bleeding per vagina
• Purulent or foul-smelling discharge may be present
(if there is an infection)
• Fundus can be visible or palpated high in abdomen
• Fundus may be soft
• Tenderness may be present (secondary infection)
• Pelvic examination: cervical os open, bright red
bleeding from os, tissue may be present in os

Unplanned Delivery of a Term Pregnancy in the

Health Centre
History
• Lightening within past 2 weeks (usually effacement and dilatation of cervix,
only in primigravida) presentation and descent of presenting part
• Frequency of micturition increased • Monitor fetal heart rate before and after a
• Easier breathing contraction for a full minute
• Greater difficulty walking
• Braxton-Hicks contractions occur from 16 Diagnostic Tests
weeks onwards but may have become • Urinalysis: routine; measure for glucose,
more noticeable to the woman in the past ketones and proteinuria
few weeks. • If poor or no prenatal care consider
• Passage of red mucus-like material per hemoglobin and random blood glucose
vagina ("bloody show")
• Fluid gush (may be described as loss of Management
bladder control but possibly amniotic Goals of Treatment
fluid) • Ensure maternal and fetal well-being
• Onset of painful, rhythmic uterine • Delivery of healthy baby
contractions, increasing in length, strength • Delivery in supportive environment.
and frequency
• Contractions may be felt in back and low Appropriate Consultation
in abdomen *Consult a physician to arrange transfer to
• Record time of onset, frequency and hospital for delivery where possible.
duration of contractions
• No history of pregnancy (concealed Adjuvant Therapy
pregnancy) Consider saline lock, use fluid only if
dehydrated or complications arise. If
Physical Findings and Initial transferring, will need IV access.
Monitoring
• Baseline TPR Nonpharmacologic Interventions
If possible, have family member(s) or
• Heart rate increased
friend(s) stay with client during labour, at
• Blood pressure may be mildly elevated
client’s discretion
• Fetal heart rate 110-160 bpm; determine • Assist and encourage client with breathing
location of heart tones
and relaxation techniques in response to
• Abdominal contour changes with client’s needs.
contraction
• Ensure adequate nutrition and hydration
• Bloody mucus may be seen on perineum status during labour as per client (PO or
• Assess length, strength and frequency of IV)
contractions • Supportive comfort measures
• Palpate to assess fetal lie, presentation and
engagement of fetal head Monitoring and Follow-Up
• Assess rupture of membranes (e.g. • Monitor progress of labour
amniotest) • Monitor contractions, maternal vital signs
• Perform vaginal examination (using sterile and fetal heart rate hourly in early labour,
technique if ruptured membranes): assess more frequently as delivery nears

• Fetal heart rate (FHR) should be • Estimated length of time required for
monitored before and after a contraction evacuation
every 15-30 minutes during the active first • If there is a possibility of the client
stage of labour and after every push in the delivering en route, keep client at Health
second stage (Fetal Health Surveillance in Centre and deliver baby there
Labour SOGC, Bodell’s book)as per • Reassess client upon arrival of transport
facility policy. team.
• Perform vaginal exams to assess
effacement and cervical dilatation (in When Delivery Is Imminent
normal labour these should not be more Ensure second health care professional
often than 4 hourly, unless there is a present.
clinical indication to do otherwise) Prepare delivery equipment, resuscitation
• Observe colour of liquor, if ruptured equipment and incubator.
membranes
Care during Delivery
Progression of Normal Labour • Control delivery of head, stop client
• Plot progress on partogram pushing and let head come out naturally
• It is important for FHR to return to normal • Support perineum to prevent tears
rate if it decelerates with a contraction. To • Once head is delivered, check for presence
encourage this, change client’s position, of cord around neck
turn on left side if lying down. Encourage • If cord is wrapped around neck, gently slip
the client to walk or remain upright a finger under cord and gently pull it over
throughout labour. head
• If cord is tightly around neck, insert two
In a primigravida (rule of thumb): fingers under cord, using two 3” straight
• Cervix will efface first, then dilate artery forceps (or whatever available) to
• Dilatation progresses at about 1 cm every clamp cord, cut between clamps and
hour unwind cord from neck.
• Full dilatation on average takes • Wipe face clear of secretions
approximately 10-12 hours. • Guide anterior shoulder out under
• Once full dilatation is achieved, delivery symphysis pubis, and deliver posterior
of baby may take 1-2 hours shoulder through the curve of Carus--do
• Unplanned labours in a community often not pull on baby
happen much faster than stated above. Be • Body will slip out quickly without much
prepared. assistance from practitioner
In a multigravida: Care after Baby is Delivered

• Effacement and dilatation are extremely • Clamp cord in two places, and cut
variable, but usually occur together between clamps after cord stops pulsating
• Time to delivery of baby is also extremely • Dry baby and wrap
variable • Keep baby warm and ensure that
respiration is established
Referral • Assess Apgar scores at 1 and 5 minutes
When considering evacuation of a client in • Give baby to mother (unless problems
labour the following factors should be identified)
considered: • Obtain 20-mL sample of cord blood
• Progress of labour • Assessment and care of newborn
• Stage of dilatation according to NWT Newborn Record Form
• Parity

Delivery of Placenta After Delivery of Placenta

Wait for delivery of placenta (can take up to • Palpate uterus to ensure it is firm
30 minutes). • If uterus is boggy massage fundus of
uterus, which is top – not front - of uterus,
Look for signs of placental separation: until firm
• Client may state she feels another • Examine perineum for tears
contraction
• Cord will lengthen Pharmacologic Interventions
• A gush of blood may occur Administer oxytocin to promote contraction
• Uterus may be seen to tighten with a of uterus after delivery of the placenta:
contraction oxytocin (D class drug), 5-10 units IM
• Do not pull on the cord to hasten or
delivery unless you are sure placenta has 5 units IV push
separated. and/or
oxytocin (D class drug), 10-20 units in a 1-L
Once the placenta has separated: bag of Ringer's lactate IV at 100-150 mL/h
• If the woman is lying/semi-recumbent in
bed, place one hand on abdomen, just Postpartum Monitoring
above symphysis and hold uterus back. • Monitor vaginal blood loss, uterine
• Hold cord and guide placenta downwards firmness and vital signs every 15 minutes
and out, following the curve of Carus during the first hour, then monitor every
• Alternatively, when you think the placenta 30 minutes for 2 hours if mother is not up
has separated, have the woman stand, and walking.
kneel or squat depending on her condition • If using more than one pad completely
and ask her to either gently push or soaked, per hour, consult
“cough” the placenta out. If you do this, • Examine and clean baby
you MUST NOT pull on the cord at all, • Encourage early ambulation if all vital
but you may gently guide the placenta out, signs normal
following the curve of Carus. If you have
difficulty with the placenta and the Referral
woman’s vital signs are completely Consult with doctor to see if transfer
normal, with no evidence of bleeding per warranted. Transfer mother and baby to
vaginam, this is a good way to get the hospital if necessary. If delivery has
placenta out, as it is usually just sitting in occurred without complications and baby
the vagina waiting to “fall” out. has no problems at birth and is term (37-42
• To aid in the deliver in the after coming weeks) there is no valid clinical reason for
membranes, rotate placenta gently as you sending Mum and Baby to hospital. There
withdraw the membranes. may be staffing reasons i.e. not enough staff
• If having difficulty, consult at earliest to observe Mum and baby for a few hours.
opportunity, preferably on speaker phone, Following normal birth Mum and Baby may
stay with patient return home after approximately 6 hours, or
• Examine placenta and membranes for at Mum’s discretion.
completeness
• Do not give oxytocin until placenta has
been delivered.
• Total blood lose is about 500 ml. If
greater, refer to post partum hemorrhage
topic. Some women may be negatively
affected by a smaller blood loss.

Documentation www.sogc.org/guidelines/public.112E-
If baby is born in Health Centre complete CPG1-April2002.pdf (Fetal Health
Registration of Live Birth, Labour and Surveillance in Labour Part 2)
Delivery Summary and Newborn Record
and any other pertinent documents Obstetric Guideline 6A, Intermittent
Auscultation in Labour-
References www.rcp.gov.bc.ca/guidelines/Obstetrics
www.sogc.org/guidelines/public/112E-
CPG1-March2002.pdf (Fetal Health
Surveillance in Labour (Part 1)

Chapter 13- Women’s Health and Gynecology

Assessment Of The Female Reproductive System.......................................................................................... 1
Examination Of The Female Reproductive System........................................................................................ 2
Common Women's Health Issues And Gynecological Problems.................................................................. 4

Abnormal Uterine Bleeding............................................................................................................................ 4
Dysfunctional Uterine Bleeding (DUB) ......................................................................................................... 5
Dysmenorrhea................................................................................................................................................. 9
Breast Lumps ................................................................................................................................................ 11
Mastitis.......................................................................................................................................................... 12
Vulvovaginitis............................................................................................................................................... 14
Human Papillomavirus (HPV) (Genital Warts) ............................................................................................ 16
Pelvic Inflammatory Disease (PID) .............................................................................................................. 18
Contraception................................................................................................................................................ 20
Menopause.................................................................................................................................................... 24
Gynecological Emergencies ............................................................................................................................ 26

Acute Pelvic Pain Of Gynecological Origin................................................................................................. 26

Assessment Of The Female Reproductive System

General • Other related problems (e.g. previous anesthetic
The following characteristics of each symptom reaction)
• Onset (sudden or gradual) Use of Contraception
• Chronology • Type used (past and present)
• Current situation (improving or deteriorating) • Difficulties with method, suitability
• Location • If discontinued, reasons for doing so
• Radiation
• Quality Sexual History
• Timing (frequency, duration) • Sexual orientation
• Severity • Regularity and type of intercourse
• Precipitating and aggravating factors • Number of partners in the past 12 months
• Relieving factors • Associated symptoms (e.g. pain, postcoital
• Associated symptoms bleeding)
• Effects on daily activities • Sexual dysfunction
• Previous treatments Breasts
• Efficacy of previous treatments • Soreness, tenderness and their relation to
menstrual cycle
Cardinal Symptoms • Redness, swelling, nipple discharge
In addition to the general characteristics outlined • Change in contour, presence of masses
above, characteristics of specific symptoms should • Is client breast-feeding?
be elicited, as follows. • History of breast cancer or polycystic breasts
Menstrual History Lymphatic System

• Age at menarche • Enlarged, painful nodes (in axilla, groin)
• Interval, regularity, duration and amount of flow
• Date of most recent menstrual period Vaginal Discharge
• Was most recent menstrual period normal? • Onset, colour, odor, consistency, quantity
• Dysmenorrhea • Relation to menstrual period
• Premenstrual symptoms (e.g. swelling, • Associated symptoms (e.g. rectal or urethral
headache, mood swings, pain) discharge, vaginal itch or burning, urinary
• Abnormal uterine bleeding symptoms, malaise, abdominal pain, fever,
rashes)
• Symptoms of menopause
• Relation to medication use (e.g. antibiotics,
• Age at menopause
steroids)
• Postmenopausal bleeding
• History of previous vaginal or pelvic infections
and their treatment
Obstetric History
• Number of pregnancies, live deliveries,
Pain
stillbirths, abortions
• Onset, location, radiation, character, severity
• Difficulties with pregnancies, deliveries
• Relation to menstruation
• Birth weight of babies
• Aggravating and relieving factors
• Problems with infertility
• Use of analgesics and their effect

• Associated gastrointestinal, urinary or vaginal Other Associated Symptoms

symptoms • Ulcerations
• Are symptoms related to an encounter with a • Persistent lesions
new sexual partner? • Sense of pelvic relaxation (pelvic organs feel as
though they are falling down or out)
• Infertility
• Pelvic infection
Examination Of The Female Reproductive System

General • Anus: lesions, ulcerations, tenderness, fissures,
Subjective hemorrhoids
• Apparent state of health
• Appearance of comfort or distress Vagina
• Colour (e.g. flushed or pale) • Inflammation
• Nutritional status (obese or emaciated) • Atrophy
• Match between appearance and stated age • Discharge
• Lesions, ulcerations, excoriation
Vital Signs • Masses
• Temperature • Induration or nodularity
• Pulse • Relaxation of perineum (ask client to bear down
• Respiratory rate and observe for any bulging of vaginal walls)
• Blood pressure
Cervix (if present)
Breasts • Position, colour, shape, size, consistency (see
For NWT Protocol and Procedure for Breast below)
Examination (Self and Clinical) see: Community • Discharge
Health Nursing Program Standards and • Erosions, ulcerations
Protocols, Adult Health, (March 2003), Appendix • Cervical tenderness
A, pp10-17 • Bleeding after contact
• Adnexal pain on movement of cervix or uterus
Lymph Nodes (Chandelier's sign)
Palpate the following areas and identify
enlargement, tenderness, mobility and consistency: Consistency of cervical tissue: normal cervix is
• Upper extremity: supraclavicular area, pink and feels firm, like the tip of the nose; in
infraclavicular area, axilla, epitrochlear nodes pregnancy, the cervix is bluish and feels softer,
• Lower extremity: inguinal nodes like the lips of the mouth
External Genitalia Uterus

• Distribution of hair • Position
• Labia majora and labia minora: lesions, • Size
ulcerations, masses, induration, areas of • Contour
different colour • Consistency of uterine tissue (within 1-2 weeks
• Clitoris: size, lesions, ulcerations postpartum)
• Urethra: discharge, lesions, ulcerations • Mobility
• Skene's and Bartholin's glands: masses, • Pain on movement
discharge, tenderness
• Perineum: lesions, ulcerations, masses,
induration, scars

Adnexa
• Ovaries cannot usually be felt unless the client is
very thin or the ovaries are enlarged.
• Tenderness
• Masses
• Consistency
• Contour
• Mobility

Common Women's Health Issues And Gynecological

Problems
Abnormal Uterine Bleeding
Definition patterns of abnormal uterine bleeding are based on
Uterine bleeding that is abnormal in amount, periodicity and quantity of flow (Tables 1 and 2).
duration or timing. The terms used to describe
Table 1: Terminology to describe abnormal uterine bleeding

Term Definition
Menorrhagia Prolonged or excessive bleeding at regular intervals
Metrorrhagia Irregular, frequent uterine bleeding of varying amounts but not excessive
Menometrorrhagia Prolonged or excessive bleeding at irregular intervals
Polymenorrhea Regular bleeding at intervals of less than 21 days
Oligomenorrhea Bleeding at intervals greater than every 35 days
Amenorrhea No uterine bleeding for at least 6 months
Intermenstrual bleeding Uterine bleeding between regular cycles
Table 2: Differential diagnosis of abnormal uterine bleeding

Type Causes
Dysfunctional uterine bleeding (e.g. menorrhagia) Anovulatory cycles
Breakthrough bleeding while on OCP Missed OCP, inadequate OCP absorption, OCP hormonal
imbalance, insufficient OCP strength
Pelvic infection
Breakthrough bleeding in first half of cycle on OCP Inadequate estrogenic activity of OCP
Breakthrough bleeding in second half of cycle on OCP Inadequate progestational activity of OCP
Postcoital bleeding Cervical disease Endometrial cancer
Postmenopausal bleeding Cervical or atrophic vaginitis Endometrial cancer
Bleeding related to cervical disorders Erosion, polyp, cervicitis, dysplasia, cancer
Bleeding related to endometrial disorders Polyp, dysfunctional uterine bleeding, uterine fibroid,
cancer (in postmenopausal women)
Bleeding related to intrauterine contraceptive devices Irritation, infection
Bleeding related to infection PID, cervicitis
Bleeding related to endocrine disorders Hypothyroidism, hyperthyroidism, Cushing’s disease,
hyperprolactinemia, stress (emotional, excessive
exercise), polycystic ovarian syndrome, adrenal
dysfunction or tumor
Bleeding related to hematological disturbances Anticoagulation, blood dyscrasias
Bleeding related to complications of pregnancy Ectopic pregnancy, spontaneous abortion, hydatidiform
mole (molar pregnancy)

Dysfunctional Uterine Bleeding (DUB)

Definition Menorrhagia may signify a bleeding disorder or a
Abnormal uterine bleeding not caused by pelvic structural lesion, such as uterine leiomyomas,
pathology, medications, systemic disease or adenomyosis or endometrial polyps.
pregnancy. It is the most common cause (in 90% Up to 20% of adolescents who present with
of cases) of abnormal uterine bleeding but is a menorrhagia have a bleeding disorder such as von
diagnosis of exclusion. Willebrand's disease. Liver disease with resultant
coagulation abnormalities and chronic renal failure
Causes may also cause menorrhagia.
Usually related to one of three hormonal-
imbalance conditions: estrogen breakthrough Polymenorrhea is usually caused by an inadequate
bleeding, estrogen withdrawal bleeding and luteal phase or a short follicular phase.
progesterone breakthrough bleeding.
Oligomenorrhea in an ovulating woman is usually
Anovulatory Dysfunctional Uterine caused by a prolonged follicular phase.
Bleeding
Anovulation is the most common cause of DUB in Intermenstrual bleeding may be caused by cervical
reproductive-age women. It is especially common disease or the presence of an intrauterine
in adolescents. Up to 80% of menstrual cycles are contraceptive device.
anovulatory in the first year after menarche.
Cycles become ovulatory an average of 18-20 Midcycle spotting may result from the rapid
months after menarche. decline in estrogen levels before ovulation.
Some women still have anovulatory cycles after For other causes of abnormal uterine bleeding, see
the hypothalamic-pituitary axis matures. Weight Table 2, above, this chapter.
loss, eating disorders, stress, chronic illness or
excessive exercise may all cause hypothalamic History
anovulation. • Age (e.g. reproductive age or menopausal)
• Amount, duration, frequency, interval of
Another cause of anovulation is polycystic ovarian bleeding
disease. This unopposed estrogen state increases • Try to determine if cycles are ovulatory or
the risk of endometrial hyperplasia and cancer. anovulatory (see Table 3, this chapter)
• Date of last normal menstrual period
Some women with chronic anovulation do not fall • Any contraception use (type, how used)
into any of the above categories and are • Hormone replacement therapy if
considered to have idiopathic chronic anovulation. postmenopausal
• Possibility of pregnancy
All causes of anovulation represent a • Signs of easy bleeding (e.g. gums) or bruising
progesterone-deficient state. suggestive of coagulopathy
• Any pain associated with bleeding
Ovulatory Dysfunctional Uterine • Past history of gynecological problems such as
Bleeding abnormal Papanicolaou (Pap) smear, fibroids,
Although less common than anovulatory bleeding,
sexually transmitted diseases (STIs),
ovulatory DUB may also occur. DUB in women
gynecological malignancy, prior episodes of
with ovulatory cycles occurs as regular, cyclic
abnormal uterine bleeding
bleeding.
• Past history of thyroid, renal or hepaticdisease
• History of strenuous physical exercise (which
may cause DUB)

• Eating disorder, significant emotional or A full gynecological examination, including

psychological stress determination of blood pressure and weight and
• Date and result of most recent Pap smear examination of thyroid, breasts, abdomen and
• Date and result of most recent mammography pelvic area (bimanual), should be performed.
Physical Findings The pelvic examination consists of careful

DUB is a symptom, not a diagnosis. The findings inspection of the lower genital tract for lacerations,
are variable, depending upon underlying cause. vulvar or vaginal pathology, and cervical lesions
The results of the examination may be deceptively or polyps. Bimanual uterine examination may
normal or obviously abnormal. reveal enlargement from uterine fibroids,
adenomyosis or endometrial carcinoma.
Table 3: Characteristics of Ovulatory and Anovulatory Menstrual Cycles

Feature Ovulatory cycle Anovulatory cycle
Cycle length Regular Unpredictable
Premenstrual symptoms Present None
Bleeding Dysmenorrhea Unpredictable bleeding pattern;
frequent spotting; infrequent, heavy
bleeding
Breasts Tender Non-tender
Basal temperature curve Biphasic Monophasic
Other Change in cervical mucus
Mittelschmerz
Differential Diagnosis whom there is no response to initial management

See Table 2, in "Abnormal Uterine Bleeding," strategies.
above, this chapter.
These tests would be ordered by a physician.
Diagnostic Tests
• Urine pregnancy testing for all patients of Endometrial biopsy and ultrasonography should be
reproductive age performed early in the investigation of bleeding in
• Complete blood count (to provide a measure of any postmenopausal woman.
blood loss and adequacy of platelet count)
• Prothrombin time (PT) and partial Management
thromboplastin time (PTT) Goals of Treatment
• Levels of thyroid-stimulating hormone (TSH) • Rule out organic pathology
and prolactin • Regulate menstrual cycles
• Liver function tests (ALT and total bilirubin) • Prevent complications
• Cervical and vaginal samples for culture
• Pap smear Specific management depends on the underlying
cause.
• Pelvic ultrasonography if organic pathology is
suspected
Premenopausal Women
If the reproductive-age woman is not pregnant, the
Refer for endometrial biopsy early in the
results of the physical examination are normal, and
investigation of any woman who is > 35 years of
all pathologic, structural and iatrogenic causes
age, postmenopause, or who has a history of
have been excluded, abnormal uterine bleeding is
prolonged exposure to unopposed estrogen in

usually dysfunctional in nature and can be endometrial carcinoma. Of all postmenopausal

managed with hormonal therapy. See Table 4, women with bleeding, 5% to 10% are found to
below, this chapter. have endometrial carcinoma. Other potential
causes of bleeding are cervical cancer, cervicitis,
Postmenopausal Women atrophic vaginitis, endometrial atrophy,
The most serious concern in postmenopausal submucous fibroids, endometrial hyperplasia and
women with abnormal uterine bleeding is endometrial polyps.
Table 4: Pharmacologic treatment for dysfunctional uterine bleeding

Age group Treatment* Comments
Premenopausal OCP Low-dose (35 mcg) monophasic or triphasic OCP can
regulate cycles while providing contraception
medroxyprogesterone 10 mg PO od for If contraception is not an issue, medroxyprogesterone can

10 days be used to regulate cycles; in a woman who has
or amenorrhea or oligomenorrhea, medroxyprogesterone
medroxyprogesterone 150 mg IM every 3 months can protect against endometrial
q3months hyperplasia
Perimenopausal medroxyprogesterone 10 mg PO od for May be used monthly to regulate bleeding pattern
10 days
Usually use 20 mcg pills; OCP can be continued until the
OCP woman has finished menopause, then change to HRT
(OCP may be relatively contraindicated in women > 35
years of age who smoke)
Postmenopausal Cyclic HRT May consider increasing the progesterone dose if early
(receiving withdrawal bleeding occurs; increase estrogen dose if
HRT) intermenstrual bleeding is present
Continuous combined HRT (B class May increase the estrogen dose for 1-3 months to
drug) stabilize endometrium; may also try increasing the
progesterone dose; if bleeding continues, consider
With continuous combined HRT, up to changing regimen to cyclic HRT or using a different type
40% of women have irregular bleeding of estrogen
in the first 4-6 months of therapy
(Rubin et al. 1996). Bleeding is more
common when hormone therapy is
started less than 12 months after
menopause occurs.
* hormonal drugs used as treatment for DUB and not as contraceptives are all B class drugs
Women Receiving Hormone interactions or malabsorption. If unscheduled

Replacement Therapy bleeding occurs in two or more cycles, further
Women receiving hormone replacement therapy evaluation is indicated.
often present with abnormal bleeding and of these,
30% have uterine pathology. Other causes include Appropriate Consultation
cervical lesions, vaginal pathology or the hormone Consult a physician before ordering diagnostic
therapy itself. tests and for medication treatment options if
urgent treatment is warranted.
Women receiving sequential hormone replacement
therapy may experience midcycle breakthrough
bleeding because of missed pills, medication


• Follow up monthly until cycles have become • Refer electively any client (if she is stable) to a
regular physician for thorough evaluation and treatment.
• Monitor hemoglobin as needed if heavy
bleeding continues despite therapy

Dysmenorrhea
Definition • Identify adnexal masses, enlargement of uterus,
Painful menstruation. enlargement and tenderness of groin nodes

• Primary dsymenorrhea: normal uterine • PID
contraction during menstruation • Endometriosis
• Secondary dsymenorrhea: endometriosis, use of • IUCD irritation
intrauterine contraceptive device (IUCD), pelvic • Cervical stenosis
inflammatory disease (PID) • Hemorrhagic ovarian cyst

Primary Dysmenorrhea None.
• Begins 6-12 months after menarche
• Pain in low abdomen and back Management
• Pain wavelike and cramping Goals of Treatment
• Lasts several hours to several days • Differentiate primary from secondary
• Begins before or at same time as menstrual flow dysmenorrhea
• Associated symptoms: nausea, diarrhea, • Relieve symptoms
headache, flushing, rarely syncope • Identify predisposing factors, underlying causes
• May increase in severity over several years (e.g. STI screening)
• Usually decreases in severity after birth of first
child Appropriate Consultation
If client is not responding to first-line therapies,
Secondary Dysmenorrhea arrange elective consultation with a physician.
• Begins several years after menarche (when
woman is in late 20s to 40s) Nonpharmacologic Interventions
• Development of moderate to severe pain In primary dysmenorrhea, reassure client that no
• May begin several days before onset of menses pelvic disease exists and that the condition will
• Pain may be constant or intermittent likely resolve itself.
• Aggravated by movement and straining at stool
• May be localized to one area or may radiate over Client Education
lower abdomen • Help client to understand the physiology of the
normal menstrual cycle and why pain may occur
• Possible associated symptoms: nausea and
vomiting, diarrhea or constipation, headache, • Counsel client about appropriate use of
painful intercourse, vaginal discharge, malaise medications, e.g. over the counter NSAIDs
(dose, frequency, side effects)
• Symptoms may be present throughout the cycle
or may begin just before onset of menses and • Teach client pelvic tilt exercises, which may
last throughout menstruation help to alleviate discomfort and backache
• Suggest that client use hot water bottles or warm
towels to relieve discomfort
Physical Findings
• Results of physical examination usually normal • Alternative birth control methods
• Temperature may be elevated in secondary • Increased activity e.g. walking
dysmenorrhea (infection)
In a client with an IUCD, consider IUCD
• Identify presence of vaginal infection, presence
malposition or infection. The IUCD may have to
of IUCD strings
be removed.
• Tenderness on movement of cervix and with
palpation of uterus may be present

Pharmacologic Interventions In a woman with moderate or severe

To manage mild symptoms of primary dysmenorrhea, starting NSAID preparations
dysmenorrhea in the young, healthy client: before the start of menstrual flow results in better
pain control.
or qid prn These preparations are contraindicated in clients
with allergy to acetylsalicylic acid (ASA) or
If client is young, healthy, sexually active and also previous history of peptic ulcer disease.
requires birth control, start OCP (A class drug).
Refer to Tables 6-8 in this chapter for information Review symptoms in 6 months.
about oral contraceptives.
Referral
Control moderate-to-severe symptoms with a Refer to a physician if there is a suspicion of a
nonsteroidal anti-inflammatory (NSAID) agent; secondary cause of dysmenorrhea or if treatment
for this menstrual cycle only, use the following: fails to control symptoms.
naproxen (C class drug), 250-mg tab, 2 tabs PO
stat, then 1 tab PO tid or qid prn for 1 or 2 days

Breast Lumps
Definition For a detailed guide to breast examination refer to
A mass or irregularity in breast. May be single or Community Health Nursing Program Standards
multiple. and Protocols (March 2003), Adult Health, pages
10-14
Causes
• Fibrocystic breast changes Differential Diagnosis
• Cyclic hormonal effects on normal breast tissue • Carcinoma
• Benign breast disease • Benign breast disease
• Malignant disease • Mastitis with or without abscess
• Trauma (hematoma)
• Infection with duct obstruction Diagnostic Tests
• Arrange mammography screening every 2 years
History from 50 to 69 years of age
• Discovery of a lump in the breast • Screen more frequently if client is at higher risk
• Identify when in menstrual cycle lump was • Arrange diagnostic mammography or breast
found (breasts may feel lumpy before or during ultrasonography if a lump is discovered
menstruation)
• Identify previous history of breast lumps Management
• Inquire about pain, nipple discharge, redness of Goals of Treatment
breast, skin changes, lactation • Rule out serious pathology
• Medication use (e.g. OCP)
• Past history of breast disease or family history Appropriate Consultation
(in first-degree female relatives) of breast Consult a physician as soon as possible if a breast
disease lump is discovered.
• Recent history of trauma to breast
• Presence of fever or systemic signs of illness Nonpharmacologic Interventions
Client Education
Physical Findings • Regular mammographic screening: encourage
screening mammography every 2 years for
• Inspect breasts with client sitting up, first with
women 50-69 years of age (earlier for women
arms at sides, then with arms raised above the
with risk factors)
head
• Instruct client about proper breast self-
• Repeat inspection with client lying down
examination
• Assess asymmetry with respect to size, shape,
• Follow up benign breasts lumps at regular
contour
intervals and instruct client to return to clinic if
• Check for redness, dimpling or thickening of changes noted
skin
• Provide teaching and support before all
• Look for nipple discharge or crusting investigative procedures
• Palpate breast and axilla with client sitting and
lying down Referral
• Identify lumps, tenderness, warmth, nodes Arrange referral to surgeon after positive
• Have client show you where she felt the lump mammogram for definitive diagnosis.
• Describe lump in terms of size, discreteness,
consistency (e.g. hard, firm, soft, fluid-like),
contour, mobility and position

Mastitis
Inflammation and infection of the breast. • Warm compresses qid for comfort
• Regular emptying of involved breast q6h by a
Causes combination of nursing and manual expression
• Usually Staphylococcus aureus, occasionally
Streptococcus Client Education
Risk Factors medications (dose, frequency)
• Lactation with blocked milk ducts • Recommend that client continue breast-feeding
• Poor breast hygiene or use a breast pump to relieve engorgement and
• Cracked nipples prevent further stagnation of milk
• Counsel client about breast hygiene to prevent
further infection and relieve cracked nipples
History
• Recent parturition (2 weeks or more before • If breast feeding, counsel about appropriate
technique
presentation)
• Affected breast(s) hard and red • Suggest application of nonscented lotion
(Lanolin based only) to heal cracked nipples and
• Intense pain in breast
prevent future cracking
• Associated fever and chills • Suggest use of properly fitting support bra to
reduce pain
Physical Findings • Prevent condition (through education about
• Temperature elevated proper breast care)
• Client in moderate distress Pharmacologic Interventions
• Affected breast shows area of redness or Mild-to-Moderate Mastitis
streaking, as well as swelling Oral antibiotics:
• Nipples may be excoriated, cracked or caked cloxacillin (C class drug), 500 mg PO qid for
with milk 7-10 days
• Skin warm to touch or
• Area of redness hard (indurated) and tender cephalexin (C class drug) 500 mg PO qid for
• Fluctuance may be detected (which indicates an 7-10 days
abscess)
• Axillary nodes enlarged and tender For clients with allergy to penicillin:
Complications 10 days
• Abscess
Antipyretics and analgesia for fever and pain:
• Cessation of breast-feeding because of pain,
which may lead to further congestion of breast
1-2 tabs PO q4-6h prn
• Sepsis or (if pain moderate to severe)
acetaminophen with codeine 8mg or 30 mg
Diagnostic Tests (C class drug), 1-2 tabs q4h prn (maximum
• Obtain sample of milk for culture and sensitivity 15 tabs) (not if breastfeeding)
Management Monitoring and Follow-Up

Goals of Treatment • Follow up in 24 and 48 hours
• Eradicate infection • Monitor for development of an abscess

Management Of Severe Mastitis Appropriate Consultation and

For any patient who appears acutely ill, with fever Pharmacologic Interventions
and malaise, the following recommendations Consult physician about IV antibiotics.
apply.
Referral
Adjuvant Therapy Transfer to hospital, as surgical incision and
Start IV therapy with normal saline to keep vein drainage may be needed.
open.

Vulvovaginitis
Definition • Symptoms may be recurrent
Inflammation and irritation of the vaginal mucosa. • Identify recent antibiotic use
• Urinary symptoms may be present
Causes • Vaginal spotting may be present
• Most common causes: infection with Candida, • Determine IUCD use
Trichomonas or Gardnerella vaginalis (bacterial • Also inquire about diabetes mellitus or
vaginosis) symptoms associated with diabetes, steroid use,
• Less commonly: other anaerobic vaginal menopause or symptoms suggestive of
bacteria menopause
• Other causes: atrophy of vaginal mucosa in
postmenopausal women, chemical irritants, Physical Findings
foreign body The physical findings associated with
vulvovaginitis (various causes) are presented in
History Table 5.
• Vaginal discharge
• Vaginal irritation, itching or burning Speculum and bimanual examination may be
• Secondary vulvar irritation, itching, burning mildly to moderately irritating, depending on
• Superficial dyspareunia (pain at the introitus severity of vaginitis.
during intercourse)
Table 5: Physical finding of vulvovaginitis

Candidiasis Trichomonas infection Bacterial vaginosis Atrophic vaginitis
External genitalia External genitalia Scant-to-moderate gray, Dry, thin, smooth, pale
reddened; vaginal walls reddened; copious frothy foul smelling (“fishy”) vaginal mucosa; tiny
covered with adherent green, foul-smelling discharge breaks in mucosal surface
white exudate; when exudate; cervix excoriated my be present
exudate is removed, and bleeds easily
underlying area may bleed
Laboratory Findings • Determine pH of discharge with pH strips, if

• Microscopic: live trichomonads, Candida yeast available
buds or hyphae and Clue cells may be observed • Urine sample for routine microscopy and culture
on normal saline wet-mount hanging-drop test and gonorrhea/chlamydia (if urine test available)
Differential Diagnosis Management

• Concurrent sexually transmitted infections Goals of Treatment
(STIs) • Differentiate between various causes of vaginitis
• Atrophic vaginitis in postmenopausal women • Relieve symptoms
• Cystitis • Identify predisposing factors
Diagnostic Tests Client Education

• Vaginal swab for routine culture and sensitivity, • Counsel client about appropriate use of
gonorrhea and Chlamydia medications (dose, frequency, compliance)
• Saline wet-mount (hanging drop): look for • Recommend abstention from vaginal sexual
trichomonads, yeast buds, hyphae, Clue cells intercourse, or use of condoms, until infection
resolves

• Abstention from alcohol if metronidazole Do not use metronidazole in those with chronic
preparations are used alcoholism. Instead use:
• Recommend lubricants if atrophic vaginitis is amoxicillin (C class drug), 500 mg PO tid for
present 7 days
• Recommend avoidance of tightly fitting
synthetic underwear if Candida infections are Monitoring and Follow-Up
recurrent • Follow up in 7-10 days, after completion of
• Teach client proper perineal hygiene to prevent therapy
recurrence • Treatment of sexual partner is not usually
indicated
For Suspected Candida Infection
Pharmacologic Interventions For Suspected Trichomonas vaginalis
clotrimazole (A class drug), 1% cream or ovule Infection
PV od, single dose or 3 days Pharmacologic Interventions
or metronidazole (C class drug), 2.0 g PO stat in a
miconazole (A class drug), 2% vaginal cream or single dose
200 mg ovule PV od, single dose or 3 days or
metronidazole (C class drug), 250 mg PO tid for
Monitoring and Follow-Up 7 days
• Instruct client to return if no resolution of
symptoms. If one or 3 days treatment not Instruct client to abstain from alcohol while taking
successful a 7-day course may be indicated metronidazole because of the antabuse-like side
• Check blood glucose level if yeast vaginitis is effects of this drug.
recurrent
• OCP may be a contributing factor Do not use metronidazole in those with chronic
• For recurrent yeast vaginal infections of alcoholism. Instead use:
unknown cause, intravaginal plain yogurt may clotrimazole (A class drug), 100 mg PV for
be of benefit to prevent recurrences (once course 7 nights
of cream or ovules is completed)
Instruct client to abstain from intercourse for
• Candida balanitis in the male sexual partner
3-4 days.
should be treated with a topical skin preparation
of clotrimazole or miconazole
Treat sexual partner:
metronidazole (C class drug), 2.0 g PO stat in a
For Suspected Bacterial Vaginosis single dose
Infection
metronidazole (C class drug), 500 mg PO bid for
• Instruct client to return if no resolution of
7 days
symptoms
Instruct client to abstain from alcohol while taking
Note: Metronidazole may be used safely in
metronidazole because of the antabuse-like side
pregnant women, although some clinicians avoid
effects of this drug.
use in first trimester. (Source: Canadian STI
Guidelines, 1998)

Human Papillomavirus (HPV) (Genital Warts)

Definition inflammation and parakeratosis are all
The human papillomavirus (HPV) is a sexually suggestive of HPV
transmitted organism. Condylomata accuminata, • Histology: colposcopy with directed biopsy is
genital warts and venereal warts are other names diagnostic for subclinical lesions, dysplasia and
for HPV. malignancy
Causes Management
HPV, a slow-growing DNA virus of the Appropriate Consultation
papovavirus family, is the causative organism. Consult a physician for medication order to treat
Over 70 strains of the virus have been identified. external warts.
Warts may appear as early as 1-2 months after
exposure, but most infections remain subclinical. Client Education
• Explain to client that therapy eliminates visible
Risk Factors warts but does not eradicate the virus and that no
• First coitus at young age therapy has been shown to be effective in
• Multiple sexual partners eradicating HPV
• History of transmitted infections • Stress that ablation of warts may decrease viral
load and transmissibility
History • Advise client to abstain from genital contact
• Painless genital "bumps" or warts while lesions are present
• Pruritus • Use of female condom
• Bleeding during or after coitus
• Malodorous vaginal discharge Pharmacologic Interventions
• Dysuria • Therapy is not recommended for subclinical
infections (absence of exophytic warts)
Physical Findings
podophyllum resin (Podophyllin 25%) (B class
To examine vaginal walls and cervix for lesions,
drug) in tincture of benzoin compound is applied
apply 3% acetic acid (vinegar); the vinegar
weekly to visible external warts by clinician until
whitens the lesions and makes them visible to the
warts resolve
eye.
• Wartlike growths on genital area that are
• Petroleum jelly may be applied to surrounding
elevated and rough or flat and smooth
skin for protection of unaffected areas
• Lesions occurring singly or in clusters, from
• Advise patient to wash resin off after 4 hours
< 1 mm in diameter to cauliflower-like
aggregates • Do not use in pregnancy
• Papillomas that are pale pink in colour • If warts remain unresolved after six applications,
consider other therapy
• Condylomata
• Short-term follow-up is not recommended if
• Molluscum contagiosum patient is asymptomatic after treatment
• Carcinoma • Long-term follow-up should include annual Pap
smears and pelvic exams
Diagnostic Tests • Encourage patient to examine her own genitalia
• Visual identification is adequate in most cases.
• Cytology: Pap smears are useful for screening;
however Pap smear results of koilocytosis,
dyskeratosis, keratinizing atypia, atypical

There is a known association between HPV Referral

infection and later development of cancer of the Consult or refer client to physician if lesions
cervix. Therefore, annual Pap smear screening persist after six consecutive treatments or when
is essential for women with HPV. cervical or rectal warts are diagnosed.

Pelvic Inflammatory Disease (PID)

Ascending infection of uterus and fallopian tubes. • Cervicitis
May be acute or chronic. • Ectopic pregnancy
• Adnexal mass with rupture or torsion
Causes (e.g. twisted ovarian cyst)
• Most common: Neisseria gonorrhoeae, • Pyelonephritis
Chlamydia • Appendicitis
• Other: anaerobes, Escherichia coli, • Inflammatory bowel disease
group B streptococci • Diverticulitis
• Often polymicrobial
Complications
Risk Factors • Recurrent episodes (in 15% to 25% of cases)
• Multiple sexual partners • Tubo-ovarian abscess (in 15% of cases)
• Client's partner has multiple sexual partners • Sepsis
• Use of IUCD • Infertility (prevalence of 12% after one episode)
• Transcervical instrumentation (e.g. IUCD • Chronic pelvic pain (in 20% of cases)
insertion) • Adhesions
• Late treated STI previously • Increased risk of ectopic pregnancy (four-to
eight-fold increase in risk)
History
• Usually younger, sexually active women Diagnostic Tests
• Multiple sexual partners (fivefold increase) • Complete blood count
• Use of IUCD for birth control • Vaginal and cervical swabs or urine (if test
• Lower abdominal pain of recent onset available) for culture and sensitivity
• Fever and chills (N. gonorrhoeae and Chlamydia )
• Vaginal discharge may be present • Urine pregnancy test
• Menstrual disturbance or painful intercourse
may be present Management
• Nausea and vomiting Goals of Treatment
• Anorexia • Relieve symptoms
• Urinary symptoms • Prevent complications

• May present acutely or subacutely • Consult a physician, because first-line drug
• Temperature may be elevated therapy must be ordered by a physician
• Heart rate may be elevated • PID can be treated with antibiotics on either an
• Client in mild-to-severe distress inpatient or outpatient basis
• Abdominal tenderness, with or without rebound
• Cervical discharge may be present Client Education
• Mild-to-severe tenderness on bimanual exam of • Explain disease course, expected outcome and
cervix and uterus future complications
• Cervical motion tenderness • Counsel client about appropriate use of
• Adnexal tenderness medications (dose, frequency, importance of
• Adnexal fullness, or a mass may be felt compliance)
• Signs of peritonitis may be present • Recommend extra rest during acute phase
• Teach client proper perineal hygiene

• Recommend avoidance of sexual intercourse and Indications for Referral and Admission
avoidance of tampon use to Hospital
• Counsel client about safe sexual activity (e.g. • Failure of outpatient therapy
use of condoms to prevent future episodes) • Nulliparity, especially in women < 20 years of
• Advise client to return to clinic if symptoms age
worsen or do not improve within 48-72 hours • Pregnancy
• Presence of tubo-ovarian abscess
Pharmacologic Interventions • Presence of gastrointestinal symptoms
Outpatient oral antibiotic therapy: • Presence of an IUCD
cefixime (B class drug) 800 mg PO stat • Client appears acutely ill
and • Inability to rule out surgical emergencies as a
doxycycline (A class drug), 100 mg PO bid for
cause (e.g. ectopic pregnancy or appendicitis)
14 days
• Unclear diagnosis
or
tetracycline (A class drug), 500 mg PO qid for • Client intolerant of outpatient therapy
14 days • Client unreliable, and noncompliance with
or therapy and follow-up is anticipated
14 days Adjuvant Therapy
• Bed rest
For clients with allergy to penicillin, use only • Start an IV with normal saline to keep vein open
doxycycline or tetracycline. • Draw blood for cultures
Analgesia and antipyretics for fever and pain: Pharmacologic Interventions

acetaminophen (A class drug), 500 mg, Consult a physician concerning choice of
1-2 tabs PO q4h prn antibiotics.
Monitoring and Follow-Up Monitoring and Follow-Up

• Arrange follow-up in 24-48 hours and again in Monitor vital signs and symptoms frequently
7-10 days
• Instruct client to return to clinic if symptoms Referral
progress despite therapy Medevac as soon as possible.
• All sexual partners should be assessed for
symptoms of STIs

Contraception
Definition Preventing Ovulation -
Prevention of pregnancy. Medroxyprogesterone (Depo-Provera®)
(B class drug)
Counseling On Choice Of • Prevents pregnancy by suppressing ovulation
Contraceptive Method • Periods may be lighter, irregular or stop
Barrier Methods completely
• Assess client's comfort, motivation and • May have slight weight gain (counsel about
compliance healthy diet and lifestyle)
• Explain proper use and application of condoms • Does not protect from STIs
(male and female) • Pap smear testing should be done annually
• Explain proper filling and insertion of
applicators with gel and foam Preventing Implantation--Intrauterine
• Demonstrate insertion and ask client to give contraceptive device (IUCD)
return demonstration • Explain how IUCD prevents pregnancy
• If available and able, fit client with an • Absolute contraindications: past history of PID,
appropriate-size diaphragm, or refer to physician active pelvic infection
for fitting • Usually contraindicated in nulliparous women
• Relative contraindications to diaphragm use: • Relative contraindications: history of repeated
recurrent cystitis and previous history of toxic sexually transmitted infections, multiple
shock syndrome partners, previous ectopic pregnancy, heavy
periods and dysmenorrhea
Preventing Ovulation--Oral • Pap smear testing should be done annually
Contraceptive Pill
• Prevents pregnancy by preventing release of Sterilization--Tubal Ligation and
ovum and causing changes in cervical mucus, Vasectomy
endometrial lining and tubal motility • If this method is requested, both partners should
• Pap smear testing should be done annually be present for counseling if desired
• Demonstrate how to perform a monthly breast • Clients must be absolutely certain that they do
self-examination not desire any more children, as these
• Teach client how to take the OCP (she should procedures are, for all intents and purposes,
take the pill at the same time each day and irreversible
should not miss any pills) • Tubal ligation: with client under general
• Instruct client to return to clinic if headaches, leg anesthesia, air is pumped into the abdomen and
pain or swelling, amenorrhea or breakthrough fallopian tubes are cut and tied
bleeding develop • Vasectomy: vas deferens is cut and tied off (can
• Instruct client about "back-up": if she forgets to be performed in the outpatients' department),
take her OCP for 2 days or more in a row, or has usually under local anesthetic
vomiting or diarrhea, a barrier method of birth • Both procedures involve some discomfort and
control will be required for the remainder of that risks, which must be explained.
cycle, in addition to the OCP, to prevent
pregnancy
• Must be taken at least one month before
effective

Management
Table 6: Principles of oral contraceptive use
History and physical
Before OCP can be started, a thorough history and physical examination must be done
Obtain full medical, gynecological and obstetrical history (See “Assessment of the female reproductive system” above,
this chapter)
In particular, identify chronic disease (e.g. cardiac disease, deep vein thrombosis, hypertension, migraines, pelvic
disease, pelvic infection, pelvic surgery, epilepsy) or medications that might interfere with OCP
Review past use of birth control: methods, effectiveness, problems, reason for discontinuation, specific
contraindications
Laboratory testing
PAP smear and swabs/urine for Chlamydia and N. gonorrhoeae for any client who has had sexual intercourse
Urinalysis and pregnancy test
Initial dose
For typical health young women, start OCP with daily dose of 30-35 mcg estrogen, combine with lowest possible dose
of any given progestogen, to provide contraception and good cycle control
Medroxyprogesterone (A class drug), 150 mg IM q3months may be initiated by RN. Any OCP containing 50 mcg
estrogen should not be started by the nurse
In older women
Client should continue using contraception until 1 year after clinical onset of menopause (i.e. periods absent for 1
year)
Low-estrogen (20 mcg) combination OCPs are useful, provided the woman is a nonsmoker with no contraindications
for OCP
Postpartum: client not breastfeeding
Clients who are not breastfeeding can expect menstruation to resume about 6 weeks postpartum
OCP may be restarted any time after delivery
Medroxyprogesterone should not be given until 72 hours after delivery if client is planning to breastfeed
OCP-enhanced thrombotic episodes are minimal at this time
Postpartum: client breastfeeding
Return of menstruation in women who are breastfeeding is highly variable
Ovulation may occur in the absence of menstruation
Lactating clients may be started on progesterone-only OCP (e.g. norethindrone [Micronor] or medroxyprogesterone
[Depo-Provera] IM)
Special notes
It is unnecessary to give the client a “rest” from her OCP
OCPs may be taken (in the absence of untoward effects) until menopause, as long as any client over 35 who is taking
OCP is a nonsmoker
Client should continue using contraception until 1 year after clinical onset of menopause (periods for about 1 year)

Goals of Treatment • Method of choice in healthy teenagers and

• Prevent pregnancy young women is OCP or Depo Provera®
• Prevent sexually transmitted infection (barrier injections
methods only)
• Identify and manage side effects Prescribing Oral Contraceptives
Choice of OCP depends on a variety of factors:
Client Education • Contraindications to OCP use must be absent
• Discuss all methods of contraception: barrier (refer to Table 7, below)
methods, spermicidal agents, diaphragm, IUCD, • Characteristics of usual menstrual flow (light,
OCP, medroxyprogesterone injections moderate or heavy) (refer to Table 8, below)
• Because smoking increases risk of serious • Presence of dysmenorrhea
OCP-related complications, client should be • Characteristics of skin (fair, oily, acne, hirsute)
offered smoking cessation counseling • Body weight (slim, average or overweight)
• Encourage client to use condoms in addition to • Choose OCP according to client's profile.
chosen method of contraception to prevent
sexually transmitted infection
Table 7: contraindications to oral contraceptive use

Absolute contraindications Strong relative contraindications Possible relative contraindications
Thrombophlebitis, thromboembolic Severe headaches, particularly Strong family history of diabetes
disorders vascular or migraine mellitus
Cerebrovascular disorders Hypertension (blood pressure Previous cholestasis during

≥140/90 mm Hg) pregnancy
Ischemic heart disease, coronary
artery disease Diabetes mellitus Congenital hyperbilirubinemia
(Gilbert’s disease)
Known or suspected cancer of the Active gallbladder disease
breast Impaired liver function at the time of
Infectious mononucleosis, acute presentation or within the past year
Known or suspected pregnancy phase
Known unreliability and low
Benign or malignant liver tumor Sickle cell disease likelihood of taking the pill correctly
Undiagnosed abnormal genital Elective major surgery planned in the

bleeding next 4 weeks or major surgery
requiring immobilization
Long-leg cast or major injury to

lower leg
40 years of age or older
At least 35 years of age and currently

a heavy smoker (>15 cigarettes/day)

Table 8: Oral contraceptive choices

Client characteristics Initial OCP*
Light periods Alesse, Triphasil, Ortho 0.5/35, Brevicon 0.5/35, Demulen 30
Moderate periods Triphasil, Demulen 30, Ortho 10/11,
Heavy periods LoEstrin 1.5/30, MinOvral Ortho 1/35, Brevicon 1/35, Ortho 10/11
Abnormally heave periods (anovulatory cycles) Consult physician
Dysmenorrhea LoEstrin 1.5/30, MinOvral Ortho 1/35, Brevicon 1/35, Ortho 10/11
Tendency towards oily skin, acne, weight gain Demulen 30, Triphasil, Ortho 0.5/35, Brevicon 0.5/35
or heavy hair growth
* Alesse and Triphasil are in the NWT formulary. All other OCPs given here are examples of what physician may
prescribe
Situations in which Close Monitoring is Monitoring and Follow-up

Needed • First follow-up examination should be done
• History of depression at 3 months
• History of epilepsy • Examinations, including Pap smears, should
• Family history of hyperlipidemia then be done annually for well women
• Family history of death of a parent or sibling due • Encourage and teach breast self-examination
to myocardial infarction before the age of 50
years Referral
• Consult a physician before starting OCP for Refer to the physician all clients requesting
clients who have "possible relative IUCDs, Depo Provera® or sterilization.
contraindications" (see Table 7) or for clients
with any circumstance in which close
monitoring is needed (see above).
• Do not start OCP for any client with any "strong
relative contraindication" (see Table 7).
• Check CPS for drug interactions

Menopause
Cessation of menses for at least one full year in a • Difficulties in adjusting to this new stage of life
previously menstruating female. (anxiety or depression)
• Osteoporosis
Causes
• Normal aging Diagnostic Tests
• Premature ovarian failure (as in menopause • Determine levels of follicle-stimulating hormone
before age 40) (FSH) and thyroid-stimulating hormone (TSH)
• Surgery (if diagnosis is unclear or if the client is less than
• Chemical or medication 40 years of age)
• Radiation
Management
• Highly variable but usually occurs when a • Offer support and reassurance
woman is between 45 and 55 years of age • Prevent complications
• Irregular menstrual cycles
• Initially, cycles may be short, with occasional Appropriate Consultation
menorrhagia Arrange elective consultation with a physician if
• Later, cycles become longer and more spaced symptoms are severe, complications are present,
out, with scant menstrual flow client is less than 40 years of age or client desires
• Eventually, menstruation ceases altogether hormone replacement therapy (HRT).
• Hot flushes and night sweats may occur
• Vaginal dryness, irritation, itching may be Client Education
present • Explain process as a normal part of aging
• Painful intercourse may be present • Assess client's feelings about aging
• Urinary urgency, frequency and dysuria may be • Provide a supportive environment rather than
present (because of urethral atrophy) dismissing symptoms, as these symptoms are
• Mild-to-severe mood swings may be present real to the client
• Anxiety, nervousness • Discuss the risks and benefits of HRT
• Sleep disturbances • Encourage balanced nutrition and regular
physical activity for physical and mental
• Depression may occur
well-being
• Memory loss
• Advise client to return to clinic if vaginal
bleeding occurs at any time after menopause
Physical Findings • Suggest use of lubricants before coitus if
• Mood and affect: evidence of depression intercourse is painful
• Breast atrophy
• Vaginal introitus smaller Pharmacologic Interventions
• Vaginal walls smooth, thin, pale, dry Herbs and Vitamins that May Be Useful in
• Cervix small Menopause
• Uterus feels small
• Ovaries not palpable Evening Primrose (Primrose Oil)
Active ingredients: gamma-linolenic acid (GLA)
Differential Diagnosis and linoleic acid
• Abnormal vaginal bleeding
• Infectious cystitis
• Infectious vaginitis

The seed oil is a good source of GLA, which is an Vitamin B6 (50 mg PO, once daily)
essential fatty acid (a nutrient that the body cannot
make but that is essential to good health). Evening Food sources: whole grains, bananas, potatoes,
primrose oil has been used for premenstrual nuts and seeds, cauliflower
syndrome (PMS) and mastalgia (sore breasts).
There are no known contraindications or drug Pyridoxine is involved in the production of brain
interactions. hormones (neurotransmitters). More than 50 other
chemical processes in the body depend on
Flaxseed Oil (Linseed Oil) pyridoxine. Vitamin B6 levels can be low in
Active ingredients: fatty acids (palmitic, steric, people with depression and in women taking
oleic, linoleic and linolenic acids) estrogen in the form of birth control pills or
hormone replacement therapy. It is safe to use
Flaxseed oil is a good source of essential fatty when taken in recommended doses.
acids (a nutrient that the body cannot make but
that is essential to good health). Flaxseed oil is Calcium (500 mg PO, 1-3 times/day) and vitamin
rich in GLA and is used by many for PMS and D (400-800 IU PO od) are recommended if diet is
breast tenderness. There are no reports of toxic inadequate in calcium-rich foods.
effects when used at recommended doses.
Calcium may be contraindicated in patients with a
Vitamin E (400-1200 IU/day) history of renal stones.
Food sources: polyunsaturated vegetable oil, Source: Canadian Consensus Conference on
seeds and nuts Menopause and Osteoporosis (Society of
Obstetricians and Gynecologists of Canada, 1998)
Vitamin E is an antioxidant. Studies done in the
late 1940s showed that vitamin E relieved hot Phytoestrogens - source soya products
flashes and postmenopausal vaginal dryness, but
more recent studies are lacking. There are other Hormone Replacement Therapy
benefits. It is known from the Nurses Health Study HRT is initiated by a physician. Frank discussion
that women who took vitamin E over a 2-year between the physician and the client regarding the
period reduced their risk of fatal heart attacks by risks and benefits of HRT should occur.
40%.
Vitamin E potentiates (causes a greater effect of) • Follow-up 1-2 months after beginning any
anticoagulant drugs such as coumadin and therapy for menopause, then follow every 6
acetylsalicylic acid (ASA). months
• Encourage presenting annually for Pap smear
• Monitor for signs of osteoporosis, abnormal
uterine bleeding
Referral
Unnecessary unless complications arise.

Gynecological Emergencies
Acute Pelvic Pain Of Gynecological Origin
Acute abdominal pain due to dsyfunction or • Ectopic pregnancy
disease of reproductive tract • Spontaneous abortion
• Pelvic inflammatory disease
Causes • Bleeding corpus luteum cyst
• Unsuspected ectopic pregnancy • Adnexal torsion
• Ruptured or twisted ovarian cyst • Mittelschmerz
• Acute pelvic inflammatory disease • Endometriosis
• Severe dysmenorrhea • Dysmenorrhea
• Cystitis
History • Pyelonephritis
• Abdominal pain of sudden or gradual onset • Ureteral stone
• Pain becoming increasingly severe • Inflammatory bowel disease
• Pain made worse with cough, straining at stool • Irritable bowel
or urination • Bowel obstruction
• Pain may be referred to the shoulder tip (e.g. in
ectopic pregnancy) Complications
• Abnormal vaginal bleeding may have occurred • Internal hemorrhage with hypovolemic shock
• Fever, chills and vaginal discharge may be Sepsis
present
• Nausea and vomiting may be present Diagnostic Tests
• Syncope may have occurred • Hemoglobin
• Urine sample for urinalysis and culture; urine
Physical Findings pregnancy test
• Temperature may be elevated • Swabs (pv) if purulent discharge
• Blood pressure may be normal, reduced or Management
hypotensive Goals of Treatment
• Client appears in moderate-to-acute distress • Relieve pain
• Client may walk slowly, bent over and holding • Prevent complications
abdomen
• Abdomen appears normal If pelvic inflammatory disease is suspected,
• Vaginal examination may reveal pus from cervix see "Pelvic Inflammatory Disease," above, this
or bleeding chapter.
• Bowel sounds may be reduced or absent
• Lower abdominal tenderness If ectopic pregnancy is suspected, see "Ectopic
• Signs of localized or generalized peritonitis may Pregnancy," in chapter 12, "Obstetrics"
be present
• Bimanual pelvic examination reveals acute Appropriate Consultation
cervical motion tenderness Consult a physician as soon as possible, unless a
• Adnexal tenderness or mass may be present minor cause has been definitively identified
• Pregnancy test may be positive (e.g. Mittelschmerz or dysmenorrhea).

Nonpharmacologic Interventions Pharmacologic Interventions

• Nothing by mouth Analgesia for pain:
• Bed rest meperidine (D class drug), 50-100 mg IM
• Consider inserting nasogastric tube if there are
signs of peritonitis or bowel obstruction Monitoring and Follow-Up
• Consider inserting a Foley catheter if patient is Monitor ABC (airway, breathing and circulation),
hemodynamically unstable vital signs, and intake and output.

• Start large-bore IV (14- or 16-gauge) with Medevac as soon as possible.
normal saline
• Adjust rate according to age and state of
hydration
• Oxygen by mask prn if client is in shock; keep
oxygen saturation > 97%

Chapter 14- General Emergencies and Major Trauma

Emergency Assessment And Treatment Of Major Trauma ......................................................................... 3
General Principles........................................................................................................................................... 3
Primary Survey ............................................................................................................................................... 3
Scene Survey................................................................................................................................................... 3
Rapid Trauma Survey ..................................................................................................................................... 4
Forced Exam ................................................................................................................................................... 4
Secondary Survey: Ongoing Exam And Detailed Exam ................................................................................ 5
Definitive Care................................................................................................................................................ 7
Major Trauma Situations................................................................................................................................. 8

Head Trauma................................................................................................................................................... 8
Cervical Spine And Spinal Cord Trauma ..................................................................................................... 10
Flail Chest ..................................................................................................................................................... 12
Pelvic Fracture .............................................................................................................................................. 14
General Emergency Situations....................................................................................................................... 16

Anaphylaxis .................................................................................................................................................. 16
Shock ............................................................................................................................................................ 19
Coma............................................................................................................................................................. 21
Overdoses, Poisonings And Toxidromes...................................................................................................... 24
Hypothermia ................................................................................................................................................. 28

Emergency Assessment And Treatment Of Major

Trauma
General Principles
Mobilize resources quickly and staff permitting:
• Designate one person to take charge of assessment
• Designate one person to begin resuscitation interventions
• Designate one person to make phone calls
Primary Survey
This assessment should proceed quickly, within
1-2 minutes of client's arrival. Nothing should interrupt this assessment except treatment of airway
obstruction or cardiac arrest.
Assessment priorities of 2-minute primary survey

1. Total overview of patient situation while approaching patient
2. Evaluation of airway, C-spine control, and initial LOC
3. Evaluation of breathing
4. Evaluation of circulation
5. Brief examination of abdomen, pelvis, extremities
Scene Size-Up
• Which BSI (body Substance Isolation) Airway
precaution do I need to take? • Patent or obstructed
• Do I see, hear, or smell anything dangerous? Do
we need help? Breathing
• Mechanisms of injury • Breathing or not?
• Is it generalizes or focused? • Is it easy, labored, shallow?
• Is it potentially life threatening? • Rate
• Do I need help?
Ventilation
Initial Assessment (See definitive care section)
General impression of the patient.
Level Of Consciousness (AVPU)

Alert
Responds to Verbal stimuli
Responds to Painful stimuli
Unresponsiveness
November 2003 Adult 14-3

Rapid Trauma Survey

Circulation Exam Of Posterior (done during
Pulse transfer to the backboard)
• Rate at neck and wrist • Inspection and palpation while moving on to
• Quality at neck and wrist - strong, weak absent stretcher - deformities, contusions, abrasions,
• It major bleeding present? penetrations, burns, lacerations, swelling,
tenderness, instability, crepitations
Skin
• Colour - good, pale, cyanotic, mottled Decision
• Condition - dry or moist • Is it a critical situation?
• Temperature - cool or warm • Are there interventions that must be cone now?
Decision History
• Is this a critical situation? SAMPLE history from a conscious client:
• Is it a rapid trauma servey or a forced exam? S for symptoms
• Are there interventions that I must do now? A for allergies
M for medications
Head And Neck P for past history
• Inspection and palpation - deformities, L for last meal
contusions, abrasions, penetrations, burns, E for events or environment related to the
lacerations, swelling of neck, any tenderness of injury
neck
• Neck veins - flat or distended Vital Signs
• Trachea - midline or deviated right or left • Check vital signs and pulse oximetry
• Are the vital signs normal?
Chest
• Inspection and palpation - deformities, Disability
contusions, abrasions, penetrations, paradoxical (Perform this exam now if there is an altered
movements, burns, lacerations, swelling, mental status. Otherwise, postpone this exam until
tenderness, instability, crepitations you perform the detailed exam)
• Are the pupils equal and reactive? (Glasgow
Abdomen Coma Score)
• Inspection and palpation - deformities, • Are there signs of cerebral herniation
contusions, abrasions, penetrations, burns (unconsciousness, dilated pupil(s), hypertension,
lacerations, swelling, soft or rigid, tenderness bradycardia, posturing)?
• Does the patient have a medical alert tag?
Pelvis
• Inspection and palpation - deformities,
contusions, abrasions, penetrations, burns, Focused Exam
lacerations, swelling, tenderness, instability, If the mechanism is limited to a certain area of
crepitations the body, then you may only need to focus on
the effected area, obtain a SAMPLE history,
Extremities and check baseline vital signs. You would
• Inspection and palpation - deformities, then have enough information to make a
contusions, abrasions, penetrations, burns, decision about urgency of transportation and
lacerations, swelling, pulses, motor function, what interventions need to be done
sensation - normal or abnormal, left or right
immediately.
14-4 Adult May 2003

Secondary Survey: Ongoing Exam And Detailed Exam

Ongoing Exam • Battle's sign (bluish discoloration over mastoid
This is the reassessment survey that gathers process)
critical information for decision making and • Raccoon-like eyes
interventions. • Clear nasal discharge indicates cerebrospinal
fluid (CSF) rhinorrhea
Subjective Changes • Blood in ear canals or hemotympanum (bluish
• Are you feeling better or worse now? purple colour behind ear drum, due to presence
of blood)
Mental Status • Check for pallor, cyanosis, diaphoresis
• What is the LOC?
• Pupils – size, equal, reaction to light Neck
• Glasgow Coma Score • Apply a cervical hard collar if not already done!
• Check the neck again for deformities,
Reaseess ABC’s contusions, abrasions, penetration, burns,
Neck lacerations and swelling
• Is the trachea midline or deviated? • Check JVP
• Are the neck veins normal, flat or distended? • Check carotid pulse again
• Is there increased swelling of the neck? • Inspect for distension of neck veins (indicating
tension pneumothorax or cardiac tamponade),
Chest tracheal deviation
• Are the breath sounds present and equal? • Assume injury to the cervical spine if trauma has
• If the breath sounds are unequal, is the chest occurred above clavicle
hyperresonant or dull?
Chest
Abdomen Inspection
• Is there ant tenderness? • Respiratory effort
• Is the abdomen soft, rigid or distended? • Equality of chest movement
• Deformity
Assessment Of Identified Injuries • Bruising
• What is the LOC? • Lacerations
• Pupils – size, equal, reaction to light • Penetrating wounds
• Glasgow Coma Score
Palpation
Check Interventions • Equality of chest movement
(See Deifinitive Care Section) • Position of trachea
• Crepitus, deformity
Detailed Exam • Fractures of the lower ribs (splenic or kidney
Head And Neck injury may also be present)
• Reassess ABC
• Inspect and palpate skull and face for Percussion
deformities, contusions, abrasions, penetration, • Area of dullness
burns, lacerations and swelling
• Feel for tenderness, instability and crepitations Auscultation
• Air entry
Check for the following which may indicate basal • Quality of breath sounds
skull fracture: • Equality of breath sounds

Cardiovascular System • Tenderness, crepitus

• Auscultate heart for heart sounds: presence, • Muscle tone
quality, faintness of sounds • Distal pulses
• Reflexes: presence, quality
Abdomen
Inspection Remember that pelvic and femoral fractures can
• Penetrating wounds, blunt trauma, lacerations result in significant loss of blood.
• Bruising (anterior, sides)
• Bleeding Back
• Distension Perform log roll maneuver with spine precautions
to assess back and rectum.
Auscultation
• For bowel sounds Inspection
• Lacerations
Palpation • Bleeding
• Abdominal guarding, rigidity, rebound • Burns
• Tenderness • Bruising: posterior chest wall, flanks, low back,
• Fractures of lower ribs (ruptured spleen, possible buttocks
penetrating wound, bowel injury and intra- • Swelling
abdominal hemorrhage possible)
Palpation
Pelvis And Genitalia • Tenderness
Inspection • Deformity
• Blood coming from urethral meatus • Crepitus
Palpation Neurological System

• Tenderness of iliac crest and symphysis pubis Do brief neurological assessment to evaluate
(indicating pelvic fracture) client's presenting level of consciousness,
• Distension of bladder pupillary size and reaction, lateralized limb
• Rectal exam to assess rectal tone weakness.
Remember that pelvic and femoral fractures can Describe level of consciousness according to
result in significant loss of blood. AVPU method (see Primary Survey above).
In addition, assess the following aspects:
Extremities • Pupil for abnormalities: position, equality,
Inspection reactivity
• Bleeding, lacerations, bruising, swelling, • Motor function: voluntary movement of fingers
deformity, burns and toes
• Leg position: unusual external rotation of a leg • Sensation: can client feel it when you touch his
may indicate fracture of the femoral neck or the or her fingers and toes?
limb
• Movement of limbs Perform detailed neurological examination and
assess client according to the Glasgow Coma
Palpation Scale after initial evaluation is complete.
• Sensation
14-6 Adult May 2003

Table 1: Glasgow Coma Score

The GCS is scored between 3 and 15, 3 being the worst, and 15 the best. It is composed of three parameters: Best Eye
Response, Best Verbal Response, Best Motor Response, as given below:
Glasgow Coma Score

Eye Opening (E) Verbal Response (V) Motor Response (M)
4=Spontaneous 5=Normal conversation 6=Normal
3=To voice 4=Disoriented conversation 5=Localizes to pain
2=To pain 3=Words, but not coherent 4=Withdraws to pain
1=None 2=No words...only sounds 3=Decorticate posture
1=None 2=Decerebrate
1=None
Total = E+V+M
Note that the phrase 'GCS of 11' is essentially meaningless, and it is important to break the figure down into its
components, such as E3V3M5 = GCS 11. A Coma Score of 13 or higher correlates with a mild brain injury, 9 to 12 is a
moderate injury and 8 or less a severe brain injury.
Source: Teasdale G., Jennett B., LANCET (ii) 81-83, 1974.
Definitive Care
• Resuscitative measures initiated earlier should Monitoring And Follow-Up
be continued (e.g. airway, IV therapy, oxygen) • Monitor and reassess ABC q15min if stable,
• Identified conditions should be managed q5min if unstable
according to their priority • Monitor hourly urine output
• Ensure airway is protected in unconscious client
• Apply suction as needed Checklist
• Administer supplemental oxygen, even if • Check airway tubes for patency
breathing appears adequate • Check oxygen rate
• Treat hypotension aggressively with IV fluid • Check IV lines for patency and rate of infusion
replacement (see "Shock," below, this chapter) • Add normal saline to catheter balloon and
• Insert Foley catheter (if no contraindications) endotracheal tube cuff for transport
• Contraindications to catheterization: blood at • Check for patency of decompression needle for
urethral meatus, blood in scrotum, obvious tension pneumothorax, if inserted
pelvic fracture • Check splints and dressings
• Check rate of hyperventilation of client with
Bandaging And Splinting decreased level of consciousness
• If necessary, finish bandaging and splinting • Check position of pregnant clients; tilt spine
injuries board slightly to the left
• Angulated fractures of the upper extremities are
best splinted as found Consultation
• Fractures of the lower extremities should be Consult a physician as soon as possible
gently straightened with traction splints (Thomas
splints) or air splints (if available)
Referral
• Check colour, sensation, warmth and movement
• Medevac as soon as possible.
before and after all limb procedures
• Pressure effects on certain injuries are
accentuated in unpressurized aircraft; maximum
flying altitudes are applicable (see Medevac
Guidelines in use)

Major Trauma Situations

Head Trauma
Definition consciousness, severe headache, post-traumatic
Blunt, forceful injury to the soft tissues or bony seizures, amnesia, evidence of basilar skull
structures of the scalp, skull or brain. fracture (CSF rhinorrhea, Battle's sign, raccoon
eyes, hemotympanum, non-focal neurologic
The initial response of the bruised brain is signs)
swelling. Bruising causes vasodilation through
increased blood flow to the injured area; because Severe Injuries
there is no extra space within the skull, an • Criteria: Depressed level of consciousness, focal
accumulation of blood takes up space and exerts neurologic signs, penetrating injury of skull or
pressure on the surrounding brain tissue. This palpable, depressed skull fractures
pressure results in deceased blood flow to
uninjured areas of the brain. Cerebral edema does Other Considerations
not occur immediately but develops over 24-48 The initial neurological assessment is critical as a
hours. Early efforts to decrease the initial baseline.
vasodilation in the injured area can save the • Head injury is frequently associated with other
person's life. severe trauma
• Hypotension in adults is never caused by an
Types Of Head Injuries isolated head injury, except if the client is near
Scalp wounds (lacerations) death; look for other injuries, including spinal
Skull injury (fracture) cord injuries
Brain injuries: • Physical examination should include a complete
• Concussion: no significant injury to brain, brief neurologic exam, as well as inspection for
period of unconsciousness then return to normal; evidence of basilar skull fracture (e.g. CSF
short-term retrograde amnesia, dizziness, rhinorrhea, Battle's sign, raccoon eyes,
headache, nausea, ringing in ears hemotympanum)
• Cerebral contusion: prolonged unconsciousness • Assume injury to the cervical spine in all cases
or serious alteration in level of consciousness; of head trauma
may have focal neurological signs • Remember that multiple trauma may be present
• Intracranial hemorrhage: bleeding into brain
tissue including acute epidural hematoma and In cases of head injury, the clinical picture will
acute subdural hemorrhage and intracerebral evolve. The client is either improving or
hemorrhage deteriorating over time; frequent reassessment is
therefore critical.
Mild Injuries Glasgow Coma Scale
• Criteria: Minor trauma, scalp wounds, no signs The Glasgow Coma Scale (see Table 1) is used to
of intracranial injury, no loss of consciousness assess the severity of coma.
• Treatment: Observe for any signs or symptoms • Assess client frequently
of brain injury; must discharge to a reliable • Monitor for a drop in the score
observer who will continue observation at home • Any drop in the score is a danger sign
• Give and explain Head Injury Sheet
Interpretation of Score
Moderate Injuries • Score < 9: severe head injury
• Criteria: Symptoms consistent with intracranial • Score 9-12: moderate head injury
injury, including vomiting, transient loss of • Score 13-15: minor head injury
14-8 Adult May 2003

Complications • Avoid tight cervical collar (any pressure on the

• Seizures external jugular veins will increase the
• Airway obstruction intracranial pressure)
• Shock • Keep nil by mouth
• Rapidly deteriorating condition
• Metabolic abnormality Monitoring and follow-up
• Record baseline observations
Diagnostic Tests • Record blood pressure, respirations, shape,
None. accommodation, reactivity and size of pupils,
sensation and voluntary motor activity
Management • Check neurological signs frequently
Remember, ABC takes priority: saving only the • Perform trauma score
head will not save the patient.
• Characteristics: No signs of intracranial injury, Non-pharmacological interventions
no loss of consciousness • Start IV therapy to keep vein open
• Treatment: Observe for 12-24 hours for any sign • Fluids are generally restricted in clients with
or symptom of brain injury; discharge to a closed-head trauma
reliable observer who will continue observations • Maintain normal cardiac output
at home • If hypotensive, suspect hemorrhage or spinal
injury (see "Shock," below, this chapter)
Adjuvant Therapy • Insert Foley catheter if client is unconscious
• Secure the airway and provide supplemental (normal saline in catheter balloon)
oxygen at 10-12 L/min • Monitor output hourly
• These measures maintain adequate oxygenation
and reduce intracranial pressure Complications
• Stabilize client on a spine board • Consult a physician as soon as able
• The neck should be immobilized in a rigid collar
and a padded head motion restriction device Referral
• Elevate head of bed to 30° unless • Medevac as quickly as possible
contraindicated (e.g. in cases of shock or back • Review recommended precautions for flight for
injury) a person with head injury (see Medevac
Guidelines in use)

Cervical Spine And Spinal Cord Trauma

Description "Spinal shock" is a separate neurologic entity
Spine Injury occurring as a result of cord injury; it presents
A sudden movement of the head or trunk that with flaccid paralysis and the client usually
produces flexion, extension, or lateral stressors recovers in hours to weeks. It frequently occurs in
that may damage the bony or connective tissues of children without associated cervical spine
the spinal column (BTLS) fractures.
Spinal Cord Injury Complications

Look for paralysis and other signs of cord injury, • Permanent paralysis
including priapism, urinary retention, fecal • Respiratory arrest
incontinence, paralytic ileus, immediate loss of all • Spinal shock
sensation and reflex activity below the level of the • Death
injury.
Diagnostic Tests
Causes None.
• Motor vehicle crash
• Falls Management
• Sports Initial care of the client who may have spinal
• Acts of violence injury is based on the suspicion of injury,
• Blunt trauma above the clavicles stabilization of the spine and prevention of further
• Diving accident neurological injury
• Motor vehicle or bicycle crash
• Fall Goals of Treatment
• Stabbing or impalement near the spinal column • Stabilize spine
• Shooting or blast injury to the torso • Prevent further damage
Physical Findings
• Tachycardia Initial Treatment
• Tachypnea • Assess and stabilize ABC
• Blood pressure may be low if in shock • Life-threatening injuries associated with spinal
• Pulse oximetry may be desaturating if in shock injuries must be addressed first, but the spine
must not be put at risk during these maneuvers
• Tenderness on palpation or movement of the
spinal column • If there is penetrating neck trauma, do not
remove foreign body
• Obvious deformity of the back or spinal column
• Immobilize neck in neutral position and restrain
• Loss of sensation
chest to properly immobilize the cervical spine
• Weakness or flaccidity of muscle groups
(sand bags are not a good tool for this purpose,
• Loss of bladder or bowel control because if you later want to move the client onto
• Priapism (sustained penile erection) a spine board, the bags may fall against the neck
• Spinal neurogenic shock leads to vasomotor and cause further injury; instead, use soft rolled
instability from loss of autonomic tone and may supports at the sides of the head, e.g. rolled
lead to hypotension or temperature instability blankets)
• Client may have hypoxia or hypoventilation if
fracture or compression occurs above C5 Stabilization of Cervical Spine
• Symptoms of neck or back pain, numbness or • All multitrauma clients should be placed on a
tingling in the limbs, weakness or paralysis of spine board with a spinal motion restriction
the limbs device.
14-10 Adult May 2003

• To complete immobilization of the cervical Nonpharmacologic Interventions

spine, the client must be fixed as a "package" to • Nothing by mouth
the spine board; tape should be placed from • Insert nasogastric tube unless there is suspicion
board to forehead and back to the other side of of associated basilar skull fracture or facial
the board trauma
• Restraints should also be placed across the • Insert Foley catheter
client's shoulders
• Taping across the chin forces the mandible Pharmacologic Interventions
posteriorly and may obstruct the airway None.
• Adults and older children may require 1-2 inches
(2.5-5 cm) of padding under the head to Monitoring and Follow-Up
approximate a neutral position Monitor ABC, vital signs, oxygen saturation (if
available), level of consciousness, respiratory
Prolonged immobilization (even < 30 minutes) on status and sensory motor deficits frequently.
a spine board will cause occipital headache and
lumbosacral pain in most people, regardless of Appropriate Consultation
underlying trauma. Consult a physician as soon as possible.

• Give oxygen 10-12 L/min by mask; keep oxygen Medevac as soon as possible.
saturation > 97%
open

Flail Chest
Definition Palpation
Unstable segment of the bony chest wall. • Tenderness in injured area
• Crepitus may be felt
Cause • Abnormal movement of chest wall may be
Chest wall trauma with fracture of three or more palpable
adjacent ribs in at least two places. The result is a
segment of the chest wall that is not in continuity Percussion
with the thorax. • Hyperresonance if pneumothorax present
• Dull if hemothorax, pulmonary contusion
Lateral flail chest or anterior flail chest (sternal present)
separation) may occur. The flail segment moves
with paradoxical motion relative to the rest of the Auscultation
chest wall. • Air entry reduced or absent in injured area
• Crackles may be present
History
• Multiple trauma (motor vehicle or other Differential Diagnosis
accident) • Chest wall contusion
• Severe chest wall pain • Simple rib fractures
• Pain aggravated by movement and respiration
• Shortness of breath Complications
• Hypoxia
Physical Findings • Hypovolemia
The physical findings depend on the severity of
• Pneumothorax
damage to the underlying lung tissue and the
presence of associated injuries.
• Hemothorax
• Perform primary survey • Pulmonary contusion
(see "Primary Survey," above, this chapter) • Myocardial contusion
• Carry out emergency interventions as necessary • Cardiac tamponade
• Perform secondary survey • Lacerated liver/spleen
(see "Secondary Survey," above, this chapter)
• Assume C-spine injury Management
Goals of Treatment
Vital Signs • Ensure patency of airway
• Heart rate • Improve oxygenation
• Respirations • Replace fluid loss
• Blood pressure • Identify and treat associated injuries
• Oxygen saturation
Inspection Consult a physician as soon as possible.
• Respiratory distress
• Sweating Nonpharmacologic Interventions
Priority is ABC.
• Cyanosis may be present
• Control airway
• Chest wall bruising
• Ensure adequate ventilation
• Abnormal chest wall motion (paradoxical
movement of chest wall) easily seen in • Protect cervical spine
unconscious client, less apparent in conscious • Control pain by gently splinting chest with a
client pillow. Do not splint aggressively


• Give oxygen 10-12 L/min by mask • Monitor mental status, vital signs, pulse
• Start two large-bore IV lines (16-gauge or oximetry, and heart and lung sounds frequently
larger) with normal saline • Confusion, agitation may be signs of hypoxia
• Adjust IV rate according to heart rate, blood
pressure and clinical response Referral
See "Shock," below, this chapter, for further
details.

Pelvic Fracture
Disruption of the bony structure of the pelvis. • Continued bleeding from the fracture or injury to
the pelvic vasculature
Causes • Shock
Such a fracture generally requires substantial • Genitourinary problems from bladder, urethral,
force, such as a motor vehicle collision or a fall prostate or vaginal injuries
from a significant height. • Infections from disruption of the bowel or
urinary system
Because of the tremendous force necessary to • Deep vein thrombosis
cause most pelvic fractures, concomitant severe • Death
injuries are common.
A pregnant woman is at increased risk of
History complications from pelvic fracture, and there is
The basic mechanism of significant blunt trauma great risk of placental abruption and uterine
should prompt consideration of a pelvic fracture. rupture
• Pain
• Loss of function Diagnostic Tests
• Symptoms of shock • Urinalysis
• Complete blood count, electrolytes
Physical Findings
• Tenderness over the pelvis that can be Management
appreciated with pelvic springing, which Goals of Treatment
involves applying alternating gentle • Stabilize fracture
compression and distraction over the iliac wings • Prevent and treat complications
• Palpable instability of the pelvis on bimanual
compression or distraction of the iliac wings. It Appropriate Consultation
is important to be very gentle when pelvic Consult a physician as soon as possible when a
tenderness is appreciated; do not rock or apply pelvic fracture is suspected or diagnosed.
great force until skeletally unstable pelvic
fractures have been excluded by x-ray, an Nonpharmacologic Interventions
overly aggressive exam can unnecessarily
• Priority is to assess and stabilize ABC (see
increase hemorrhage
"Emergency Assessment and Treatment of Major
• Instability on hip adduction (pain on any hip Trauma," above, this chapter)
motion suggests the possibility of an acetabular
• Address acute, life-threatening conditions
fracture, in addition to a possible hip fracture)
• Avoid excessive movement of the pelvis
• Signs of urethral injury in the male, such as
scrotal hematoma or blood at the urethral meatus
• Consider gentle wrapping of pelvis
circumferentially with a sheet or pelvic sling to
• Vaginal bleeding in a female
maintain anatomical position and minimize
• Hematuria internal bleeding
• Check for rectal bleeding (Earle's sign) • Transport on a backboard
• Grey-Turner's sign, a flank ecchymosis
(associated with retroperitoneal bleeding) Do not insert a urinary catheter until you have
• Neurovascular deficits of the lower extremities confirmed that there is no urethral injury (by
physical exam).
• Hip dislocation or fracture
• Femur fracture


• Obtain large-bore IV access and administer • Closely monitor vital signs and pulse oximetry
normal saline as needed (see "Shock," above, • Monitor the client for signs of ongoing blood
this chapter) loss and signs of infection
• Give oxygen by mask; keep oxygen saturation • Monitor for development of neurovascular
> 97% problems in the lower extremities

Treat pain with narcotic analgesics after • Medevac
consultation with physician

General Emergency Situations

Anaphylaxis
Definition • Early respiratory difficulties (e.g. wheezing,
Rare and potentially life-threatening allergic dyspnea, tightness of the chest)
reaction. The symptoms develop over several • Palpitations
minutes, may involve multiple body systems (e.g. • Hypotension, which may progress to shock and
skin, respiratory system, circulatory system) and collapse
may progress to unconsciousness only as a late
event in severe cases. Rarely is unconsciousness Cardiovascular collapse can occur without
the sole manifestation of anaphylaxis. respiratory symptoms.
Anaphylaxis must be distinguished from fainting Severe Reaction

(vasovagal syncope), which is a more common • Severe respiratory distress (lower respiratory
and benign occurrence. Rapidity of onset is a key obstruction characterized by high-pitched
difference. When a person faints, the change from wheezing, upper airway obstruction
a normal to an unconscious state occurs within characterized by stridor)
seconds. Fainting is managed simply by placing • Difficulty speaking
the patient in a recumbent position. Fainting is • Difficulty swallowing
sometimes accompanied by brief clonic seizure
• Agitation
activity, but this generally requires no specific
treatment or investigation. • Shock
• Loss of consciousness
Causes
• Vaccines Physical Findings
• Injectable drugs • Tachycardia
• Insect sting/bite (e.g. bee, spider) • Tachypnea, labored respiration
• Medication (e.g. penicillin) • Blood pressure low normal (client hypotensive if
in shock)
• Inhalation
• Pulse oximetry may show hypoxia
• Food substance
• Client in moderate-to-severe distress
• Latex rubber
• Use of accessory muscles of respiration
• Chest: air entry reduced, mild-to-severe
History
wheezing
Anaphylaxis usually begins a few minutes after
injection or ingestion of the offending substance • Client flushed and diaphoretic
and is usually evident within 15 minutes. The • Generalized urticaria (hives)
symptoms may include the following: • Facial edema
• Sneezing • Diminished level of consciousness
• Coughing • Skin feels cool and clammy
• Itching
• "Pins-and-needles" sensation of the skin Differential Diagnosis
• Flushing of the skin • Asthma
• Facial edema (perioral, oral or periorbital • Foreign-body aspiration
urticaria) • Angioedema
• Anxiety • Pulmonary embolism
• Nausea, vomiting • Vasovagal syncope (fainting)

Complications injection was given, if anaphylaxis was caused by

• Hypoxia injected substance or immunization)
• Shock
• Airway obstruction due to edema of upper SC epinephrine injection is appropriate for mild
airway cases or those treated early. A single SC injection
is usually sufficient for mild or early anaphylaxis.
• Convulsions
• Aspiration In severe cases, an IM injection should be given
• Death because this route leads more quickly to
generalized distribution of the drug.
Diagnostic Tests
None. Epinephrine can be repeated twice at 20-minute
intervals, if necessary. In severe reactions it may
Management be necessary to give these repeat doses at shorter
Goals of Treatment intervals (10-15 minutes).
• Improve oxygenation
• Alleviate symptoms If anaphylaxis was caused by a vaccine given
• Prevent complications subcutaneously, an additional dose of 0.005 mL/kg
• Prevent recurrence (maximum 0.3 mL) of aqueous epinephrine
(1:1,000) can be injected at the vaccination site to
Early recognition and treatment of anaphylaxis is slow absorption of the vaccine. This should be
vital. given shortly after the initial dose of epinephrine
in moderate to severe cases. Local injection of
Nonpharmacologic Interventions epinephrine into an intramuscular vaccination site
• Place the client in a recumbent position is contraindicated because it dilates vessels and
(elevating the feet if possible) speeds absorption of the vaccine. (Health Canada
[2002] Canadian Immunization Guide, 6th Ed)
• Establish an oral airway if necessary
• If anaphylaxis was caused by injected substance, Speedy intervention is of paramount importance.
place a tourniquet (when possible) above the site
Failure to use epinephrine promptly is more
of injection; release for 1 minute every 3
dangerous than using it quickly but improperly.
minutes
Epinephrine Dose
Adjuvant Therapy The epinephrine dose should be carefully
Severe Anaphylaxis determined. Calculations based on body weight
• Give oxygen by mask; keep oxygen saturations are preferred when weight is known. When body
> 97% weight is not known, the dose of epinephrine
• Start IV therapy with normal saline to keep vein (1:1,000) can be approximated from the subject's
open, unless severe anaphylaxis and signs of age (Table 2).
shock are evident (refer to "Shock," below, this
chapter, for details of fluid resuscitation in Excessive doses of epinephrine can compound a
shock) subject's distress by causing palpitations,
tachycardia, flushing and headache. Although
Pharmacologic Interventions unpleasant, such side effects pose little danger.
Promptly administer: Cardiac dysrhythmias may occur in older adults
but are rare in otherwise healthy children and
aqueous epinephrine (D class drug), 1:1,000, young adults.
0.01 mL/kg (maximum dose 0.5 mL) SC or IM
(in the limb opposite that in which the original

Table 2: Appropriate dose of epinephrine 1:1,000 according to age

Age Dose
2 to 6 months* 0.07 ml 0.07 mg
12 months* 0.10 ml 0.10 mg
18 months* to 4 years 0.15 ml 0.15 mg
5 years 0.20 ml 0.20 mg
6-9 years 0.30 ml 0.30 mg
10-13 years 0.40 ml ** 0.40 mg
≥ 14 years 0.50 ml ** 0.50 mg
* Dose for children between the ages shown should be approximated, the volume being intermediate between the
values shown or increased to the next larger dose, depending on practicability.
** For a mild reaction a dose of 0.3ml can be considered
Source: Health Canada (2002) Canadian Immunization Guide (6th ed)
Severe Anaphylaxis seriously ill, because pain results when the drug is
In addition to the epinephrine, give the following: given intramuscularly. This drug has a high safety
diphenhydramine hydrochloride (A class drug) margin, which means that precise dosing is less
important.
The approximate doses of diphenhydramine for
injection (50 mg/mL solution) are shown For Bronchospasm
in Table 3. salbutamol (C class drug), 4-8 puffs q15-20min
(three times) via metered dose inhaler (MDI)
Table 3: Appropriate dose by injection of (maximum 20 puffs; otherwise, intolerable side
diphenhydramine hydrochloride (50mg/mL effects will develop)
solution)
Age Dose Monitoring and Follow-up
< 2 years 0.25 mL 12.5 mg Severe Anaphylaxis
Monitor airway, breathing and circulation (ABC),
2-4 years 0.5 mL 25 mg vital signs and cardiorespiratory status frequently.
5-11 years 1 mL 50 mg
≥ 12 years 1 – 2 mL 50 – 100 mg
Any Anaphylaxis
Source: Health Canada (2002) Canadian Immunization Consult a physician as soon as possible; discuss
Guide (6th ed). use of IV steroids.
This drug should be reserved for clients who are Referral

not responding well to epinephrine or may be used Medevac as soon as possible, in all but the
to maintain symptom control in those who have mildest cases.
responded (since epinephrine is a short-acting
agent), especially if transfer to an acute care Because anaphylaxis is rare, epinephrine vials and
facility cannot be effected within 30 minutes. other emergency supplies should be checked
monthly and should be replaced if outdated.
Oral administration of diphenhydramine is
preferred for conscious clients who are not

Shock
Definition
A condition that occurs when perfusion of tissue • Tachycardia more pronounced
with oxygen becomes inadequate. As a result, the • Pulse weak and thready
cells of the body undergo shock, and grave cellular • Oxygen saturation decreased
changes occur. Eventually cell death follows.
Tachycardia is one of the early indicators of
Shock is categorized in several ways, for example, volume depletion. It may not be as apparent in
according to the state of physiologic progression elderly clients as in younger ones. Tachycardia
that has occurred. may be mild if the client is taking certain
medications (e.g. β-blockers, calcium-channel
Arterial blood pressure is often preserved by blockers).
compensatory vasoconstrictive mechanisms until
very late in shock. An over-reliance on arterial Differential Diagnosis
blood pressure readings can delay recognition and
• Sepsis
timely treatment of shock.
• Myocardial infarction
History
• Anaphylaxis
• Nausea
• Status asthmaticus
• Lightheadedness, faintness
• Thirst
Complications
• Loss of consciousness
• Angina
Other symptoms depend upon underlying cause. • Myocardial ischemia or infarction
• Renal failure
Physical Findings • Death
Remember: "ABCs" (airway, breathing and
circulation) are the priority. Diagnostic Tests
• Pulse oximetry (oxygen saturation)
Physical findings depend on whether the client is
in early or late shock. Management
Remember: "ABCs" (airway, breathing and
Early Shock circulation) are the priority.
Loss of approximately 15% to 25% of blood
volume is enough to stimulate early shock. Goals of Treatment
• Tachycardia (slight to moderate) • Restore circulating blood volume
• Blood pressure normal • Improve oxygenation of vital tissues
• Postural blood pressure drop present • Prevent ongoing volume losses
• Narrowed pulse pressure
• Pallor Appropriate Consultation
• Thirst • Consult physician as soon as possible
• Diaphoresis
• Delayed capillary refill possible Nonpharmacologic Interventions
• Anxiousness, restlessness • Assess and stabilize ABC
• Ensure that airway is patent and ventilation is
Late Shock adequate (use oxygen as needed)
Caused by loss of 30% to 45% of blood volume. • Insert oral airway and ventilate with Ambu bag
• Hypotension (using oxygen), as needed

• Control any external bleeding; use direct After Initial Resuscitation

pressure to control bleeding from external • Insert indwelling urinary catheter
wounds • Insert a nasogastric tube prn
• Put in head-down position
Adjuvant Therapy • Monitor ABC, vital signs (including pulse
• Give oxygen to keep saturation > 97% oximetry) and level of consciousness as often as
• Start 2 large-bore IV lines (14- or 16-gauge or possible until condition is stable
greater) with normal saline • Frequent reassessment for continuing blood loss
• Give 20 mL/kg IV fluid rapidly as a bolus over is important
15 minutes • Monitor hourly intake and urine output
• Reassess for signs of continuing shock • Identify and manage underlying cause of
• If shock persists, continue to administer fluid in hypovolemia
20 mL/kg boluses and reassess after each bolus • Assess stability of pre-existing medical
• Adjust IV rate according to clinical response problems (e.g. diabetes mellitus)
• Ongoing IV therapy is based on response to
initial fluid resuscitation, continuing losses and Referral
underlying cause Medevac as soon as possible.
• Aim for heart rate < l00 bpm, systolic blood
pressure > 90 mm Hg
The amount of fluid required for resuscitation is

difficult to predict on initial assessment.
Caution in Cases of Internal Hemorrhage

The use of large amounts of IV fluids in a client
with uncontrolled internal hemorrhage from blunt
or penetrating trauma may increase internal
bleeding and ultimately lead to death.
Administration of IV fluids while increasing
blood pressure will also dilute clotting factors and
cause more hemorrhage. Use fluids judiciously to
maintain peripheral perfusion. Early blood
transfusion and surgical intervention to achieve
homeostasis is very important in this situation.

Coma
Definition Once the immediate life-threatening concerns have
Altered level of consciousness indicating diffuse been addressed, the secondary survey can be
or bilateral cortical impairment of cerebral carried out (see "Secondary Survey," above, this
function, failure of brainstem-activating chapter)
mechanisms (or both).
• Monitor vital signs, including pulse oximetry (if
Causes available)
Coma can be caused only by: • Obtain abbreviated, targeted history
• Bilateral cortical disease • In particular, determine if person has had any
• Compromise of reticular-activating system See recent illness, antecedent fever, rash, vomiting
"Differential Diagnosis," below. or trauma or has any chronic illnesses; explore
recent exposure to infection, medication or
Tips intoxicants
T- trauma, temperature
I - infection Past medical history and family history should be
P- psychiatric obtained when time permits.
S- space-occupying lesions, stroke,
subarachnoid hemorrhage, shock Observations in the secondary survey should
attempt to uncover signs of occult infection,
Vowels trauma, or toxic or metabolic derangements.
A- alcohol and other drugs
E- endocrine, exocrine, electrolytes Signs suggestive of specific toxidromes should be
I- insulin (diabetes) sought (see "Overdoses, Poisonings and
O- oxygen (lack of), opiates Toxidromes," below, this chapter).
U- uremia
Physical Findings
Initial Approach To Client With Coma Level of Consciousness
Of Unknown Origin • Assess level of consciousness using the Glasgow
Perform primary survey (see "Primary Survey," coma scale (see Table 1, in "Head Trauma,"
above, this chapter) above, this chapter).
Nonpharmacologic Interventions Respiratory Pattern

• Assess and stabilize ABC • Control of breathing is centered in the brain,
• Insert oral airway lower pons and medulla and is modulated by the
cortical centers in the forebrain
• Place in recovery position, unless there are
contraindications • Respiratory abnormalities signify either
metabolic derangement or neurological insult
• Check glucose
• Several patterns exist (e.g. Cheyne-Stokes
respiration, apneustic breathing, post-ventilation
Adjuvant Therapy
apnea)
• Give oxygen to keep oxygen > 97%
• Start IV therapy with normal saline to keep vein Eye Findings
open
Pupillary Signs
• Pupils generally resistant to metabolic insult
Consult physician. Treatment as per physician's • Remember that dilatation of pupils may be
order. secondary to topical or systemic drugs

• Dilatation of pupils in an alert person is not • Respiratory problems, including hypoxia,

likely attributable to increased intracranial hypercapnia
pressure and herniation • Intoxication, including that caused by
• Dilatation of pupils in an unconscious patient barbiturates, alcohol, opiates, carbon monoxide,
may herald imminent uncal herniation benzodiazepines
• Small reactive pupils generally indicate • Infections (severe, systemic), including sepsis,
metabolic problem or diencephalic lesion pneumonia, typhoid fever
• Unilateral, dilated, fixed pupils indicate lesion of • Shock, including hypovolemic, cardiogenic,
third nerve or uncal lesion septic, anaphylactic
• Bilateral pinpoint pupils indicate pontine lesion • Epilepsy
• Pupils fixed in midposition indicate midbrain • Hypertensive encephalopathy
lesion • Hyperthermia (heat stroke), hypothermia
• Bilateral large, fixed pupils indicate tectal lesion
Coma with meningeal irritation but without
With cerebral lesions, the eyes will deviate toward localizing signs may be caused by:
the side of the lesion, whereas with brain-stem • Meningitis
lesions, the eyes deviate away from the lesion. • Subarachnoid hemorrhage from ruptured
aneurysm, arteriovenous malformation
About 5% of the normal population has anisocoria
(asymmetric pupils). Coma with focal brain stem or lateralizing signs
may be caused by:
A brief funduscopic exam may reveal papilledema • Pontine hemorrhage
or retinal hemorrhage. • Stroke (cerebrovascular accident [CVA])
• Brain abscess
Motor Examination • Subdural or epidural hemorrhage
• Try to elicit motor response to verbal or physical
stimuli Coma in which client appears awake but is
• Assess muscle tone, strength and reflexes for unresponsive may be caused by:
normality and symmetry • Abulic state: frontal lobe function depressed, so
• Ability of client to localize, as well as absence client may take several minutes to answer a
or presence of abnormal posture, helps in question
assessment of severity of involvement • Locked-in syndrome: destruction of pontine
• Decorticate posturing (flexion of the upper motor tracts; is able to look upward
extremities with extension of the lower • Psychogenic state: unresponsive
extremities) suggests involvement of the
cerebral cortex and subcortical white matter Diagnostic Tests
• Decerebrate posturing (rigid extension of the • Determine blood glucose level
arms and legs) usually represents added brain-
• Blood cultures as applicable
stem involvement at the level of the pons
Management
Coma with no localizing central nervous system
signs may be caused by: • Nothing by mouth
• Metabolic insult, including hypoglycemia, • Insert nasogastric tube unless there is suspicion
uremia, Addison's disease, diabetic ketoacidosis, of associated basilar skull fracture or facial
hypothyroidism, liver disease trauma
• Children and young adults will often experience • Insert Foley catheter
hypoglycemia and may present with coma after
ingesting alcohol, including mouthwash


If you suspect meningitis, do not withhold Monitor ABC, vital signs, pulse oximetry, level of
antibiotics. Antibiotics should be started before the consciousness, respiratory status and sensory
client goes to the hospital. Discuss antibiotic motor deficits frequently.
therapy with physician.
Referral

Overdoses, Poisonings And Toxidromes

Definition • Toxidrome characterized by sedation,
Ingestion of a substance in sufficient quantity to hypotension, bradycardia, respiratory
induce symptom complexes associated with toxic depression, usually pinpoint pupils (may not be
effects. present with mixed overdose)
Specific Poisonings And Clinical Petroleum Distillates

Toxidromes • Examples: gasoline, fuel oil, model airplane glue
Acetaminophen • Main toxic effect: pulmonary (from inhalation)
• Main toxic effects: hepatic, occurring 24-72
hours after ingestion Salicylates (e.g. Aspirin)
• Client may also have nausea and vomiting • Main toxic effects: tinnitus, nausea, vomiting,
hyperventilation (primary respiratory alkalosis),
Carbon Monoxide metabolic acidosis, fever, hypokalemia,
• Main toxic effects: central nervous system hypoglycemia, seizures and coma
effects, including confusion, coma, seizures, • Many patients are misdiagnosed on initial
headache, fatigue and nausea; arrhythmias or presentation as having sepsis or gastroenteritis
cardiac ischemia possible (because of fever, acidosis, vomiting and other
• Diagnosis: clinical background (e.g. exposure to symptoms). This misdiagnosis is particularly
furnace or car exhaust [especially in children common in the elderly.
who have been riding in the back of pick-up
trucks]); level of carboxyhemoglobin needed to Tricyclic Antidepressants
confirm • Main toxic effects: cardiac arrhythmias,
• Arterial oxygen saturation as measured by pulse anticholinergic effects (see toxidrome for opiate
oximetry is frequently normal in cases of carbon poisoning, above), vomiting, hypotension,
monoxide poisoning. confusion and seizures
• Cardiac complications: prolonged QRS and QT
Caustic Agents intervals, other arrhythmias
• Examples: alkaline (drain cleaner), bleach and • Neurologic complications: agitation, seizures
battery acid (household bleach is usually not a • Hypotension: Treat initially with IV fluids (see
problem, except for superficial burns) "Shock," above, this chapter)
• Main toxic effects: local tissue necrosis of the
esophagus with alkali and of the stomach with The client may appear fine and then rapidly
acids, as well as respiratory distress; obvious deteriorate. He or she will need to be admitted to a
facial or oral burns and emesis; hoarseness and monitored unit. Be prepared to manage the client's
stridor reflecting epiglottic edema (especially airway. Even if the client is asymptomatic 6 hours
with acids) after ingestion, he or she must be admitted to
hospital for psychiatric examination.
Cocaine
• Main toxic effects: seizures, hypertension, Assessment And Management:
tachycardia, paranoid behavior or other General Approach
alterations in mentation, rhabdomyolysis, Remember: your first priority is ABC
myocardial infarction and stroke (CVA) • Remember to decontaminate gut (see procedure
below), clothing, skin and environment
Opiates • If client is unconscious, see "Coma (Not Yet
• Examples: heroin, morphine, clonidine, codeine, Diagnosed)," above, this chapter
diphenoxylate • Determine to the best of your ability what was
ingested

• For any client with overdose, draw blood sample of caustic materials or petroleum distillates, and in
for determination of serum acetaminophen level cases of overdose with tricyclic antidepressants,
(see "Acetaminophen" above, this section) and theophylline or any agent that might cause a
toxicology screen change in mental status.
• Contact the nearest poison control center for
further information about the toxin in question Ipecac inhibits retention of charcoal and thus
delays administration of charcoal.
Consult a physician as soon as you are able after The dose is 30 mL for an adult, followed with
the initial assessment and stabilization of ABC. water.
Gut Decontamination Gastric Lavage

Activated Charcoal (A class drug) • May remove more stomach contents than ipecac
• Treatment of choice in most overdoses involving • Not effective beyond 1.5 hours after ingestion,
ingestion but you may want to try it in severely ill clients
• May be indicated for overdose with • Use largest nasogastric tube available or
theophylline, tricyclic antidepressants, orogastric tube
phenobarbital, phenytoin, digoxin • Most effective if charcoal is given 20-30
• Does not work for metals such as iron or lithium minutes before lavage; repeat charcoal when
• Administer 10-25 g for children, 50-100 g for lavage is finished
adults (1 g/kg) • Airway protection is recommended (client
• A sorbitol mixture reduces transit time but should be fully conscious)
should be used only with the first dose if • Instill 300-mL aliquots (amounts) of saline, then
multiple doses of charcoal will be used remove until saline is clear on removal or until 5
• If client will drink the mixture, this mode of L of fluid has been used for irrigation
administration is acceptable; otherwise, • Lavage alone is not adequate for gastric
administer by nasogastric tube emptying and delays administration of charcoal
• 30% of clients will vomit after administration of
charcoal; in this case, charcoal can be Management Of Specific Overdoses
administered again And Toxidromes
• Use of multiple-dose charcoal is still Acetaminophen
controversial • Toxic dose: 140 mg/kg or >10 g in adults (in
alcoholic clients, the toxic dose is often much
Polyethylene Glycol (PEG) and Electrolytes (B less if the client is taking acetaminophen
class drug) regularly, even as little as 4 g/day)
• Used for sustained release medication overdoses • Vomiting and unable to keep down charcoal,
• Promotes catharsis consider metoclopramide (B class drug)
• Consult poison control centre for specific • If ingestion is in toxic range, treat with:
dosing advice N -acetylcysteine (D class drug), 20%,
140 mg/kg PO or IV and then 70 mg/kg every
Ipecac 4 hours for 17 doses; repeat any doses vomited
Ipecac is a non-formulary item and rarely used within 1 hour of administration (72-hour PO
now in cases of overdose or poisoning. protocol)
• Do not withhold N-acetylcysteine even if 24-26
Ipecac is only partially effective in emptying hours after ingestion; late administration, though
gastric contents and may propel pills beyond the not as effective as early administration, still
pylorus. Because of the risk of aspiration, ipecac is reduces mortality
contraindicated in obtunded patients and those
unable to protect the airway, in cases of ingestion

• Charcoal use is acceptable in acetaminophen Opiates

overdose and only minimally interferes with Use the following drug with caution in those who
N-acetylcysteine; are narcotic addicts, as it may precipitate acute
• charcoal should be given early and opiate withdrawal. If this is a concern, the client's
N-acetylcysteine at least 4 hours later airway must be supported until the narcotic wears
off.
Carbon Monoxide
• Administration of 100% oxygen (to displace Always observe the client until there is no chance
carbon monoxide from hemoglobin) for 90-120 of further respiratory depression.
minutes
• Giving fresh air only – takes 7 hours to displace This is especially important with naloxone, which
carbon monoxide from the hemoglobin has a relatively short half-life.
• Hyperbaric oxygen for 30 minutes reduces long
term sequelae naloxone (D class drug), 5 MCG/kg IV (usually
start with 0.4-2 mg in adults); dose may be
• Even if client seems well or is recovering from
repeated if needed, up to a maximum of 10 mg
CNS insult, consult physician and transfer
patient to hospital
This is a short-acting drug (half-life 1.1 hours).
Caustic Materials Client may have recurrent narcotization when
• Do not induce emesis or perform lavage naloxone wears off.
• Charcoal is not indicated
• If the client has visible burns, he or she has a Petroleum Distillates
50% chance of lower burns of significance; • Do not perform lavage or induce vomiting if
however, absence of visible lesions does not rule swallowed
out significant injury (10% to 30% will have
• If no symptoms within 6 hours, no need for
burns beyond the mucosa)
further observation
Cocaine Salicylates (e.g. Aspirin)
• Cocaine has a relatively short half-life, so most • Toxic dose: 150 mg/kg (300 mg/kg is highly
symptoms are self-limited
toxic)
• For coronary vasospasm, hypertension or • IV administration of normal saline to maintain
tachycardia, observation is probably adequate,
blood pressure (see "Shock," above, this
because of the short half-life
chapter)
• For other cases, treat as for myocardial
• Urine alkalinization (to promote excretion of
infarction
salicylates)
• Myocardial infarction and CVA may occur up to
72 hours after cocaine use
Tricyclic Antidepressants
• Concurrent use of alcohol increases the • Avoid emesis (client may aspirate)
likelihood of cardiac vasospasm
• Charcoal and lavage are mainstays of treatment
• Not all chest pain represents myocardial (see "Gut Decontamination," above, this
infarction (e.g. pneumomediastinum in crack section)
use, bronchospasm).
• Client may appear fine and then rapidly
• Seizures are generally self-limited but will deteriorate
respond to normal seizure treatment (see "Status
• Client should be admitted to a monitored unit
Epilepticus (Acute Grand Mal Seizure)," in
chapter 8, "Central Nervous System") • Be prepared to manage client's airway
• CNS symptoms such as agitation and paranoia • If client is asymptomatic 6 hours after
can be treated with diazepam or lorazepam ingestion, he or she should still be admitted to
hospital for psychiatric evaluation and care

• Cardiac complications: prolonged QRS, QT Monitoring and Follow-Up

interval, other arrhythmias Monitor ABC, level of consciousness, vital signs,
• Neurologic complications: agitation, seizures oxygen saturation, intake and urine output
• Seizures usually brief and self-limited; treat as frequently until the client is stable.
outlined in "Status Epilepticus (Acute Grand
Mal Seizure)," in chapter 8, "Central Nervous Referral
System" Medevac as soon as possible.
• Avoid phenytoin
• If hypotension occurs, treat initially with IV
fluids (see "Shock," above, this chapter)

Hypothermia
Definition Assessment of Temperature
Core temperature of < 35°C. Axillary and oral measurements are poor measures
of core temperature. Rectal temperature more
Risk Factors closely approximates the core temperature and is a
• Endocrine or metabolic disorders (e.g. practical method for use in the field.
hypoglycemia)
• Infection (e.g. meningitis, sepsis) For clients with cold skin, rectal temperature
should be determined with a low-reading
• Intoxication
thermometer (i.e. capable of measuring
• Intracranial pathology (e.g. head trauma)
temperatures as low as 21°C).
• Submersion
• Environmental exposure Core Temperature 35°C to 36°C
• Major burns Client feels cold, is shivering
• Iatrogenic (cold IV fluids, exposure during
treatment) Core Temperature 32°C to 35°C
• Slowing of mental faculties
History • Slurred speech
The evaluation and treatment of hypothermia is • Mild in coordination
essentially the same whether the client is wet or • Muscle stiffness
dry, on land or in water.
• Inappropriate judgment
• Irritability
• One or more of above risk factors
• Shivering apparent
• The hypothermic client should be assessed
carefully for coexisting injury or illness
Core Temperature 32°C
• Signs and symptoms of hypothermia may be Shivering stops
mimicked by alcohol, diabetes mellitus, altitude
sickness, overdose and other conditions;
Core Temperature < 31°C
therefore, thorough assessment is imperative
• Semi-comatose
• Associated significant illness or injury may
exacerbate hypothermia • Progressive decrease in level of consciousness
• Coma likely at temperatures < 30°C
Physical Findings • Cyanosis
In the cold client, rectal temperature is one of the • Tissue edema
vital signs.
Core Temperature 29°C
In terms of the "ABCs," think A, B, C and D for • Respiratory activity slow, may be difficult to
hypothermic clients: detect
A for airway • Heart rate slow; pulse may be difficult to
B for breathing palpate
C for circulation
D for degrees (body-core temperature) Core Temperature < 28°C
• Vital signs absent
In the cold client, body-core temperature is an • Pupils dilated and unresponsive
important sign. Although obtaining the body-core • Respiratory arrest
temperature is useful for assessing and treating • Ventricular fibrillation
hypothermia, there is tremendous variability in
individual physiologic responses at specific
temperatures.

Management client with a vapor barrier (such as a plastic

Goals of Treatment garbage bag), cover the head and neck, and move
• Rewarm core the client to a warm environment; consider
• Prevent or manage complications covering client's mouth and nose with light fabric
to reduce heat loss through respiration.
General Principles
The client with severe hypothermia must be Mild Hypothermia
handled very gently. The cold heart is highly Rewarm passively and gradually:
prone to cardiac arrest, and even cautious
movement of the client may induce cardiac arrest. Step 1: Place client in as warm an environment as
possible
• Ensure that any items, oxygen or fluids (both
oral and IV) coming into contact with the client Step 2: Increase heat production through exercise
are warmed beforehand (without sweating) and fluid replacement with
high-calorie, warm, sweet fluid; this method of
• Oxygen should be heated to 40.5°C to 42.2°C
adding heat is particularly important when
and humidified, if possible
emergency care is not readily available, as in
• Because cold skin is easily injured, avoid direct remote or prolonged-transport environment
application of hot objects or excessive pressure
(e.g. uninsulated hot water bottles) Step 3: Rewarm passively through application of
• The inside of a vehicle and any rooms where insulated heat packs to high heat transfer-loss
hypothermic clients are treated should be warm areas such as the head, neck, underarms, sides of
enough to prevent further heat loss (ideally the chest wall and groin; apply heavy insulation to
above 26.7°C) the same areas to prevent further heat loss (goal is
• Splinting should be performed, when indicated to increase temperature by 1°C to 2°C per hour)
and with caution, to prevent additional injuries
to frostbitten tissues Step 4: Consider warm shower or bath if the client
• Do not give caffeine or alcohol is alert
Cardiopulmonary resuscitation (CPR) has no Do not leave client alone.

significant effect on survival of hypothermic
clients in the following situations and should not Severe Hypothermia with Signs of Life (e.g.
be initiated: Pulse and Respiration)
• Cold-water submersion for > 1 hour Treat the client as outlined in steps 2 and 3 above,
• Core temperature < 15.5°C with the following exceptions:
• Obvious fatal injuries • Do not put a severely hypothermic client in a
• Client frozen (e.g. formation of ice in airway) shower or bath
• Chest wall so stiff that compression is • Do not give a client fluids by mouth unless he
impossible or she is capable of swallowing and protecting
• Rescuers are exhausted or in danger the airway
• Treat hypothermic clients very gently (do not
Rise in core temperature may lag behind change in rub or manipulate or apply direct heat to
skin temperature and may continue to drop, so extremities)
monitor rectal temperature frequently.
In addition, the following measures should be
Basic Treatment for All Cases of taken:
Hypothermia • Reassess ABC and vital signs frequently
Prevent further heat loss: insulate from the ground, • Give warm, humidified oxygen at 10-12 L/min
protect from the wind, eliminate evaporative heat or more
loss by removing wet clothing or by covering

• Administer warmed (to 37°C) normal saline • Clients with moderate-to-severe hypothermia
by IV may have large amount of fluid sequestration
• Clients with moderate-to-severe hypothermia and may need aggressive fluid resuscitation; an
may have a large amount of fluid sequestration initial bolus of 20 mL/kg is indicated; repeat as
and may need aggressive fluid resuscitation; an necessary
initial bolus of 20 mL/kg is indicated; repeat as • Rewarm passively as outlined above
necessary, but do not overload with IV fluids
• Consider instillation of warm fluids via Foley No drugs are used in resuscitation unless core
catheter temperature > 32°C and drugs are ordered by
a physician.
Severe Hypothermia with No Signs of Life
• If no pulse (after checking for up to Consultation
45 seconds), no respiration and no If resuscitation has been provided in conjunction
contraindications, start CPR unless with rewarming techniques without the return of
contraindicated spontaneous pulse or respiration, and core
• Ventilate with Ambu bag with 50% warm, temperature is > 34°C continue efforts but contact
humidified oxygen; aim for 12-15 ventilations the physician for recommendations.
and 80-100 compressions; continue as long as
you can Referral
• Administer warmed (to 37°C) normal saline Medevac as soon as possible.
by IV

Chapter 15- Mental Health

Foreword............................................................................................................................................................ 1
General Information ......................................................................................................................................... 1

Definitions ...................................................................................................................................................... 1
Cultural Roots Of Mental Illness And Mental Health .................................................................................... 1
Communication............................................................................................................................................... 4
Mental Illness Prevention And Mental Health Promotion.............................................................................. 5
Mental Health Assessment.............................................................................................................................. 11

Clinical Assessment And Management ........................................................................................................ 11
Common Mental Health And Psychiatric Problems.................................................................................... 16

Violent Or Acutely Agitated Psychiatric Clients.......................................................................................... 16
Alcohol Withdrawal...................................................................................................................................... 20
Alcohol Withdrawal Delirium ...................................................................................................................... 24
Affective Disorders....................................................................................................................................... 26
Psychotic Disorders ...................................................................................................................................... 33
Anxiety Disorders ......................................................................................................................................... 39
Cognitive Impairment ................................................................................................................................... 41
Suicidal Behavior.......................................................................................................................................... 44
Sexual Assault............................................................................................................................................... 48
Family Violence............................................................................................................................................ 50
Resource Utilization In Community Mental Health Care........................................................................... 53

Guidelines For Resource Utilization In Mental Health Care........................................................................ 53
Program Consultants..................................................................................................................................... 54
Foreword
This chapter was originally written for First Nations and Inuit Health Branch by J.P. Kehoe, Director, Mental
Health Services, Yukon Region. The 2000 revision was prepared by Dr. S. Callaghan and C. Sargo, RN(EC),
Nurse Practitioner. This chapter has been reviewed by Dr Ross Wheeler, Mental Health Services,
Yellowknife.
Please refer also to the "Mental Health Act", Information for Health Centres (August 2001) binder.
Each Health Centre should have a copy of the Mental Health Act, NWT (1988) available at
http://www.canlii.org/nt/sta/pdf/type181a.pdf for reference.
In dealing with mental health issues in a community, it is essential that nurses develop good working
relationships with the multidisciplinary team available in the local community. This may include mental
health workers, social workers, registered psychiatric nurses, addictions workers, counselors, elders and
RCMP.

General Information
Definitions
Mental Health Mental Illness
Mental health is a difficult concept to define. Mental illness refers to the behavior of a person
There is, however, some agreement in the who displays some or all of the following
literature that mental health is evident in the characteristics:
following personal characteristics: • social maladjustment
• self-awareness and accurate self-perception • impaired reasoning or intellectual functioning
• self-actualization (realizing one's full potential) • disorders of thinking, memory or orientation
• autonomy (independence in thought and action) • delusions or disorders of perception
• accurate perception of reality • exaggerated, inappropriate or otherwise
• commitment impaired emotional responsiveness
• possession of "mastery" skills (social and • impaired judgment or impulse control
occupational ability to deal with the • unrealistic self-appraisal.
environment)
• openness and flexibility. Unlike the diagnosis of most physical disorders,
diagnosis of a mental illness does not often imply
a specific cause.
Cultural Roots Of Mental Illness And Mental Health

Concepts Of Abnormality Some disorders may be exotic and specific to a
Beliefs about mental illness are intimately linked particular culture (e.g. Windigo among the Cree
with concepts of religion, social values, norms and and Ojibwa; Pibloktog among the Inuit). Attempts
ideals of human relationships. This is true of any have been made to reconcile these disorders with
culture. the scientific classifications of mental disorders,
with the unusual symptoms being attributed to
These shared beliefs determine the nature of cultural determinations and the underlying process
traditional medicine and provide the framework thought to be the same across cultures.
for interpreting symptoms and guiding action in
response to them. "Western" medicine and Some disorders may fit neither classification
psychiatry are premised on the belief that mental system and may be a recent development in
illness is caused by biological and experiential response to cultural change. The "totally
events; many other cultures ascribe a metaphysical discouraged" syndrome (depression, alcoholism,
or spiritual cause as well. lack of social responsibility, neglect of family,
suicidal behavior) described for the Sioux may be
Members of any culture rarely have insight into such a disorder.
their own culturally learned ideas and values
regarding normal and abnormal behavior; typically The "labeling process" (diagnosis and
these values are seen as correct and proper for interpretation) provides a language for both the
everyone (ethnocentrism). patient and the therapist by which they each can
The expression of mental illness is heavily conceptualize the distress. This process gives
determined by culture. Symptoms of a disorder reassurance, dictates treatment and assigns
that are prominent in one culture may be meaning. Where the two do not share the same
insignificant or absent in another and may even be "world view" (concept of normal and abnormal
interpreted as normal in a third. behavior, concepts of cause and effect in
interpersonal behavior, ideas and appropriate
treatment), the treatment is likely to fail or to be

less than maximally effective. The intervention own culturally learned ideas and values in order to
must be culturally relevant. be able to appreciate the client's ideas and values
and offer appropriate assistance.
Prevalence And Expression Of Mental
Illness Failing to understand these often subtle differences
Rates of specific disorders appear to vary from in behavioral norms can easily lead to major
culture to culture and are influenced by cultural misunderstandings, loss of credibility, anger and
variations in stress inducers, cultural differences in frustration on both sides.
defining abnormality and cultural variations in
personality (i.e. certain personality patterns may Because values and ideals vary from culture to
be more or less resistant to stress by virtue of culture, it is impossible to enumerate all the
temperamental type, cognitive styles and possible differences. Mainly for purposes of
physiological coping patterns). illustration, some commonly cited values of First
Nations and Inuit people are given below.
Culturally related stresses that have been identified
include the following: It must be emphasized that these values do not
• Value conflict: conflicts causing uncertainty and necessarily hold true for all First Nations and
confusion with no stable frame of reference Inuit, but they do alert the healthcare practitioner
to the kinds of differences that can exist and to the
• Social change: habitual forms of adaptation are
possible consequences, for both understanding the
challenged
client and providing a mental health service, if
• Acculturation stress: social change set in motion
these differences are not recognized.
by different cultures coming into contact
• Life events: the greater the number of life Non-Interference
adjustments (e.g. deaths in the family, financial
A high degree of respect for a person's
stress, trouble with the law, marital problems)
independence leads to the view that giving
and the greater their impact, the greater the
instructions, coercing or even persuading another
stress
person, including a child, is inappropriate. This
• Goal-striving discrepancy: rising expectations ethic may be perceived by another culture as
with little hope of their being realized apathy, neglect, indifference, lack of social
• Role discrimination: stress applied especially to responsibility or evasiveness.
certain social strata (e.g. age group, gender),
which causes feelings of inadequacy and lack of Anger
self-worth Displays of anger could jeopardize the voluntary
• Role conflict: being required to switch back and cooperation essential to survival of a close-knit
forth from one role to another group. Hostility must be suppressed. It has been
suggested that this practice may lead to a
The manifestation of mental health disorders particular vulnerability to depression.
varies across cultures, but there is a fair degree of
agreement that some behaviors, such as extreme Time
sadness, motor retardation and agitation, are signs Time is a personal, flexible concept and is not
of mental disturbance. related to the clock so much as to feeling ready to
act.
Values And Ethics Of A Culture
Ethics refers to the rules of behavior--what is Sharing
customary or expected in a society. To understand Group survival is more important than personal
a client, it is necessary to have a basic prosperity. Sharing assures the survival of the
understanding of that person's values and his or group.
her expectations of self and others. It is important
to remember at this point that the practitioner
should have developed an insight into his or her

Cooperation and the family and community provide support. In

Competition can interfere with group others, particularly when the person has been
cohesiveness. Cooperation increases the sense of violent or has caused others to suffer, the
solidarity and pools effort, talent and resources. disruption to community well-being may lead to
rejection, including subtle forms of banishment. In
Excellence such cases, the individual may assume a "sick
Gratitude is rarely shown or verbalized because role," and the prognosis is less favorable.
each individual is expected to behave at a
"normal" (i.e. excellent) level. Look at the helping network and learn how the
means of social influence usually employed bring
Teaching and Learning about resocialization to community norms and
Teaching is based on modeling rather than goals.
deliberate instruction. Practice and observation
occur spontaneously in the learner who is ready to Members of any culture have expectations about
learn. techniques of healing. These expectations should
be tapped and included in treatment or
A Cultural Accommodation Approach management plans.
The scientifically trained professional is often best
cast in the role of consultant rather than primary Some members of a community will have a
therapist. The consultant then provides his or her sanctioned role as folk healer, shaman, "doctor" or
expertise though more natural and mutually wise elder. These and other people who have
acceptable resources, usually those within the special relationships with the client may be the
client's own culture. primary agents for dealing with the client.
The mental health service should be integrated as The particular role of an indigenous healer or
completely as possible into the helping systems therapist as either direct therapist or consultant
currently accepted by the culture. must be carefully considered in each case. Firm
guidelines cannot be provided, but the following
An attempt should be made to learn: should be evaluated in establishing the respective
• what the culture considers normal and abnormal role of the indigenous healer and the professional:
• what the sociocultural causes of disorders are • the type of illness (disorders in which the cause
assumed to be is assumed to have a large sociocultural
component are probably more responsive to the
• what the sociocultural responses are to the
indigenous healer)
disorder, including traditional or folk healing
practices and networks • the need for chemotherapy or other physical
therapy and the need for surveillance of the
• what the community expects of you and your
response to medications
agency.
• degree of risk to the client, the healer and the
This assessment process may be informal or community presented by each option, and
formal and should include consultation with community expectations regarding responsibility
"culture-brokers," those who are able to operate in for care of the client
both cultures. • acceptability of each alternative to the client
• potential for harm from the expected choice of
Ideally, culture-specific profiles of disordered techniques of the indigenous healer
behavior should be developed, along with a • ability of the indigenous healer and the medical
description of how the behavior is perceived to staff to work together
relate to various sociopsychological factors.
Traditional and folk healing techniques as applied
Be aware that in some cultures and with some to mental illness should be respected even though
disorders, the individual is not held responsible, they appear to be at variance with scientifically

based practices. Non-specific factors in the healing including the scientific approach, and this is
process may be operative in any approach and may particularly true in mental health.
have a significant effect, especially if the client
identifies the treatment as appropriate. Assume that the client has competencies and
resources for "self-righting" during difficulties (i.e.
Unless the "scientific" technique is demonstrably do not be paternalistic or encourage dependency).
more effective, and more effective in the cross- Be aware of your own values and expectations and
cultural context specifically, the indigenous healer any points of conflict with the other culture.
should be a significant part of the treatment plan,
given that such practice has cultural support and is Other individuals in relationships with the client
desired by the client. may also be able to supply social influence to the
benefit of the client.
Notwithstanding the above cautionary note,
collaboration with native or folk healers does Involve the target population or members of the
provide an opportunity for exchange of knowledge community generally in development of programs
and perceptions, which may work both ways. All and services. Community ownership of services
forms of healing are dynamic and changing, increases their acceptability and appropriateness.
Communication
In communication with someone of another • Gauge the level of the client's vocabulary and
culture, it can be expected that there will be respond accordingly.
numerous sources of misunderstanding, even if the • Be alert to non-verbal cues and to the fact that
two parties are speaking the same language. gestures can have different meanings in different
Cultural training, and perhaps even language itself cultures.
(Whorfian hypothesis), structures one's perception • Some emotional subjects are taboo and must be
of reality. handled tactfully or indirectly.
• Some questions may be inappropriate and
In mental health services, it is especially important offensive for certain groups of people, such as
to communicate effectively for the following pubescent girls, elderly people or married
reasons: women. This factor may depend also on the age
• A clear understanding of the client's symptoms, and gender of the inquirer.
circumstances and perception of the problem is • Cultures vary widely in terms of appropriate
necessary. distances between speakers (personal space),
• Many mental disorders are diagnosed by depending upon their relationship and the topic
disturbances of thinking and perception, which and purpose of the conversation. Standing or
can only be determined verbally and must be approaching too close might be perceived as
differentiated from culturally normal ideas. being "pushy" or aggressive; someone standing
• To the extent that verbal techniques are used in too distant may be interpreted as cold,
treatment, communication must be effective. impersonal or anxious.
• An interpreter is obviously necessary when a
The following are some of the considerations that different language is spoken, but he or she can
should routinely be taken into account in also be helpful in providing a "cultural"
communicating and counseling in a cross-cultural interpretation, clarifying and explaining for both
situation. parties (see "Use of an Interpreter," below, this
chapter).
• Words, even in the same language, can have • The communication "style" varies from culture
different cultural meanings. Paraphrase and to culture (e.g. opening exchanges, getting to the
question the client to be sure of mutual point, directness, bluntness, self-disclosure by
understanding. the interviewer).

• It may be advisable for the counselor uncomfortable. Use the person's name
(interviewer, therapist, nurse) to explain his or (remember that self-esteem is in part tied to
her point of view, values and assumptions. one's name). Speak slowly, but do not shout.
• The degree to which each client identifies with Volume does not compensate for difficulty with
his or her culture must be assessed. vocabulary or syntax.
• The client's environment should be kept as the • Discuss confidentiality. Be sure that you
focus of the interview; attempt to address the understand the interpreter's relationship to the
problem and understand it from the client's client and that it does not pose a problem.
perspective. • Ask the interpreter for feedback at each step to
• The interviewer must be prepared to be flexible be sure that communication takes place. As
to meet the client's expectations of where the appropriate, ask for brief summaries to ensure
interview should lead. that all three parties have a mutual
• Interest and genuineness are traits of the understanding of what has been discussed.
interviewer that can be recognized readily by • Explain to the interpreter that impressions of
clients of almost any culture. feelings and emotions should be described, in
addition to the client's verbalizations.
Some of these items require an in-depth • If appropriate, ask the client for a summary of
knowledge of the culture. Consult experienced what has been discussed.
healthcare and social service professionals and • Be alert for incongruence between verbal and
para-professionals, elders, cross-cultural workers, non-verbal communication, and ask the
interpreters and other members of the community interpreter to check out any suspected problems.
itself. • Have the interpreter choose the appropriate
words for possibly sensitive or taboo subjects,
Firsthand experience and knowledge are best, but such as sex, and indicate to him or her that you
do not overlook the anthropological and historical are not expecting a literal translation. Ask for a
literature on your area and its people. translation of what was said to be sure that the
translator's interpretation was close enough to
Use Of An Interpreter the intended meaning.
Communication is most effective when the • Ask the interpreter about correct protocol (dress,
participants share a common tongue and culture, handshakes, type of questions that may be asked,
so that verbal and nonverbal messages are "personal space," use of first names, presence of
congruent and cultural meanings are clear. The the interpreter).
following guidelines can be expected to • The interpreter is a professional and should be
compensate only partially for the degrees of acknowledged appropriately for the service
difference between speakers. provided.
• Be respectful and polite. Maintain eye contact if

it does not appear to make the interpreter
Mental Illness Prevention And Mental Health Promotion

General health. It addresses both the high-risk populations
To lessen the incidence of mental disorders and to (predisposing factors) and the high-risk situations
promote the achievement of self-actualization, (precipitating factors, such as stress).
competency and well-being are the two sides of
the prevention-promotion coin. Mental health promotion seeks to stimulate and
encourage the development of skills and attitudes
Mental illness prevention attempts to set the stage conducive to positive mental health, and is thus
for the realization of mental health by tackling the more than just the avoidance of mental illness.
predisposing and precipitating factors of mental ill

Widespread disorders affecting large numbers of ultimately diffused throughout the community, and
people are practically never brought under control the tasks of mental health workers are to convey
by attempts to treat each individual afflicted. this message to the community and to activate its
Prevention and health promotion are theoretically members.
much more cost-effective, although the results are
not always as quickly apparent as in one-to-one A caution should be observed in initiating any
treatment. Such approaches also often require community program. No matter how apparently
social and environmental change that is not so benign, any intervention that is powerful or
readily accepted (e.g. changing child-rearing comprehensive enough to produce beneficial
practices; providing sex education; eliminating outcomes may also produce undesirable side
poverty, discrimination, poor housing and effects. Smaller, less ambitious interventions are
unemployment; and "humanizing" social perhaps safer if for no other reason than that their
institutions). potential for harm is less.
Prevention in mental health cannot be as disease- Preventable Psychiatric Disorders

specific as in physical health, with a few Genuine disease-specific prevention of mental
exceptions (see "Preventable Psychiatric disorders is recognized as possible in about five
Disorders," below, this chapter). categories of disease, and this is true in part only
because the causes are known in these instances.
Certain conditions do not inevitably lead to
specific mental disorders, except in the few cases Acute and Chronic Poisoning
noted. Prevention is often a "shot in the dark" in • Acute poisoning: intentional or accidental
this sense. Health promotion, on the other hand, ingestion of drugs, inhalants or solvents
has a more tangible and identifiable target, namely • Chronic poisoning: prolonged exposure to
the improvement or development of observable industrial toxins or prolonged use of medications
skills and behaviors identified as mentally healthy. or addicting drugs
• Fetal poisoning by maternal use of alcohol or
General strategies applied in preventing mental drugs
illness:
• case-finding through surveys, routine medical or Preventive Measures
developmental assessments, or other agency
• Change in environment
referral
• Change in lifestyle
• early psychosocial intervention
• Change in healthcare system (storage of drugs;
• prompt diagnosis and referral for treatment
prescribing and dispensing practices)
• examination of the social and environmental • Reduction in exposure to industrial poisons
correlates of mental illnesses and the
psychosocial stressors
• Better safety standards and monitoring
• provision of services and promotion of social • Better labeling of household and industrial
poisons
and environmental change.
• Establishment of poison control centers
Both the prevention and health-promotion • Public health education
strategies of healthcare call for a change in
caregiver attitudes concerning causation, away Infections Damaging to Central Nervous
from an individualistic and individual pathology System (CNS)
model and toward a more socially and community- • Infection during fetal period (e.g. rubella,
oriented approach to causation and intervention. syphilis, toxoplasmosis)
• Infectious diseases during childhood (e.g.
Prevention and mental health promotion are best pertussis, influenza, measles, meningitis,
achieved by a coordinated network of services and mumps, tuberculosis)
agencies. Responsibility for mental health is

Preventive Measures Mental Health Promotion

• Good prenatal care
• Treatment of maternal infections General
• Immunization Promoting mental health means enhancing the
competencies and well-being of individuals,
Genetically Transmitted Disorders groups and communities. This concept differs
• Tay-Sachs disease from the traditional public health model of
• Phenylketonuria prevention, which distinguishes three spheres of
• Galactosemia intervention: primary and secondary prevention,
which are designed to reduce the prevalence of a
• Tuberous sclerosis
disorder, and tertiary prevention, which is aimed at
• Huntington's chorea
reducing the severity of chronic disorders.
Although this model has been effective in
Preventive Measures preventing a range of communicable and
• Genetic counseling nutritional diseases, it has not been as successful
• Screening and early detection in preventing mental and behavioral disorders.
• Special diet (for phenylketonuria and
galactosemia) The mental health promotion model is based on
the premise that psychosocial stressors increase
Nutritional Deficiencies susceptibility to mental ill health but do not
• Wernicke's encephalopathy inevitably lead to a specific disorder.
• Beriberi
• Kwashiorkor Therefore, the goal of mental health promotion
• Pellagra interventions is to improve the well-being and
• Anorexia personal strengths of both at-risk and normal
• General nutritional deficiencies populations and to modify the social and
environmental factors that impair mental health
Preventive Measures and well-being.
• Dietary supplementation
The target for an intervention may be individuals,
• Nutritional education groups or even systems.
Injuries and Systemic Disorders
Strategies for Promoting Mental Health
Affecting the CNS
Promoting Natural Social Support Systems
• Injuries (e.g. falls, gunshot wounds, motor Social support systems (relatives, friends) are
vehicle crashes) effective buffers protecting the individual from the
• General systemic disorders (e.g. erythroblastosis effects of external stressors, including personal
fetalis, hyperthyroidism, cretinism, intracranial loss, psychosocial transitions or crises.
masses, prematurity)
Their impact can be strengthened by systematic
Preventive Measures reinforcement through the following steps:
• Legislation affecting legal driving age, use of • Identify the high-risk populations (e.g. young
protective equipment (e.g. helmets), use of mothers, unemployed men, recently divorced
seatbelts, highway speed limits women, children of divorce and mentally
• Improvements to industrial safety handicapped children).
• Legislation affecting gun control • Assess the informal or natural social resources
• Public education promoting safe practices potentially available.
• Early diagnosis and treatment (e.g. • Identify the natural helpers: those who have or
hyperthyroidism and intracranial masses) could learn the skill or competency and who
• Good prenatal care have access to the at-risk population.

• Give them the necessary assistance, training and are just some of the agencies that can have a
consultation support and continue to do so as powerful impact on an individual's immediate or
long as necessary. eventual mental health.
Enhancing Caregiver Competence Consultation may be aimed at:

Increasing the skills and knowledge of • increasing awareness of mental health concerns
professional and para-professional caregivers • improving access to services
increases the probability that those individuals will • encouraging mental health promotion activities
positively affect the mental health of the broader within the agency (e.g. mental health programs
population. in the schools)
• changing the system to meet the needs of the
This goal can be achieved through a variety of population served.
strategies, including case conferencing, inter-
agency workshops, conferences, in-service Insights into mental health problems gained from
training programs, sharing of audiovisual the health services perspective should be shared
materials, study groups, "think-tanks," task forces with other agencies, either formally or informally.
and joint sponsorship of consultation or training
sessions by experts. Strategies For Prevention And
Mental Health Promotion
Building Community Networks
Pre-School Child and Maternal Mental
The "competent community" is analogous to the
competent, mentally healthy individual.
Health
Prenatal and postnatal care programs have been
shown to significantly improve the health of both
There exists a sense of autonomy, control and self-
mother and child and to reduce the risk of a variety
worth. Insofar as mental health is concerned, this
of mentally impairing disorders linked to the
state is promoted through the development of
physical dimension of health (e.g. phenylketonuria
community networks, which foster inter-agency
and conditions affecting the brain), but such
cooperation, coordination of effort and community
programs are also valuable for psychological
involvement in matters related to mental health.
phenomena such as bonding and postnatal
maternal depression.
Providing Mental Health Education
Mental health education seeks to assist the public
It is important to identify and intervene with
and professionals to acquire the knowledge, skills
children who are at risk or vulnerable because of a
and attitudes that will contribute directly to their
living situation that is hazardous to mental health,
own mental health and the mental health of others.
such as parental neglect, inadequate housing, lack
It makes them more knowledgeable consumers of
of stimulation, or abusive parents or siblings.
mental health (and related) services, as well as
increasing their ability to provide care and support
Day care and "Moms' Groups" provide relief for
and to recognize mental health problems. It
mothers from child-care pressures and
ultimately influences public policies that affect the
responsibilities and permit a natural exchange of
mental health of individuals and groups in the
mutual support and parenting skills between
community.
mothers.
Program Consultation Routine developmental assessment aims to
Informed consultation, especially to human identify children who are not maturing at a normal
services agencies, can help create a more level (a variety of developmental spheres are
responsive system for addressing mental health examined, so that appropriate medical and other
problems and for promoting mental health. attention can be provided).
Schools, the courts, social welfare agencies, day-
care services, senior citizen homes and the media

Children should have facilities and resources Life Change and Crisis
available for exercising their bodies, their Bereavement counseling aims at giving support,
creativity and their minds and for learning social particularly to high-risk groups, such as parents
skills. who have experienced the death of a child and
anyone whose spouse or parent has died. The latter
Mental Health in the School situations (death of a spouse or parent) have been
A number of affective and social education kits are identified as factors increasing the risk of suicide
available for teaching awareness, acceptance of either immediately, in the case of death of a
feelings, attitudes, values and development of spouse, or in later life, in the case of death of a
social and interpersonal skills. parent.
Social and interpersonal problem-solving can be Planning for retirement assists the individual to
taught as a curriculum item. Numerous programs adjust to the many changes that take place upon
are available for the entire range of grades from retirement. Counseling themes include finances in
kindergarten to high school. retirement, use of leisure time, changing health,
Children can be taught to: accommodations and changing relationships.
• analyze interpersonal problems
• generate solutions for consideration Divorce is a stressful time for the separating adults
• determine suitable means of implementing a and the children involved. Children of divorce are
solution or achieving a goal known to have more mental health problems than
• recognize the consequences of the various children in intact marriages. Counseling to
alternative solutions. facilitate divorce and to support the children
affected are both identified as valuable preventive
There is often a correlation between academic programs.
problems and mental and behavioral disorders.
Early identification and remediation of learning Premarital and marriage enhancement courses or
disabilities would help to prevent later counseling prepare couples for stresses in marriage
development of problems related to low self- and encourage constructive problem-solving and
esteem, lack of confidence, and social or mutual support.
vocational deficiencies.
Parenting courses are available in a number of
Programs can be developed specifically for high- forms and focus on various age groups of children.
risk students, who are often identifiable in the Parent support and self-help groups serve a similar
early school years. function. In some programs, observation nurseries
have been used to teach parents of preschoolers in
Preventive programs may be child-focused, formal a more immediate and practical fashion.
curriculum courses or may be implemented
informally as opportunity presents. In either case, Programs aimed at preventing the sexual abuse of
there is a need for programs of teacher training in children have been developed for use in a variety
affective education and social skills. of settings, including the school.
Parent-teacher study groups, teacher "think-tanks," Single parent counseling and self-help groups
peer tutoring and student self-help groups are support the parent who must play usual roles while
innovative approaches that have been used for providing for his or her children.
mental health promotion within the school.
Programs are available for children facing
Although their long-term effectiveness is yet to be hospitalization and surgery. These programs
solidly demonstrated, family life education, sex reduce the stress of separation and the
education, and alcohol and drug abuse programs in uncertainties and fears associated with entering
the school are presumed to have a preventive hospital.
function.

Distress phone-in lines or counseling services for General Population

people in acute crisis, such as suicidal or Stress management courses are often available
distraught individuals, prevent further breakdown through employers or community agencies and are
of the person's ability to cope. Whether or not such purely preventive in intent.
services actually prevent suicide is uncertain; thus,
suicide prevention should probably not be their Assertion training provides an opportunity to learn
main purpose. a social skill that significantly reduces stress and
anxiety in interpersonal relations.
Violence can be prevented through a number of
strategies, beginning with intervention and Mental health education raises the level of
services to the victims and offenders. These consciousness and helps the community and
services include support, legal counseling, individuals to identify the mental health problems
protection for victims and treatment for the in their environments.
offender. At another level, preventive efforts
might address the inappropriate socialization that Community development programs mobilize the
some children receive, the prosecution of community itself, focus attention on services or
offenders to underline society's disapproval, and mental health promotion, and often directly
the media, institutional, and public attitudes that involve those who are at risk in the solution to
support and encourage violence in general. what is or could be their problem.

Mental Health Assessment

Clinical Assessment And Management
General • insomnia
The purpose of mental health assessment is to • lethargy, fatigue
provide specific information about a client's • weight loss or gain, loss of appetite (anorexia)
behavior, thoughts and feelings and the relation of • palpitations
these factors to the client's background, • nausea, vomiting
experiences and present circumstances. It provides • headaches
the database for describing, diagnosing and
eventually treating problems. The information may Integrative patterns and client's relations to:
be gathered from direct interviews with the client • others
or from material provided by relatives or referring
• self
agencies.
• things and ideas
• present situation
History
• reality
Client Profile
General description of the client:
Relevant History
• Age
Personal--Sketch of Life History
• Sex
• Stays in hospital and illnesses
• Ethnic origin
• Education
• Marital status
• Occupational background
• Number and age of siblings or children
• Social adjustment
• Spouse or parents
• Sexual history
• Living arrangements
• Interests, hobbies, recreation
• Occupation
• Substance abuse
• Education
• Outstanding life events
History of Presenting Problem
• Suicidal, homicidal or violent behavior
Client's perception of problems in daily living.
Familial--Sketch of Family and Placement
Difficulties or changes in: within Family
• relationships • Birth order
• usual level of functioning • Relationships with siblings
• behavior • Integrity of family unit
• perceptions • Mental health of family members
• cognitive abilities • Perceived place within family
• Relationship with parents
Increase in feelings of:
• depression, helplessness Clinical Examination
• anxiety Mental and Emotional Status
• being overwhelmed Appearance
• suspiciousness • Physical condition and general health
• confusion • Dress
• Eye contact
Somatic changes: • Posture
• gastrointestinal • Relatedness to interviewer

Behavior Special Preoccupations

• Motor activity • Hallucinations (any modality)
• General level • Delusions
• Gait • Illusions
• Gestures and mannerisms • Depersonalization (one's reality is lost)
• Awareness of environment • Derealization (things do not seem real)
• Hypochondriacal
Speech • Obsessions
• Sound and volume • Rituals or compulsions
• Rate • Fears and phobias
• Barriers to communication • Sense of grandiosity or worthlessness
• Nihilism (the order of things has disappeared)
Mood • Morbid thought
• Appropriateness • Religiosity
• Overall impression (e.g. depressed, anxious,
angry, apprehensive, apathetic) Reality Orientation
• Affect (and its appropriateness) • Knowledge of time, place, month and year
• Emotionality (dominant emotion, range of • Remote and recent memory
emotions, liability) • Ability to distinguish between internal and
external stimuli
Thought Processes
• Quality Suicidal or Homicidal Risk
• Appropriate See "Suicidal Behavior," below, this chapter.
• Tangential
• Concrete or abstract Evaluation and Interpretation
• Flight of ideas (stereotypic) Determine need for emergency actions:
• "Word salad," confusion • Overt homicidal or violent impulses
• Neologisms (words created by client) • Potential suicide
• Confabulation (fabrication of events or facts due • Inability to function
to memory impairment; not lying) Identify strengths.
• Idiosyncratic or unusual word usage Make provisional diagnosis.
• Cognitive ability: concept formation, level of
intelligence, articulateness (precision, Possible Goals Of Treatment
vocabulary level) • Remove symptoms (e.g. reduce anxiety)
• General characteristics: speed of thought, • Change attitude
spontaneity, flexibility or rigidity, distractibility, • Change behavior (e.g. cessation of compulsive
continuity, alertness, blocking (interruptions in hand-washing, habit change, self-control)
train of thought), attention and retention • Develop insight (e.g. an understanding of one's
motivation, the reasons for emotional response
Thought Content or the causes of disordered behavior)
• Central themes • Improve interpersonal relationships (e.g. getting
• Self-concept along with one's family, overcoming social
• Insight and awareness anxiety or shyness, controlling anger)
• Judgment • Improve personal efficiency (e.g. increase ability
• Suicidal or homicidal ideation to accept responsibility, be productive)
• Improve social efficiency (e.g. improve ability
to function socially within the community)

• Prevent and educate (e.g. increase ability to Expert "Placebo Effect"

adapt and cope in the future) Persuasion and influence through personal
qualities of the helper:
Treatment Methods • caring and compassion
General • manner
Apart from the physical and medical treatments • confidence
provided to mental health clients, there are a • warmth
number of psychological means by which medical • genuineness
and health personnel can influence a client's • empathy
behavior in a therapeutic manner. The goal of this
psychosocial influence may be to: Modeling
• directly affect emotional response in the client Providing an appropriate example or model of the
(e.g. relaxation training, reassurance, desired behavior. This may require guided practice
confrontation) by the patient under optimal, non-threatening
• change the client's self-perceptions (e.g. by conditions (e.g. as in treatment of phobias, social
challenging unrealistic beliefs or faulty anxiety or lack of assertiveness).
reasoning or through vocational counseling)
• provide an opportunity for learning new coping Basic Learning Principles
or self-enhancing (confidence-building) skills Systematic use of positive reinforcement,
(e.g. vocational rehabilitation, assertiveness extinction, punishment and other learning
training, social skills training) or parenting skills principles to increase or decrease behaviors.
• directly teach new behaviors to replace or
counter the maladaptive ones (e.g. systematic Prior Practicing
desensitization for phobias, training in anger Role playing and rehearsal of desired behavior.
management or other forms of self-control).
Environmental Restructuring
Means of Influence Establishing or altering either the physical or the
Providing "Expert" Testimony social environment so as to permit or encourage a
Communications from an individual recognized by desired change in behavior.
the client as having special knowledge or
expertise: Human Services and Resources Coordination
• "naming" the disorder Referring clients to other professionals or bringing
• providing feedback them into contact with a wider variety of
• assisting the client to reflect on, interpret and resources.
confront the problem(s)
• evaluating the situation Mobilizing the Client's Own Resources
Creating internal states that are conducive to
Providing "Expert" Directions behavior change (e.g. sleep, rest, deep muscle
Getting the client to do something through one or relaxation, nutrition, fitness).
more of the following means:
• verbal instructions Patient Evacuation
See "Hospitalization and Medical Evacuation,"
• orders
under "Psychotic Disorders," below, this chapter.
• recommendations
• suggestions Involuntary Admission
• limit-setting See "Involuntary Admission," under "Psychotic
• policy statements Disorders," below, this chapter.
• permission

Records And Confidentiality guaranteed under the Privacy Act of Canada. If

General any voluntary disclosure is made without the
Medical records and information about medical client's consent, such as reporting a criminal
and psychosocial interventions for mental health offence, the Commissioner of the Privacy Act
problems require the utmost care to ensure must be notified in writing and the Commissioner
confidentiality. In many cases these records may choose to disclose the informant's name to the
contain personal information of the same degree of client.
sensitivity as pertains to such medicosocial
There is no requirement under the law to report the
problems as abortion, sexually transmitted
commission of an offence or the intent to commit
infections, unplanned births, addictions and
an offence. Such a decision must be based on
forensic examinations.
ethical and moral principles, such as the safety of
These records should be treated with great care. individuals, including the client, especially where
Medical and psychiatric information should not be the potential exists for homicide, suicide or
shared with family (including spouse or children), physical assault. It is advisable to get a second
friends or other healthcare professionals unless the opinion in such cases by consulting an
client has provided informed consent, preferably experienced professional, discussing the
in writing. alternatives and clarifying the facts and principles
that will guide your decision.
There are a number of respects in which breaching
the confidentiality of mental health records can be The Access to Information Act permits clients to
particularly damaging. have copies of their medical records, but the
• Clients presenting with mental health problems director of an institution or program may refuse to
are more vulnerable to public embarrassment disclose the records if it is deemed to be not in the
and to the prejudices and biases of others, best interest of the individual.
including employers.
No written or verbal information regarding a client
• Because of the personal and social nature of should be given to any individual, including the
mental health problems, disclosure may have an police, without either the written consent of the
impact on others besides the client involved. client or presentation of a subpoena.
• Legal issues may be involved, and the client
may be compromised. Information requested by human services agencies
• Disclosure would undermine public confidence having legal guardianship of a child may be
in the service, the personnel and the agency. granted without consent of the natural parents.
• Some clients, because of personality disorders or
mental illness, are more likely to try to gain All material in client records is the permanent
access to information or to misuse anything property of the Government of the Northwest
learned. Territories, Department of Health and Social
Services. Requests by a client for copies of or
Guidelines access to such records should be in writing and
Doctor-client or nurse-client "privileged should be directed to the responsible managerial
communication" does not exist in Canada. level.
All medical personnel are required by law to give
evidence if subpoenaed for that purpose. Deliberate or unwarranted violation of patient
There is no clear statement in common law with confidentiality is subject to disciplinary action up
regard to breach of confidentiality, which means to and including summary dismissal for cause.
that each case would be contested on the basis of
principles other than common law precedent. In many jurisdictions, legislation requires
disclosure of certain offences or suspected
Confidentiality of a client's medical records or the offences. For example, child abuse must be
purpose and content of any medical intervention reported in all of the provinces and territories.
(even the fact that the client has been seen) is

Age of Consent A decision about ability to give consent is also

Minors are those under the legal age to give based on the providers' assessment of the client's
consent for treatment. The age at which consent competence to understand the issues and
can be legally given varies from province to implications of the illness or situation and the
province and is usually between 16 and 20 years. consequences of treating or not treating.
It is advisable for the nurse to review the relevant
age-of-consent legislation for the province or Maintaining Confidentiality
territory of employment. As with all medical records, vigilance must be
exercised to ensure that confidentiality is not
The issue of age of consent is of concern in the breached, whether deliberately or accidentally.
delivery of mental health services because,
technically, it can affect the availability of Medical charts should be in secure storage when
confidential mental health consultation and not in use.
treatment to someone deemed not medically
competent. For example, must the parent or Care should be taken that documents of any sort
guardian of a minor be advised of the request for that could identify a client as having a mental
service? health problem, or any information related to that
Should the parent or guardian have access to fact, are not within view of the public, other
records or information pertaining to the contact? Is clients or staff not directly concerned with the
parental consent required to accept a minor for client in question. Even appointment calendars can
counseling or treatment? be inadvertently disclosing.
In the absence of firm guidelines, general Anyone who inquires about a mental health client
principles might be taken from a statement on age should be politely refused any information, unless
of consent for use by physicians: disclosure of the information is authorized by the
• Clients > 16 years of age should be entitled to client.
consent to their own surgical, medical or dental
treatment. Telephone conversations with respect to a client
• Clients < 16 years of age should be able to should be conducted where they will not be heard.
consent to their own treatment only if the Similarly, client interviews or consultations should
physician has ascertained that the client is able be held in private.
to understand and appreciate the nature and
consequences of the proposed procedure. When some risk exists to a client (or to others) and
• In cases in which physicians have decided that a the family is providing for the safety and security
client < 16 years of age has the maturity and of the client, the facts necessary to reduce the risk
ability to understand the consequences of the should be disclosed. No more information than is
proposed procedure, and thus may give consent necessary should be volunteered without the
to his or her own treatment, the physicians are client's knowledge.
advised to prepare written notes to substantiate
this decision.
• Special protection must be provided for minors,
regardless of whether they have reached 16
years of age, whose physical or mental disability
precludes their having the capacity to consent to
treatment.

Common Mental Health And Psychiatric Problems

Violent Or Acutely Agitated Psychiatric Clients
Most psychiatric clients are not particularly Toxic Psychoses
dangerous or violent. However, clients with the • Alcohol intoxication
following conditions may demonstrate violent • Stimulant intoxication
behavior: • Hallucinogenic intoxication
• Personality disorders • PCP (phencyclidine) intoxication
• Substance abuse
• Organic brain disorders or states with impaired Withdrawal Delirium
impulse control • Alcohol
• Acute-phase manic disorders • Other chemical substance
• Paranoid psychotic disorders
• Organic functional disorders in which delusions Personality Disorders
or hallucinations are present • Borderline
• Paranoid
When clients behave violently, the behavior is • Histrionic
often unpredictable and irrational, since it is a
• Antisocial
product of the client's psychopathology. The true
source of anger may not be apparent and actions
Disorders of Impulse
may be illogical, as in the case of persecutory
delusions, or actions may be abrupt and • Explosive disorder
unexpected, as in hallucinatory states. • Control
Causes Organic Disorders

The causes of violence in mentally ill clients are • Acute brain syndrome
the same as in those without mental illness: • Chronic brain syndrome
• Fear • Dementia
• Frustration • Delirium
• Disappointment
• Feelings of inferiority Management
• Invasion of personal space These guidelines for the management of violence
assume that the violent person is a bona fide
• Loss of self-esteem
psychiatric or medical patient. In some cases, the
• Feelings of humiliation
individual may have a personality disorder for
• Defense against a perceived threat (real or which emergency treatment is not possible or
imaginary) appropriate. In this situation, the violence is best
viewed as a matter for the police.
Differential Diagnosis Of Potential
Underlying Disorders Ultimately, you must use your own judgment to
Functional Psychoses determine if and when to intervene with a
Functional psychoses may be related to: potentially violent patient. Trust your feelings and
• Bipolar disorder judgment. If you feel threatened, act accordingly.
• Schizophrenic disorder
• Brief reaction psychoses Goals of Treatment
In order of priority:
• Protect yourself, others and the client

• Avoid or minimize an outburst of physical Acute Situation: General Guidelines for

violence Management
• Recognize and reduce anxiety and fear in the If you are concerned, try not to see the client alone
client and avoid standing too close to the client, as this
may be perceived as a violation of personal space
Appropriate Consultation and add to the problem. Keep the door open and
Whenever possible, medical consultation and ensure that both you and the client have an
assistance should be sought in dealing with violent unobstructed path to the door, so that either of you
clients. When circumstances make this impossible can escape from the room if the situation is
at the critical moment, the physician should be perceived as dangerous.
consulted as soon as possible afterward to discuss
the action taken and the choice and dosage of any Do not see the client if he or she has a weapon of
medication given. The correct diagnosis is very any sort. Call for assistance.
important in the case of the violent client, and a
consultation is an essential part of the management Do not hesitate to call the police if the client
procedure. becomes too threatening.
Nonpharmacologic Interventions Do not argue with or otherwise threaten the client's

Prevention self-esteem.
Consider creating a crisis protocol in advance:
• If circumstances permit, call for assistance Do not threaten to use force unless it is
before becoming involved with the client. immediately available.
• Know how to use approved physical
interventions to restrain the client or defend Approach the client calmly and quietly, in a
yourself. professional, confident and friendly manner. Be as
• Be familiar with escape routes that you might relaxed and reassuring as possible.
need.
Use non-verbal methods to control the client as
• Keep potential weapons (e.g. scissors, scalpels,
much as possible, for example, through careful use
letter openers) out of reach of clients.
of "personal space" boundaries, firmness, tone of
voice and eye contact.
Whenever possible, try to predict and prepare for
the disturbed behavior by noting the following:
Care must be exercised to observe and judge the
• Changes in the client's personality effects of these actions, since what may be
• Indicators such as increasing verbal aggression, psychologically subduing or calming to one client
postural tension, facial expression, tone of voice may be provocative to another. Attempts to "talk a
and belligerence client down" may even increase some clients'
• Any previous history of violence, assaultive, agitation.
homicidal or suicidal behavior, or threats to kill
or injure self or others Show interest in the client's complaint, fear or
• State of intoxication or impairment by drugs or suspicion. Acknowledge it, but do not agree or
history of substance abuse disagree. Indicate that your purpose is to try to
• Extreme agitation, fearfulness or pacing help the client deal with the problem.
• Any record of interventions or actions that have
been effective for managing the client in the past Attempt to determine the reason for the anger or
violence and respond accordingly.
Anticipating and preventing violent behavior is
always the best strategy. Watch for signs of organic brain disorder,
substance abuse, suicide attempts (e.g. scars on
wrists) or fighting and for evidence of a weapon.

Do not respond to anger with anger: approach the • Ensure that the restraints are snug enough to
situation with a non-threatening, non-punitive and hold the client, but not so tight as to cause injury
non-judgmental attitude. Do not take personally or or cut off circulation.
respond to insults or abusive language. • Beware of being bitten.
• Remain aware of your own feelings throughout.
Physical Restraints Violent psychiatric clients may not know who
Involuntary restraint and involuntary you are or where they are. They may be terrified
hospitalization are covered under the respective and have no definite target for their rage. Above
ordinances of the province and territories. These all, do not respond with anger or take personally
pieces of legislation should be referred to and their what the unstable person may do or say to you.
implications clearly understood. To restrain Remember as well that the unstable person is
someone or to force them to involuntarily undergo quite likely to remember what was said during
treatment in ways other than provided for by an outburst of this sort. Unprofessional language
legislation can lead to civil litigation and criminal or conduct is inappropriate at any time.
assault charges.
Types of Restraints and Their Application
If medication is contraindicated, inappropriate or Leather wrist and ankle restraints are preferred to
insufficient, and physical restraints are deemed body restraint with a Posey jacket because of the
necessary: danger of strangulation with the latter.
• Use restraints as a last resort when a client
cannot be controlled by verbal or non-verbal Leather wrist and ankle restraints:
communication and is a threat to himself or • are easy to apply
herself or others or is destructive of property. • require three or more people to place them
• Inform the client of your intentions, explaining • should be applied with the client in a face-down
that the restraints will be applied because the position.
client is unable to control himself or herself.
• To ensure your safety and the safety of the Restrain the client's arms at his or her sides and
client, three or more people are needed. The secure the tie-ends to the stretcher or bed. Restrain
mere show of force may prove sufficient to the legs straight out, and beware of being kicked.
allow the client to calm down without the use of
force. Pharmacologic Interventions
• Explain the procedure in advance and continue If it is deemed in the client's best interest because
talking reassuringly to the client throughout. he or she is at risk of injuring self, others or
• Have a clear plan of action. Decide who will do property, or is likely to leave the premises before
what and, if possible, assign at least one person adequate treatment, chemical sedation should be
to each limb. considered. If possible, consult a physician first.
• Remove glasses, watches, jewelry or anything Otherwise, give:
else that might be used as a weapon or could lorazepam, 1 mg PO (C class drug) or 1-2 mg IM
cause accidental injury. (D class drug)
• If the client is armed with a potential weapon, Do not use benzodiazepines such as lorazepam in
defend yourself with objects (e.g. hold a a person acutely intoxicated with alcohol, as these
mattress in front of you or throw a blanket over drugs are additive for respiratory depression.
the client).
• Place the client face down, if possible, as the Monitoring of a Client Who is Medicated
range of motion is limited in this position; or Restrained
otherwise, keep the client off balance. After Restraints Are Applied
• Do not count on your own strength equaling that • Check distal circulation frequently.
of the client. A disturbed, violent person can be • Remove any remaining potentially dangerous
surprisingly strong. items from the client, including jewelry, glasses,
• Place one limb at a time into restraints. belt, shoes, matches and contents of pockets.

• Examine client for weapons concealed in the If a secure room is used for confining a violent
hands (e.g. small, sharp objects such as broken person after removal of restraints:
glass, which may have been grabbed during • Exit the room with the same care as you would
application of the restraints). use in approaching the client.
• Evaluate regularly the need for hydration, • Do not let the client get between you and the
nutrition and elimination. door.
• Provide assistance with personal hygiene and • Never enter alone.
grooming. • Visit frequently to provide human contact and
reality testing.
Other Aspects of Monitoring • Always announce your intentions when you
Watch for side effects of psychotropic medications enter the room.
and explain them to the client. • Be cautious with utensils and hot liquids when
serving meals.
Evaluate the client's self-control and capacity for • Do not leave potentially dangerous items in the
appropriate behavior on a continuing basis. room.
Remove restraints when the person is sedated or Referral: Hospitalization and Medical
calmed. Evacuation
The decision as to whether to admit to a local
Remove the restraints one limb at a time, using the hospital, treat on an outpatient basis or evacuate to
same precautions as when they were applied. a psychiatric hospital depends on several factors
and should, of course, be made in consultation
Watch for flare-ups of violent behavior. with the best qualified available physician,
preferably a psychiatrist.

Alcohol Withdrawal
Syndrome experienced after cessation of or Consultation
reduction in alcohol ingestion by a person who has If possible, consult a physician before instituting
been drinking for several days or longer. Most medications.
alcohol-dependent individuals experience their
first withdrawal symptoms after 10-15 years of Nonpharmacologic Interventions
alcohol abuse. • For client with mild symptoms good
psychological support may be sufficient (time
Symptoms begin within 3-6 hours after cessation spent with client listening and supporting
or reduction in drinking and may last 2-3 days. through physical symptoms
Malnutrition, fatigue, depression or physical • Increased rest
illness may aggravate the symptoms. • Hydration and nutrition: high-protein, high-
carbohydrate diet and adequate fluid intake
Symptoms include coarse tremor of hands, tongue • For client with moderate-to-severe symptoms,
and eyelids and at least one of the following: IV therapy with normal saline may be necessary,
• Nausea and vomiting depending on the severity of symptoms and
• Malaise or weakness dehydration; adjust rate appropriately to correct
• Autonomic hyperactivity (tachycardia, sweating, or prevent dehydration (for details, see
elevated blood pressure) "Dehydration (Hypovolemia)," in chapter 5,
• Anxiety "Gastrointestinal System")
• Depressed mood or irritability
• Orthostatic hypotension Psychological Support for Client
Moderate-to-Severe Symptoms
Associated Symptoms • Calm, firm direction in response to demanding
• Headache and dry mouth or volatile patient (see "Violent or Acutely
• Complexion often puffy and blotchy Agitated Psychiatric Clients," previous section,
• May have mild peripheral edema this chapter)
• Gastritis • Presence of a supportive person helps to
• Fitful sleep decrease anxiety and agitation and increase
• Misperceptions and illusions safety
• Brief, poorly formed hallucinations (in any • Diversionary activities and conversation help to
modality) may be experienced direct attention away from symptoms
• Quiet, calm environment decreases irritability
Major motor seizures occur in 5% to 10% of cases and promotes rest
of alcohol withdrawal (usually one or two grand • Respond to hallucinations and misperceptions by
mal seizures in the first 48 hours). reassuring the client of reality and identifying
misperceptions as symptoms of withdrawal;
People with a history of epilepsy are likely to avoid arguing with or validating misperceptions
experience withdrawal seizures.
The symptoms of alcohol withdrawal may Consult with physician if sedation is required.
progress to delirium tremens (see "Alcohol
Withdrawal Delirium," next section, this chapter) Physician may prescribe
diazepam (C class drug) 20mg PO
See Fig 1, page 24-25 for diagnosis of alcohol or
withdrawal. lorazepam (C class drug) 4mg PO/SL
and
thiamine (D class drug), 100 mg IM od for 3 days

Moderate-to-Severe Symptoms Monitoring and Follow-Up

Treatment with medication on an outpatient basis Monitor for seizure activity.
is complicated by the danger of the alcohol abuser
mixing alcohol with the medication or Referral
indiscriminately "sharing" the drugs with other Medevac. Detoxification should take place in a
community members. supervised setting to monitor medication use (if
medication is used), maximize safety and observe
Discretion should be used unless the client can be for signs of withdrawal seizures or delirium
closely monitored. tremens (see "Alcohol Withdrawal Delirium," next
section, this chapter).
Fig 1: Diagnosis and Management of Alcohol Withdrawal

Addiction Research Foundation Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)
Patient _____________________ Date ___/___/___

y m d
Time _____ : _____ (24-hour clock, midnight = 00:00)

Pulse or heart rate, taken for 1 minute: ___________
Blood pressure: __________ / _________
NAUSEA AND VOMITING — Ask "Do you feel sick to your stomach? Have you vomited?" Observation.
0 no nausea and no vomiting
1 mild nausea with no vomiting
2
3
4 intermittent nausea with dry heaves
5
6
7 constant nausea, frequent dry heaves and vomiting
TREMOR — Arms extended and fingers spread apart. Observation.

0 no tremor
1 not visible, but can be felt fingertip to fingertip
2
3
4 moderate, with patient's arms extended
5
6
7 severe, even with arms not extended
PAROXYSMAL SWEATS — Observation.

0 no sweat visible
1 barely perceptible sweating, palms moist
2
3
4 beads of sweat obvious on forehead
5
6
7 drenching sweats

ANXIETY — Ask "Do you feel nervous?" Observation.

0 no anxiety, at ease
1 mildly anxious
2
3
4 moderately anxious, or guarded, so anxiety is inferred
5
6
7 equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions
AGITATION — Observation.
0 normal activity
1 somewhat more than normal activity
2
3
4 moderately fidgety and restless
5
6
7 paces back and forth during most of the interview, or constantly thrashes about
TACTILE DISTURBANCES — Ask "Have you any itching, pins and needles sensations, burning sensations,
numbness or do you feel bugs crawling on or under your skin?" Observation.
0 none
1 very mild itching, pins and needles, burning or numbness
2 mild itching, pins and needles, burning or numbness
3 moderate itching, pins and needles, burning or numbness
4 moderately severe hallucinations
5 severe hallucinations
6 extremely severe hallucinations
7 continuous hallucinations
AUDITORY DISTURBANCES — Ask "Are you more aware of sounds around you? Are they harsh? Do they
frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not
there?" Observation.
0 not present
1 very mild harshness or ability to frighten
2 mild harshness or ability to frighten
3 moderate harshness or ability to frighten
VISUAL DISTURBANCES — Ask "Does the light appear to be too bright? Is its colour different? Does it hurt
your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?"
Observation.
0 not present
1 very mild sensitivity
2 mild sensitivity
3 moderate sensitivity

HEADACHE, FULLNESS IN HEAD — Ask "Does your head feel different? Does it feel as if there is a band
around your head?" Do not rate for dizziness or lightheadedness. Otherwise, rate severity.
0 not present
1 very mild
2 mild
3 moderate
4 moderately severe
5 severe
6 very severe
7 extremely severe
ORIENTATION AND CLOUDING OF SENSORIUM — Ask "What day is this? Where are you? Who am I?"
0 oriented and can do serial additions
1 cannot do serial additions or is uncertain about date
2 disoriented for date by no more than 2 calendar days
3 disoriented for date by more than 2 calendar days
4 disoriented for place and/or person
Total CIWA-Ar score: _______

Rater's initials: _______
Maximum possible score: 67
This scale is not copyrighted and may be used freely.
Fig 2: Diagnosis and management of acute alcohol withdrawal

Management of acute alcohol withdrawal
Severity of
withdrawal
(CIWA-Ar score) Monitoring Treatment
Mild (< 15) Assess symptoms with CIWA-Ar Thiamine use and supportive care are sufficient if patient has a
scale every 4 hours CIWA-Ar score < 10 and no hallucinations or disorientation.
Benzodiazepine therapy may be indicated if score is > 10. The goal
is a CIWA-Ar score below 8 for 2 consecutive readings
Moderate (16– Assess symptoms with CIWA-Ar Thiamine, supportive care and benzodiazepine therapy.
20) scale at and 1 hour after each Benzodiazepine dose every hour, up to 3 doses, until CIWA-Ar
benzodiazepine dose; once score score is < 10. If no improvement, reassess diagnosis and
is< 10, then reassess every 4 benzodiazepine dose. Respiratory monitoring advised
hours
Severe (> 20) As for moderate withdrawal As for moderate withdrawal
Note: CIWA-Ar = Clinical Institute Withdrawal Assessment for Alcohol.

Figs. 1-2: Source: Holbrook, A et al. (1999) Diagnosis and management of acute alcohol withdrawal. CMAJ 160:675-80

Alcohol Withdrawal Delirium

Alcohol withdrawal delirium is also known as • Memory disturbances, amnesia for period of
"delirium tremens" or "the DTs." DTs
• Perceptual disturbances: illusions, delusions and
This condition can be differentiated from alcohol hallucinations, usually of a disturbing nature
withdrawal by the presence of symptoms of • Hallucinations are usually visual but may
delirium (see "Alcohol Withdrawal," previous involve any of the senses; often suggestible (e.g.
section, this chapter). See also Fig 1, this chapter, client may accept imaginary drinks)
for CIWA-Ar scoring. • Restlessness, agitation, irritability, anxiety; may
reach state of panic (or may exhibit opposite
This condition should be regarded as a medical extreme, with psychomotor retardation)
emergency. • Speech disjointed and incoherent at times;
speech may be pressured or retarded
Definition • Sleep-wakefulness cycle disrupted
An acute, potentially life-threatening, organic, • Coarse, irregular tremor, especially of hands
psychotic reaction involving delirium. The cause
• Emotional disturbances: fear, anxiety,
involves the cumulative toxic effects of excessive
depression, anger, euphoria and emotional
alcohol intake and chronic nutritional deficiencies
lability
over an extended period (5-15 years). The most
common precipitating factor is cessation or
• May become self-destructive
reduction in drinking, although the condition may • Seizures (grand mal): always precede the
also result from acute infection or injury, development of delirium
dehydration or emotional trauma in a person who
continues to drink. Management
Assess and stabilize ABC (airway, breathing and
Course circulation) and treat presenting seizures first, as
Onset usually occurs the second or third day after necessary (see "Status Epilepticus (Acute Grand
cessation or reduction in drinking, although it Mal Seizure)," in chapter 8, "Central Nervous
occasionally occurs earlier. System")
Clinical features develop over a short period and Appropriate Consultation

fluctuate over the course of a day. Consult a physician as soon as you are able to do
Exacerbations often occur at night. so.
The condition usually runs its course in 2-5 days Nonpharmacologic Interventions
but may persist for several weeks depending on Hydration and Nutrition
premorbid personality, physical condition, severity • Encourage high fluid intake if client is alert and
of complications, and promptness and airway and gag reflex are patent.
thoroughness of treatment. • Start IV therapy with normal saline, if necessary.
• Adjust rate according to level of hydration.
Signs And Symptoms • Give high-protein, high-carbohydrate, low-fat
• Autonomic hyperactivity: tachycardia, sweating diet (in frequent small meals).
and elevated blood pressure
• Fever may be present Encourage Orientation
• Keep room well lighted to avoid
Delirium misinterpretation of shadows (use a night light
• Clouded consciousness (reduced awareness of after dark).
environment), disorientation, confusion, • Explain to client where he or she is and what is
distractibility happening.

• The presence of a familiar environment or restraints in "Violent or Acutely Agitated

person is often helpful. Psychiatric Clients," above, this chapter).
• Remove dangerous objects.
Decrease Anxiety • Use a calm, firm approach.
• Speak in a calm, firm manner. • Seek assistance if problems arise; even when
• Allow the client some control over environment delirious, the client will often respond to a show
by permitting movement and actions within safe of strength.
limits.
• Offer gentle reassurances and direction; give Pharmacologic Interventions
advance warning of any nursing intervention. Consult a physician for medications which may
• Minimize stimulation in environment (the area include:
should be quiet and uncluttered, away from
outside activities). Sedatives:
diazepam (D class drug), 5-10 mg IV
Hallucinations, Delusions, Illusions or
• Avoid arguing about misperceptions, but also diazepam (C class drug), oral administration
avoid validating or supporting them.
• Gently reassure client of your reality, but don't For hallucinations and delusions:
expect acceptance of this. haloperidol (B class drug), 2-5 mg IM q4-8h prn
• Forewarn client before touching him or her; the +
client may be startled and frightened by your benztropine (B class drug) 1-2mg PO, IM, IV
and
touch and may lash out to protect himself or
herself. thiamine (A class drug), 100 mg IM od for 3 days
• Be aware that the client will respond to
delusions and hallucinations as if they were real. Monitoring and Follow-Up
• Client is often in poor physical condition and
• Avoid low-voiced conversations within earshot
may require treatment of concomitant health
of the client, as he or she may misinterpret them
problems
in a paranoid way. If you are frightened by the
client, seek assistance, as clients are often • Maintain record of vital signs q15min until
sensitive to your fears and anxieties. stable
• Monitor hourly intake and output; care must be
Rest taken not to overload the system
• Provide a calm, quiet environment. • Keep client under careful observation--see
"Violent or Acutely Agitated Psychiatric
• Sedate early; avoid allowing agitation to reach
crisis level. Clients," above, this chapter
• Prohibit visitors other than calming friends or • The client is at risk of impulsive destructive
family members. behavior because of anxiety, impaired judgment
and disorientation
• Sponging and back rubs can be used to induce
relaxation.
Referral
Medevac. Hospitalization is recommended to
Safety
ensure safety and supervision, full medical
• Continuous supervision. management and avoidance of further alcohol
• Restrain physically only when absolutely consumption.
necessary (see information about use of physical

Affective Disorders
Definition Criteria For Major Depression
A disturbance of moods, usually recurrent, in At least one episode of dysphoric mood and/or
which either a full or partial manic episode or a loss of interest or pleasure in all or almost all usual
major depressive syndrome (not due to other activities and pastimes, sufficient to disturb
physical or mental disorder) is present. normal function or to cause distress. Dysphoric
mood is characterized by depression, sadness,
Types hopelessness and irritability. The mood
Bipolar disorder: the full characteristic syndrome, disturbance must be prominent, pervasive and
either mania or depression, is present relatively persistent.
Major depression At least five of the following symptoms present

nearly every day for a period of at least 2 weeks:
Other and atypical affective disorders: the • Change in appetite or weight (increase or
syndrome is only partially present or is atypical in decrease)
terms of severity or duration • Insomnia at any stage of sleep but especially in
• Schizoaffective disorder morning, early awakening
• Dysthymic disorder (depressive neurosis) • Increased sleeping (hypersomnia)
• Seasonal affective disorder • Psychomotor agitation (inability to sit still,
pacing, hand-wringing) or retardation (slowed
Criteria For Manic Episode speech, long pauses before answering, low or
One or more periods of predominantly elevated, monotonous speech, lowed body movements,
expansive or irritable mood (the so-called "high"), decreased amount of speech)
lasting at least 1 week. • Loss of interest or pleasure in sex, decrease in
libido
Presence of three or more of the following signs • Anhedonia - loss of pleasure, decrease in
and symptoms (when not impaired): activities as unable to enjoy
• Hyperactivity, restlessness, excessive • Loss of energy
participation in multiple activities, increased • Wants to cry but can't
activity (work, social, sexual) • Fatigue
• Pressure of speech (unusually talkative and • Feelings of worthlessness, self-reproach, or
apparently unable to control it); speech loud, excessive or inappropriate guilt (may be of
rapid and difficult to interpret delusional nature and proportions)
• Flight of ideas (thoughts racing and changing • Complaints or evidence of diminished ability to
quickly, loose associations) think or concentrate (slowed thinking,
• Inflated self-esteem, grandiosity (may be indecisiveness, can't read a book or follow TV)
delusional) and recurrent thoughts of death, suicidal
• Decreased need for sleep; excessive energy ideation, wishes to be dead or suicide attempt
• Distractibility (evident in speech or activity)
• Poor judgment (e.g. buying sprees, sexual Absence of bizarre behavior and inappropriate
indiscretions, reckless investment, behavior that mood (mood inconsistent with content of
is out of character) delusions or hallucinations).
Neither bizarre behavior nor delusions or Not due to or superimposed on schizophrenia,

hallucinations are present in the premorbid paranoid disorders, organic mental disorder,
condition or after remission. The disorder is not bereavement, infectious disease, hypothyroidism,
due to any organic mental disorder, such as substances such as reserpine, alcohol dependence
substance intoxication (has client just been put on or other chronic mental disorder.
antidepressants?) or multiple sclerosis.

Severity and duration must be sufficient to warrant • The course of bipolar major affective disorders
label of "major" depression, as distinct from more is variable
chronic, less severe, periodic mood disorders (see • Episodes may be separated by many years of
"Dysthymic Disorder (Depressive Neurosis)," normal functioning
below, this section). • Episodes may occur in clusters
• In 20% to 35% of cases there is chronic
Age Considerations in Depression impairment of social and occupational
Prepubertal Children functioning
• Mood disorder may be inferred from behavior • Episodes frequently follow a psychosocial
(withdrawn posture, facial expression) stressor
• Mood should have persisted for 3-4 weeks
• Child may fail to gain expected weight rather History
than losing weight • Client has had one or more manic episodes
• Psychomotor retardation may appear as • Current condition, if depressed, meets criteria
hypoactivity (underactive) for a major depressive episode
• Mood change may appear as apathy, loneliness,
sullenness, irritability, crying Age at Onset
• First manic episode usually occurs before age
Adolescent Children 30, second episodes cluster around age 50
• Negativistic or frankly antisocial behavior may • Major depression may occur at any age,
appear as an equivalent of mood disorder including childhood
• Sulkiness, withdrawal from family and social
activities, and retreat to his or her room are Course of Manic Episodes
frequent • Episodes typically begin suddenly
• Loss of self-confidence, loss of interest, somatic • Rapid escalation over a few days
complaints, and expression of unhappiness or • Duration from a few days to months
hopelessness are common in both adults and • Most individuals experiencing manic episodes
adolescents will eventually have a major depressive episode
• School difficulties are common • Initial episode in bipolar disorder is often manic
• May be particularly sensitive to rejection
Course of Depressive Episodes
Elderly Adults • Onset is variable, often unnoticed
• Disorientation, memory loss, distractibility, • Symptoms develop over a period of days to
apathy and difficulty in concentrating may be weeks but may occur suddenly
signs of dementia or major depression or both
• Prodromal symptoms (anxiety, phobias, mild
• In doubtful cases, treat as depression and depression) may occur over a longer period
consider failure to respond as further evidence of
• Approximately half of all individuals
the alternative diagnosis or consider wrong drug
experiencing a major depressive episode will
and consult.
have a recurrence
Bipolar Disorders Dysthymic Disorder (Depressive
A bipolar disorder is a major effective disorder
that may present as predominantly manic, Neurosis)
predominantly depressed or mixed. Definition
Chronic disturbance of mood involving either
Prevalence depressed mood or loss of interest or pleasure; not
of sufficient severity or duration to meet criteria
• Bipolar disorder occurs in less than 2% of the
for a major depressive episode.
general population
• The sex distribution is equal for bipolar disorder

Prevalence May be superimposed upon or secondary to

• Common, perhaps affecting up to 25% of chronic mental disorder, personality disorder or
general population at some time in their lives to organic mental disorder.
a degree warranting clinical aid
• In adult population, more common in females; History
sex ratio equal in children and adolescents Age at Onset
• Usually begins in early adult life
Criteria for Dysthymic Disorder • May begin at any age
Presence of depressed mood more often than not, • May follow an episode of major depression
with symptoms characteristic of depression
syndrome but not as severe as major depressive Course of Dysthymic Disorder
episode. • Usually no clear onset
• Has a chronic course
Duration of 2 years, relatively persistent or
intermittent, and may be separated by normal Other Disorders In Which Depression
periods lasting up to a few weeks but not more
than a few months at a time. Is Present
Unhappiness, fearfulness and hopelessness can
In children and adolescents, duration of 1 year. appear as symptoms in a number of mental
disorders, as well as in healthy people undergoing
During the periods of depression, at least two of periods of stress. Whether the symptoms constitute
the following symptoms are present: a genuine mental disorder is in part determined by
the severity, duration and resulting degree of
• Insomnia or hypersomnia
impairment.
• Low energy level or chronic tiredness
• Feelings of inadequacy, loss of self-esteem or Uncomplicated Bereavement
self-depreciation
• Signs and symptoms of a full depressive
• Decreased effectiveness or productivity at syndrome may be present
school, work or home
• Guilt, if present, is chiefly about things done or
• Difficulty with concentration or difficulty in not done by the survivor
thinking clearly
• The survivor may wish that he or she had died
• Social withdrawal with the deceased
• Loss of interest in or enjoyment of pleasurable • The survivor regards the depressed mood as
activities normal
• Irritability or excessive anger • The reaction may be delayed but rarely occurs
• Inability to respond with pleasure to praise or later than the first 2 or 3 months after the death
rewards • The duration of "normal" bereavement varies
• Less active than usual; pessimistic, brooding, considerably among different cultural and
feeling sorry for self subcultural groups; abnormally long, intense or
• Fearfulness or crying debilitating bereavement is viewed as such by
• Recurrent thoughts of death or suicide others of the same group
• Morbid preoccupation with worthlessness,
Absence of psychotic features, such as delusions, prolonged and marked functional impairment,
hallucination, incoherence or loosening of thought and marked psychomotor retardation suggest
associations. major depression rather than single bereavement
The depressed mood is clearly distinguishable Management

from the individual's usual mood by virtue of its Describe for the bereaved the frequently observed
intensity or effect on functioning. or expected stages of bereavement: anger, despair,
guilt, depression, acceptance.

Allow time to grieve and do not force acceptance in excess of the normal and expected reaction to
of the death, which may take 1 or 2 years to be the stressor
fully achieved. The person should be permitted • Disturbance is not part of a pattern of such
and even encouraged to talk about the death and disturbances
feelings related to it. • Disturbance eventually remits after the stressor
ceases
Members of the family can be expected to go
through the grieving process at different rates, and Management
will have certain reactions to that fact. They may Supportive counseling, including:
be upset by each other or may attempt to protect • Explanation of the reaction for the individual,
each other from the unhappy feeling. Some stressing its transient nature
members may feel guilt with regard to loving or • Mobilization of natural supports (family,
enjoying other people or having fun while other friends)
members of the family are still grieving. • Encouragement of a realistic sense of
competency
The person may be experiencing guilt over a
• Mobilization of the individual's personal
number of things, including past unresolved
resources and strengths
issues, being a survivor or experiencing
enjoyment. Similarly, anger is a common reaction,
Evaluation of suicide potential (see "Suicidal
because life goes on for others.
Behavior," below, this chapter)
There is a tendency to idealize the deceased
person, which may create problems for other Management Of Affective Disorders
family members, particularly the surviving parent, Manic Phase (Bipolar Disorder)
who may be unfavorably compared with the Nonpharmacologic Interventions
deceased. Management of clients in the manic phase of an
affective disorder is usually difficult, trying and
The bereaved person often becomes suddenly stressful for everyone involved: the client, the
aware of his or her own mortality, which heightens family and the helping professional. Manic clients
any sense of insecurity. seldom have insight into the mood disturbance and
feel better than ever. They resent the idea that they
The bereaved person could be forewarned of the need treatment, particularly any treatment that
"anniversary phenomenon," in which the loss is re- includes bringing them down from the "high" and
experienced 1 year later. This is a normal placing external controls on their movements.
experience and can be used to deal with
unresolved grief in a constructive way. The manic client is usually coerced into attending
a healthcare professional by family or police
The belief systems of the person with respect to officers and is usually hostile, agitated and perhaps
life after death should not be challenged, nor belligerent.
should the person be persuaded toward any
particular belief. The person should simply be The client will attempt to tone down the feelings
supported in his or her beliefs if they provide of excitement and grandiosity in order to appear
comfort and support. normal and will rationalize or deny symptomatic
behavior. The history presented by family or
Adjustment Disorder with Depressed others should be given considerable weight in
Mood making a diagnosis and deciding about treatment
• Identifiable psychosocial stressor occurred and management.
within 3 months of onset of disorder
• Maladaptive reaction consists of impairment of The basis of management is sensitivity and
social or occupational functioning or symptoms firmness. The helping person should be sensitive
to the fact that the client is frightened and will do

almost anything to defend against attacks, whether Consideration might be given to long-term lithium
real or imagined, on his or her self-esteem. maintenance therapy, as this medication is of great
benefit in preventing or dampening future manic
Avoid reacting to the client's defensive assaults. attacks.
The professional should recognize the source of
the client's anger, be concerned and respond Before lithium therapy is started, the following
calmly. Such a response will reassure the client baseline diagnostic tests should be done:
that there is no need to fear counterattack by the • Complete blood count
professional. • Electrolytes
• Renal function
The professional's firmness indicates to the client • Liver function
that external controls will be used if the client is • Thyroid
unable to exercise restraint or is overwhelmed by
• Electrocardiography (ECG) should be done
impulses. The client may respond by testing the
professional's determination. Seek help from the
Occasionally, high doses of medication fail to
RCMP if at all necessary.
settle a highly agitated manic client, and the client
is in danger of physical collapse or poses a danger
In the initial stages of management, it is often
to staff or other patients.
necessary to employ the services of other staff or
police officers, who would be capable of subduing
and restraining the client. Do not hesitate to call
for reinforcements. (See "Violent or Acutely • Follow up weekly until the client is stable, then
Agitated Psychiatric Clients," above, this chapter.) monthly (as symptoms abate, medication doses
can be tapered, often to the point of
discontinuation)
If possible, consult a physician before giving any • Follow-up with regular, widely spaced
medication. appointments allows for working through certain
psychological issues, such as the client's
vulnerability to future episodes and the need for
Medication is essential to control the disordered medication
behavior, to alleviate stress and to treat the • If the client is on long-term lithium therapy,
underlying disorder. Initial treatment is with a blood samples should be taken every 6 months
major tranquilizer: for complete blood count, electrolyte levels, and
lorazepam, 1 mg SL (C class drug) or 2-4 mg IM renal, liver and thyroid function; similarly, ECG,
(D class drug) if available, should be done every 6 months for
these clients
In severe cases, neuroleptic tranquilizers may be • Both the client and the family should be
necessary (but you must consult with a physician educated with regard to bipolar disorder, and the
first): early signals of manic relapse and the course to
haloperidol (B class drug), 0.5-5.0 mg PO bid to take should be fully discussed
tid prn or 2-5 mg IM q4-8h prn
Referral
An antiparkinsonian agent may have to be added • Most manic clients are best treated in the
to counteract extrapyramidal side effects caused relatively controlled and safe environment of the
by the haloperidol. hospital
• Outpatient treatment runs risks arising from the
Treatment with lithium carbonate (B class drug) client's impaired judgment and erratic,
may also be instituted, but the therapeutic effects unpredictable moods and behavior
of this agent do not begin to take hold until after a • Involuntary hospitalization may have to be
week or more of treatment. considered (through the justice of the peace, a
police officer or a physician, if available, for a

"Form 1" admission) and may in fact be the best Sleep medications are rarely indicated, except for
course because of the client's unpredictability short-term use, as insomnia secondary to
and the likelihood of a change of mind after depression usually responds to nighttime
voluntary admission antidepressant medication.
Depressive Phase (Bipolar Disorder and Monitoring and Follow-Up

Major Depressive Disorder) It is customary to continue the prescription of
Appropriate Consultation antidepressants for some 6-9 months after the
Consult a physician for all depressed clients. depressive episode has remitted.
Nonpharmacologic Interventions Medication doses are then tapered gradually, and

The depressed client usually seeks help of his or the medication can be discontinued, provided there
her own accord, perhaps with some coaxing from are no signs of relapse.
family or friends. The client will usually be
cooperative with those in a position to offer relief Some depressive episodes do not remit completely
and escape from misery. Be sensitive to the and the residual milder depressive symptoms can
possibility that the client may, nonetheless, find be treated with longer-term antidepressant therapy.
the experience of needing help quite humbling.
Adolescents are usually especially reluctant Patients with a high rate of relapse may be given
because of fear of what their peers might think or longer-term antidepressant treatment.
the possibility that they are "crazy". Such fears
should be dealt with directly and realistically. Lithium maintenance therapy is effective in many
patients with recurrent depressive disorders.
Milder depressive episodes and "situation" or
"reactive" depression can often be treated without The prescription of medication always occurs in
medication. Treatment of these cases involves the context of a working alliance between the
providing support (professional or otherwise), client and the professional. It does not obviate the
working through conflicts, altering relationships need for support, the resolving of psychological
and developing counter-depressive attitudes and and interpersonal difficulties, and education about
skills. the nature of the affective disorders.

The more depressed client may be unable to Most depressed patients can be managed on an
engage in useful therapeutic work with the treating outpatient basis. The decision to hospitalize will
professional; in this case, medication is indicated. hinge on a variety of factors, including the
Treatment usually begins with selective serotonin following:
re-uptake inhibitors (SSRI) antidepressants • Suicidal tendencies (see "Suicidal Behavior,"
(e.g. paroxetine, fluvoxamine maleate or below, this chapter)
sertraline), to which 70% to 80% of clients will • Degree of functional impairment
have a favorable response. Consult a physician to • Intensity of suffering
order these medications. • Availability of family and community supports
• The nature of the hospital program
The antidepressant effects of these medications • The wishes of the client
often take 3 weeks or longer to become apparent.
These drugs may cause troublesome side effects Dysthymic Disorder
such as nausea, headache and diarrhea. They are Treatment is often lengthy and the results mixed.
the safest of the antidepressants if taken as an
overdose.

Nonpharmacologic Interventions Self-help groups may be useful for dysthymic

The thrust of treatment will be psychotherapeutic. clients for learning how to cope and for the
Insight-oriented, psycho-educative, supportive and support provided by other members.
behavioral approaches are most frequently used.
Behavioral treatment is usually aimed at the
The client should be encouraged to look at self- specific behavioral variables affecting depressive
defeating, depressogenic patterns of behavior and symptoms, particularly the behaviors that are
the anxieties, guilt and anger associated with them. currently punished (e.g. ignored or coercively
controlled) and those that are reinforced or
Clients may be taught to be assertive rather than encouraged (e.g. well-meaning attention
controlling in passive ways and to confront rather inadvertently supporting depressive symptoms).
than avoid frightening or personally threatening
situations. The sense of mastery and the Some possible causes for depression and examples
experience of positive feelings and gratification of behavioral treatment responses are given in
counter the depressive feelings. Table 1 to illustrate some of the possibilities of
outpatient treatment of depression.
Table 1: Causes of Depression and Behavioral Treatment in Dysthymic Disorders

Problem Treatment
Inability or reluctance xpress one’s opinions or to Assertiveness training
initiate suggestion
Indecision, poor planning, poor coping strategies Decision-making and problem-solving skills
Unrewarding social interactions, anxiety about social Social skills training, relaxation training
contact, social withdrawal
Marital problems, coercive control by spouse Marital counseling, communication skills training,
assertiveness training
Rumination over past events, negative self- Cognitive self-control, “thought-stopping’ techniques
evaluation, worry
Feeling of helplessness, that there is no use trying Retraining in mastery and personal effectiveness strategies
Lack of enjoyment, gradual loss of interest “Reinforcement sampling”, re-exposure to potentially
rewarding activities, increasing pleasant activities
Loss of behavioral productivity Performance of graduated tasks, planning or rewards for
successful performance
Pharmacologic Interventions A considerable proportion of dysthymic clients

Dysthymic clients may respond to antidepressant become psychologically dependent on their
medication (especially SSRIs, as outlined above), medications. Thus, medications should be used
but the response is less predictable and less judiciously, and efforts should be made
complete than in major depressive disorder. If periodically to discontinue them.
symptoms intensify, a trial of medication may be
indicated. Monitoring and Follow-Up
Regular follow-up is important, to monitor
Minor tranquilizers (e.g. lorazepam) may be
progress in behavioral changes and to offer
prescribed by the physician for very brief periods
encouragement and support.
(7-10 days) from time to time to counter
associated anxiety, panic or phobic symptoms and
the avoidance and withdrawal that they engender. Referral
Refer to a physician for follow-up as needed,
especially if the client is on medication or there is
no response to treatment after a reasonable trial.

Psychotic Disorders
General • Catatonic type
Psychosis can present as delusions, hallucinations, • Paranoid type
disorganized speech, bizarre behavior, catatonia,
withdrawal and downward social drift. History and Physical Findings
The typical client will present in an excited,
The psychotic episode may be an accompanying agitated state, often with fearfulness or hostility,
symptom of underlying psychiatric illness of hallucinations and delusions, confusion and
which mania, depression and schizophrenia are the disorganization, vigilance and over-activity. Mood
most common. is often labile and behavior unpredictable.
Other psychotic disorders include delusional First, assess for medical conditions that might
disorder, brief psychotic disorder and account for the symptoms and any accompanying
schizoaffective disorder. delirium or dementia.
Schizophrenia Ascertain the role of any substance use

Schizophrenia is the most common chronic (intoxication or withdrawal) or medication.
psychotic disorder, with a lifetime prevalence of
0.5% to 1%, occurring equally among men and Characteristic Symptoms
women. Onset is usually in adolescence or young Content of Thought (Delusions and
adulthood. A higher prevalence is noted among Preoccupation)
family members of people with schizophrenia, and • Persecutory: beliefs that others are spying on,
there is a higher concordance rate in monozygotic plotting against or spreading rumors about the
than dizygotic twins. Although genetic factors are person
involved, nongenetic factors are thought to be • Delusions of reference: events or objects are
important. given peculiar and unusual significance, such as
believing that the radio announcer is directing
The condition may present with insidious onset, or comments to the individual personally
onset may seem sudden, with an acute psychotic • Thought broadcasting: belief that one's thoughts
break; however, prodromal symptoms are often are broadcast to the external world
identified retrospectively. • Thought insertion: belief that thoughts that are
not one's own are being inserted into one's head
Essential Features • Delusions of being controlled: belief that one's
• Presence of certain psychotic features with feelings, impulses or actions are being imposed
characteristic symptoms involving multiple from external sources
psychological processes • Other somatic, grandiose, religious or nihilistic
• Deterioration from a previous level of delusions; markedly illogical thinking; or
functioning preoccupation with certain ideas
• Onset before age 45
• Duration of at least 6 months Form of Thought (Formal Thought Disorder)
• Loosening of associations: ideas shift from one
Types of Schizophrenic Disorders unrelated thought to another
Schizophrenic disorders with overt psychotic • Speech may be incoherent and incomprehensible
features are currently differentiated into several • Speech may be vague, overly abstract, overly
types based on the predominant symptoms. Of concrete, repetitive or stereotyped
these, three are most distinctive and are classically • New words (neologisms) may be created, ideas
described: may be repeated as if the person is stuck on one
• Disorganized type (also know as hebephrenic track (perservation), train of speech may be
type) interrupted (blocking) or sounds rather than

meaningful concepts may govern word choice, Psychomotor Behavior

which results in meaningless rhyming or • Observed especially in chronically severe and
punning ("clanging"). actively florid forms
• Catatonic posturing: rigid, bizarre posturing
Perception • Catatonic excitement: purposeless, stereotyped,
• Auditory hallucinations: the most common form; excited movement unrelated to external stimuli
usually of voices speaking directly to the • Catatonic stupor: client appears unaware of the
individual and occasionally giving commands, environment
which may create danger for the individual or • Catatonic negativism: client actively counteracts
others or resists instructions or attempts to be moved
• Tactile hallucinations: typically involve • Mannerisms, grimacing or waxy flexibility
electrical, tingling or burning sensations (remains passively in any position in which he
• Somatic hallucination: sensation of snakes or or she is placed)
insects crawling inside the abdomen or other
bizarre internal sensations Criteria for Schizophrenic Disorder
• Visual, gustatory and olfactory hallucination: • At least two of the following during active phase
such hallucinations may occur in schizophrenia, of the disorder (lasting at least 1 month):
but in the absence of auditory hallucinations, • Delusions: this alone will suffice for the
they raise the possibility of organic mental diagnosis if delusions are bizarre (somatic,
disorder grandiose, religious, nihilistic, persecutory or
jealous)
Affect
• Hallucinations: this alone will suffice for the
• Blunting of affect: severe reduction of intensity diagnosis if hallucinations include voices,
of emotional expression speaking to one another or providing
• Flattening: virtually no signs of affective commentary
expression • Disorganized speech: incoherence, marked
• Inappropriate affect: affect and speech or loosening of associations, markedly illogical
ideation are discordant • Catatonic or grossly disorganized behavior.
• Negative symptoms (ambivalence, flattened
Sense of Self
affect, avolition, anhedonia, asociality, apathy)
• "Loss of boundaries": extreme confusion about • Deterioration from previous level of functioning
one's identity and the meaning of existence
in such areas as work, social relations and self-
• May be manifested in delusions of control by care
outside force
• Duration of disturbance of at least 6 months,
with 1 month of active phase, at some time
Volition
during the person's life
• Inadequate interest or drive • Onset before age 45 years
• Inability to follow a course of action to its • Not due to an organic mental disorder or mental
conclusion retardation, mood disorder, substance use or
• Extreme ambivalence about alternative courses medical condition
of action, which leads to inaction • Symptoms occurring before (prodromal) and
after (residual) the active phase of the illness
Relationship to External World should be considered in calculating the duration
• Withdrawal from involvement with external of the disorder:
world • social isolation or withdrawal
• Preoccupation with egocentric and illogical • marked impairment in role functioning as
ideas and fantasies (client "living in his or her wage-earner, student or homemaker
own world")
• markedly peculiar behavior (e.g. collecting
• Emotional detachment garbage, hoarding food)

• marked impairment in personal hygiene and entail the use of physical restraint. In many
grooming instances, a show of force, for example, by having
• speech digressive, vague, over-elaborate, police or security officers present, will settle the
circumstantial (not getting to the point) or client sufficiently so that physical means of
metaphorical control need not be used.
• odd or bizarre ideas, magical thinking, ideas of
reference, over-valuing one's importance Care must be taken to avoid exacerbating the
• unusual perceptual experiences (e.g. sensing situation by failing to give the excited client
the presence of a force or person not actually enough physical and psychological room
present) (especially if he or she is suspicious or paranoid).
Thus, noise should be minimized. Eye contact may
Course be disturbing, as it may be interpreted as
• Active phase usually preceded by a prodromal threatening or aggressive. You should maintain a
considerable physical distance to avoid being
phase (anxiety, phobias, mild depression);
change in personality often noted by friends and struck and also to appear less threatening to the
relatives; length of prodromal stage highly frightened client. Questions asked should not be
variable, and prognosis worse for the slowly probing, and sensitive areas, if identifiable from
developing disorder previous background history, should be avoided.
Delusion should not be challenged or supported.
• Onset of active phase often precipitated by a
psychosocial disorder
If the excited, psychotic client appears on the
• Residual phase usually follows active phase; verge of violence or escape, you should not
clinical picture resembles prodromal phase, obstruct the escape route or end up in an enclosed
although some of the psychotic symptoms may space alone with the client. It is preferable to allow
persist the client to bolt than to risk being assaulted. (See
• Return to premorbid functioning is unusual, and also "Violent or Acutely Agitated Psychiatric
acute exacerbations with increasing residual Clients," above, this chapter.)
impairment between episodes is common
Differential Diagnosis Medication is indispensable in the treatment of
• Affective disorders (mania and depression) acute psychosis and the long-term management of
• Organic or toxic psychosis (induced by drugs or schizophrenia; it is used to control disordered
medical illness) behavior, to provide symptomatic relief and as a
specific treatment of the disorder.
Management of Acute Psychotic State
The acutely psychotic or delirious client should be If possible, before starting medications, do
admitted to a room that can be readily observed baseline ECG, complete blood count and liver
but that has minimal noise and light stimulation. function testing (LFT).
Treat medical conditions or substance withdrawal Consult a physician before initiating medication.
as necessary.
Acute treatment is initiated with major
Appropriate Consultation tranquilizers such as haloperidol (high potency) or
Consult a physician before initiating any loxapine (intermediate potency), often in
medications. combination with a benzodiazepine, such as
lorazepam.
Start by ensuring your own safety, the safety of Side effects of the major tranquilizers are
other clients and staff, and the safety of the orthostatic hypotension, dry mouth, blurred vision,
affected client. This is done by establishing firm constipation, drowsiness and several
control of the situation as soon as possible; it may extrapyramidal side effects.

Monitoring and Follow-Up Involuntary Admission

Client should be monitored regularly for mental Legal requirements must be met before a person
status (orientation, presence of psychotic can be hospitalized against his or her will. You
symptoms, mood disorders, suicidal ideation), must refer to the Mental Health Act, NWT (1988).
functional status, self-care, nutrition and side
effects of medications (akathisia, dizziness, • In most cases there must be evidence of risk of
sedation, signs of parkinsonism, tardive dyskinesia physical harm before an unwilling person can be
and orthostatic hypotension). admitted. The recommendation of one or more
physicians is required.
Referral • In most areas, involuntary admissions are
Almost all acutely psychotic patients will need reviewed by a review or appeal board.
hospitalization, and sometimes this must be • In communities where there are few doctors,
accomplished on an involuntary basis. Sometimes relatives or other concerned individuals may be
hospitalization can be avoided, especially if the able to apply for a warrant to have the person
client has solid family and community supports taken into custody and assessed at the nearest
and under circumstances where the staff members hospital. Evidence for such an application is
know the client well and are familiar with his or usually heard by a justice of the peace or a
her particular disorder and the natural course of magistrate.
previous relapses and remissions. • Involuntary admission may be avoided if the
client's family is able to demonstrate solidarity
Hospitalization and Medical Evacuation and strength in trying to convince the client to
The decision as to whether to admit the client to a enter voluntarily. The family must, of course, be
local hospital, treat the client on an outpatient well informed and genuinely convinced
basis or evacuate the client to a psychiatric beforehand of the need for hospitalization.
hospital depends on a number of factors and • The client or guardian should be advised of the
should, of course, be taken in consultation with the procedures involved in involuntary admission,
best qualified available physician, preferably a as well as the client's legal rights and appeal
psychiatrist. The following should be considered: provisions.
• Is this the first known psychotic episode? How Long-Term Maintenance and
certain is the diagnosis? Is there a need for close
Rehabilitation of the Stabilized
observation and monitoring?
• How competent are the local medical and non- Schizophrenic Patient
medical resources to deal with schizophrenia Pharmacologic Interventions
and with this client in particular? How available For a considerable number of clients, the long-
is psychiatric consultation, if it is required? term use of major tranquilizers is necessary to
afford the chance of a stable partial or full
• How dangerous, frightened or unpredictable is
remission. However, because some schizophrenic
the client now or has he or she been in the past?
clients may remain well for years, or even
How compliant with directions and medication?
indefinitely, without medication, and because
• Is the client in need of shelter? To what extent is vulnerability to relapse cannot be predicted after
the family disrupted by the client? Would it be
one episode, medication should be tapered and, if
dangerous or disruptive to return the client to the
possible, discontinued in fully remitted patients
family?
after a first psychotic break.
Whether the client enters hospital voluntarily or
The maintenance dose should be the lowest dose
involuntarily, it is very important that the family
that prevents relapse. Discovering this dosage is
be kept informed of his or her progress and that
usually a matter of long-term, careful follow-up
they maintain as close contact with the client as
and monitoring - a collaborative effort involving
possible.
the client, the nurse practitioner and the physician.

Although the typical neuroleptic medications are Parkinsonian Side Effects

often effective in suppressing the florid signs Muscle rigidity, tremor, facial masking, drooling
(so-called "positive symptoms"), the negative and loss of associated movements.
symptoms (such as lack of initiative, flatness of
affect and poverty of ideas) are more difficult to Treatment involves reducing the medication
control and often require the newer atypical dosage and/or administering oral antiparkinsonian
neuroleptics (e.g. risperidone, clozapine, agents such as benztropine, which may be
olanzapine). prescribed in doses of 1-8 mg/day.
Many clients are less than fully compliant. Relapse Akathisia

thought to be due to inadequate doses of Inner restlessness, which can be excruciatingly
medication may, in fact, result from the client not distressing and which only sometimes is
having taken the medications as prescribed. To manifested in outward restless movements. This
some extent, compliance problems can be side effect, which can only be alleviated in the
alleviated by using long-acting injectable major same manner as the parkinsonian side effects, is
tranquilizers such as fluphenazine enanthate and sometimes mistaken for agitation due to the
fluphenazine decanoate, the effects of which last increasing schizophrenic disorder. It can increase
about 2 and 3 weeks, respectively. risk of suicide.
A serious and often irreversible side effect of long- Monitoring and Follow-Up
term tranquilization is tardive dyskinesia, a For about two-thirds of clients experiencing an
neurological condition characterized by the acute psychotic episode requiring hospitalization,
gradual appearance of involuntary movement. treatment will be a life-long proposition. Return to
These movements usually involve facial normal is unusual, and usually the schizophrenic
musculature and appear as lip-smacking, chewing, person remains disabled in one way or another and
sucking and tongue-thrusting. At times, the requires long-term rehabilitation and supportive
extremities, limbs and trunk may be involved. care.
Upon appearance of these signs, consideration Visits should be regular and frequent to prevent re-
must be given to reducing dosages of, or even hospitalization and to monitor drug compliance,
discontinuing, the medication. Unfortunately, this effectiveness and side effects. After an acute
is often not possible without the client relapsing episode, there is a 70% chance of relapse within 1
into psychosis. Anti-parkinsonian agents are of no year if the patient is not taking medication, but
value in this condition and no single effective only a 30% chance if the medication regimen is
remedy has been found to date. being followed. The nurse is often in the best
position to monitor compliance and drug
The side effects of medication for schizophrenia effectiveness and even to provide the primary
include acute dystonic reaction, parkinsonian side therapy under the direction of a consulting
effects and akathisia. psychiatrist.
Acute Dystonic Reaction Frequent, regular contacts are invaluable in

Moderate to severe muscle spasms, usually of the preventing re-admission to hospital.
neck (causing tilting of the head), back muscles
(causing arching), and tongue or eye. These often The client should be assisted to engage in active
dramatic and frightening effects are easily social programs, to combat the tendency to
reversed. withdraw.
Asses and stabilize ABC (airway, breathing and The client should be assisted to make use of
circulation). Consult a physician about use of: educational, employment, training and recreational
benztropine (B class drug), 2 mg IM opportunities. Advice and assistance may also be

required with respect to housing, financial families where there is a high degree of critical
assistance, legal matters and other social services. emotional expression.
• Help the family to recognize the early warning
In the early stages of recovery, the client may need signs of relapse (especially increased social
close supervision, such as that provided in isolation, moodiness, difficulty thinking or
sheltered workshops (vocational), transition homes sleeping, increased irritability or the return of
and day hospitals or day-care programs. symptoms previously in remission).
• Advise the family to encourage the patient to be
Personal Counseling self-sufficient by doing as much as possible for
The schizophrenic client will likely experience a himself or herself. It is never easy to determine
number of stresses and problems directly or just what the client is capable of doing, and
indirectly related to the disorder, for which judicious trial and error, with constant alertness
personal counseling is desirable: to signs of stress, is perhaps the only way.
• Sexual dysfunction may be a side effect of the • Calm the family's fears with regard to the client,
medications and may present as decreased libido and discuss with them any feelings of guilt or
or cessation of menstruation. shame they might experience. Give them the
• Courtship: the client may experience severe facts with regard to the causes of the disorder.
interpersonal anxiety and need social skills Encourage patience with respect to the client's
training and counseling in this regard. anger or depression.
• Genetic risk: genetic counseling and planning • Help family members to achieve a realistic
for parenthood may be appropriate. understanding of the disorder so that they are
• Family adjustment: the client may need help in neither unrealistically optimistic nor despairing.
dealing with problems with other family They in turn can help the client with accepting
members, since these problems are often a direct the limitations imposed by the disorder (e.g. on
result of the client's symptoms and may be long- education, marriage, self-sufficiency).
standing. • Have the family assist and encourage the client
• Self-care: the client may need help and to attend treatment sessions or other social
supervision with regard to personal hygiene, appointments.
grooming, nutrition, financial management and • Emphasize the importance of keeping the client
purchases. socially active.
• Interpersonal difficulties: the client may require • Prepare the family for what will happen if the
marital or family counseling, divorce client has to be hospitalized locally or evacuated
counseling, or counseling and social skills for treatment.
training with regard to getting along with friends • The family itself may require some counseling
and acquaintances. because of the stresses of the illness, the
caretaker role and the embarrassment
Family Support experienced by family members.
• Educate the family on the nature of • Where no family is available to provide support,
schizophrenia, the cause of the disorder, its volunteers or professional caregivers (e.g. group
treatments, and the family's role in supporting or boarding home supervisors) might be
and managing the client at home or in the encouraged to play a similar role.
community.
• Advise family members about how to behave In larger communities, schizophrenic patients have
toward the patient, how to deal with the client's formed self-help groups. Although this may not be
thought disorders and paranoid thinking, how to practical in a small community, such groups may
remotivate and encourage the client, and how to be able to provide resource material and ideas that
respond to bizarre behavior and withdrawal. could be applied in the care and self-care of a
• Caution family members against talking about small number of clients.
the client in his or her presence and to avoid
being critical. The prognosis is poorer in

Anxiety Disorders
Definition • Techniques and strategies to alleviate anxiety
Subjective experience of fear, foreboding or panic. (e.g. chemical substances used or abused)
Distinguished from "normal" anxiety by its • Associated thoughts or behaviors intrusive?
intensity or duration or the extent of disturbance • Review use of caffeine, any other stimulants,
and dysfunction in the absence of an appropriate any recreational drug use
stimulus. Symptoms may be present as a • Review current medications, any over-the-
generalized pattern or in discrete periods counter (OTC) or herbal drugs
("attacks"), which may or may not be preceded by • Review for symptoms consistent with
a triggering stimulus. Condition may present as underlying medical illnesses
"stress" (client not coping or functioning as well as • Review past medical and past psychiatric history
usual), a mood disorder, a substance use problem,
or one or more somatic complaints.
• Mental status exam: emphasis on survey for
History depression; explore for any suicidal or homicidal
Symptoms appear in three clusters: emotional, feelings or plans; explore whether client is
physiologic and cognitive. victim of abuse (if so, take steps to ensure
client's safety)
Emotional • Cardiorespiratory exam
• Sense of doom • Thyroid and other exams as indicated by history
• Apprehension
• Fearfulness Differential Diagnosis
• Worry • Anxiety disorders: generalized anxiety, panic
disorder with or without agoraphobia, social
Physiologic phobia, specific phobia, obsessive-compulsive
• General: insomnia, fatigue, weight loss disorder, post-traumatic stress disorder,
• CNS: tremor, muscle aches, headaches, adjustment disorder with anxiety (< 6 months in
dizziness, lightheadedness, parasthesias duration)
• Autonomic: sweating, dry mouth, increased • Other psychiatric disorders: depression,
heart rate, flushing somatization, hypochondrias, personality
• Gastrointestinal: stomach upset, diarrhea, disorders, victim of abuse (physical, sexual or
anorexia, choking emotional), psychosis, dementia
• Cardiorespiratory: shortness of breath, • Medical disorder: endocrine (hyperthyroidism,
hyperventilation, chest pain, palpitations hypoglycemia, Cushing's disease),
cardiorespiratory (e.g. congestive heart failure
Cognitive [CHF], cardiac arrhythmia, mitral valve
• Poor concentration prolapse, chronic obstructive pulmonary disease
• Poor memory [COPD], pulmonary embolism, among others)
• Recurrent intrusive thoughts • Substance use or withdrawal: especially
caffeine, alcohol, cannabis, cocaine,
Other Aspects of History amphetamines, but any medication may be
• Age at onset, pattern over time responsible
• Symptoms experienced, onset, triggers
(environment, situation, stimulus), duration, Comorbidity is common, so actively pursue
severity, associated avoidance behavior, level of depression, substance abuse, somatization.
distress, dysfunction and limitations
• Life events or stressors that may correlate
temporally with onset

Complications a benzodiazepine (minor tranquilizer) may be

• Inability to perform activities of daily living indicated
• Social phobias
• Substance abuse Nonpharmacologic Interventions
• Have the client reduce the use of stimulants,
Diagnostic Tests especially caffeine
• Complete blood count • Help the client to reduce self-medicating with
• Electrocardiography (ECG) non-prescribed drugs, if applicable
• Thyroid-stimulating hormone (TSH) • Review techniques to promote relaxation:
breathing exercises, meditation, progressive
muscle relaxation, aerobic exercise
Management
Depending on the type of anxiety disorder,
definitive treatment may involve psychotherapy,
lorazepam (C class drug), 0.5-1.0 mg PO bid to
desensitization therapy and medications.
tid prn for 5 days
Benzodiazepines, tricyclic antidepressants, SSRIs
and occasionally neuroleptics may each have a
role.
• Follow up weekly
Appropriate Consultation • Support and education about the illness process
Consult physician: for the client as well as for the family are critical
• If there are any safety concerns • Arrange follow-up with physician at next
• If an underlying medical problem is suspected, available visit for all but very severe cases
since management will need to be tailored for
the diagnosis Referral
Medevac urgently if there is profound disturbance,
• If symptoms are so intense as to interfere with
if there are safety issues or if the client needs more
normal function, in which case a short course of
definitive treatment.

Cognitive Impairment
Definitions History
• Dementia: syndrome of acquired progressive Elicit the history from the client, but it is just as
global impairment of cognitive function important to elicit corroborating information from
sufficient to interfere with normal activities a caregiver, friend or the family.
(may be due to an underlying reversible or • Client may present complaining of memory
irreversible process) problems, problems with attention or focus, or
• Delirium: acute deterioration of ability to concentration difficulties
maintain attention or focus, consequently • More often, a caregiver or family member
accompanied by disorientation and fluctuating accompanies the client, having noticed the
level of consciousness and often associated with client's difficulties with tasks that previously
perceptual disturbances; usually due to an were not a problem (e.g. self-care, home care,
underlying organic problem shopping, finances)
• May present with concerns of inappropriate or
Delirium and dementia are both syndromes with bizarre behavior, because of delusions and
large differential diagnoses for underlying causes. hallucinations
More than one factor may be involved. • May present because of accompanying
depression or anxiety
These conditions are commonly seen in but are not • Determine onset of symptoms and temporal
limited to the elderly. course
• Record symptoms noted, objective behaviors
Causes observed
Reversible Causes • Elicit degree of disturbance and dysfunction (ask
• Medications about specifics, such as shopping, driving, self-
• Metabolic derangements (e.g. blood glucose, care, handling of money, work performance or
sodium, potassium, calcium, vitamin B12 hobbies, as applicable; also inquire about ability
deficiency; thyroid, renal or liver impairment) to learn a new task)
• Hypoxia from cardiopulmonary illness
• Intracranial pathology (e.g. neoplasm, normal- Symptoms Associated with Underlying
pressure hydrocephalus, infection, subdural Medical Disorders
hematoma, stroke) • Constitutional: fevers, sweats, weight loss,
• Sensory deficit states (e.g. hearing or visual fatigue
impairment) • Sensory: vision, hearing changes
• Infections (e.g. urinary tract infection, • Neurologic: new headache, tremor, ataxia,
pneumonia) dizziness, seizure, focal deficits, transient
ischemic attack (TIA)
Irreversible Causes • Endocrine: symptoms of thyroid problems,
• Alzheimer's disease diabetes mellitus, hypercalcemia
• Vascular (multi-infarct) dementia • Cardiopulmonary: shortness of breath, cough,
• Chronic alcohol abuse chest pain, sleep apnea, palpitations
• Parkinson's disease • Gastrointestinal and genitourinary symptoms: as
• Huntington's disease deemed necessary (it is important to inquire
• Head trauma about incontinence)
• Neoplasm
Risk Factors and Past Medical History
• Trauma
• Falls
• Alcohol or benzodiazepine use

• Risk factors for cerebrovascular accident Differential Diagnosis

• Occupational exposure • Dementia
• Sexual exposure • Delirium
• Previous history of cancer • Depression
• Anticoagulation or antithrombotic medication • Age-related memory or cognitive decline
• Nutrition • Substance use or abuse, medications
• Borderline intellectual function, mental
Medication retardation
• OTC or otherwise acquired drug or remedy • Other psychiatric disorders: psychotic, amnestic
or dissociative
Psychiatric Assessment
• Assess for mood, anhedonia, hopelessness, Delirium, dementia and depression can be difficult
apathy, vegetative symptoms of depression to distinguish.
• Inquire about suicidal tendency
• Assess for psychotic symptoms (e.g. thought Depression in the elderly is often referred to as
disorder, delusions, hallucinations) pseudodementia because the accompanying apathy
• Assess for psychosocial stressors (e.g. losses, and associated cognitive difficulties often mimic
abuse or neglect) dementia.
• Observe speech, affect, mannerisms, grooming,
psychomotor skills Diagnostic Tests
Unless the underlying cause is obvious, blood
Mental Status Examination should be drawn for the following tests:
• Most widely used tool is Folstein's Mini Mental • Complete blood count
Status Examination • Electrolytes
• Most sensitive items for dementia are impaired • Calcium
time orientation, problems with naming, • TSH
inability to spell "world” backwards, and • Blood glucose
problems with copying an overlapping design
• Having the client draw a clock representing a Other investigations will be driven by the history
certain time is also helpful and presentation.
• Assessing judgment, by asking the person to
interpret hypothetical situations (e.g. waking to Management
find the house on fire) is also helpful Management is ultimately driven by the diagnosis.
Physical Examination Goals of Treatment

The physical exam is directed by the differential • Identify and correct reversible causes
diagnosis, as generated by the history, but must • Ensure safety of the client
include the following: • Optimize functioning and quality of life
• Vital signs
• Hearing and vision assessments (including Appropriate Consultation
fundi) Consult a physician if client is assessed as
• Cardiovascular and pulmonary exam (note delirious or in acute distress, if there are
carotid bruits, evidence of atherosclerotic unexplained new neurologic symptoms or focal
disease) deficits, or if there are risk factors for serious
• Full neurologic exam, noting especially tremor, intracranial pathology (e.g. anticoagulant
cogwheeling rigidity, shuffling gait, deep tendon medication, history of trauma, previous cancer).
reflexes, focal deficits in sensory and motor
function, aphasia


• Educate and support caregivers and family Follow up regularly (e.g. monthly or more often as
• Encourage measures to ensure safety, and aid necessary), preferably on a home visit, to enable
the client in optimal functioning and you to assess the client functioning in his or her
independence own environment.
• Mobilize available community resources such as
home care, friendly visitors Arrange for all clients with non-urgent symptoms
to see the physician at the next available visit.
If agitation or behavioral issues are the concern,
manage according to guidelines in "Violent or Referral
Acutely Agitated Psychiatric Clients," above, this Medevac may be necessary for clients with
chapter. potential underlying organic pathology or if the
risk-safety assessment requires that client be
Pharmacologic Interventions admitted to hospital (i.e. adequate supervision and
If at all possible, do not medicate. In particular, a safe environment with family or friends not
avoid sedation, as it may cause falls and worsen otherwise possible).
symptoms of impairment.

Suicidal Behavior
General Information friend or relative, financial distress, chronic or
• The suicide rate has remained relatively constant incurable illness, and interpersonal conflict and
for the total Canadian population over the last disappointments.
decade. • Lack of social support: Absence of supportive
• The average suicide rate among First Nations and caring friends and relatives; a sense of
and Inuit people is more than twice the rate for isolation and the feeling that nobody cares or
Canadians as a whole, or more. understands.
• Suicides are increasing among young people and • Presence of models: Suicides among relatives,
teenagers, and suicide is now the second most friends or acquaintances and publicity about
frequent cause of death among Canadian males recent suicides; this factor can also influence the
between 15 and 30 years of age. means by which suicide is attempted. This
• The age-specific suicide rate for young First affects everybody.
Nations and Inuit males is several times the • Expectations: Helplessness, pessimism and
national average for this age group. feelings of worthlessness; the impression that
• Males are more likely to complete a suicide than others would be better off if the person were
females. dead; and a sense of powerlessness and lack of
• More females than males are treated for suicide control in the person's life.
attempts. • Attention to gestures: Inadvertent reinforcement
• For every successful suicide, there are several or encouragement of suicidal behavior by
unsuccessful attempts (estimates are that there attending exclusively or primarily to the suicidal
may be 50 times as many unsuccessful attempts behavior itself (threats, gestures or attempts).
as successful ones). • Availability of lethal means: Presence of or easy
• Most people who commit suicide give warning access to guns, drugs or other instruments that
either verbally or through changes in their are "conventional" means of suicide in the
behavior. experience of the individual (e.g. through
common knowledge, media depiction or
• Many have seen a healthcare provider within the
personal knowledge of suicides or attempts by
previous month.
other).Suicide is often an impulsive act; easy
• The strongest predictor of suicide is psychiatric
access to means increases the likelihood of
illness.
completing the act.
• Firearms and hanging are most often used in
• Any loss (real or imagined): Especially if the
completed suicides.
loss results in diminished self-esteem or self-
• Suicide is a highly variable and rare event, and confidence.
accurate prediction is almost impossible.
• Suicide is not significantly influenced by
Characteristics Associated With
seasonal, meteorological, cosmic or other
environmental factors. Suicidal Risk
• Alcohol use is implicated in most suicides, • Presence of a suicide plan, with reasonable and
either at the time of the suicide or in terms of available means
chronic abuse. • Living alone, particularly if socially isolated and
• There is no evidence that "crisis lines" in if few family resources or other social supports
themselves, without back-up and professional are available
attention, significantly reduce suicide rates in • Marital status: separated, widowed or divorced,
their service areas. common-law or single
• Age: risk increases with age, especially among
the elderly, but there has also been a recent
Factors Promoting Suicidal Behavior increase in risk among young males, and is
• Negative life events: Personal stressors such as highest in those 15-25 years of age
unemployment, domestic problems, death of a
• Gender: male

• Race: Caucasian, Aboriginal neglect of personal appearance, and change in

• Preoccupation with feelings of hopelessness, behavior or personality.
helplessness and negative expectations for the
future Factors Promoting Adolescent Suicide
• Previous attempt or threat • Loss of love object or significant person
• Death of parent while subject was a child • Identification with deceased parent
• Poor physical health (e.g. acute or chronic • Identification with a living person who is
condition, terminal illness) expressing depressed or suicidal ideas
• Heavy alcohol or other substance use • Parental rejection and hostility or disparagement
• Psychiatric illness, especially depression or of the child
schizophrenia • Use of alcohol or drugs
• Recent separation from a loved one (e.g. • Chronic social isolation
bereavement) • Inability to express rage or respond to
• Unemployment disappointment and loss; wish to retaliate
• Poor impulse control • Long-standing history of problems
• Current state of feeling hopeless and helpless
Assessment Of Present Risk
• See general characteristics (preceding section) Guidelines For Interviewing Suicidal
• Severe feelings of hopelessness, despair, Clients
emptiness or worthlessness • Establish supportive, trusting, calming and non-
• Severe insomnia judgmental relationship. Reassure the client that
• Agitation and restlessness you will respect his or her confidentiality.
• Depression or schizophrenia; diminished grasp • Interview the client alone, at least initially, and
of reality allow him or her to talk freely and for as long as
• Recent suicide attempt desired.
• Manner of previous attempt; client's expectation • Determine level of risk on basis of factors and
of lethality of attempt characteristics described above.
• Voices telling subject to harm self • Assess adequacy of social supports, as well as
• Desire to make active suicide attempt strengths and weaknesses of the family.
• Preoccupation with suicide • Assess for depression or other mental illness.
• Actual preparation for contemplated attempt • Ask directly about suicidal thoughts, intent and
fantasies.
Child And Adolescent Suicide • If suicidal thoughts are present, inquire about
• Suicide is rare among children < 14 years of age plans and how completely they and their
but has increased significantly among older consequences have been thought through; ask
adolescent males and is now the second most also about wills, farewell notes, giveaways.
common cause of death in this age group. • Evaluate your own reaction and trust "intuitive"
• Suicide threats, gestures or attempts are most feelings about the client's intent.
often efforts to communicate despair, frustration • Explore the motives for suicide. Try to gain an
and unhappiness and should be responded to as understanding of how the situation is perceived
such. by the client (e.g. no other options, escaping life,
• Boys succeed more often because of their use of manipulating a situation, trying to cause change
more lethal methods. in or trying to hurt another, plea for attention or
help, wishing to join a deceased loved one). Try
• Most youngsters who attempt suicide talk about
to find a reason to live.
it with at least one person before the attempt.
• Do not try to talk the person out of suicide or
• Non-specific behavioral clues include anorexia,
convince him or her that things are really not so
psychosomatic complaints, rebellious behavior,
bad. These efforts may only firm the person's
resolve.

• Interview significant others such as spouse, • Offer assistance in making referrals to mental
parents and siblings. health or social service personnel, as indicated
by the circumstances.
Guidelines For Management • Treatment for children and adolescents will
Threatened or Suspected Intent ultimately involve a family intervention plus
• If intent is serious and imminent, admit to a individual treatment of the child aimed at
medical facility for observation and treatment if enhancing self-esteem and sense of importance
possible. in the family or social environment.
• Consult mental health personnel, preferably a • Treatment of an adult will consist of individual
psychiatrist, or staff on psychiatric unit at counseling appropriate to the presumed cause of
Stanton Territorial Hospital, by telephone or the problem and usually will also involve family
make direct referral if resources are locally members and various health and social service
available. professionals.
• If risk is high and client is uncooperative with • Long-term treatment in all cases should be done
treatment efforts, consider compulsory detention by, or under the direction or supervision of, a
under the Mental Health Act competent mental health professional. The role
• Enlist the aid of spouse, family, elders or friends of front-line medical staff depends upon their
for supporting, motivating and monitoring the training and the local presence or absence of
client. specialists in health and social services.
• "Play for time," as suicidal intent tends to wax • If the client is being treated on an outpatient
and wane, and preventive counseling can be basis, the therapist or others must be available to
effective during the non-suicidal intervals. Try respond at all times.
to establish a time-limited "contract" with the • Recognize the limits of your own personal
would-be suicide during which you are prepared responsibility and the impossibility of
to help the person work on his or her problems. guaranteeing that an individual will not commit
Ask, in effect, "How much time can you give so suicide even after intervention and treatment.
that you and I can work together on this matter?"
• If the client is intoxicated, do not attempt to Unsuccessful Attempt
counsel but either directly or indirectly provide • Ensure that adequate emergency medical
sympathetic support and continuous monitoring treatment has been given and that the possibility
until the client is sober. of undetected drug overdose (in addition to the
• If the client is to return home, ensure that apparent method) has been considered.
firearms, drugs and other means of suicide are • Remove anything that might be used in another,
removed. A person seriously intent on suicide impulsive attempt, especially if the client is
will find a way, but obstacles can delay the intoxicated or impaired by drug overdose.
action and allow time to reconsider. • Convey the idea that this potentially fatal act
• In the case of children or adolescents, temporary may be turned into a positive and constructive
removal from the home may be advisable and experience for the individual and for the family,
may require admission to a health or social where relevant.
welfare facility. • Make careful records and tag the chart tonsure
• Counseling the family in the case of a child or that the suicidal potential is recognized on
married adult should begin immediately in order subsequent admissions or contacts. Risk of
to: suicide is very high among those who have
• assist them in understanding what is attempted suicide previously.
happening • Continue to monitor and provide support in view
• advise them of the treatment options and of the increased risk of suicide after an attempt.
resources
• motivate them to assist the client in treatment
• deal with their guilt, remorse or self-blame

Completed Suicide: Interventions for Suicide Prevention

Survivors • The suicide problem is best viewed as a total
• Family, friends and loved ones left behind by community responsibility, which requires a
suicide often suffer guilt, anguish, despair, and cooperative community response.
depression. They are tortured by self-blame, • The community's "gatekeepers" should be
denial, confusion, ambivalence, shame, loss and trained to recognize suicidal symptoms, assess
anger. risk and undertake appropriate management or
• These "survivors" themselves become at high referral of anyone at risk.
risk for suicide and depression. • Healthcare professionals should take the
• The bereaved need sympathy, consolation, initiative and encourage others to do likewise in
encouragement, distraction and opportunity for encouraging at-risk individuals to talk about
abreaction. Every culture has its own techniques their problems; make them aware that resources
for contending with loss and bereavement. are available, and actively assist with referrals.
Local knowledge is important. • Recognize the role of changing social
• The process has failed for an individual if the conditions, value systems and social
following features are present: organization in the etiology and epidemiology of
• typical symptoms of bereavement persist suicide; encourage community activities that
without evidence of relief, recovery or strengthen social and family solidarity and
restitution purpose.
• symptoms become exaggerated, such as • In view of the problem of a high number of
complete denial of the death suicide attempts, a mental health promotion
• deviant behavior violates convention or strategy (see "Mental Health Promotion," in
culturally expected grieving or jeopardizes "Mental Illness Prevention and Mental Health
physical health and safety. Promotion," above, this chapter) is preferred to
• It is recommended that intervention with those one specific to suicide "prevention."
left behind by suicide begin as quickly as
possible: within 2 or 3 days after the event.

Sexual Assault
General • Most rape victims use more than one active
Sexual assault is any unwanted touching or sexual strategy (e.g. pleading, reasoning, screaming,
act that is forced on a victim (usually female) kicking) in attempting to prevent the assault.
without consent. It includes kissing; grabbing of • Sexual assault is a crime, whether the offender is
the breast, buttocks or genitals; holding the victim known or unknown to the victim. Spouses can
and rubbing against her or squeezing her; tearing be charged with sexual assault.
or pulling at the victim's clothing; and attempted
or completed vaginal, anal or oral intercourse. Immediate Effects
• Somatic disturbances, including nausea,
Force is the exertion of power by the offender that vomiting, poor appetite, insomnia, nightmares,
causes the victim to comply against her will. It headaches, fatigue, and specific or general
includes, but is not limited to, physical violence or soreness
threats of physical violence to the victim or a • Gynecological problems, including vaginal
loved one. Sexual assault does not include discharge, itching and burning sensations, and
exhibitionism, voyeurism, verbal or gestural menstrual dysfunction
obscenities, or sexual harassment, although these • Disturbance of affect, including anxiety, terror,
too may be unwanted and psychologically depression, excitability, loss of temper, guilt,
disturbing. self-blame and mood swings
• Cognitive changes, including difficulty in
Ninety percent of victims are female. Little is
concentrating, fear of being alone, fear of death,
known about the effects of sexual assault on male
fear of the offender's return and fear of a
victims; accordingly, the following discussion
recurrence
focuses on the effects of sexual assaults committed
by men against females.
• Interpersonal difficulties at work or school and
with friends and family members; mistrust of
others (especially men) is common
Statistics
• Alcohol or drug use or abuse
• Six percent of adult women report having been
raped and 21% report having been subjected to
• Suicidal thoughts and attempts
some other form of sexual assault (excluding
unwanted kissing) at least once in their lives. Longer-Term Effects
• Women who are physically or emotionally • Feelings of being alone
abused constitute an at-risk group for sexual • Suspicion and distrust of others
assault. • Self-imposed restrictions in daily life
• Nearly half of the victims are < 17 years of age • Episodic depression
at the time of the assault (see "Child Sexual • Sexual dysfunction
Abuse," in the Pediatric Clinical Guidelines).
• Twenty-one percent of all rapes and 17% of The degree and severity of both the immediate and
other forms of sexual assault occur in the longer-term effects of sexual assault depend on the
victim's home. nature of the assault, with attempted and
• Two-thirds of all rapists are known to the victim, completed rape being the most psychologically
and in one-third of all rapes the offender is either damaging. One-quarter of rape victims do not
a present or former intimate partner of the consider themselves fully recovered even as long
victim. as 4-6 years after the assault.
• In a significant number of rapes (12%), weapons
are used or displayed. Almost 10% of rapes are Course Of Recovery
accompanied by severe beatings, and 15% of Three phases in recovery after sexual assault have
rape victims sustain injuries that require medical been identified.
attention.

• Acute phase: Immediately follows the assault prophylaxis. Discuss the client's need and wish for
and is characterized by symptoms described prophylaxis for sexually transmitted infections
above. (STIs).
• Recoil phase: Emotional and physical symptoms
wane, and victim may resume her normal day- Accord the victim the dignity of making her own
to-day activities. During this phase, she is likely decisions about who can be told that she has been
to deny or minimize the effects of the assault assaulted and indicate that, whatever her decision,
upon her and refuse offers of assistance. she has your support.
• Reintegration phase: May occur weeks, months
or even years after the assault. At this time, the Provide information on police and court
victim re-experiences the symptoms procedures and on what may be expected as a
characteristic of the acute phase. This is consequence of specific legal intervention. The
sometimes triggered by an upcoming court decision to contact the police must be made by the
appearance or the anniversary of the assault. victim.
During this time, the experience of the assault is
integrated into the entirety of the victim's life. Keep all information given by the victim
confidential unless she specifically requests
Intervention otherwise.
Immediately after the assault, allow the victim to
wait in a quiet room away from any noise and Offer to talk to the victim's family and friends
confusion. Whenever possible, a female nurse or about their reactions to the rape and the ways in
resource person should remain with the woman which they can support the victim during the
throughout her stay at the medical facility. recovery process. If the victim so wishes, explain
to the family the importance of allowing the victim
Maintain an empathetic, non-judgmental and non- to talk about her experience at her own pace.
intrusive attitude that communicates understanding
of the emotional upheaval the victim is Inform the victim of any services specifically
experiencing. If the victim is reluctant to talk available for sexual assault victims. In many areas,
about her experience, do not probe or otherwise rape crisis centers located in major urban centers
pressure her to do so. On the other hand, if the will accept collect long-distance telephone calls.
victim elects to vent, validate her emotions and
"normalize" her reactions (i.e. let her know that Help the victim to clarify the problems that need
her experiences are not dissimilar to those of other immediate attention (e.g. where and with whom
victims). she can stay in order to feel safe) and assist her in
taking actions to solve these problems.
Explain the medical procedures that the victim
will undergo and the rationale for them (i.e. to Arrange a follow-up appointment at which time
determine any injuries, test for sexually bruising not evident during the initial examination
transmitted infections and document assault for can be documented and the victim's adjustment
possible legal proceedings). Be familiar with the can be monitored. During this appointment, it is
adult sexual assault examination (ASAE) kit. important to give the victim information about the
recovery phases. In particular, the victim should
When possible, ask the victim if she would prefer know that the symptoms she is currently
a female professional caregiver. In all cases, experiencing will subside (the time frame is
another woman should be present in the room variable), but she is likely to re-experience these
during the medical examination. symptoms as part of the recovery process.
If it appears that the victim is unable to function, a
Determine whether the sexual assault could have psychiatric and psychological referral should be
resulted in a pregnancy; if so, discuss the considered.
possibility of administering immediate pregnancy

Family Violence
Maintain a high index of suspicion and include Apart from the obvious physical evidence, there
matter-of-fact screening for abuse as a routine part are a number of more subtle physical and
of good healthcare. psychological symptoms that should be noted:
• Anxiety attacks or depression
Information about child abuse and child sexual • Psychosomatic complaints, including headache,
abuse is presented in the Pediatric Clinical pains in the chest or abdomen, insomnia, fatigue
Practice Guidelines and backache
• Stiff neck or shoulder muscles (due to violent
Spousal Abuse shaking), which mimic the symptoms of
The healthcare system, and nurses, physicians and whiplash
public health personnel in particular, are in a • Damage to the eardrums
strategic position to identify and assist people who • Marital problems, especially where reference is
are in abusive relationships. Battered women often made to fighting (arguing), jealousy,
do not recognize the nature of the problem or impulsiveness or drinking on the part of the
identify themselves as "battered," and in cases husband or wife
where they do, they frequently conceal the • Substance abuse problems
situation because of shame or fear of retaliation. • Repeated suicidal gestures or attempts
The healthcare facility often provides the first
• Uncontrollable crying
opportunity to put the problem in perspective for
the victim and advise her about her options.
Such vague or non-specific symptoms often lead
the healthcare provider to feel that "There is
There are four major categories of physical injury
something going on and I do not know what it is."
or trauma frequently exhibited by but not limited
These complaints, coupled with frequent visits to
to women seeking medical attention after assault:
the healthcare facility, poor compliance with
• Serious bleeding injuries, especially to the head treatment recommendations and unresponsiveness
and face; in the case of sexual assault, there may to treatment, form what is known as the spousal
be vaginal or anal tearing that requires stitching abuse syndrome.
• Internal injuries, concussion, perforated
eardrums, damaged spleen or kidney, abdominal Guidelines for Assessment and
injuries, punctured lungs, severe bruising, eye
Management
injuries and strangulation marks on the neck To confirm the abuse, you must ask the woman or
• Burns from cigarettes, hot appliances, scalding man directly if the partner is hitting or threatening
liquids or acid to do so. Both men and women tend to minimize
• Broken or cracked jaw, arm, pelvis, rib, abuse, and it is often useful to give examples and
collarbone or leg to phrase questions in such a way that the client
feels that he or she has permission to talk about the
Notice also signs of old, untreated injuries. Some abuse.
women do not attend medical services or are not
allowed to do so. Evidence of previous injuries • Interview and examine the assaulted client by
may establish the presence of a pattern. Note your herself or himself or with an advocate present.
observations and suspicions on the chart so that The client will not feel free to talk if her or his
other medical personnel will be alert for other partner is nearby.
indications of abuse. • A female client may be more comfortable
talking to a woman, whether a nurse, doctor or
Pregnancy increases susceptibility to assault. social services worker. Clients should be asked
about their preference.

• Allow the client to talk at her or his own pace. definition and a lack of recognition of the
Do not pressure. This may be the only chance problem, elder abuse is under-reported.
the client has to disclose.
• Indicate that you believe what is being said. Be As for other victims of family violence, shame,
supportive. Discuss options, but do not give embarrassment and fear may make disclosure of
advice. Avoid wording that implies blame. abuse difficult.
• Avoid expressions of disgust, horror or anger in
response to the abuse; also avoid "putting down" The family is the greatest source of abuse, with the
the abuser. most frequent offenders being a son, a daughter
• Let the client know that no one deserves or has and a spouse, in that order. An elderly person, like
to tolerate abuse. a child, is often dependent and can represent a
• Assess present danger. If there are children in burden to the caregiver, which results in either
the home, assess whether they are in danger. If intentional or unintentional abuse. Elderly people
you honestly believe that there is a clear danger, are often unwilling to lay charges because of their
address it immediately. dependence, lack of alternatives, fear of
abandonment and reprisal, fear of
• Offer assistance in arranging for safety. Possible
institutionalization or sense of loyalty to the
safe refuges are abuse shelters, transition homes
family.
or the home of a sympathetic relative or friend.
• Offer to contact the police should the client wish
Factors unique to the elderly abused victim:
to lay a charge or to have the police lay a charge.
• Without intervention, the abuse is likely to
Make sure that you know the procedures and the
continue for the remainder of the person's life.
victim's legal rights to make it easier to decide
and to act. • Institutionalization may be the only alternative
to the present living situation.
• Help set up a safety plan. Assist the person in
leaving the home or the relationship if that is
Those at highest risk for abuse by family members
desired, but do not pressure the person to do so.
are single or widowed women > 75 years of age
Try to reduce anxiety and provide necessary
who are living with relatives and who have
information so that rational, informed decisions
moderate to severe physical or mental
regarding life and safety can be made.
impairments, such that assistance is required to
• Provide information on the resources and
meet basic needs.
community supports available. If a support
group for assaulted women or men exists in the
Types of Abuse of the Elderly
community, ask if the person would like to be
contacted by one of its members.
Physical
• Document the physical and psychological signs
of abuse carefully and thoroughly in the
• Assault
appropriate chart or record. This report should • Rough handling
include a description of the injuries requiring • Gross neglect
medical attention and the treatment provided and • Withholding of food or personal or medical care
a description of any injuries not requiring
medical attention (e.g. bruises and minor Psychosocial
lacerations). • Confinement
• Isolation
Elder Abuse • Lack of attention
Because of the greater need for and use of medical • Intimidation
services by elderly people, healthcare • Verbal or emotional abuse
professionals are in an ideal situation to detect
potential and actual cases of elder abuse. Financial
However, because of the absence of a standard • Withholding finances
• Fraud

• Theft • Use outreach programs such as a home nursing

• Misuse of funds program, Meals on Wheels, homemakers, and
• Withholding means for daily living home help aids to enable the elderly person to
remain in his or her residence and community.
The most frequent type of abuse is financial, • Consult community social services to determine
followed by psychosocial and physical. what form of assistance would be available to
the elderly person and the care providers.
Symptoms of Physical Abuse and • Ensure regular medical and nursing care, using
Neglect frequent home visits to monitor the risk to the
• Bruises, welts, burns and other similar lesions elderly person.
for which adequate explanation is lacking • Ensure that there is an accurate and complete
• Sores, ulcerations and other similar lesions that medical and social history on the medical record
do not heal so that this information is available if legal
• Undernourishment and dehydration when mental decisions are made concerning the abused
alertness enables expression of needs but person.
immobility prevents independently meeting • Establish a positive relationship with both the
those needs elderly person and the caregiver/abuser.
• Oversedation or withholding of prescribed drugs • Engage social services and other members of the
• Failure to keep medical appointments for needed extended family to reduce the stress on the
care (because no one will take the person to the caregiver's family.
appointment) • Provide counseling to the abused elderly person
and the caregiver to discover and resolve hidden
Emotional or Psychological Symptoms conflict that may be at the root of the problem.
• Denial of any problems in relation to caregivers • As a last resort, removal from the home may be
and/or over protectiveness of caregivers necessary. If consent cannot be obtained through
• Emotional withdrawal and passivity; resignation counseling, it may be necessary to proceed by
to current life situation way of the legal process, including appointment
• Fear and anxiety of a legal guardian.
• Unusual ease in settling into a medical setting
(relief from abusive situation) Special Considerations in Conducting an
• Absence of expectations of being comforted Interview about Potential Elder Abuse
• In the initial stages, the suspected victim should
be interviewed separately and the degree of risk
Assessment and Management
to the person's physical and emotional well
• Assess mental competence and refer to territorial
being should be determined.
mental health legislation to determine possible
courses of action. • Members of the family, boarding home staff or
other caregivers should be interviewed
• If protective legislation for vulnerable or elderly
separately.
adults exists, report suspected cases of abuse to
the agency mandated to investigate and • Note the client's mental status, behavior,
intervene. emotional responses and attitudes toward the
caregivers.
• The elderly person, if judged competent, is
entitled to make decisions that effect his or her • Note the attitude of the caregivers toward
life. The language used when discussing the caregiving, control of the client's activities,
elderly person's living situation should reflect extent of outside contacts, and the physical and
this (i.e. avoid infantilization). emotional well being of their charge.
• Determine whether abuse or neglect reflects • Ensure that the best-qualified and most
inadequate preparation or unrealistic appropriate (with respect to mandate) resource
expectations on the part of the caregivers. person is notified and made responsible for
conducting the necessary interviews and
investigations.

Resource Utilization In Community Mental Health

Care
Perhaps in no other clinical area is the Much of mental health (and, conversely, mental
mobilization and coordination of paramedical and illness) is the product of social experiences in a
non-medical resources more important for variety of contexts (family, friendships, school,
effective treatment and prevention than in mental work, recreation, community). These same
health. "contexts" can be mobilized to provide therapeutic
or health-promoting environments and
experiences.
Guidelines For Resource Utilization In Mental Health Care

Identify the resources currently or potentially Keep the informal resources, particularly the
involved with the client or the mental health family and, where possible, the client, centrally
problem. Consider both formal (social service, involved in the process. Doing so encourages a
medical, educational) and informal (family, sense of mastery, independence and responsibility.
spouse, friends, volunteers) resources.
Work with others, where possible. The natural
Make or facilitate referral to appropriate services caregivers generally have more contact and a more
or agencies and enlist the help of informal intense and meaningful involvement with the
resources. Some effort may be required to "sell" client and therefore have a significant impact. The
the service to the client or to persuade the resource professionals' role is to provide information and
to become involved. There may be stigma, fear, guidance to the caregivers so that their interactions
misunderstanding, mistrust or indifference on the with the client will be salutary and even
part of either the client or the resource. deliberately systematic and therapeutic in some
cases.
Coordinate or encourage coordination of all the
resources involved. Face-to-face meetings of both This same principle applies to more formal
the formal and informal resource persons, while "helpers," such as volunteers, church members and
time consuming, are ultimately more efficient. clergy, self-help organizations and even the other
They also permit the following to take place: community agencies providing service to the
• sharing of information client. Some of these agencies have frequent and
• assignment of goals significant contact with clients and can play an
• identification of expectations of both the client active role in treatment and follow-up.
and the resource person
• clarification of responsibilities Provide support for the caregivers, for example by
• establishment of communication networks offering back-up to informal helpers, by linking
resources working on similar problems, by sharing
• development of a mutually acceptable plan
information about community resources and by
• avoidance of duplication of effort providing technical assistance. If possible, offer
• a public commitment to provide a service or take training through workshops or information
action. sessions in your specialty to help the resources
(formal and informal) to serve their mental health
Collaborate with the other resources in providing charges.
the service. Conduct joint client interviews where
appropriate. Offer treatment or other programs Ensure that communication between the concerned
jointly with other resources. resources is open and adequate.

Discuss with the resource people involved the traumatic and more long-standing problems such
limits and constraints imposed by the principle of as parenting difficulties, mental retardation,
confidentiality (see "Records and Confidentiality," learning disabilities, juvenile delinquency and
in "Clinical Assessment and Management," above, substance abuse.
this chapter).
Effective case-finding and resource utilization
Participate as a resource in the development of depend on well-informed professional and lay
self-help and parent support groups for various communities.
classes of mental health problems, providing the
necessary support and supervision. Community resource directories, advertisements
of special events (e.g. talks, open houses, health
Establish formal liaison between the agencies most fairs) and interagency conferences are good means
immediately involved with mental health for keeping the community aware of its resources.
problems. This might be by way of standing or ad
hoc interagency committees. It is better to have Volunteer corps are extremely helpful with
such committees in place relatively permanently inpatient care and preventive activities. The
than to have to assemble one as each problem Canadian Mental Health Association is a
arises. This is particularly true for traumatic particularly valuable resource for a community,
personal experiences requiring mental health and development of a local chapter and use of its
intervention, such as child abuse, sexual abuse and resources are encouraged.
wife battering, but could be extended to less
Program Consultants
In sparsely populated, resource-poor areas, the individual feels frustrated and dissatisfied, and
professional in almost any discipline is often nothing gets done.
expected (or expects himself or herself) to be an
expert in every aspect of his or her profession. Consultation on mental health programming is
Recognizing the unrealistic nature of this available from a number of sources (Health
expectation does not always allay the feeling that Canada, universities, provincial or territorial
one should know or be able to do something. departments of health and human resources, the
Canadian Mental Health Association and various
At the same time, this feeling of responsibility special interest groups), which should be used as
often persuades one not to bother someone else resources in any way possible. Most agencies are
with the problem, with the result that the more than willing to share their knowledge and
expertise.

Introduction
The original Clinical Practice Guidelines for Nurses in Primary Care (FNIHB, July 2000) contain
information on common health problems and common emergency conditions seen in the adult population. We
acknowledge the work of the First Nations and Inuit Health Branch of Health Canada in developing the
clinical guidelines and appreciate their permission us to use their guidelines, review and update them again
and revise them specifically for the NWT.
The pediatric guidelines consist of 20 sections. Each one includes an assessment (history and physical
examination) of the body system in question, along with clinical practice guidelines on common disease
entities and emergency situations seen in that system. The most current resources available have been used in
the revision and are referenced where possible.
The adult and pediatric guidelines are intended to be used together and are consequently published in one
binder for the NWT.
These guidelines are intended for use, in conjunction with the NWT Health Centre Formulary (July 2003) as
well as the Community Health Nursing Program Standards and Protocols (March 2003) along with the
reference sources from each of these manuals and Clinical Practice Information Notices as they are issued by
the GNWT Department of Health and Social Services.
All drugs referenced in these guidelines are in the NWT Health Centre Formulary (July 2003), with the
exception of some drugs which have been used as examples of possible physician prescriptions. There are a
few situations where A or C class drugs should be prescribed by a physician only - in these cases the
classification will remain A or C but the text will clarify that these drugs in this circumstance should be
prescribed by a physician only (e.g. salicylates in treatment of rheumatic fever)
NWT Health Centre Formulary (July 2003) classifications have been used.
A class drug - RN initiated, based on nurse assessment of patient, no limitation on duration of treatment
B class drug - Physician initiated, based on consultation with MD, duration/frequency to be
specified by MD
C class drug - RN may initiate 1 course. A course is defined as several successive doses of medication over
time. The time is the period that the specific drug is expected to produce therapeutic effects.
A course may not exceed 2 weeks without consulting a physician. If the condition does not
resolve, the expectation is that the nurse will consult a physician. If further medication is
needed, a physician order is required.
D class drug - RN one dose - reassess patient, contact MD if further treatment is required
You will find that many drugs have been reclassified to a C classification. This is to emphasize the point that
if a patient returns with no resolution of the problem the RN should consult with a physician rather than
continue to treat ineffectively
September 2004 Pediatrics 1

Acknowledgments
Elizabeth Cook
Jo-Anne Hubert
Karen Graham
Marie-Claude Lebeau
Marnie Bell
Nicole Chatel
Rachel Munday
in helping to review and revise these guidelines
Preface
These Clinical Practice Guidelines are intended primarily for use by registered nurses working in health
centers located in the Northwest Territories.
All nurses are encouraged to use other current resources, text or internet, to supplement the information in
these guidelines. All nurses are reminded that this manual is a "guideline", however, nurses are encouraged to
base their practice on this guideline whenever possible.
It is also important to note that the guidelines contain useful information but are not intended to be
exhaustive. Consequently, the manual is to be used for reference and educational purposes only and should
not be used under any circumstances as a substitute for clinical judgment, independent research or the seeking
of appropriate advice from a qualified healthcare professional.
Nurses must consult with a physician whenever a situation warrants. Appropriate medical advice is to be
obtained by telephone in cases where the condition of the client is at all serious or in cases where the
condition of the client is beyond the scope of practice and expertise of the nurse to manage autonomously.
Although every effort has been made to ensure that the information contained in the guidelines is accurate and
reflective of existing healthcare standards, it should be understood that the field of medical science is in
constant evolution. Consequently, the reader is encouraged to consult other publications or manuals. In
particular, all drug dosages, indications, contraindications and possible side effects should be verified and
confirmed by use of the current edition of the Compendium of Pharmaceuticals and Specialties (CPS) or the
manufacturer's drug insert.
These guidelines will be available on the GNWT intranet website. In the printed version you will notice
adequate white space between subjects. This is partly for ease of future revisions, but also to encourage you
to make your own notes (e.g. mnemonics for remembering things, recent reference sources, cross references
to other DHSS GNWT documents), as needed, if you have your own copy of the guidelines.
Every effort will be made to keep these Clinical Practice Guidelines current. Appendix 1 provides the
opportunity for the Guidelines Users to submit suggested changes and so assist with the Guidelines update
process.
2 Pediatrics September 2004

Chapter 1 – Guidelines for Pediatric Health

Assessment
Introduction ....................................................................................................................................................... 1
Health Maintenance Requirements ................................................................................................................. 1
Pediatric History ............................................................................................................................................... 2

Tips And Techniques ...................................................................................................................................... 2
Components Of The Pediatric History............................................................................................................ 2
Pediatric Physical Examination ....................................................................................................................... 2

Technique........................................................................................................................................................ 2
Developmental Milestones.............................................................................................................................. 3
Physical Examination Of The Newborn.......................................................................................................... 3

General............................................................................................................................................................ 3
Vital Signs....................................................................................................................................................... 3
Growth Measurements.................................................................................................................................... 3
Skin ................................................................................................................................................................. 4
Head And Neck............................................................................................................................................... 4
Respiratory System ......................................................................................................................................... 5
Cardiovascular System ................................................................................................................................... 5
Abdomen......................................................................................................................................................... 6
Genitalia.......................................................................................................................................................... 6
Musculoskeletal System ................................................................................................................................. 7
Central Nervous System ................................................................................................................................. 7
Apgar Score .................................................................................................................................................... 8
Assessment Of Gestational Age...................................................................................................................... 9
Screening Tests ............................................................................................................................................... 9

Introduction
The clinical assessment of infants and children such as dietary requirements and prevalence of
differs in many ways from that for adults. Because disease, expected normal laboratory values, and
children are growing and developing both responses to drug therapy will be different from
physically and mentally, values for parameters those observed in adults.
Health Maintenance Requirements

Well children should have regular health • Appropriate nutrition
maintenance visits, often done at well-baby • Safety measures
clinics. Such visits customarily occur immediately • Expected developmental and behavioral events
after birth, at 2 weeks of age, at the times when
immunizations are indicated (2, 4, 6, 12 and 18 In addition, an assessment should be made of the
months) and subsequently at 1- or 2-year intervals. quality of physical care, nurturing and stimulation
At each visit, the child should undergo an that the child is receiving.
appropriate history, physical examination and
developmental assessment, and anticipatory The most important components that should be
guidance should be provided about the following assessed at each time period are given in
topics: Table 1-1.
Table 1-1: Components of well-child assessments at various ages

Health parameter Most important ages for assessment
Height, weight Every visit, from birth to 16 years
Head circumference Every visit in the first 2 years of life
Growth chart plotting Every visit
Blood pressure Once in the first 2 years, once at 4-5 years, during school-age years only if there is
a risk or concern about high blood pressure, and every second year during
adolescence
Eye assessment Every visit in the first year of life
Strabismus Every visit in the first year of life
assessment
Visual acuity testing Initial screening (e.g. Snellen chart) at 3-5 years; every 2 years between 6 and 10
years, then every 3 years until 18 years
Dental assessment Every visit
Speech assessment Every visit
Developmental Every visit, formal Nipissing Developmental Screen at 6, 12, 18 months, 3 years 4-
assessment 6 years
Sexual development Every visit
School adjustment Every visit after child reaches school age
Chemical abuse Consider during assessments of children > 8 years
Immunizations According to the NWT Immunization Schedule
Hemoglobin Screen at 6-12 months, more often if high risk for anemia
Safety counseling Every visit
Nutrition counseling From birth to 5 years, and for teenagers
Parenting counseling Every visit
September 2004 Pediatrics 1-1

Pediatric History
Tips And Techniques
Children understanding of the child's terminology for
Children who can communicate verbally should be various body parts.
included as historians, with additional details
provided as necessary by parents or caregivers. Adolescents
Questions, explanations and discussions occurring Adolescents should be granted privacy and
with children present should take into account confidentiality.
their level of understanding. Young children may • Interview the adolescent alone
be assisted in providing details of the history by • Discussions with parents or caregiver should
such techniques as having them play roles or draw occur separately, with the adolescent's
pictures. The interviewer should gain an permission. See also chapter 19, "Adolescent
Health."
Components Of The Pediatric History

The pediatric history includes many of the same • Detailed dietary history for the first year of life,
components as the adult history, but some specific including history of vitamin supplements and
elements are highlighted. The chief complaint, fluoride use
history of present illness, history of past illnesses, • Developmental history
allergy and drug history, family history and review • Social history, including questions about any
of systems are the same as for an adult. In recent separations, deaths, family crises, friends,
addition, the pediatric history should include the peer relationships, day-to-day care
following information: arrangements, progress in school
• Pregnancy and perinatal history
• Immunization history
Pediatric Physical Examination

Clinicians should be aware of the different sizes of small children, ratio of surface area to weight
body parts in children relative to adults: head relatively larger.
relatively larger, limbs relatively smaller and, in
Technique
Much information can be obtained by observing • Color
the child's spontaneous activities while the history • Responses to parental comforting measures
is being conducted, without touching the child. For
this purpose it is useful to have an age-appropriate For a young child, parts of the physical
toy available. examination can be conducted with the child either
being held by the parent or caregiver or supported
Without touching the child, observe: on that person's lap.
• Gait
• Breathing frequency and pattern Generally, the least stressful parts of the exam
• Responses to sound should come first, with more intrusive or
• Grasp patterns distressing parts later (e.g. examination of the
pharynx with the child restrained).
1-2 Pediatrics September 2004

The order of the examination must be varied to Measurements of length and weight should be part
suit the situation. of every health maintenance visit (along with
measurement of head circumference in the first 2
Care should be taken to select appropriate-sized years of life). These parameters should be
equipment when examining a child (e.g. blood recorded on gender-appropriate growth curves,
pressure cuff should be two-thirds of the length of which should form part of the child's health
the upper arm). record.
Developmental Milestones
Assessment of developmental progress should be Table 1-2: Approximate ages for milestones in
part of each complete health assessment. the first two years of life
Developmental milestones are achieved at Milestone Approximate age
different ages in different children; the Social smile 1 month
approximate ages at which developmental Sit 7 months
milestones occur are presented in Table 1-2. More Vocal babble 9 months
detailed assessments are indicated when it appears Pull to stand 9-10 months
that the child is not progressing normally. Pincer grasp 12 months
Walks alone 13 months
As part of each complete health assessment, Ten words 18 months
attempts should also be made to assess responses Hand preference 18 months
to sound and ability to see. Many words (two 24 months
together)
Physical Examination Of The Newborn

General
Observe the entire infant at the beginning of the • Consciousness, alertness, general behavior
examination, before the assessment of specific • Symmetry of body proportions and body
organ systems. It is important that the infant be movements (e.g. arms and legs, facial grimace)
completely undressed and in a warm environment • State of nutrition and hydration
with adequate illumination. • Colour
• Any sign of clinical distress (e.g. respiratory)
Assess the following:
Vital Signs
Average values of vital signs for newborns: • Respiratory rate 30-60/minute, up to 80/minute
• Temperature 36.5°C to 37.5°C if infant is crying or stimulated
• Heart rate 120-160 beats/minute • Systolic blood pressure 50-70 mm Hg
Growth Measurements
Measure and record length, weight and head • Average weight at birth 3500-4400 g
circumference. If the infant appears premature or • Average head circumference at birth 33-35 cm
is unusually large or small, assess gestational age
(see Table 1-4, below, this chapter). For additional information about growth
measurements, see "Well-Child Care," in chapter
• Average length at birth 50-52 cm 3, "Prevention."

Skin
Colour • Transient neonatal pustular melanosis: Small
• Pallor associated with low hemoglobin vesicopustules, generally present at birth,
• Cyanosis associated with hypoxemia containing WBCs and no organisms; intact
• Plethora associated with polycythemia vesicle ruptures to reveal a pigmented macule
• Jaundice associated with elevated bilirubin surrounded by a thin skin ring
• Erythema toxicum: Most common newborn
rash, consisting of variable, irregular macular
Lesions
patches and lasting a few days
• Milia: Pinpoint white papules of keratogenous
material, usually on nose, cheeks and forehead,
• Café au lait spots: Suspect neurofibromatosis if
there are many (more than five or six) large
which last several weeks
spots
• Miliaria: Obstructed eccrine (sweat) ducts
appearing as pinpoint vesicles on forehead, scalp
and skin folds; usually clear within 1 week
Head And Neck

Head • Look for fleshy appendages, lipomas or skin
Check for: tags
• Overriding sutures • Perform otoscopic examination if sepsis is
• Anterior and posterior fontanels (size, suspected; check canals for discharge and
consistency) tympanic membranes for colour, brightness,
• Abnormal shape of head (e.g. caput bony landmarks and light reflex
succedaneum, molding, encephaloceles)
• Measure head circumference. Nose: Inspection
• Look for flaring of the alae nasi, which is a sign
Eyes: Inspection of increased respiratory effort
• Check cornea for cloudiness (sign of congenital • Look for hypertelorism or hypotelorism
cataracts) • Check for choanal atresia, as manifested by
• Check conjunctiva for erythema, exudate, orbital respiratory distress; neonates are obligate nose
edema, subconjunctival hemorrhage, jaundice of breathers, so first check to determine if air is
sclera coming from nostrils; if not and choanal atresia
• Check for pupillary size, shape, equality and is suspected, a soft nasogastric tube can be
reactivity to light (PERRL: pupils equal, round, passed through each nostril to check patency
reactive to light), accommodation normal
• Red reflex: hold ophthalmoscope 15-20 cm (6-8 Palate: Inspection And Palpation
inches) from the eye and use the +10 diopter • Check for defects such as cleft lip and palate
lens; if normal, the newborn's eye transmits a
clear red colour back; black dots may represent Mouth: Inspection
cataracts; a whitish colour may suggest • Observe size and shape of mouth
retinoblastoma • Microstomia: seen in trisomy 18 and 21
• Macrostomia: seen in mucopolysaccharidosis
Ears: Inspection • "Fish mouth": seen in fetal alcohol syndrome
• Check for asymmetry, irregular shape, setting of • Epstein pearls: small white cysts containing
ear in relation to corner of eye (low-set ears may keratin, frequently found on either side of the
suggest underlying congenital problems, such as median line of the palate
renal anomalies)

Tongue: Inspection Neck

• Macroglossia: indicates hypothyroidism or Inspection
mucopolysaccharidosis • Symmetry of shape
• Alignment: torticollis is usually secondary to
Teeth: Inspection sternocleidomastoid hematoma
• Natal teeth (usually lower incisors) may be • Neck mass (cystic hygroma is the most common
present type)
• Risk of aspiration if these are attached loosely
Palpation
Chin: Inspection • Palpate all muscles for lumps and the clavicles
• Micrognathia may occur with Pierre Robin for possible fracture
syndrome, Treacher Collins syndrome and • Lymph nodes cannot usually be palpated at
Hallerman Streiff syndrome birth; their presence usually indicates congenital
infection
Respiratory System
Inspection • Breasts may be slightly enlarged secondary to
• Cyanosis, central or peripheral (transient bluish presence of maternal hormones
colour may be seen in extremities if infant is
cooling off during the examination) Auscultation
• Respiratory rate and pattern (e.g. periodic • Breath sounds
breathing, periods of true apnea) • Inspiratory to expiratory ratio
• Observe chest movement for symmetry and • Adventitious sounds (e.g. stridor,
retractions crackles,wheezes, grunting)
• Use of accessory muscles, tracheal tug,
indrawing of intercostal or subcostal muscles Percussion is of little clinical benefit and should be
avoided, especially in low-birth-weight or preterm
Palpation infants, as it may cause injury (e.g. bruising,
• Any abnormal masses (palpate gently) contusions).
Cardiovascular System
• Respiratory rate • Abnormal location of PMI can be a clue to
• Heart rate pneumothorax, diaphragmatic hernia, situs
• Blood pressure in upper and lower extremities inversus viscerum or other thoracic problem
• Capillary refill (<2 seconds is normal)
See normal values in "Vital Signs," above, this • Peripheral pulses: note character of pulses
chapter. (bounding or thready; equality); any decrease in
femoral pulses or radial-femoral delay may be a
Inspection sign of coarctation of the aorta
• Colour: pallor, cyanosis, plethora
Auscultation
Palpation • Note rate and rhythm
• Locate point of maximal impulse (PMI) by • Note presence of S1 and S2 heart sounds
positioning one finger on the chest, in the fourth • Note presence of murmurs (consider murmurs
intercostal space medial to the midclavicular line pathologic, as in congenital heart defects, until
proven otherwise)

Abdomen
Inspection Palpation
• Shape of abdomen: flat abdomen may signify • Check for any abnormal masses
decreased tone, presence of abdominal contents • Liver and spleen: it may be normal for the liver
in chest or abnormalities of the abdominal to be located about 2 cm below the right costal
musculature margin; spleen is not usually palpable; if it can
• Contour: note any abdominal distension be felt, be alert for congenital infection or
• Masses extramedullary hematopoiesis
• Visible peristalsis • Kidneys: should be about 4.5-5.0 cm vertical
• Diastasis recti length in the full-term newborn
• Obvious malformations (e.g. bowel contents • Techniques for kidney palpation: place one hand
outside of abdominal cavity [omphalocele]; this with four fingers under the baby's back, then
abnormality has a membranous covering [unless palpate by rolling the thumb over the kidneys; or
it has been ruptured during delivery], whereas place the right hand under the left lumbar region
gastroschisis does not) and palpate the abdomen with the left hand to
• Umbilical cord: count the vessels (there should palpate the left kidney (do the reverse for the
be one vein and two arteries); note colour, any right kidney)
discharge • Hernias: umbilical or inguinal
Auscultation Percussion usually omitted unless problems such

• Bowel sounds as abdominal distension are noted.
Inspect the anal area for patency and for presence

of fistulas or skin tags.
Genitalia
The genitalia should be carefully assessed, with Palpation
particular attention to any malformation, • Testes: ensure that both testicles are descended
abnormalities or sexual ambiguity. into scrotum
Male Genitalia Female Genitalia

Inspection Inspection
• Glans: color, edema, discharge, bleeding • Check labia, clitoris, urethral opening and
• Urethral opening: should be located centrally on external vaginal vault
the glans (in hypospadias, the opening is found • Whitish discharge often present; this is normal,
on the undersurface of the penis) as is a small amount of bleeding, which usually
• Foreskin (prepuce): usually difficult to retract occurs a few days after birth and is secondary to
completely maternal hormone withdrawal
• Scrotum: in full-term infant, scrotum should • Hymenal tags, if they occur, are normal
have brownish pigmentation and should be fully
rugated

Musculoskeletal System
Inspection And Palpation • Count the toes
Spine • Examine foot creases for assessment of
• Check for scoliosis, kyphosis, lordosis, spinal gestational age (see Table 1-4, below, this
defects, meningomyelocele chapter)
• Examine the hips last, using Ortolani-Barlow
Upper Extremities maneuver
• Assess the shoulder girdle for injury and the
clavicles for fracture (especially if the delivery Technique for Ortolani-Barlow hip examination:
was traumatic and in large infants with a history • Place middle fingers over greater trochanters
of shoulder dystocia) (outer upper legs)
• Assess mobility of the shoulder and extension of • Position thumbs on medial sides of knees
the elbow • Abduct the thigh to 90° by applying lateral
• Inspect palmar creases for assessment of pressure with thumb
gestational age (see Table 1-4, below, this • Move knee medially and then replace knee in
chapter) starting position
• Count the fingers • If there is a "clunk," the hip may be dislocatable
• If there is a "click," the hip may be subluxable
Lower Extremities
• Assess the feet and ankles for deformity and
mobility
Central Nervous System

• Assess state of alertness • Begins when the corner of the baby's mouth is
• Check for lethargy or irritability stroked or touched. The baby turns the head and
• Posture: For term infant, normal position is one opens the mouth to follow and "root" in the
with hips abducted and partially flexed and with direction of the stroking. This helps the baby to
knees flexed; arms are adducted and flexed at find the breast or bottle to begin feeding.
the elbow; the fists are often clenched, with
fingers covering the thumb Sucking Reflex
• Assess tone; for example, support the infant with • Begins about the 32nd week of pregnancy
one hand under the chest; the neck extensors • Is not fully developed until about 36 weeks
should be able to hold the head in line for 3 • Disappears by about 4 months after birth
seconds; there should not be more than 10% • Premature babies may have weak or immature
head lag when the infant is moved from a supine sucking ability
to a sitting position
Moro Reflex
Reflexes • Present at birth
Reflexes are involuntary movements or actions • Disappears by about 4-5 months after birth
that help to identify normal brain and nerve • Often called a startle reflex because it usually
activity. Some reflexes occur only in specific occurs when the baby is startled by a loud sound
periods of development. The following are some or movement
of the reflexes seen in newborns. • In response to the sound, the baby throws back
the head, extends the arms and legs, cries, and
Rooting Reflex then pulls the arms and legs back in
• Present at birth
• Disappears by about 4 months after birth

Tonic Neck Reflex Stepping, Placing or Dancing Reflex

• Appears about 2 months after birth • Present at birth
• Disappears by about 6-7 months after birth • Disappears by 2 months after birth
• When the baby's head is turned to one side, the • When dorsum of foot is placed under a table
arm on that side stretches out and the opposite edge, the infant will step, lifting and placing the
arm bends up at the elbow foot on to the table surface
• Often called the fencing position
Other Reflexes
Palmar Grasp Reflex Reflexes must be symmetric.
• Present at birth • Biceps jerk tests C5 and C6
• Disappears by about 2-3 months • Knee jerk tests L2-L4
• Stroking the palm of a baby's hand causes the • Ankle jerk tests S1 and S2
baby to close the fingers in a grasp • Landau or truncal incurvation reflex tests T2
• Reflex is stronger in premature babies through S1
• Anal wink tests S4 and S5
Apgar Score
Apgar scoring (Table 1-3) is done at 1 and 5 At 5 Minutes
minutes after birth. If necessary, it is repeated at >7: no asphyxia
10 minutes after birth. <7: high risk for subsequent dysfunction of central
nervous system
Interpretation 5-7: mild asphyxia
At 1 Minute 3-4: moderate asphyxia
<7: depression of nervous system 0-2: severe asphyxia
<4: severe depression of nervous system
Table 1-3: Determination of Apgar score

Feature evaluated 0 points 1 point 2 points
Heart rate 0 < 100 beats/min > 100 beats/minute
Respiratory effort Apnea Irregular, shallow or gasping breaths Vigorous, crying
Color Pale or blue all over Pale or blue extremities Pink
Muscle tone Absent Weak, passive tone Active movement
Reflex irritability Absent Grimace Active avoidance
* Sum the scores for each feature. Maximum score = 10, minimum score = 0

Assessment Of Gestational Age

Gestational age can be assessed on the basis of the newborn's external characteristics.
Table 1-4: Assessment of gestational age

External
28 weeks 32 weeks 36 weeks 40 weeks
characteristic
Ear cartilage Pinna soft, remains Pinna harder, but Pinna harder, springs Pinna firm, stands
folded remains folded back into place when erect from head
folded
Breast tissue None None Nodule 1-2mm in Nodule 6-7mm in
diameter diameter
Male genitalia Testes undescended, Testes in inguinal Testes high in Testes descended,
scrotal surface canal, a few scrotal scrotum, more scrotum pendulous,
smooth rugae scrotal rugae covered in rugae
Female genitalia Prominent clitoris Prominent clitoris; Clitoris less Clitoris covered by
with small, widely larger, well- prominent, labia labia majora
separated labia separated labia majora cover labia
minora
Plantar surface of Smooth, no creases 1 or 2 anterior 2 or 3 anterior Creases cover the
foot creases creases sole
Screening Tests
Phenylketonuria (PKU) Other Abnormalities Found On
• For newborns tested for PKU in the first 24 Neonatal Screen
hours of life, capillary blood screening test for • The neonatal screen uses a technique of thin
PKU should be repeated at age 2-7 days layer chromatography to search for abnormal
amino acid levels (of which phenylalanine is
Congenital Hypothyroidism one)
• Screening for congenital hypothyroidism (by
TSH level in dried capillary blood sample) • The neonatal screen also checks for biotinidase
should be performed in the first 7 days of life. If levels
the TSH level is abnormal the laboratory will
automatically check T4 level on the same
sample.
• If the child was born in hospital, verify whether
this type of screening was done there

Chapter 2 – Pediatric Procedures

Restraint............................................................................................................................................................. 1
General............................................................................................................................................................ 1
Procedure ........................................................................................................................................................ 1
Venipuncture ..................................................................................................................................................... 1
General............................................................................................................................................................ 1
Sites................................................................................................................................................................. 1
Procedure ........................................................................................................................................................ 2
Intravenous Access............................................................................................................................................ 2
Vascular Sites ................................................................................................................................................. 2
Types Of Needles............................................................................................................................................ 2
Procedure ........................................................................................................................................................ 3
Complications ................................................................................................................................................. 3
Intraosseous Access........................................................................................................................................... 3
General............................................................................................................................................................ 3
Sites................................................................................................................................................................. 4
Procedure ........................................................................................................................................................ 4
Complications ................................................................................................................................................. 4
Insertion Of Nasogastric Tube ......................................................................................................................... 5

General............................................................................................................................................................ 5
Procedure ........................................................................................................................................................ 5
Suturing.............................................................................................................................................................. 5
Use Of Local Anesthesia ................................................................................................................................ 5

Restraint
General
If holding the child firmly is not sufficient to keep needed for many children between 1 and 6 years
him or her immobile for a procedure, a wrapping of age.
technique can be used. This technique will be
Procedure
Use a sheet or blanket to wrap the child as shown Fig. 2-1: Wrapping Technique to Immobilize a
in Fig. 2-1. If a limb is required for the procedure Child for a Procedure
(e.g, for IV access), leave it outside the wrapping.
Venipuncture
General
For venipuncture, always make your first attempt It is sometimes easier to feel a vein than to see it.
in the largest, most prominent vein you can find.
Sites
Preferred (Upper Extremity) Other (Less Well Known)
• Forearm veins (e.g. cephalic, median basilic or • Saphenous vein, just anterior to medial
median antecubital); these are the best choices in malleolus (lower extremity)
all age groups, but can be difficult to find in • Small veins on ventral surface of wrist or larger
chubby babies one on inner aspect of wrist proximal to thumb
• Veins on the dorsum (back) of the hand
• Tributaries of the cephalic and basilic veins,
dorsal venous arch

Procedure
• Immobilize child by either holding or wrapping • Insert needle just far enough to get "flashback"
(see "Restraint," above, this chapter). of blood.
• Practice universal precautions against • Apply gentle suction to prevent the vein from
contamination with child's body substance collapsing.
(e.g. gloves, possibly goggles, safe disposal of • If flow is very slow, try "pumping," by
needle). squeezing the limb above the site of the
• Apply tourniquet proximal to site; rubbing or puncture.
warming the skin will help to distend the vein.
• Use a 25- or 23-gauge butterfly needle with
syringe attached, bevel up.
• Stabilize vein by applying traction.
Intravenous Access
Vascular Sites
Best Sites, In Order Upper Extremity
• Dorsum of hand • Forearm veins (e.g. cephalic, median basilic or
• Feet median antecubital); these veins can be difficult
• Saphenous vein to find in chubby babies
• Wrist • Veins on the dorsum (back) of the hand
• Scalp: a good site in infants, as veins are close to • Tributaries of the cephalic and basilic veins,
the surface and are more easily seen than in the dorsal venous arch
extremities; useful for administration of fluid or
medication when the child's condition is stable, Lower Extremity
but rarely useful during full resuscitation efforts • Saphenous vein, just anterior to medial
• Antecubital vein malleolus
• Median marginal vein
• Dorsal venous arch
Types Of Needles
Over-The-Needle Catheters
• Cathilons or IV catheters are the most stable Advantages
• 24- or 22-gauge needle is usually used in infants • May be used to obtain blood samples
• Required for volume resuscitation efforts • Design (i.e. the wings) facilitates insertion
because there is a handle to be gripped
Advantages • Wings allow the needle to be taped more
• More comfortable than butterfly needle securely in place
• Frequency of infiltration into interstitial space is Disadvantages
lower Butterfly needles tend to be inserted interstitially
more frequently and should not be used for
Butterfly primary venous access in volume resuscitation
• Especially useful for scalp veins efforts.
• 25- to 23-gauge needles are most commonly
used in infants

Procedure
• Practice universal precautions against • Once the needle is through the skin, adjust the
contamination with child's body substances (e.g. angle of the cannula so that it is parallel to the
gloves, possibly goggles, safe disposal of skin, and advance it slowly into the vein far
needle). enough to get "flashback" of blood, then go in
• Assemble necessary equipment. another millimeter or so to ensure that the plastic
• Immobilize the child well, but avoid restraints if catheter is also in the vein before trying to thread
at all possible. it.
• Always make first attempt in the largest, most • Remove the tourniquet and attach IV infusion
prominent vein you can find - take your time to set. Make sure there are no air bubbles in the
ensure you have identified the best vein. tubing before connecting it.
• If a scalp vein is chosen, you may have to shave • Run in some IV fluid. If the IV line is patent,
the skin around it. tape the needle and catheter securely in place.
• Apply tourniquet, if appropriate.
• Cleanse the skin. These small catheters are fragile. Avoid bending
• Stabilize the vein. them, and always tape them securely, preferably
using an arm board and half a plastic medicine cup
• If using a catheter needle, insert it through the
to cover the site.
skin at an angle of 30° to 45°.
Complications
Local Systemic
Systemic Sepsis
Cellulitis Air embolism
Phlebitis Catheter fragment embolism
Thrombosis Pulmonary thromboembolism
Hematoma formation
Intraosseous Access
General
Purpose • Severe dehydration associated with vascular
• Used to administer IV fluids and medications collapse or loss of consciousness (or both)
when attempts at IV access have failed • Unresponsive child in need of immediate drug
• For use in emergency situations only and fluid resuscitation: burns, status asthmaticus,
sepsis, near-drowning, cardiac arrest,
Indications anaphylaxis
Attempt intraosseous access in the following
situations in children of all ages, when venous Contraindications
access cannot be rapidly achieved within three • Pelvic fracture
attempts or 60-90 seconds: • Fracture in the extremity proximal to or in the
bone chosen for the intraosseous access
• Multisystem trauma with associated shock or
severe hypovolemia (or both)

Sites
Preferred children because of the greater thickness of the
• Anterolateral (flat) surface of the proximal tibia, proximal tibia relative to the distal tibia)
1-3 cm (one finger's breadth) below and just • Distal femur
medial to the tibial tuberosity • Medial malleolus
• Anterior superior iliac spine
Other Possibilities
• Distal tibia, 1-3 cm above the medial malleolus
on the surface of the tibia near the ankle
(believed by some to be the best site in older
Procedure
• Practice universal precautions against • When the needle reaches the bone, exert firm
contamination with child's body substances downward pressure, rotating the needle in a
(e.g. gloves, possibly goggles, safe disposal of clockwise-anticlockwise manner. Be careful not
needle). to bend the needle.
• Assemble necessary equipment. • When the needle reaches the marrow space, the
• Immobilize the child well, but avoid restraints if resistance will drop (indicated by a "pop").
at all possible. • Attach a 10-mL syringe and aspirate some blood
• Place the child in the supine position and and marrow to determine if the needle is
externally rotate the leg to display the medial correctly positioned (other indicators of correct
aspect of the extremity. positioning: the needle will stand upright by
• Identify the landmarks for needle insertion. itself, IV fluid flows freely, no signs of
• Cleanse the puncture site. subcutaneous infiltration are apparent).
• If the child is conscious, use local anesthesia • If aspiration is unsuccessful but you believe that
(see section on local anesthesia in "Suturing," the needle is in the bone marrow, flush needle
below, this chapter). with 10 mL normal saline.
• Use an intraosseous needle, size 14-18g. • Secure needle with tape.
• Angle the needle away from the joint. Insert the • Use as you would a regular IV line. For
needle 1-3 cm below the tibial tuberosity, example, fluids can be infused quickly for
through the skin and subcutaneous tissue, resuscitation of a child who is in shock.
perpendicular to the long axis of the bone.
Complications
• Extravasation • Lower extremity compartment syndrome
• Tibial fracture • Obstruction of needle with marrow, bone
• Osteomyelitis fragments or tissue
• Epiphyseal injury

Insertion Of Nasogastric Tube

General
Tube Size • Neonates: size 5-8 French
Estimate length of tube needed by extending the • Young children: size 12-16 French
tubing from the tip of the child's nose to the ear
lobe and then to the xiphoid process.
Procedure
• Assemble required equipment. stethoscope over the stomach as a small amount
• Explain procedure to child (if he or she is able to of air is instilled into the tube.
understand) and parents or caregiver. • Tape the tube in place.
• Lubricate tip of tube and slide it into the nostril • Attach to drainage bag.
along the base of the nose, advancing the tube
slowly. Some pressure may be needed to enter Withdraw the tube if choking or coughing occurs
the nasopharynx. Try to have the child assist by during placement.
swallowing.
• Once the tube has been advanced the desired
distance, check the position either by aspirating
gastric contents or by listening with a
Suturing
Use Of Local Anesthesia
General • Use a 28- or 27-gauge needle (the size found on
• Lidocaine (1%, without epinephrine) is the local insulin syringes) and inject slowly
anesthetic that should be used
• To avoid systemic toxic effects, instill no more For detailed information on wound management
than 4 mg/kg (0.4 mL/kg of a 1% solution and suturing, see "Skin Wounds," in chapter 9,
without epinephrine) "The Skin," in the adult clinical guidelines.

Chapter 3 – Prevention
Definitions Of Prevention ................................................................................................................................. 1
Primary Prevention ......................................................................................................................................... 1
Secondary Prevention ..................................................................................................................................... 1
Tertiary Prevention ......................................................................................................................................... 1
Immunization..................................................................................................................................................... 1
Injuries ............................................................................................................................................................... 1
Definition........................................................................................................................................................ 1
Commonest Types Of Injuries........................................................................................................................ 1
Injury Prevention Strategies ............................................................................................................................ 2

General............................................................................................................................................................ 2
Anticipatory Guidance And Counseling......................................................................................................... 2
Well-Child Care ................................................................................................................................................ 4

Well-Child Visit.............................................................................................................................................. 4
Pre-School Entry Assessment ......................................................................................................................... 7
Specific Issues For Preventive Care Of Adolescents...................................................................................... 8
Appendix 3-1: Hearing Screening.................................................................................................................... 9

Infants And Pre-School Children.................................................................................................................... 9
Toddlers And Pre-Schoolers (3-5 Years Of Age)........................................................................................... 9
Appendix 3-2: Vision Screening..................................................................................................................... 10

General Principles And CPS Guidelines....................................................................................................... 10
Suggested Screening Techniques For Infants And Pre-School Children...................................................... 10
Visual Acuity Testing ................................................................................................................................... 11

Definitions Of Prevention
Prevention consists of activities directed toward eliminating risk factors that might lead to those
decreasing the probability of specific illnesses or outcomes.
dysfunctions in individuals, families and
communities. It is the concept of reducing Prevention has three components: primary,
unwanted health outcomes by reducing or secondary and tertiary prevention.
Primary Prevention
Activities aimed at intervention before natural history of susceptibility. Immunization is
pathological changes have begun and during the an example of primary prevention.
Secondary Prevention
Activities aimed at early detection of disease and complications and limit disability when cure is not
prompt treatment, to cure disease during its possible. A screening program is an example of
earliest stages or to slow its progression, prevent secondary prevention.
Tertiary Prevention
Limiting the effects of disease and disability for rehabilitation for people who already have residual
people in the earlier stages of illness and providing damage.
Immunization
For a detailed discussion of all issues related to Immunization Guide, 6th edition (Health Canada
vaccines and immunization, refer to the Canadian 2002). Follow the NWT immunization schedule.
Injuries
Definition
An injury is the result of any type of trauma, In terms of potential years of life lost, injuries are
whether intentional or unintentional. Injuries are significant contributors to total mortality. They are
preventable. among the leading causes of death and disability in
children of all age groups and the leading cause in
children >1 year of age.
Commonest Types Of Injuries

Infants And Toddlers Older Children (8-15 Years)
• Falls • Injuries related to bicycling and other sports
• Near-drowning
• Burns, scalds Youth (15-20 Years)
• Poisonings • Firearms-related injuries

Injury Prevention Strategies

General
• Preventing injuries requires effort from the total roads) and by regulations (e.g. requiring seat
community belts and bicycle helmets)
• Preventing injuries requires a detailed history of • A large part of preventing injuries is educating
exposure to potentially injurious activities within parents and caregivers about potential dangers to
the family and at school children and methods of avoiding injuries; this is
• Identifying children and families at risk is a an important role for the healthcare worker,
critical step in preventing injuries particularly nurses (during well-baby clinics and
• The environment can be modified by illness visits)
construction (e.g. fences around water, safer
Anticipatory Guidance And Counseling

The parents or caregiver should be educated about • Keep cleaning solutions, solvents and
the following strategies to minimize the risk of medications out of reach of a crawling infant
injury. (i.e. in upper cupboards)
• Avoid use of walkers, which represent a
Birth To 6 Months significant cause of injury
• Position child on back for sleeping, to prevent • Protect steps and stairways with gates
sudden infant death syndrome (SIDS) • Avoid peanuts, peanut butter, seeds and round
• Never leave child unattended in bathtub candies
• Use approved infant car seat (properly • Advise older children not to share small food
restrained) to protect child in vehicle items or objects (e.g. gum, peanuts, pennies)
• Ensure that mattress fits snugly in crib and that it with an infant
provides good body support (i.e. not made of • When child is near water, ensure that he or she is
feathers, not too soft); space between bars wearing a life jacket and is under continual
should be approved by CSA International supervision
(formerly the Canadian Standards Association)
• Because children like to put things in their 1-2 Years
mouths, keep small, hard objects that could be • Never leave child unattended in bathtub
swallowed out of reach, and avoid toys with • Set temperature on hot water tank at 54°C to
small parts that could come off while in the prevent scalding
child's mouth • Supervise child while he or she is close to
• Plagiocephaly ("flat head") prevention - ensure vehicular traffic
young infants have supervised tummy time • Use approved infant car seat in vehicles
several times a day while awake; place infants' • Turn pot handles away from edge of stove
heads in different positions for sleep
• Keep poisonous substances locked up or out of
reach
6-12 Months • Advise older children not to share small food
• Never leave child unattended in bathtub items or objects (e.g. gum, peanuts, pennies)
• Use approved infant car seat in vehicles with an infant
• Cover electrical outlets • When child is near water, ensure that he or she is
• Keep electrical cords and plugs out of reach or wearing a life jacket and is under continual
covered to prevent burns from chewing exposed supervision
cords or putting plugs in mouth

2-5 Years • Provide guidance about sexual activity,

• Never leave child unattended in bathtub including how to say No to unwanted touching
• Ensure that child uses a seat belt when in a • Provide instruction about gun safety
vehicle • Provide instruction about boating safety
• Ensure that child wears a helmet while bicycling • Ensure that young adolescent uses a seat belt
or skateboarding when in a vehicle
• Avoid transporting children 2-5 years of age on • Ensure that young adolescent wears a helmet for
ATVs and snowmobiles bicycle, ATV, snowmobile and skateboard use
• Keep matches and lighters out of reach • Ensure that young adolescent receives
• Keep poisonous substances locked up or out of instruction about water safety and swimming
reach skills
• Advise older children not to share small food
items or objects (e.g. gum, peanuts, pennies) 15-20 Years
with a younger child • Provide guidance about risk-taking behavior
• When child is near water, ensure that he or she is (particularly alcohol and substance abuse)
wearing a life jacket and is under continual • Provide guidance about sexual activity,
supervision including how to say No to unwanted touching
• Provide instruction about gun safety
5-10 Years • Provide instruction about boating safety
• Ensure that child wears a helmet for bicycle, • Ensure that young adult uses a seat belt when in
ATV, snowmobile and skateboard use a vehicle
• Ensure that child uses a seat belt when in a • Ensure that young adult wears a helmet for
vehicle bicycle, ATV, snowmobile and skateboard use
• Teach child how to prevent playground injuries
and how to use playground equipment safely Home Safety
• When child is near water, ensure that he or she is • Ensure that house is equipped with fire alarms
wearing a life jacket and is under continual and fire extinguishers
supervision • Establish exit routes, and ensure that all
• Ensure that child receives instruction about members of the family are aware of them
water safety and swimming skills • Ensure that firearms and ammunition are stored
• Teach child to avoid contact with strangers safely
• Ensure that dangerous chemicals are stored
10-15 Years safely, particularly if there are small children in
• Provide guidance about risk-taking behavior the home
(particularly alcohol and substance abuse)

Well-Child Care
Well-Child Visit
Purposes • Limbs, specifically muscle tone, motion,
• Immunization symmetry and hips (for congenital dislocation;
• Parental support regarding feeding, safety and in newborn period and at every visit up to 12
nurturing of children months of age)
• Screening for developmental or physical • Skin
problems • Growth measurements
• Parental education, counseling and anticipatory • Observe for achievement of major
guidance developmental milestones
Components Of Well-Child Visit Remain alert for ocular misalignment, vision

Review the child's health record and the family disorders, tooth decay, and child abuse or neglect.
record, so that you are aware of previous health
concerns and can plan what should be done during Growth Measurement
the current visit. Measurement of a child's weight, height and head
circumference is most important in the health
Review the child's immunization record. Ensure assessment process, because growth is a major
that consent for immunization is on file. characteristic of childhood.
Atypical growth patterns can be indicators of
Discuss with the parents or caregiver the child's pathologic processes.
health and progress:
• Current general health Correct measuring techniques and accuracy are
• Achievement of developmental milestones essential if the measurements are to be useful in
• Feeding habits evaluating growth. In addition, the measurements
must be appropriately recorded on a growth chart
• Sleeping habits
and compared to norms for the child's age and to
• Behavior
his or her previous growth pattern. If the child's
• Relationships with family members measurements consistently follow the relevant
growth curve, the growth pattern is considered
Perform a physical examination. Observe the normal.
following aspects:
• Nutritional status A graph gives an easily understood pictorial
• Character of cry (in infants <6 months of age) display of the child's growth and should alert the
• Color observer early to deviations from normal.
• Vision
• Hearing Failure to thrive should be suspected if the child's
• Activity level growth curve drops by two or more major
• Any other aspect, as dictated by concerns raised percentiles. In this situation, the child is
in the history considered at high risk. See "Failure to Thrive," in
chapter 17, "Hematology, Endocrinology,
In addition, examine: Metabolism and Immunology."
• Hair, scalp, fontanels
• Eyes, ears, nose, mouth (including dentition), Abnormal Growth Problems
throat Any child with growth or developmental problems
• Lungs, heart should be referred to a physician.
• Abdomen, genitalia

Weight Disproportionate Macrocephaly

• Above-normal weight combined with normal • If the head size is large relative to the child's
height: consider over-nutrition height and weight, close attention must be given
• Above-normal weight combined with below- to the physical examination and assessment of
normal height: consider a genetic cause (e.g. developmental status. Look for associated
Down's syndrome) or endocrine problems (e.g. physical findings such as a bulging fontanel or
hypothyroidism, Cushing's disease) split sutures, neurologic abnormalities or delays
• Below-normal weight combined with normal in reaching developmental milestones
height and head circumference: consider under- • Above-normal head size combined with normal
nutrition, failure to thrive, iron deficiency, weight and height: consider primary
psychosocial deprivation, hypothyroidism hydrocephalus, hydrocephalus secondary to
• Below-normal weight combined with below- associated disease of the central nervous system,
normal height and head circumference: consider primary familial megalocephaly or
organic cause (e.g. renal failure, iron deficiency, megalocephaly secondary to associated disease
lead intoxication, immune deficiencies, inborn of the central nervous system or to a metabolic
errors of metabolism, HIV infection) storage disease (e.g. Krabbe's disease,
neurofibromatosis)
Height
• Above-normal height combined with normal Evaluation
weight and head size: in 90% of cases, this A three step approach should be taken in
combination of growth parameters represents a evaluating a child with an abnormal growth curve.
familial tendency; the rate of growth is normal, 1. Check the growth data for accuracy.
although the absolute percentile value is greater 2. If a growth problem is substantiated, assess the
than normal; may also be caused by excess child closely for associated symptoms, abnormal
production of growth hormone, hyperthyroidism findings on physical examination or delays in
or Marfan's syndrome development. Obtain parents' measurements.
• Above-normal height, weight and head size: 3. Any abnormality in a child's rate of growth
consider a pathologic process (e.g. acromegaly) requires further assessment. Consult a physician
or a chromosomal disorder (e.g. Klinefelter's for advice. Children with suspected growth
syndrome) abnormalities who are otherwise normal should
• Below-normal height: consider a pathologic be followed closely to determine their growth
process (e.g. deficiency of growth hormone, rate.
hypothyroidism, chronic anemia), a
chromosomal disorder (e.g. Turner's syndrome) Appropriate Screening
or failure of a major organ system (e.g. GI, The idea of screening for early detection of disease
renal, pulmonary or cardiovascular) is appealing, but it is valuable only if the following
conditions pertain:
Head Circumference • The disease can be diagnosed reliably by a
Disproportionate Microcephaly simple, acceptable test
• Head size that is small relative to the child's • Effective treatment is available
height and weight is often an indicator of a • The benefits outweigh the costs
pathologic process
• Below-normal head size combined with normal The following situations are those in which
weight and height: consider craniosynostosis, screening is thought to be useful in child care.
prenatal insult (e.g. maternal drug or alcohol
abuse), maternal infection, complications during Phenylketonuria (PKU)
pregnancy or birth, chromosome defects • All newborns should be screened for PKU by
• Disproportionate microcephaly requires means of a capillary blood sample before
immediate evaluation (at the time of diagnosis) discharge from the hospital

• For any newborn who undergoes this type of See "Iron Deficiency Anemia in Infancy," in
screening at less than 24 hours of age, the chapter 17, "Hematology, Endocrinology,
screening test must be repeated between 2 and 7 Metabolism and Immunology."
days of age
Developmental Screening
Congenital Hypothyroidism In monitoring the health of children,
• All newborns should be screened for TSH level developmental assessment is an important function
by means of a dried capillary blood sample in that should not be neglected. Such assessment is
the first week of life done by making inquiries of the parents or
• If child was born in hospital, verify that this type caregiver and by clinical observation of the child's
of screening was done before discharge achievement of major age-appropriate milestones.
Others Assess achievement of developmental milestones

The routine neonatal heel-prick test is able to for all children at every opportunity, formal
screen for some other more rare conditions (e.g. Nipissing screening should take place at 6, 12, 18
Maple sugar urine disease, transient neonatal or months, 3 years and 4-6 years.
familial tyrosinemia, biotinidase deficiency)
The earlier developmental delays are detected, the
Hemoglobin Screening sooner an intervention can be undertaken.
The prevalence of anemia is high among Hopefully, early intervention will minimize the
Aboriginal children 6-24 months of age. In long-term impact on the child. It is critical that
addition to ethnic background, other risk factors steps be taken to alleviate developmental problems
for anemia are prematurity and low birth weight, before the child reaches school age.
breast-feeding beyond 6 months of age without
addition of iron rich solids, lack of access to or The Canadian Task Force on Preventive Health
inability to consume iron-fortified products, diet of Care recommends that developmental screening be
cow's milk only in the first year of life and low excluded from the periodic health examination of
socioeconomic status. asymptomatic children.
The Canadian Task Force on Preventive Health However, formal developmental testing (e.g.
Care (formerly Canadian Task Force on the Nipissing, as well as other testing tools that are
Periodic Health Examination 1994) recommends available) may be helpful if a concern about
that screening for hemoglobin level be performed developmental delay is either expressed by the
at 6-12 months of age, optimally at 9 months. parent or caregiver or suspected by the healthcare
Hemoglobin should be monitored more frequently professional.
in children in whom anemia has been identified
and treatment has begun. (For information on developmental screen refer
to: A Guide for Using the Nipissing District
Table 3-1: Normal hemoglobin levels in Developmental Screen in the NWT, May 2002).
children
Any child with suspected delay(s) should be
Age Hemoglobin level (g/L) referred promptly to a physician for assessment.
1 month 115 – 180
2 months 90 – 135 Hearing Screening
Hearing impairment is one of the most important
3-12 months 100 – 140 causes of speech delay, educational difficulties
1-5 years 110 – 140 and behavioral difficulties. Early intervention can
6-14 years 120 – 160
help to prevent significant speech and educational
delays. Therefore, the most important time to
screen is during infancy. Unfortunately, this is also
the most difficult time to test a child's hearing.

The parents or caregiver should be asked about the for abnormalities and the corneal light reflex test.
child's hearing ability as part of every well-child Infants should also be examined for strabismus (by
visit. In addition, the clinician should observe the means of the cover-uncover test) in the first year
child's response(s) to sounds. of life (see also "Strabismus [Squinting]," in
chapter 8, "The Eyes").
Formal hearing screening by such methods as
tympanometry or pure-tone audiometry is reserved The Task Force also recommends that initial
for high-risk (e.g. repeated ear infections or strong screening of visual acuity be undertaken in the
family history) or symptomatic children. pre-school period (3-5 years of age). If visual
acuity on Snellen charts is 20/30 or less,
The Canadian Task Force on Preventive Health optometric assessment is advised.
Care does not recommend routine formal testing
of asymptomatic children for hearing impairment See Appendix 3-2, this chapter, for details of
in the pre-school years. Furthermore, such testing vision screening. For more detail on pediatric eye
is of little benefit in asymptomatic older children care, see chapter 8, "The Eyes."
and adolescents.
When Screening Does Not Work
Temporary conductive hearing loss secondary to Urine
otitis media or serous otitis media with effusion is Routine urinalysis is not recommended for
common in Aboriginal communities and may asymptomatic children.
persist for long periods of time (months).
Consultation with a physician is important for Scoliosis
management of chronic otitis media with hearing The natural history of scoliosis is not well
loss. understood, and treatments have not been well
evaluated. The screening test itself is not very
See Appendix 3-1, this chapter, for details of sensitive or specific. Any abnormalities in posture,
hearing screening. spinal symmetry or curvature identified by the
child or the child's parents or caregiver should be
Vision Screening referred to a physician for assessment.
The Canadian Task Force on Preventive Health
Care recommends that all well-child visits during Observe the spine in adolescents who present for
the first 2 years of life include an eye examination other reasons.
to check for abnormalities of vision. This
examination should include inspection of the eyes
Pre-School Entry Assessment

It is important that all children undergo a detailed allows time for any medical, surgical or social
pre-school assessment in preparation for starting referrals to be made before school starts in the fall.
school. The purpose of the assessment is to ensure
readiness for school and to identify and correct Components Of The Pre-School Entry
any health problems that might interfere with the Assessment
child's performance in school. It is important that a parent or the main caregiver
accompany the child for this visit.
The assessment is generally done at 4-5 years of • Review of child's past health history, as well as
age, before the child enters kindergarten. the family's health history
• Review of present health status
It is best to organize one or more special clinics in
the spring of each year to carry out pre-school
entry assessments for all children of the
appropriate age living in the community. This

Brief Physical Examination Health Counseling for Parents or

• Eyes, ears, nose, throat, teeth Caregiver as Necessary
• Respiratory system • Offer nutritional counseling
• Check for cardiac murmurs • Recommend provision of intellectual stimulation
• Abdomen (e.g. exposure to books and reading)
• Genitalia • Provide anticipatory guidance about
• Musculoskeletal system developmental milestones
• Provide information about resources available
Screening for school-age children (e.g. dental care,
• Growth: measure height and weight, and plot on audiology, optometry, speech therapy)
growth chart • Allow time to discuss the results of the
• Vision: Goodlite illiterate "E" chart or random assessment with the parents or caregiver and to
dot "E" chart let them raise concerns or ask questions
• Hearing • Initiate referrals to specific healthcare
• Speech: gross screening for articulation professionals or agencies as required to address
• Developmental screening: formal Nipissing any identified health problems (with parental
screen if indicated by concerns expressed by the approval and consent)
parents or caregiver or by a healthcare • Record all information on the child's personal
professional health history and immunization record and in
• Hemoglobin, urinalysis: should be done general file as necessary
selectively for children whose medical history • Instruct the parents or caregiver to notify the
indicates a past or ongoing problem such as school of any identified health problem that
anemia or urinary tract infection might have implications for the child's school
• Review of immunization status: obtain attendance or performance
appropriate consents and update immunizations
according to accepted schedule; refer to the
NWT immunization schedule and to the
Canadian Immunization Guide, 6th edition
(Health Canada 2002)
Specific Issues For Preventive Care Of Adolescents

See chapter 19, "Adolescent Health."

Appendix 3-1: Hearing Screening

Perform gross hearing screening for all children to a sound stimulus (e.g. clapping hands) in a
during child health clinics. Gross screening younger child and pure-tone audiometric screening
includes questioning the parents or caregiver about in the older pre-schooler (3 years of age) if a
the child's hearing ability, observing the response concern has been raised about hearing.
Infants And Pre-School Children

Age Procedure Method Normal Response
Newborn to 2 Startle response Produce a loud noise near Child is startled, jumps at the noise,
months (Moro reflex the child’s ear (e.g. clap blinks, widens eyes, cries
hands or slap table surface)
3-5 months Ability to track sound Produce a noise (e.g. ring Child’s eyes shift toward sound; child
stimulus bell, call child’s name, sing) responds to mother’s voice or coos
when he or she is engaged
6-8 months Sound recognition Produce noise out of child’s Child turns head in response to sound;
line of vision (e.g. ring bell, responds to name; babbles in response
call child’s name, sing) to verbalization
9-12 months Sound localization Call child’s name or say Child localizes to source by turning
words from outside child’s head or body toward sound; may try to
field of vision imitate words
12-24 months Speech development Engage child in
(normal for age) conversation or question
parent or caregiver about
speech
Toddlers And Pre-Schoolers (3-5 Years Of Age)

Pure-Tone Audiometry Using Play 6. Set audiometer at 25 dB and 1000 Hz and
Response present tone in left earphone.
Procedure 7. If child responds correctly, proceed to test
1. Demonstrate method to child: put on ear 2000, 4000 and 6000 Hz at 25 dB.
phones, pretend to hear a sound, say "I hear it" 8. Switch to right ear and present 1000, 2000,
and, at the same time, place a block in a box or 4000 and 6000 Hz at 25 dB.
a plastic ring on a ring holder. 9. Record results on audiography sheet (child
2. Place ear phones correctly on child. should be able to hear all frequencies at 25
3. Give a block or ring to the child. dB).
4. Produce a tone at 50 dB and 1000 Hz, and 10. Retest, later in the day, frequencies for which
guide child's hand to place block in box or ring response was "doubtful."
on ring holder. 11. Children who do not hear all frequencies
5. After practice, when child seems to understand should be referred for further assessment by a
the procedure and responds correctly, proceed physician.
with the screening.

Appendix 3-2: Vision Screening

General Principles And CPS Guidelines
Screen all children for vision abnormalities.
Screening should include inspection of the eye 6-12 Months Of Age
structures for abnormalities, the corneal light • Conduct examination as for newborn to 3
reflex test, the cover-uncover test in the younger months of age.
infant or child, and visual acuity testing in older • Observe ocular alignment to check for
children 3 years). strabismus. The corneal light reflex should be
central and the cover-uncover test normal.
The Canadian Paediatric Society has made the
• Observe fixation and following.
following recommendations for vision screening
(Community Paediatric Committee, CPS 1998).
3-5 Years Of Age
Newborn To 3 Months Of Age • Conduct examination as for newborn to 3
• A complete examination of the skin and external months of age.
eye structures, as well as the conjunctiva, • Conduct visual acuity testing.
cornea, iris and pupils, is an integral part of the • Any child with visual acuity less than 20/30
physical examination of all newborns, infants should be referred for optometric assessment.
and children.
• The retina should be inspected (by means of the 6-18 Years Of Age
red reflex) for opacities of the lens (cataracts) • Visual acuity should be assessed (e.g. by Snellen
and signs of posterior eye disease chart) every 2 years until 10 years of age, then
(retinoblastoma). every 3 years until 18 years of age.
• Failure of visualization or abnormalities of the • Any child with visual acuity less than 20/30
red reflex are indications for referral to an should be referred for optometric assessment.
ophthalmologist.
• Corneal light reflex should be tested to detect
ocular misalignment.
Suggested Screening Techniques For Infants And Pre-School

Children
Birth To 4 Months Of Age (Near-
Visual Acuity) Tests For Strabismus (Squint)
Observe child and ensure that the following occur: Procedure for Corneal Light Reflex Test
• Regards face (of examiner or mother) in line of 1. Sit at child's eye level.
vision 2. Hold a light source (penlight) 13 inches (32 cm)
• Follows object or light to midline away from the child, in front of your own nose.
• Follows object or light past midline 3. Ask child to focus on the light, if child is old
• Follows object or light through 180° enough to understand and follow the instruction.
4. Observe position of the light reflex of each
• Grasps rattle when offered
cornea and of the eyes.
• Reaches toward an object placed in line of
vision Responses
• Normal: both eyes are focused in same position,
3-4 Months Of Age And Over and the light reflects off the same area of the
As for children 1-4 months of age, but add tests cornea, usually slightly to the nasal side of the
for strabismus. pupil center

• Abnormal: eyes are not aligned in position, and 4. Repeat steps 1, 2 and 3 for the other eye.
the light reflexes are asymmetric, i.e. coming off
different areas of the cornea; this may indicate For further explanation, see "Strabismus
squinting (Squinting)," in chapter 8, "The Eyes."
If response is abnormal for the corneal light reflex Responses

test, perform the cover-uncover test to further • Normal: both eyes are focused in the same
assess for strabismus. position
• Abnormal: covered eye will deviate and may
Procedure for Cover-Uncover Test swing back into alignment when the cover is
Perform this test only if the child is able to removed; in more obvious cases, the eye will
cooperate. remain deviated after the cover is removed or
1. Cover one eye with an opaque object (a large always appears deviated
plastic spoon-shaped cover designed for this
purpose may be available; otherwise, Referral
improvise). Children with abnormal responses on the corneal
2. Instruct or try to get the child to fix his or her light reflex test and the cover-uncover test should
gaze on a light source (held in front of him or be seen as soon as possible by a physician.
her) with the uncovered eye. Referral to an ophthalmologist may be necessary.
3. Quickly remove the cover from the covered eye,
and observe the position of that eye.
Visual Acuity Testing

Visual acuity of 20/30 or less requires referral for "E" chart. This test is preferably administered in
further optometric assessment. the child's own language.
3-5 Years Of Age 6-18 Years Of Age

If the child is able to comprehend instructions, use If the child knows the alphabet, use a Snellen
the Goodlite illiterate "E" chart or the random dot chart. Otherwise, use the symbol or "E" charts.

Chapter 4 – Fluid Management

Fluid Management ............................................................................................................................................ 1
Fluid Requirements In Children...................................................................................................................... 1
Dehydration In Children ................................................................................................................................. 1

Fluid Management
Fluid Requirements In Children
General Information Table 4-1: Daily maintenance fluid
Maintenance fluid is the amount of fluid the body requirements (24 hour period)
needs to replace usual daily losses from the
respiratory tract, the skin, and the urinary and GI Calculation
tracts. 100 mL/kg for the first 10 kg body weight
+ 50 mL/kg for the next 10 kg body weight
A well child usually drinks more than maintenance
requirements. If a child takes in significantly less + 20 mL for each kilogram of body weight over 20 kg
than maintenance requirements, he or she will Examples
gradually become dehydrated.
For 10 kg child: 10 kg x 100 mL/kg = 1000 mL
The requirement for maintenance fluids varies For 15 kg child: (10 kg x 100 mL/kg) +
with the weight of the child (Table 4-1). Infants (5 kg x 50 mL/kg) = 1250 mL
need more fluid per kilogram of body weight than For 25 kg child: (10 kg x 100 mL/kg) +
do older children. Various medical conditions will (10 kg x 50 mL/kg) + (5 kg x 20 mL/kg) = 1600 mL
also affect these requirements (Table 4-2).
Table 4-2: Conditions modifying daily fluid
requirements
Requirement increased Requirement decreased
Fever,* sweating, Meningitis
vomiting or diarrhea
Congestive heart failure
Diabetes
Renal failure
Burns
* Daily maintenance fluids should be increased by
12% for every degree Celsius body temperature
above 37.5°C (rectal)
Dehydration In Children
Definition
Abnormal decrease in volume of circulating therefore more prone to loss of water, sodium and
plasma. potassium during illness.
Causes History
• Gastroenteritis (most common cause in • Fever
childhood) • Vomiting
• Inadequate fluid intake • Diarrhea
• Diabetes mellitus • Urine output
• Burns • Lethargy
• Pyloric stenosis • Irritability
• GI obstruction
All body systems must be reviewed to ascertain
Newborns and young children have a much higher underlying cause.
water content than adolescents and adults and are

Physical Findings
Table 4-3: Clinical features of dehydration

Mild dehydration Moderate dehydration Severe dehydration
Feature
(< 5%) (5-10%) (> 10%)
Heart rate Normal Slightly increased Rapid, weak
Systolic blood Normal Normal to orthostatic, Hypotension
pressure > 10 mmHg change
Urine output Decreased Moderately decreased Markedly decreased, anuria

Mucous Slightly dry Very dry Parched
membranes
Anterior fontanel Normal Normal to sunken Sunken

Tears Present Decreased, eyes sunken Absent, eyes sunken
Skin* Normal turgor Decreased turgor Tenting
Skin perfusion Normal capillary refill Capillary refill slowed (2-4 Capillary refill markedly
(<2 seconds) seconds); skin cool to touch delayed (>4 seconds); skin
cool, mottled, gray
* Skin condition is less useful in diagnosis of dehydration in children >2 years
Diagnostic Tests Nonpharmacologic Interventions

• Urinalysis to check for ketones • Using the criteria presented in Table 4-3, decide
• Blood glucometry to rule out diabetes (if no if child is mildly, moderately or severely
diarrhea) dehydrated.
• Weigh child (without clothes).
Management • Once you have determined the degree of
Goals of Treatment dehydration, calculate the fluid deficit according
• Correct dehydration using oral rehydration to Table 4-4 (using the percent dehydration
therapy (ORT) with or without IV fluids values shown in the column headings for Table
• Treat shock or impending shock 4-3).
• Prevent complications (e.g. seizures or edema)
Table 4-4: Calculating fluid deficit
Calculation
Consult a physician as soon as possible for any Fluid deficit (L) = weight (kg) x % dehydration
infant or young child with signs of dehydration. If
the child has presented with severe signs (e.g. Example
shock), this consultation may have to wait until the For an 8 kg child with 10% dehydration:
child's condition has been stabilized. 8 kg x 10% = 0.8 L deficit
When you have calculated the deficit, add

maintenance requirements (see Tables 4-1 and
4-2) and rehydrate according to Table 4-5.

Table 4-5: Fluid resuscitation

Moderate dehydration
Mild dehydration (<5%) Severe dehydration (>10%)
(5-10%)
• Start ORT: 10 mL/kg/hr for 6-8 • Attempt ORT as in mild • Medical emergency
hours dehydration: 15-20 mL/kg/hr for
6-8 hours • NS or Ringer’s lactate 20 mL/kg
• Reassess at 4 hour intervals IV over 20 minutes
• Reassess at 4 hour intervals
• From 8-24 hours give ORT ad • Monitor blood pressure
libitum • From 8-24 hours give ORT ad
libitum • Repeat bolus (to a maximum of 3
• Replace deficit over 6-8 hours, boluses in first hour) if signs of
add maintenance requirement to • Give fluid frequently, in small shock persist (e.g. tachycardia,
deficit amounts decreased systolic blood pressure,
poor perfusion, skin gray and
• Give extra ORT after each • Replace deficit over 6-8 hours, mottled)
diarrheal stool (e.g. 5-10 mL/kg) add maintenance requirement to
deficit • Once response occurs, calculate
• Monitor urine output (should be at remaining deficit; replace 50% of
least 1 mL/kg/hr) • Give extra ORT after each the deficit over 8 hours, remainder
diarrheal stool (e.g. 5-10 mL/kg) over next 16 hours (be sure to add
• Continue breast-feeding; if child maintenance requirements to total
is bottle fed, early refeeding of • Monitor urine output (should be at IV therapy
child’s normal formula (within least 1 mL/kg/hr)
6-12 hours) is recommended • Monitor urine output (should be at
• Continue breast-feeding; if child least 1 mL/kg/hr)
• Full diet should be reinstituted is bottle fed, early refeeding of
within 24-48 hours, if possible child’s normal formula (within 6- • If unable to start an IV line in 3
12 hours) is recommended attempts (or within 60-90
• Delay refeeding only if there is seconds), establish intraosseous
severe protracted vomiting access
• For intraosseous infusion, see

Chapter 2; this technique can save
the child’s life and is not
technically difficult; when line is
in place use as you would a
regular IV line.
Monitoring and Follow-Up General Comments about Fluid

Reassess level of consciousness (according to Management
pediatric Glasgow coma scale, Table 15-1, in IV therapy should usually be used only for severe
chapter 15, "Central Nervous System"), vital dehydration or intractable vomiting; oral therapy is
signs, skin perfusion, skin turgor and urine output always safer. However, the oral replacement
frequently. solution (ORS) may be administered by
nasogastric tube if necessary.
Referral
Medevac any child with moderate to severe Use an ORS such as Pedialyte® or Gastrolyte® to
dehydration as soon as possible. replace the calculated deficit. If the child is breast-
feeding and is able to nurse, then breast-feeding
should be continued for maintenance

requirements; supplement with Pedialyte® or Some increase in stools does not matter, as long as
Gastrolyte® to make up the deficit. the child takes in enough to keep up with losses. In
other words, treat on the basis of the child's
Increase the amount of maintenance fluids if there condition, not on the basis of the stools.
are ongoing fluid losses (e.g. if diarrhea
continues). If the child is vomiting, he or she will usually
tolerate fluids by mouth if given in small amounts
If a marked increase in diarrhea occurs when a (one sip at a time). If child will not suck, try
bottle-fed child returns to his or her usual cow's giving sips frequently by spoon.
milk formula, consult a physician about changing
to a soy-based formula (e.g. Prosobee® or Allow mother and other family members to
Isomil®). Switch back to regular cow's milk administer fluid. Increase daily maintenance fluids
formula within 7-10 days. by 12% for every degree Celsius body temperature
above 37.5°C (rectal).
Do not go back to Pedialyte® unless there is a
marked increase in stools while on soy formula.
Quick reference Example

1. Weigh child 15 kg baby
2. Determine degree of dehydration (Table 4-3) Moderately (10%) dehydrated
3. Calculate fluid deficit (Table 4-4) 15 kg x 10% = 1500 mL
4. Add maintenance requirements (Table 4-1 and 4-2) (10 kg x 100 mL) + (5 kg x 50 mL) =
1250 mL
5. Total fluid requirements in 24 hours Total = 2750 mL
6. Rehydrate according to Table 4-5 15 kg x 15-20 mL = 225-300 mL/hr x 6-8 hours

Chapter 5 – Child Abuse

Definitions .......................................................................................................................................................... 1
Child Abuse .................................................................................................................................................... 1
Physical Abuse................................................................................................................................................ 1
Sexual Abuse .................................................................................................................................................. 1
Neglect ............................................................................................................................................................ 1
Situations In Which Child Abuse Occurs ....................................................................................................... 1
History And Physical Examination ................................................................................................................. 2

Indicators Of Possible Physical Abuse ........................................................................................................... 2
Differential Diagnosis Of Physical Abuse...................................................................................................... 2
Indicators Of Sexual Abuse ............................................................................................................................ 2
Indicators Of Emotional Abuse ...................................................................................................................... 3
Indicators Of Neglect...................................................................................................................................... 3
Management ...................................................................................................................................................... 3
Legal Aspects ..................................................................................................................................................... 4
Refer to NWT Child and Family Services Act 1998, amended 2002, available at:
http://www.canlii.org/nt/sta/pdf/type35a.pdf

Definitions
Child Abuse Emotional Abuse
Any injury intentionally inflicted upon a child by Acts or omissions by a parent, caregiver or other
an older person. person that are damaging to a child's physical,
May involve physical, sexual or emotional abuse intellectual or emotional development. Such acts
or neglect. or omissions may include unwillingness or
inability to provide care, control, affection or
Physical Abuse stimulation, or exposure of the child to family
An act or omission by a parent, caregiver or other violence.
person that results in injury to a child. Such acts
include inflicting blows that cause bruising, Neglect
striking a child with a fist or instrument, and Child neglect includes situations in which children
kicking, throwing or shaking a child. An omission have suffered harm, or their safety or development
is the failure to prevent an injurious act. has been endangered as a result of the caregiver's
failure to provide for or protect them. Unlike
Sexual Abuse abuse, which is usually incident-specific, neglect
Any exploitation of a child for the sexual often involves chronic situations that are not as
gratification of an adult or older person. Sexual easily identified as specific incidents.
abuse is a criminal offense under the Criminal
Code of Canada; hence, involvement of the local Trocmé et al, (2001) Canadian Incidence Study of
police force and local child-protection authorities Reported Child Abuse and Neglect
is essential in all investigations of sexual abuse.
Situations In Which Child Abuse Occurs

The occurrence of child abuse usually depends on A high-risk child is one who may have special
the interplay of three components: a high-risk physical needs or who is perceived as undesirable
parent, a high-risk child and a crisis. for a variety of reasons (e.g. unwanted, of dubious
paternity, irritable).
High-risk parents tend to have low self-esteem,
few supports and difficulty establishing trust. Not The crisis is an event, major or minor, within the
all abused children become abusing parents, but family that precipitates the abusive event.
many abusing parents were abused as children.

History And Physical Examination

If during a routine exam you begin to suspect It is important to document any physical signs,
abuse, refer to Management section following. which lead you to report your suspicion of abuse,
without jeopardizing any subsequent investigation.
Indicators Of Possible Physical Abuse

General Table 5-1: Estimating ages of healing bruises
• Family history of abuse Color of bruise Days since injury
• Delay in seeking medical attention after an Red 0-1
injury Bluish purple 1-4
• Inconsistencies in the history
Greenish yellow 5-7
• History incompatible with the presenting
problem Yellowish brown ≥8
Source: Rudolph's Fundamentals of Pediatrics (Rudolph
Specific and Kamei, 1998)
• Unexplained bruises and welts, especially if on
multiple body surfaces or if in a recognizable Document:
pattern (e.g. belt marks, fingerprints) • Detailed description of the injury
• Injuries at various stages of healing (Table 5-1) • Measurements and drawings where appropriate
and in areas of the body not normally injured • Colour, size and age of lesions
during play (e.g. axilla, neck, ear) • Child's behaviour
• Unexplained burns • Details of any spontaneous explanations
• Unexplained fractures provided
• Any fractures in the first year of life
Do not question the child, the parent or the
caregiver. Report your suspicions to the Social
Worker.
Differential Diagnosis Of Physical Abuse

• Accidental injury (e.g. unrestrained child in • Mongolian spots
motor vehicle collision, bicycle accident)
• Dermatologic condition (e.g. impetigo, contact
dermatitis)
Indicators Of Sexual Abuse

Specific Less Specific
• Bruises or lacerations of genitalia • Difficulty walking
• Vaginal or penile discharge • Pain or itching in genital area
• STIs • Behavioral symptoms: sexualized behavior in
• Vaginal bleeding play, delinquent behavior, self-destructive
• Pregnancy (if child <14 years of age and an behavior, runaway behavior
adult male was involved) • Depression in a child or adolescent

Indicators Of Emotional Abuse

• Failure to thrive (in some infants) • Developmental lags
• Behavioral disturbances
Indicators Of Neglect
• Failure to thrive • Abandonment
• Unattended physical or medical needs • Failure to supervise
• Poor hygiene
Management
The steps in managing a case of suspected abuse "closing down" the child. The child must continue
are outlined below to think that what she has to say is important, and
she must feel safe enough so that she can relate the
1. Suspect abuse complete disclosure to the social worker.
2. Report your suspicions verbally and in writing 2. Don't make promises to the child that you have
to a social worker. Your involvement with the no way of keeping. For example, telling a child
case should then stop here, except at the specific that "everything is alright" or "now you will get
request of the social worker or RCMP. Note that the help you need" are promises that cannot be
if you are involved in examining the child guaranteed.
specifically in relation to a suspicion of abuse, you
may be called upon as a witness in any subsequent 3. Once a disclosure has been made or enough
court proceedings. information given so that you suspect abuse, do
not continue with questioning. It is the role of the
Handling A Disclosure Of Abuse social worker and/or RCMP to question the child
1. Listen to disclosures in a caring and calm about the details of abuse. They will then be able
manner. Let the child tell her story in her own to document this information first-hand and
way - don't ask leading questions about the present it in court if needed. If you question the
disclosure. Make sure the child knows that you child for details, it could cause serious problems
believe her and that what happened to her was not with the investigation.
her fault. Let her know that telling someone was
the right thing to do and that now you are going to 4. Immediately after a disclosure you should
contact the social worker to try to get some help document and date any comments or statements
for her. The child may receive some comfort from made by the child during the disclosure. Try to
knowing that she is not alone and that other use the child's exact words. Keep notes about the
children have gone through this. Do not judge the child's behaviour and emotional state, as well as
events, circumstances or individuals involved, and the circumstances at the time of the disclosure, e.g.
don't express to the child what you think she might "Child stayed in chair with face hidden and cried
be feeling, e.g. "You must hate him for what he for 15 minutes".
did to you".
5. Call and make a report of child abuse to a
When the child has finished what she has to say social worker.
and has disclosed enough so that you suspect
abuse, tell the child that you are not allowed to 6. Follow up this verbal report with a written
hear any more because it is important that she report to the social worker you spoke to.
share her disclosure with a social worker. It is 7. Make two copies of the written report and all of
very important to end the disclosure without your notes, as well as any written/drawn material

that may form part of the child's disclosure. Give • Feelings of guilt for having told
the originals to the social worker you first speak • Fear and anxiety about what may happen next
to. Mail a copy of the written report and all • Anger or withdrawal
supporting documents to the Director of Child and • Uncertainty
Family Services in Yellowknife. Keep a copy of • Feelings of being blamed
all documentation on the child's chart.
• Feelings of low self-esteem
8. Maintain confidentiality. You may, however,
• Feelings of shame
need to let other health care professionals know
10. Be aware of your own feelings about the
about the incident in order that they can care for
disclosure.
the child appropriately, following correct
protocols, and also be on the alert for possible
11. Practice using non-leading or open questions
other cases, either in the same family, or in the
and comments.
community.
For more information refer to GNWT Education,
9. If you have continued contact with the child,
Culture and Employment (1995) "Dealing with
recognize and respect the child's feelings in the
Child Abuse": A Handbook for School Personnel.
days following the disclosure. These may include:
Legal Aspects
The Criminal Code of Canada is penal in nature, In Canada, any person who has information about
intended to punish the perpetrator. Conviction potential abuse or who is concerned that a child
under the Criminal Code requires proof beyond a needs protection is legally obliged to report the
reasonable doubt, but investigations and situation to a child-protection agency or the police.
appropriate placement may be initiated whenever Failure to do so is considered an offense
suspicion of abuse arises. Child-protection punishable by summary conviction. Those who
legislation has been enacted in all Canadian report in good faith are protected from legal
provinces and territories. The purpose of this action.
legislation has been to determine what is in the
best interests of the child. Investigations under Nurses should be familiar with:
these acts are considered civil in nature, with the (1) the NWT legislation
degree of proof based on a balance of probability. (2) the appropriate child-protection and law
enforcement representatives in the community.

Chapter 6 – Dysfunctional Problems Of Childhood

Introduction ....................................................................................................................................................... 1
Common Dysfunctional Problems ................................................................................................................... 1

Learning Disabilities....................................................................................................................................... 1
Fetal Alcohol Spectrum Disorders.................................................................................................................. 2
Attention Deficit Hyperactivity Disorder (ADHD) ........................................................................................ 6

Introduction
The topics discussed in this chapter include a Assessment of these problems requires, above all,
variety of physiologic, psychologic and social establishing a good rapport with the family and the
problems that may interfere with important child. Usually, the initial interview is lengthy; this
functions of daily living. is the session during which trust is established.
The history and physical examination vary with
the presenting complaint.
Common Dysfunctional Problems

Learning Disabilities
Definition Examination
Inability to process language and its symbols or Most aspects of the examination required to define
lack of arithmetic-related skills at a level equal to a specific learning disability are performed by a
peer group. psychologist and education specialists.
Affected children usually suffer from learning Perform a physical examination to rule out the
disability in a specific area and are normal in all following conditions:
other areas of development. • Hearing and vision problems
• Medical problems
Causes • Fetal alcohol syndrome (FAS)
Specific learning disabilities are generally thought • Abuse
to be biologic in origin, although the exact • Iron deficiency anemia
mechanisms and biology have not yet been • Neurologic abnormality
determined.
Major psychiatric disturbances, social deprivation, • Poor school performance (common)
or loss of vision or hearing can also produce poor • Poor motivation (family disorganization)
learning skills and must be differentiated from • Global developmental delay (mental retardation)
specific disabilities. • Depression
• Sensory disorders (e.g. hearing loss secondary to
History otitis media)
• Current and past behavior and school • Cerebral palsy
performance (look for specific patterns and for
hyperactivity, which is often associated with a Management
learning disability) Nonpharmacologic Interventions
• Perinatal history (perinatal asphyxia or • Advocate for the child in the education system
intrauterine injury may play a role in some • Support the child's self-esteem
cases), prematurity • Support child and parents or caregiver with
• Family history (such disorders often run in behavioral strategies in conjunction with
families) psychologic counseling and education
• Early development: recognition of risk factors • Recommended (by Canadian Paediatric Society)
such as delayed language development video "1-2-3 Magic: Training your children to
• Social, environmental, family and social factors, do what you want" (120 min.), 1990. Ask your
which may aggravate the problem (e.g. constant family resource library, or order a copy ($39.95
derision may lead to low self- esteem) US + $6.00 s/h) 1-800-442-4453.
• History of meningitis, head trauma • Arrange for treatment by specialists


• Follow up two or three times a year with the • Most management of this problem should be
child and the parents or caregiver to assess done through the education system.
progress and provide support • Refer the child to a physician for evaluation as
• Liaise annually with the school (with parental soon as possible (elective).
consent) • A baseline assessment by a pediatrician is
indicated.
Fetal Alcohol Spectrum Disorders

Introduction FAS, including reduced or delayed growth,
Alcohol is a known teratogen that can cause birth single birth defects, or developmental learning
defects by affecting the growth and proper and behavioral disorders that may not be noticed
formation of the fetus's body and brain (Olson et al until months or years after the child's birth.
1992). Exposure to alcohol before birth can lead to • Alcohol-related birth defects (ARBD)
long-term developmental disabilities in the form of • Alcohol-related neurodevelopmental defects
motor, speech or behavioral problems. The range (ARND)
of disability varies, even for those with a diagnosis
of fetal alcohol syndrome (FAS). Collectively, these alcohol related developmental
disabilities are now often referred to as Fetal
There is no definitive information as to the Alcohol Spectrum Disorders (FASD).
quantity of alcohol that may be safely consumed
during pregnancy. Full-blown FAS is more likely The Canadian Paediatric Society (March 2002)
to occur if intake of alcohol during pregnancy is advises healthcare professionals, including family
heavy or continuous (Olsen 1992), but detrimental physicians, pediatricians and others to whom
effects have also been observed after intermittent children are referred, to increase their awareness
or binge drinking. Children born to mothers who of maternal alcohol use during pregnancy, so as to
consumed on average one or two drinks per day identify the possible causes of birth defects and
and who may occasionally have consumed up to other developmental disorders and to identify and
five or more drinks at a time are at higher risk for prevent risks for subsequent pregnancies.
learning disabilities and other cognitive and
behavioral problems. High-Risk Populations
Women who drink and have the following
Abnormalities related to prenatal exposure to characteristics:
alcohol occur along a continuum. Many terms • Low socioeconomic status
have been and are still used to describe the • Poverty
severity of these alcohol-related abnormalities. • Lack of education
• Smoker
• Fetal alcohol syndrome (FAS): Medical • Use of other illicit drugs
diagnosis referring to a set of alcohol-related
disabilities associated with maternal use of
• Poor health
alcohol during pregnancy. Recognized in
Higher prevalence rates have been found in
Canada as one of the leading causes of
Manitoba and British Columbia Aboriginal
preventable birth defects and developmental
populations. Families with one or more children
delay in children.
affected by FAS are at much higher risk of
• Atypical FAS: Birth defects or developmental recurrence.
abnormalities for which alcohol is being
considered one of the possible causes. Used to
Recent research suggests women who have a
describe children with prenatal exposure to
college education or are still students, who are
alcohol, but only some of the characteristics of
unmarried, who smoke and who come from

households with an annual income of more than Diagnostic Criteria

$50,000 are also at risk of having a baby with See Table 6-1 below
FASD.
Table 6-1 Age-related diagnostic criteria for fetal alcohol spectrum disorders (DSM-IV, 1994,
American Psychiatric Association)
Age Criteria
Infants History of prenatal alcohol exposure
Facial abnormalities
Growth retardation – height, weight, head circumference
Hypotonia, increased irritability
Jitteriness, tremulousness, weak suck
Difficulty ‘habituating’, getting used to stimulation
Preschool History of alcohol exposure, growth retardation, facial abnormalities

Friendly, talkative and alert
Temper tantrums and difficulty making transitions
Hyperactive; may be oversensitive to touch or over-stimulation
Apparent skill levels may appear to be higher than their tested levels of ability
Attention deficits, developmental delays – speech, fine motor difficulties
Middle History of alcohol exposure, growth retardation, facial abnormalities

childhood Hyperactivity, attention deficit, impulsiveness
Poor abstract thinking
Inability to foresee consequences of actions
Lack of organization and sequencing
Inability to make choices
Lack of organizational skills
Inappropriate behaviour – overly affectionate – does not discriminate between family and strangers,
lack of inhibitions
Communication problems – lack of social skills to make and keep friends, unresponsive to social
clues, uses behaviour as communication
Difficulty making transitions
Academic problems – reading and mathematics
Behaviour problems – “stretched toddler”
Adolescent History of alcohol exposure, growth retardation, facial abnormalities

and adult Intelligence quotient – average to mildly retarded with wide range; continued school difficulties
Difficulty with adaptive and living skills
Attention deficits, poor judgment, impulsivity leads to problems with employment, stable living and
the law
Serious life adjustment problems – depression, alcoholism, crime, pregnancy and suicide
Prevention Strategies as well as those who influence such women,

Pregnancy presents the healthcare professional including their partners, their families and the
with an excellent opportunity to encourage community.
behavioral change, as women are generally
receptive to suggestions about controlling their All efforts should be family-centered and
alcohol consumption during pregnancy culturally sensitive; should address the pregnant
According to the Canadian Paediatric Society woman, her partner and her family in the context
(March 2002), prevention efforts should target of their community; and should be comprehensive,
women before and during their childbearing years, drawing on all services appropriate to the often-

complex social, economic and emotional needs of responsibility to inform women at risk and to
these women initiate appropriate referrals and supportive
interventions.
The CPS also recommends that healthcare
professionals working with members and leaders To identify any woman who is using alcohol
of communities must be consistent in advising during pregnancy, screen all pregnant women with
women and their partners that the prudent choice basic questions about their alcohol use (see
is not to drink alcohol during pregnancy "Primary Prevention" above).
Primary Prevention If the woman answers Yes to any of those

Become involved in educating women, their questions, pose some additional screening
partners and the community in general about the questions to assess her level of risk:
adverse effects of alcohol on a fetus. • In a typical week, on how many days do you
drink?
Goals of primary prevention: • On those days, how many drinks do you usually
• Early recognition of women who drink alcohol have?
during pregnancy
• Appropriate counseling to reduce or eliminate In addition, administer a standard screening test,
alcohol use before conception and during such as the T-ACE questionnaire
pregnancy • T for tolerance: How many drinks does it take
• Early recognition and intervention for any child to make you feel high? (score 2 for more than 2
born with alcohol-related effects drinks, score 0 for 2 drinks or less)
• A for annoyance: Have people annoyed you by
Ask all female clients of childbearing age some criticizing you about your drinking? (score 1 for
basic questions about alcohol consumption: a Yes response)
• Do you use alcohol? • C for cut down: Have you felt you should cut
• Has alcohol ever caused a problem for you or down on your drinking? (score 1 for a Yes
your family? response)
• Do you regularly use any other drugs or • E for eye opener: Have you ever had a drink
substances (e.g. illicit drugs, prescription or first thing in the morning to get rid of a
OTC drugs)? hangover or to steady your nerves? (score 1 for a
Yes response)
Discuss contraceptive methods with women and • Any score >2 indicates high risk
their partners and enhance access to contraception.
For women identified as being at high risk of
Encourage awareness of and access to community having a child with FASD, take the following
resources for alcohol abuse. steps:
• Ask such women why they drink
Be aware of, use and offer educational handouts • Counsel pregnant women who are using alcohol
on the effects of alcohol in pregnancy. about the effects of alcohol on the fetus and their
own health
Secondary Prevention • Counsel pregnant woman on the benefits of
According to the Canadian Paediatric Society stopping or reducing the use of alcohol at any
(March 2002), healthcare professionals play an time during the pregnancy
essential role in identifying women who drink at • Provide client with educational materials to
levels that pose a risk to the fetuses and to facilitate behavioral change
themselves. Screening should be implemented to • Follow up closely, and provide support and
identify women at high risk for heavy alcohol encouragement
consumption before and during pregnancy.
Similarly, healthcare professionals have a

The Canadian Pediatric Society (March 2002) • Identify and treat women and their partners who
recommends that healthcare professionals inform already have one FASD child and who plan to
women who have occasionally consumed small have more children
amounts of alcohol during pregnancy that the risk
to the fetus in most situations is likely minimal. Management
They should also explain that the risk is related to Consult a physician as soon as possible about any
the amount of alcohol consumed, body type, child suspected of suffering the effects of alcohol
nutritional health and other lifestyle characteristics in utero.
of the expectant mother. If exposure has already
occurred, healthcare professionals should inform Referral
the mother that stopping consumption of alcohol at The care of a child with FASD requires a
any time will benefit both fetus and mother. coordinated, multidisciplinary, team approach to
maximize the child's potential for good quality of
Tertiary Prevention life.
• Strategies should include early diagnosis of the
condition and programs designed specifically for There is a small window of opportunity, up to age
children with FASD and their parents or 10 or 12, to achieve the greatest benefit for a child
caregivers affected by alcohol in utero. This is the period
• Refer women who are at high risk to appropriate when the greatest development of fixed neural
treatment resources for alcohol abuse pathways occurs, and thus when it is easiest to
develop alternative coping pathways to work
around damaged areas of the brain.

Attention Deficit Hyperactivity Disorder (ADHD)

Definition • Perinatal: delivery, asphyxia, illnesses
A cluster of behavioral symptoms: • Family history: ADHD, related behavioral
• Poor attention span disorders
• Impulsiveness • Past medical history: illnesses such as
• Hyperactivity meningitis, injuries, hospital admissions
• History of school progress and behavior (talk
Not all children with the disorder will exhibit all with teacher)
three behaviors. For example, some very quiet • Symptoms (see Table 6-2) usually present
children have a poor attention span. before child enters school
Causes The diagnosis is usually established by the

Genetic Syndromes presence of at least 8 of 14 possible characteristics
• Fragile X syndrome over a period of at least 6 months (Table 6-2).
• Phenylketonuria (PKU)
• Gilles de la Tourette syndrome Physical Examination
• Complete general examination: look for
Intrauterine or Prenatal Damage dysmorphic features of genetic conditions,
• Fetal alcohol exposure FASD
• Intrauterine anoxia • Examine ears and check hearing
• Examine eyes and check vision
Postnatal Factors • "Soft neurologic signs" often present
• Prematurity (e.g. increased reflexes, poor coordination, poor
• Meningitis balance)
• Significant head injuries • Educational evaluation done through the school
system
May be familiar without a specific cause. In most
affected children, there is no obvious contributing Differential Diagnosis
cause. • Acting-out behavior disorders
• Reaction to a highly stressful environment
History • Deafness
• Prenatal: pregnancy, exposure to drugs or • Pervasive developmental disorder (e.g. autism)
alcohol

Table 6-2: Diagnostic criteria for Attention-Deficit/Hyperactivity Disorder (DSM-IV, 1994, American
Psychiatric Association)
A. Either (1) or (2):
(1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is
maladaptive and inconsistent with developmental level:
Inattention
(a) often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
(b) often has difficulty sustaining attention in tasks or play activities
(c) often does not seem to listen when spoken to directly
(d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
(not due to oppositional behavior or failure to understand instructions)
(e) often has difficulty organizing tasks and activities
(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as
schoolwork or home-work)
(g) often loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books or tools
(h) is often easily distracted by extraneous stimuli
(i) is often forgetful in daily activities
(2) six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to
a degree that is maladaptive and inconsistent with developmental level:
Hyperactivity
A. often fidgets with hands or feet or squirms in seat
B. often leaves seat in classroom or in other situations in which remaining seated is expected
C. often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may
be limited to subjective feelings of restlessness)
D. often has difficulty playing or engaging in leisure activities quietly
E. is often “on the go” or often acts as if “driven by a motor”
F. often talks excessively
Impulsivity
G. often blurts out answers before questions have been completed
H. often has difficulty awaiting turn
I. often interrupts or intrudes on others (e.g. butts into conversation or games)
C. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
D. Some impairment from the symptoms is present in two or more settings (e.g. at school or work and at home).
E. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
F. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia,
or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g. Mood Disorder,
Anxiety Disorder, Dissociative Disorder, or a Personality Disorder)
Management Appropriate management includes the

Goals of Treatment involvement of a multidisciplinary team, of which
• Improve academic achievement educational specialists are the mainstay. Many
• Improve attention span specific methods can be used to overcome the
• Control hyperactivity (behavior) child's weaknesses and take advantage of his or
her strengths.
• Decrease impulsivity

The medical role involves advocacy and Behavioral Strategies

sometimes the administration of medication. The Counsel parents or caregiver about behavioral
school and the parents or caregiver should monitor strategies:
for desired effects and side effects (e.g. impaired • Decrease environmental stimuli
growth or tic). • Focus on the child's positive traits to increase
self-esteem
Nonpharmacologic Interventions • Give simple directions
• Support for the family • Make eye contact with the child
• Advocacy within the educational system and • Use "time out" as a disciplinary tactic
within the community
• Monitor medication use, dosage, side effects Pharmacologic Interventions
Drug of choice:
Client Education methylphenidate (B class drug), starting dose
• Explain nature, course and treatment modalities 0.5 mg/kg in two doses, morning and noon and
of the disorder readjust according to response
• Stress importance of regular follow-up
• Counsel parents or caregiver about medication: This drug is not recommended for children
appropriate use, dosage and side effects <6 years of age.
This drug can improve concentration and, in

higher doses, reduce hyperactivity. Its use is still
controversial, and it should be prescribed only by
a physician after full evaluation.
Drug-free periods during school holidays will

result in catch-up growth.

Chapter 7 – Nutrition
Nutritional Principles........................................................................................................................................ 1
General............................................................................................................................................................ 1
Types Of Nutrients.......................................................................................................................................... 1
Infant Feeding Principles.................................................................................................................................. 1

General............................................................................................................................................................ 1
Adequacy Of Intake ........................................................................................................................................ 1
Feeding Choices................................................................................................................................................. 2
Breast-Feeding ................................................................................................................................................ 2
Formula Feeding ............................................................................................................................................. 6
Vitamin And Mineral Supplements ................................................................................................................ 7
Solid Foods ..................................................................................................................................................... 8
Nutritional Deficiency Disorders ..................................................................................................................... 9
Common Nutritional Problems...................................................................................................................... 10

Obesity.......................................................................................................................................................... 10
Nutritional Rickets........................................................................................................................................ 12
Iron Deficiency Anemia In Infancy .............................................................................................................. 13

Nutritional Principles
General • Protein: contributes to energy intake and
supplies amino acids for tissue growth and
For normal growth, a child's nutritional intake replacement
must include protein, fat, carbohydrate, water, • Carbohydrates: provide caloric energy and thus
vitamins, minerals and trace elements in adequate help limit the need for protein and fat
amounts. For many nutrients, deficiency states can • Fats: contribute substantially to energy needs
occur if intake is inadequate. Similarly, a variety because of high caloric density (9 kcal/g); some
of diseases are associated with excess intake of essential fatty acids are important for growth of
specified nutrients. the infant's nervous system
• Water: necessary to sustain life and growth
Types Of Nutrients • Vitamins: essential cofactors in metabolic
• Energy (expressed as kilocalories [kcal]): processes
needed for metabolic functions and growth; • Minerals: necessary in small quantities for
available from protein, carbohydrate and fat growth and metabolism; deficiency states are
clinically recognized for only a few minerals
Infant Feeding Principles

General Six well-soaked diapers and yellowish stool daily
are also indicators of adequate nutritional intake.
Healthy infants obtain nutrition in a pattern that
encourages social interaction with parents and Average daily energy requirement is 115 kcal/kg
caregivers. Thus, infant feeding provides both during the first year of life, although there is some
nutrition for growth and an opportunity for social variation from one child to another. The average
interaction, both of which are crucial to the infant's caloric content of formulas and breast milk is
well being. Infants should always be held while 20 kcal/oz or 67 kcal/100 mL (1 oz = 30 mL)
being fed in an effort to prevent nursing bottle
caries of the teeth.
Adequacy Of Intake
Adequacy of intake is best determined by
observing weight gain. Expected gain is as
follows:
• 30 g/day in the first 3 months
• 15-20 g/day in the second 3 months

Feeding Choices
Breast-Feeding
In the first 6 months of life, an infant's Technique
requirements for water, energy and major nutrients • Mother should be in a comfortable position,
can best be met by human milk. usually sitting or reclining with baby's head in
crook of her arm (side-lying position is often
For this reason, as well as for the emotional useful following delivery by cesarean section)
benefits to the child and the immunologic benefits • Bring baby to mother (to minimize stress on
in terms of protective effects against infection mother's back)
(especially in populations where refrigeration is • Baby's belly and mother's belly should face each
lacking or water supplies are suspect), breast milk other or touch (belly-to-belly position)
is the best choice for feeding infants.
• Initiate the rooting reflex by tickling baby's lips
with nipple or finger; as baby's mouth opens
Advantages wide, mother guides her nipple to back of the
• Fewer respiratory, GI and otitis media infections baby's mouth while pulling the baby closer; this
• Ideal food: easily digestible, nutrients well maneuver will ensure that the baby's gums are
absorbed, less constipation sucking on the areola, not the nipple
• Increased contact between mother and baby and, • It is important that the baby be allowed to nurse
perhaps, added self-esteem for mother within the first hour after birth
• Economical, portable, affords ease of meeting
infant's feeding needs quickly Positioning And Latching On
• May decrease occurrence of allergies in Source: Baby & Parent Health Program,
childhood Community Health Services, Halton Regional
• Mothers often like it more than bottle-feeding Health Department
• More rapid and complete reversion of mother's
pelvis and uterus to non-puerperal state
Contraindications
• HIV infection or active TB
• Substances of abuse will pass into human milk;
see Table 7-1, below, this chapter, for
information about drugs that are passed into
milk
Fig. 7-1: Cradle Position for Breast-Feeding
Physiology
• Stimulation of areola causes secretion of
• Breast-feed in a sitting position, with good back
oxytocin
support, as soon as possible.
• Oxytocin is responsible for letdown reflex,
• Place a pillow on your lap to bring baby to
whereby milk is ejected from cells into milk
breast height.
ducts
• Position baby with his or her head resting on
• Sucking stimulates secretion of prolactin, which
your forearm, facing you (belly to belly), with
in turn triggers milk production
your hand supporting the diaper area.
• Milk is therefore created in response to nursing,
• Baby's face should be across from the breast, the
i.e. nursing increases the supply of milk
mouth across from the nipple and the head tilted
slightly back.

• Place four fingers under breast and thumb on

top, well back from nipple and areola.
• Lightly tickle baby's lower lip with nipple. Have
patience.
• When mouth opens wide (as big as a yawn)
quickly point nipple at opening and pull baby
onto breast.
• If baby is positioned correctly, the nose should
be resting on top of breast and not buried in
breast tissue. Do not press on breast to make
"breathing space."
• If there is pain, take baby away from breast and
repeat. Fig. 7-2: Football Hold for Breast-Feeding
• Check "latch." Mouth should be big with lips • Sit in upright position with good back support.
turned back. Chin should be well underneath
• Place one or two pillows at your side.
breast, and nose should be resting on top.
• Lie baby on pillows at your side.
• Listen for baby swallowing. If baby is feeding
well, you will see short bursts of sucking and • Support the back of the neck with your hand.
swallowing with pauses between. The jaw This allows the baby's head to tilt back a little.
movement goes past the ears, sometimes making • Hold your breast as described for the cradle
the ears wriggle. position.
• Let baby feed at first breast until he or she • Tickle baby's lower lip. Wait for his or her
pushes nipple out of mouth; offer a burp and mouth to open and pull the baby onto the breast.
continue on other breast. The baby may not suck
for as long on the second breast. Start on that
side during the next feeding session.
• If baby starts wriggling during the feeding, he or
she may need to burp. Take the baby off the
breast, offer a burp and then latch on again.
• Each baby is different and each will take a
different period of time to feed. If a feeding is
taking an hour or more, the baby is probably not
latched on properly. Contact someone to watch
you nurse and check the latch.
If you have difficulty feeding your baby in the Fig. 7-3: Alternative Position for Breast-
cradle position, try the football hold. Feeding
This hold can work well in the following • Sit in upright position with good back support.
situations: • Place a pillow in front of you.
• Cesarean birth • Lie baby across your body facing you.
• Small baby • Hold breast with hand on same side (right breast,
• Mother experiencing more difficulty with one right hand).
side than the other • Support back of baby's neck and shoulders with
• Mother with flat nipples other hand.
• Tickle baby's lower lip. Wait for the baby's
mouth to open wide and pull the baby onto the
breast.
• When baby is feeding well, try taking hand from
breast and putting it around the baby for support.

Mother's Diet While Nursing • Solids may be introduced at 4-6 months (WHO
• Adequate caloric and protein intake now recommends 6 months for introduction of
• Plenty of fluids solids)
• Prenatal vitamins
Mothers who are planning to return to work should
start switching the baby to chosen alternative
Signs Of Adequate Nursing
feeding about a week ahead of time, for the hours
• Breasts become hard before and soft after
of the day when the mother will be away.
feeding (noted in the first few weeks after the
birth)
Breast Care
• Six or more wet diapers in 24 hours
• Porous breast shields collect any milk that drips;
• Baby satisfied and weight gain appropriate
shields should be changed when wet to prevent
(average 1 oz or 30 g per day in the first few
skin maceration
months)
• Correct positioning, with nipple and areola well
• Growth spurts should be anticipated around 10
into the infant's mouth, helps prevent nipple
days, 6 weeks, 3 months and 4-6 months
soreness and cracked nipples
• During growth spurts, baby will nurse more
• For cracked nipples, express some milk, and
often over a period of several days, which will
allow the milk to air dry on the nipples; ensure
increase milk production to allow for further
the infant is latching on correctly
adequate growth
• When one nipple is sore, feedings should be
started on the side that is not sore; it may be
Client Education helpful to change the feeding position (e.g. from
Antepartum sitting to lying) when nipples are sore
Promote advantages of breast-feeding early and
regularly during the course of the pregnancy.
Possible Complications
Plugged Milk Ducts
Postpartum Mother is well except for sore lumps in one or
Counsel women on the following aspects of
both breasts, without fever.
breast-feeding:
• Technique Apply moist hot packs to lump(s) before and
• Natural history during nursing. The mother should nurse more
• Colostrum present in breast at birth but may not frequently on the affected side. Ensure good
be seen technique.
• If baby is feeding well, he or she will be
adequately nourished Mastitis
• Milk will not come in before third day Woman has a sore lump in one or both breasts,
postpartum accompanied by fever or redness of the skin
• Frequent nursing (at least 9 times/24 hours) will overlying the lump. She may be quite ill. Other
lead to milk coming in sooner and in greater possible sources of fever should be ruled out (in
quantities particular, endometritis and pyelonephritis).
• Mother should allow baby to determine duration
of each nursing session Apply moist hot packs to the lump(s) before and
• Baby will lose weight over the first few days and during nursing. The mother should nurse more
may not regain birth weight until 7 days frequently on the affected side.
• Most supplemental vitamins are unnecessary,
however as babies in northern communities have Administer antibiotics (e.g. cloxacillin, C class
very limited exposure to sun vitamin D should drug) for Staphylococcus aureus (the most
be given; see "Vitamin and Mineral common organism) for at least 7 days. The mother
Supplements," below, this chapter should get more rest and use acetaminophen as
• Breast milk alone is adequate for first 6 months necessary. The fever should resolve within 48

hours; otherwise, consider changing the antibiotic. Signs

The lump should also resolve. A persistent lump • Insufficient weight gain in an infant who is
may be an abscess, which must be drained receiving food only by breast-feeding
surgically. • Infant may latch on poorly
• Infant may suck inconsistently
Engorgement • Letdown reflex may be inconsistent
Engorgement usually develops just after milk first • Some infants appear hungry (indicated by crying
comes in (day 3 or 4). It is characterized by warm, soon after feedings), whereas others are content,
hard, sore breasts. but gain poorly
To resolve, offer baby more frequent nursing. The
Risk Factors
mother may have to hand-express a little milk to
• Mother has previous experience with this
soften the areola enough to let baby latch on. The
problem
baby should be allowed to nurse long enough to
empty the breasts. The problem usually resolves • Physical abnormality of the breast
within a day or two. • No breast enlargement during pregnancy
• History of breast surgery
Flat or Inverted Nipples
When stimulated, inverted nipples will retract Management
inward, whereas flat nipples remain flat. Check for Goal is always to preserve breast-feeding, if
either of these conditions during the initial possible.
prenatal physical. • Frequent feeding sessions
• Breast pumping (with an electric pump, if
Nipple shells (doughnut-shaped inserts, Woolwich available) after each feeding
shells) can be worn inside the bra throughout • Increase maternal fluid intake
pregnancy to gently force the nipple through the • Ensure mother gets adequate rest
center opening of the shell. The baby can nurse • Monitor the infant's well being
successfully even if the shell does not correct the
problem before birth. A lactation consultant If signs of failure to thrive or dehydration appear,
(available in Yellowknife) or a member of the La consult a lactation specialist and a physician. It
Leche League may be a good resource in this may be necessary to give formula supplements
situation. after breast-feeding sessions, or a switch to
formula feeding may be indicated.
Problems Of Lactation
Source: Baby & Parent Health Program, Breast Milk Toxicology
Community Health Services, Halton Regional Most maternal medications are secreted in some
Health Department quantity into breast milk (Table 7-1). The risks of
discontinuing the mother's medication must be
Insufficient Lactation weighed against the risks to the baby. Sometimes
This problem is almost always due to improper the medication can be replaced, and sometimes the
feeding techniques, which can be remedied. effect on the baby is not sufficient for concern.
Occasionally, it is due to problems other than
technique. Any medication marked with an asterisk in Table
7-1 is an absolute contraindication to breast-
feeding.

Table 7-1: Drugs and breast-feeding

Drug Excreted in milk Possible effect on infant and recommendations
Alcohol Yes Infants more susceptible to effects
Ampicillin Yes Diarrhea, candidiasis
ASA Yes Complications rare
Caffeine Yes Jitteriness possible
Carbamazepine Yes Decreased weight gain
Cephalexin No None
Chlorpromazine Yes (minimal) Safe for infant
Codeine Yes (trace) Neonatal depression; no effect later in usual doses
Contraceptives Yes Uncertain long-term effects
Diazepam Yes Drowsiness; may increase jaundice; avoid in infants < 1 month of age
Digoxin Yes (minimal) Usually none
Erythromycin Yes Jaundice; avoid in infants < 1 month of age
Isoniazid (INH)* Yes May be toxic to infant. Do not breastfeed
Methyldopa Yes Galactorrhea
Metronidazole Yes (high) Contraindicated in infants < 6months of age
Nitrofurantoin Yes (trace) Avoid
Nystatin No None
Penicillin Yes Usual antibacterial effects
Phenobarbital Yes Lethargy
Phenytoin Yes Usually none
Prednisone Yes Usually no effects
Propranolol Yes Hypoglycemia; usually no effects
Propylthiouracil* Yes Risk of goiter in infant. Do not breastfeed
Senna No None
Tetracycline Yes Tooth discoloration. Use alternative medication
Theophylline Yes Irritability
Thiazide diuretics Yes Low risk of dehydration, electrolyte imbalance
Formula Feeding
General Information fortified with iron is now the standard
Commercially prepared formulas resemble breast recommendation for all infants who are fed
milk in protein, fat and carbohydrate composition. formula from birth. Infants weaned from the breast
The immunological components are missing. before 9 months of age should receive an iron-
Some other components (e.g. certain essential fortified formula. Evaporated milk formulas
amino acids) may be lacking depending on the provide adequate energy and nutrient content and
formulation, Commercial infant formula that is are less expensive, provided they are mixed

correctly. They lack an adequate supply of iron Where mothers are forced by circumstances to use
and may interfere with absorption of iron from evaporated milk formula, appropriate mixing is
other sources. The composition of whole cow's essential (see below), and daily ferrous sulfate
milk is inappropriate for infants and promotes supplements (2 mg elemental iron per kilogram
blood loss from the gut. It should not be used in body weight) are recommended. For the at-risk
the first 9 or 10 months of life. Partly skimmed infant (e.g. low birth weight and premature infants,
and skimmed milk should never be used in the extremes of poverty or a history of iron deficiency
first year of life, because the lack of fat can be in siblings), provision from birth of daily
difficult for the kidneys to handle. See Table 7-2 supplemental iron through formula or Fer-In-Sol®
for volume and frequency of formula feeding. is especially important.
Table 7-2: Approximate volume and frequency Recipes For Formula

of feedings Commercial Infant Formulas
No of bottles Intake • Ready to feed: give as is, without dilution
Age
per 24 hours (mL/bottle)
• Concentrate: mix 1:1 with water
1st week 6 – 10 30 – 80
• Powdered: follow instructions; over- or under-
1 – 4 weeks 7 or 8 60 – 120 dilution of powdered formula can be dangerous
1 – 4 months 4 or 5 210 – 240
5 – 9 months 3 or 4 210 – 240
Evaporated Milk
3 oz milk + 5 oz water + 1 tbsp sugar = one 8-oz
bottle (30 mL = 1 oz)
When refrigeration is lacking, it is suggested that
bottles be boiled before formula is prepared. After 6 months, use 4 oz milk + 4 oz water (no
added sugar)
Vitamin And Mineral Supplements

Children in some First Nations and Inuit In general, in the NWT we use surface water (from
communities may require fluoride rivers and lakes) without natural fluoride as the
supplementation, except if the community has water supply is largely produced by natural
high levels of natural fluoride in the water supply. precipitation. Only a few large communities add
The regional dental officer can provide fluoride as part of water treatment due to potential
information on the situation in your community. hazard of overfluoridation in small communities.
Yellowknife, Inuvik, and Tuktoyaktuk have
Recommended dose of fluoride is as follows fluoride added to their water. Nahanni Butte, Wha
(Canadian Paediatric Society 1996): Ti, Wrigley, and Fort Liard are on wells and
• 6 months to 2 years: 0.25 mg/day would have some natural fluoride. (source EHO
• 3-4 years: 0.50 mg/day 25/7/2003)
• >5 years: 1 mg/day
Table 7-3 indicates requirement for vitamin D in
relation to type of feeding. For infants living in
Multiple vitamins are generally not recommended,
northern communities, the recommended dose of
but Tri-Vi-Sol® with fluoride is an adequate
vitamin D is 800 IU/day.
preparation for children 0-2 years of age.
It is preferable to give vitamin D (e.g. D-Vi-Sol®)

separately from fluoride (e.g. Pedi-Dent® or
Karidium®).

Table 7-3: Vitamin D requirements

Vitamin D
Type of feeding
requirement
Breast Yes
Commercial formula No
Evaporated milk No
Minimal cow’s milk with Yes
breast milk, juice supplements
Solid Foods
Iron-fortified infant cereal should be added to the should be added initially in small quantities, one at
diet as a first supplement at age 4-6 months (one a time, after cereals have been started. Vegetables
grain type at a time). Prepared baby foods, if used, or meats should be started before fruits.

Nutritional Deficiency Disorders

Nutritional deficiencies can present clinically as cardiovascular, musculoskeletal and neurologic
symptoms and signs in multiple body systems. systems. See Table 7-4 for information on the
Common body parts and systems affected include clinical manifestations of common nutritional
the skin, hair, nails, eyes, mouth, neck, and deficiencies.
Table 7-4: Physical signs of nutritional deficiency disorders

System Sign Deficiency
General appearance Reduced weight for height Calories
Skin and hair Pallor Anemias (iron, vit B12, vit E, folate and copper
Edema Protein, thiamine
Nasolabial seborrhea Calories, protein, vit B6
Dermatitis Riboflavin, essential fatty acids, biotin
Photosensitivity dermatitis Niacin
Acrodermatitis Zinc
Follicular hyperkeratosis (sandpaper-like) Vitamin A
Depigmented skin Calories, protein
Purpura Vitamins C + K
Scrotal or vulval dermatitis Riboflavin
Alopecia Zinc, biotin, protein
Depigmented, dull hair Protein, calories, copper
Subcutaneous tissue Decreased Calories

Eyes (vision) Poor adaptation to dark Vitamins A, E, zinc
Poor colour discrimination Vitamin A
Bitot’s spots, xerophthalmia, keratomalacia Vitamin A
Conjunctive pallor Nutritional anemias
Fundal capillary microaneurysms Vitamin C
Face, mouth, neck Angular stomatitis Riboflavin, iron

Cheilosis Vitamin B6, niacin, riboflavin
Bleeding gums Vitamins C + K
Atrophic papillae Riboflavin, iron, niacin
Smooth tongue Iron
Red tongue (glossitis) Vitamins B6, B12, niacin, riboflavin, folate
Parotid swelling Protein
Caries Fluoride
Anosmia Vitamins A, B12, zinc
Hypogeusia Vitamin A, zinc
Goiter Iodine
Cardiovascular system Heart failure Thiamine, selenium, nutritional anemias
Genital Hypogonadism Zinc
Skeletal Costochondral beading Vitamins D, C
Subperiosteal hemorrhage Vitamin C, copper
Cranial bossing Vitamin D
Wide fontanel Vitamin D
Epiphyseal enlargement Vitamin D
Craniotabes Vitamin D, calcium
Tender bones Vitamin C
Tender calves Thiamine, selenium
Spoon-shaped nails (koilonychias) Iron
Transverse nail lines Protein
Central nervous system Sensory or motor neuropathy Thiamin, vitamins E, B6, B12
Ataxia, areflexia Vitamin E
Ophthalmoplegia Vitamin E, thiamine
Tetany Vitamin D, Ca++ , Mg++
Retardation Iodine, niacin
Dementia, delirium Vitamin E, niacin, thiamine
Source: Nelson's Essentials of Pediatrics (Behrman et al 1999)

Common Nutritional Problems

Obesity
Definition • Family history of obesity, hypertension,
An excess in weight of 20% or more relative to the cardiovascular disease, diabetes mellitus,
calculated ideal weight for age, sex and height, cerebrovascular accident
determined from standard pediatric growth charts. • Past medical history, including illnesses,
Many Aboriginal children have a high weight-to- surgeries, admissions to hospital
height ratio on standard growth charts. Rapid • Physical activity pattern
increases in weight-to-height ratios are of concern, • Older child: school performance, peer
as is obesity in older children. relationships, parental relationships, child's
perception of his or her body
Causes
• Most commonly exogenous, due to excessive Physical Findings
caloric intake for basal needs and low energy • Overall appearance
output. • Blood pressure
• Genetic influences: Obese children <3 years old • Weight and height (with exogenous obesity,
without obese parents are at low risk for obesity linear growth is usually accelerated; with
in adulthood, but among older children, obesity endocrine or metabolic disorders, linear growth
is an increasingly important predictor of adult is usually retarded)
obesity, regardless of whether the parents are • Hypoventilation (may suggest Pickwickian
obese. Parental obesity more than doubles the syndrome)
risk of adult obesity among both obese and non- • Fat distribution
obese children <10 years old.
• Increased subcutaneous tissue
Risk factors influencing the development of
• Increased triceps skin-fold thickness
obesity in children: • Skin: striae, irritations (intertrigo)
• Parental overweight • Stage of sexual maturation
• Overweight at birth • Presence of orthopedic problems (e.g. scoliosis,
• Physical inactivity genu valgum, slipped femoral epiphyses)
• Irregular snacking • Other causes of obesity associated with signs
relevant to underlying cause (e.g. hirsutism,
• Poor food choices
acne, striae, hypertension, mental deficiency)
• Lack of availability of variety of nutritious foods
To rule out a congenital syndrome, check for
History hypogonadism, short stature, dysmorphic features,
• Child's birth weight small extremities and mental retardation.
• Early feeding history
• Age at onset of obesity Differential Diagnosis
• Dietary history (during the week and on • Diabetes mellitus
weekends) • Hypothyroidism
• Caloric intake beyond calculated norms for age • Cushing's disease
• Food preferences, snacks, where are meals eaten • CNS diseases (e.g. meningitis, brain tumors,
and with whom, moods associated with food cerebrovascular accident or head trauma may be
• Child and family feeding patterns associated with onset of obesity due to
• Use of food as reward or part of social function hyperphagia and decreased activity)

• Genetic or congenital disorders (e.g. Down's dysfunctional uterine bleeding (this test must be
syndrome) ordered by a physician)
Complications Management
• Accelerated bone growth and skeletal maturation Goals of Treatment
• Accelerated maturation, with early menarche Change behavior so that more energy is used by
and decreased final height, often seen in girls the child for growth, activity and metabolic
• Hyperinsulinemia processes than is consumed.The whole family
must be included in the management of this
• Decreased levels of growth hormone
problem.
• Decreased levels of prolactin in girls
• Decreased levels of testosterone in boys Appropriate Consultation
• Increased rates of amenorrhea and dysfunctional • Consult a physician if you suspect an underlying
uterine bleeding in girls physiologic, metabolic or psychologic disorder
• Hyperlipidemia as the cause of obesity
• Hypertension • In infants and toddlers, treatment should be
• Choledocholithiasis cautious; consult a physician before any
• Slipped capital femoral epiphyses investigation or treatment is begun
• Legge-Calvé-Perthes disease and genu valgum
• Increased respiratory illness in toddlers <2 years Nonpharmacologic Interventions
old Prevention
• Pickwickian syndrome (increased daytime • Early preventive measures, with emphasis on
sleepiness and hypoventilation) families in which one or both parents are
• Obstructive sleep apnea overweight
• Psychosocial sequelae (e.g. low self-esteem, • Promotion of prolonged breast-feeding may help
abnormal body image, difficulty developing peer decrease the prevalence of obesity in childhood
relationships, social withdrawal and isolation) • Because obese children have a high risk of
• Adult obesity becoming obese adults, such preventive
measures may eventually result in a reduction in
With more children becoming overweight, the the prevalence of cardiovascular diseases and
prevalence of insulin-resistance causing type 2 other related diseases
diabetes in children is rising. The earlier diabetes • For obesity due to other causes, underlying
begins, the earlier in life the complications tend to disorders must be treated
occur. The development of diabetes in children is
a serious public health threat. See "Diabetes Older Children with Exogenous Obesity
Mellitus in Aboriginal Children," in chapter 17, • Program of decreased caloric intake and
"Hematology, Endocrinology, Metabolism and increased exercise over a long period
Immunology." • Reducing television, videotape and video game
use may be a promising, population-based
Diagnostic Tests approach to prevent childhood obesity
• Random blood glucose by glucometry
• TSH and T4 levels (if child is of short stature) Monitoring and Follow-Up
• Urinalysis (for glucose) Follow up monthly to monitor height and weight
• Lipid profile (in adolescents) until optimal weight has been achieved.
• Pelvic ultrasonography to rule out polycystic
ovaries in adolescent girls with amenorrhea or

Nutritional Rickets
Definition • Thickening of costochondral junction (rachitic
A disorder characterized by failure of growing rosary)
bone matrix to become mineralized. Under- • Prominence of wrists and knees
mineralized bones are less rigid than normal, and • Muscle weakness
bone deformities result. • Awkward gait
• Dental caries
Causes • Hepatic or renal enlargement (only if rickets is
• Vitamin D deficiency related to liver or renal disease)
• Calcium deficiency • Seizures (due to low calcium) may be presenting
• Phosphorus deficiency complaint
• Component of multi-vitamin deficiency
(northern infant syndrome) Differential Diagnosis
• Chronic renal insufficiency
Children at Risk • Biliary atresia
• Infants of mother whose prenatal diet contained • Chronic liver disease
little vitamin D • Inflammatory bowel disease
• Small, premature infants
• Breast-fed infants who do not receive vitamin D Complications
supplementation • Permanent leg bowing, occasionally requiring
• Children whose diet is lacking in vitamin D or corrective surgery
who have insufficient exposure to sunlight • Contractures of the pelvis may cause difficulty
• Children with chronic renal insufficiency with labour and delivery
• Children with biliary atresia or chronic liver
disease Diagnostic Tests
• Children with inflammatory bowel disease Discuss any diagnostic tests with a physician.
• Knee and wrist x-ray, if available (one view
History only, as rickets is a symmetric condition)
• Diet containing little vitamin D (breast milk, tea, • X-ray will show irregular cortices and bony
juices as primary fluid sources) margins, widened metaphyses, widened growth
• Low exposure to sun because of pigmented skin plates and osteopenia
or winter season
• Low vitamin D intake by mother during Management
pregnancy Nonpharmacologic Interventions
• Bone pain Preventive: encourage vitamin supplementation
• Delayed standing or walking and milk intake (if mother not lactose intolerant)
• Anorexia during pregnancy.
• Seizures (due to low calcium)
• Pathologic fractures In communities where rickets is common,
• Family history of rickets encourage nutrition education and vitamin D
supplementation for all children <2 years old.
Physical Findings
• Growth slowed (short stature)
• Bossing deformity of the head
• Craniotabes
• Premature fusion of sutures
• Bowing of legs

Pharmacologic Interventions Children >2 years old who do not drink adequate
Prevention: Recommendations of the amounts of milk enriched with vitamin D should
Canadian Paediatric Society be given 400 IU/day of vitamin D during the
Source: Indian and Inuit Health Committee, winter. The long days during the summer should
Canadian Paediatric Society (1988; reaffirmed provide enough sunlight to produce adequate
April 2000) amounts of endogenous vitamin D.
Infants who are entirely breast-fed should be given Treatment

400 IU/day of vitamin D. This amount may be Discuss with a physician the initial vitamin D dose
increased to 800 IU/day during the winter for for treating rickets. A common regimen is:
children living in the far North. The administration
of 800 IU/day should be limited to children vitamin D (A class drug), 400 units/mL;
<2 years old, who are at greatest risk for rickets. 5000 to 10,000 units/day for 5 weeks, followed by
400 units/day (curative dose)
Infants who are bottle-fed with formulas made
from fortified whole or canned milk have Monitoring and Follow-Up
sufficient amounts of vitamin D during the • Blood and urinary calcium levels should be
summer but should receive a supplement of monitored if vitamin D therapy is used
400 IU/day of vitamin D during the winter. • Discuss frequency of monitoring with a
physician
Pregnant women and nursing mothers in the North
should take 400 IU/day of vitamin D either as Referral
fortified milk or in addition to their vitamin and Refer all cases of suspected rickets to a physician
mineral supplementation, which provides for evaluation as soon as possible.
400 IU/day of vitamin D.
Iron Deficiency Anemia In Infancy

See "Iron Deficiency Anemia in Infancy," in chapter 17, "Hematology, Endocrinology, Metabolism and
Immunology."

Chapter 8 – The Eyes

Assessment Of The Eyes ................................................................................................................................... 1
Common Problems Of The Eye ....................................................................................................................... 3

Red Eye........................................................................................................................................................... 3
Conjunctivitis.................................................................................................................................................. 6
Allergic Conjunctivitis.................................................................................................................................... 8
Ophthalmia Neonatorum................................................................................................................................. 9
Nasolacrimal Duct Obstruction (Dacryostenosis)......................................................................................... 11
Strabismus (Squinting) ................................................................................................................................. 12
Hordeolum Or Stye....................................................................................................................................... 13
Chalazion ...................................................................................................................................................... 13
Emergency Problems Of The Eye.................................................................................................................. 14

Orbital Cellulitis ........................................................................................................................................... 14
Periorbital Cellulitis (Preseptal).................................................................................................................... 15
Corneal Abrasion .......................................................................................................................................... 16
Conjunctival, Corneal Or Intraocular Foreign Bodies .................................................................................. 16
Acute Angle-Closure Glaucoma ................................................................................................................... 16
Chemical Burns............................................................................................................................................. 16
Blunt Or Lacerating Ocular Trauma ............................................................................................................. 16
Uveitis (Iritis)................................................................................................................................................ 16
For more information on the history and physical examination of the eyes in older children and adolescents,
see Chapter 1, "The Eyes," in the NWT Clinical Practice Guidelines for Primary Community Care Nursing
(Adult) 2003
For many ocular diseases and conditions, clinical presentation and management are the same in adults and
children. For more information, see Chapter 1, "The Eyes," in the NWT Clinical Practice Guidelines for
Primary Community Care Nursing (Adult) 2003

Assessment Of The Eyes

General • Lacrimation
The following characteristics of each symptom • Itching
should be elicited and explored: • Discharge
• Onset (sudden or gradual) • Ear pain
• Chronology • Nasal discharge
• Current situation (improving or deteriorating) • Sore throat
• Location • Cough
• Radiation • Nausea or vomiting
• Quality
• Timing (frequency, duration) Medical History (Specific To Eyes)
• Severity • Eye diseases or injuries
• Precipitating and aggravating factors • Eye surgery
• Relieving factors • Use of corrective eyeglasses or contact lenses
• Associated symptoms • Concurrent URTI
• Effects on daily activities • Immunocompromise from other illness or
• Previous diagnosis of similar episodes medications
• Previous treatments • Environmental exposure to eye irritants
• Efficacy of previous treatments • Systemic inflammatory disease (e.g. juvenile
rheumatoid arthritis)
Cardinal Symptoms • Diabetes mellitus
In addition to the general characteristics outlined • Chronic renal disease
above, additional characteristics of specific • Bleeding disorders
symptoms should be elicited as follows. • Allergies (especially seasonal)
• Current medications
Vision
• Recent changes Personal And Social History (Specific
• Blurring To Eyes)
• Corrective measures (glasses, contact lenses) • Concerns reported by parent, caregiver or
teacher about child's vision (e.g. squinting,
Other Associated Symptoms headaches caused by reading)
• Pain • Use of protective eyewear for sports and other
• Irritation activities
• Foreign-body sensation • Housing and sanitation conditions
• Photophobia • School or daycare exposure to eye infection
• Diplopia

Eye • Corneal clarity, abrasions and lacerations
Examine the bony orbit, lids, lacrimal apparatus, • Lens opacities (cataracts)
conjunctiva, sclera, cornea, iris, pupil, lens and • Red reflex (which is abnormal if there is retinal
fundi. Note the following: detachment, glaucoma or cataract)
• Hemorrhage or exudate
• Visual acuity (which is decreased in keratitis, • Optic disk and retinal vasculature
uveitis and acute glaucoma)
• Swelling Palpate the bony orbit, eyebrows, lacrimal
• Discharge or crusting apparatus and pre-auricular lymph nodes for
• Discoloration (erythema, bruising or tenderness, swelling or masses.
hemorrhage)
• Position and alignment of eyes Apply fluorescein stain to test for corneal integrity
(e.g. strabismus): use corneal light reflex test, (if there is a possibility that trauma has occurred).
cover-uncover test
• Reaction of pupil to light An ENT examination, including the lymph nodes
• Extraocular movements (which are associated of the head and neck, should also be performed if
with pain in uveitis) there are symptoms of a systemic condition, such
• Visual field (test in older children if there is as viral URTI.
concern about glaucoma)

Common Problems Of The Eye

Red Eye
Definition Causes
Inflammation in and around the structures of the There are numerous causes of red eye in children
eye. (Table 8-1).
Table 8-1: Features of various causes of red eye in children

Conjunctivitis Corneal
injury or Uveitis (Iritis) Glaucoma
Bacterial Viral Allergic infection
Vision Normal Normal Normal Reduced or Reduced Very reduced
very reduced
Pain - - - + + +++
Photophobia +/- - - + ++ -
Foreign +/- +/- - + - -
body
sensation
Itch +/- +/- ++ - - -
Tearing + ++ + ++ + -
Discharge Mucopurulent Mucoid - - - -
Pre- - + - - - -
auricular
adenopathy
Pupils Normal Normal Normal Normal or Small Moderately
small dilated or
fixed
Conjunctival Diffuse Diffuse Diffuse Diffuse with Ciliary flush Diffuse with
hyperemia ciliary flush ciliary flush
Cornea Clear Sometimes Clear Depends on Clear or Cloudy
faint punctate disorder lightly cloudy
staining or
infiltrates
Intraocular Normal Normal Normal Normal Reduced, Increased
pressure normal or
absent
+, present (to various degrees); -, absent; +/-, may be present
*Hyperthyroidism may cause conjunctival injection.
History • For newborns, inquire about exposure to silver

• An accurate history is very important nitrate or the possibility of maternally acquired
• History may point to a systemic illness such as infections such as gonorrhea
juvenile rheumatoid arthritis or the possibility of
trauma Physical Findings
• Ask about preceding viral URTI (which would • Assess both eyes for symmetry
indicate infectious conjunctivitis) • Carefully document any evidence of external
• Ask the child (if of an appropriate age) about trauma
visual acuity, pain on movement of the eye and • Assess visual acuity and pupillary reaction,
contact with chemical agents or makeup (the last essential for measuring improvement or
of which might indicate allergic conjunctivitis) deterioration

• Examine the anterior segment of the globe with • Ophthalmia neonatorum

a small penlight, and use a fluorescent stain to • Conjunctivitis (bacterial, viral or allergic)
assess for corneal abrasion or ulcers • Traumatic injury (e.g. corneal abrasion)
• Assess ocular mobility by checking range of • Foreign body
movement • Glaucoma
• Uveitis (iritis)
Features Of Dangerous Red Eye • Periorbital or orbital cellulitis
The first step is to differentiate major or serious
causes of red eye from minor causes. The Management
following danger signs call for urgent consultation Some of the diseases (e.g. ophthalmia
and/or referral to a physician. neonatorum) associated with red eye are covered
• Severe ocular pain, especially if unilateral in detail elsewhere in this chapter.
• Photophobia
• Persistent blurring of vision See table of contents of the chapter for topic
• Exophthalmos (proptosis) headings.
• Reduction of ocular movements
• Ciliary flush Referral
• Irregular corneal reflection of light When in doubt about the diagnosis or if there is
• Corneal epithelial defect or opacity significant associated ocular trauma or decreased
• Pupil unreactive to direct light visual acuity, urgent consultation with and referral
• Worsening of signs after 3 days of to a physician is indicated.
pharmacologic treatment for conjunctivitis
• Immunocompromise (e.g. neonate, For more details about the causes, assessment and
immunosuppression) management of conditions associated with red eye,
see "Red Eye," in chapter 1, "The Eyes," in the
NWT Clinical Practice Guidelines for Primary
Differential Diagnosis Community Care Nursing (Adults) 2003
See Fig. 8-1.

Fig 8-1: Differential Diagnosis of Red Eye
Trauma?
yes no
Corneal fluorescein stain for negative Decreased vision or severe

ulcer pain
yes no
positive
Corneal abrasion Conjunctivitis (allergic

Foreign body or infectious)
Assess for increased intraocular

pressure and consult physician
yes no
Glaucoma
Iritis
Iritis

Conjunctivitis
Definition Children with mild viral or superficial bacterial
Inflammation of the conjunctival membrane of the conjunctivitis do not usually have significant
eye. This is one of the most common causes of red systemic symptoms.
eye in children.
Physical Findings
Causes • Assess both eyes for symmetry
Viral or bacterial conjunctivitis is common in • Carefully document all evidence of external
children. trauma
• Assess visual acuity and pupillary reaction,
The allergic form is more common in adolescents. essential for measuring improvement or
See "Conjunctivitis" (allergic type), in Chapter 1, deterioration - both should be normal
"The Eyes," in the NWT Clinical Practice • Examine the anterior segment of the globe with
Guidelines for Primary Community Care Nursing a small penlight, and use a fluorescent stain to
(Adult) 2003 assess for corneal abrasion or ulcers if history or
physical findings suggest corneal abrasion
Bacterial Pathogens • Assess ocular mobility by checking range of
• Chlamydia movement
• Hemophilus influenzae (non-typable) • Check for reddened conjunctiva (unilateral or
• Neisseria gonorrhoeae bilateral
• Staphylococcus aureus • Check for discharge (purulent, watery, milky),
• Streptococcus pneumoniae which is usually present
• In an adolescent, gonococcal or chlamydial • Check for white granules (phlyctenules) on the
infection should be considered if the history is edge of the cornea surrounded by erythema
supportive of this diagnosis and the adolescent is
sexually active Differential Diagnosis
• Infectious conjunctivitis
Viral Pathogens • Trauma
• Adenovirus • Foreign body
• Enterovirus • Allergic conjunctivitis
• Epstein-Barr virus and herpes zoster virus (less • Keratitis
common) • Glaucoma
• Measles and rubella viruses • Uveitis (iritis)
• Periorbital or orbital cellulitis
History • Measles-associated conjunctivitis
• Eye red and itchy
• Discharge or sticky eye common upon waking in Complications
the morning • Spread of infection to other eye structures
• Sensation like that of sand in the eye • Spread of infection to others
• Commonly, a viral URTI has preceded the eye
infection
Diagnostic Tests
• Complicating bacterial infections, such as otitis • Measure visual acuity if >3 years old
media, may be evident
• Perform a general assessment if the child
appears systemically ill (e.g. fever)


Goals of Treatment Never use steroid or steroid-and-antibiotic
• Relieve symptoms combination eye drops, because the infection may
• Rule out more serious infections (e.g. uveitis) progress or a corneal ulcer may rapidly form and
• Prevent complications cause perforation.
• Prevent spread of infection to others
Bacterial Conjunctivitis
Appropriate Consultation Topical antibiotic eye drop:
Consult a physician if any of the following occur: polymyxin B gramicidin eye drops (C class drug),
• Significant associated eye pain 2 or 3 drops qid for 5-7 days
• Any deficit in visual acuity or colour vision or
• Suspicion of keratoconjunctivitis or other more erythromycin 5mg/1g (B class drug) qid x 7-10
serious cause of red eye days
• Evidence of periorbital cellulitis
• No improvement after 48-72 hours of treatment An antibiotic eye ointment may be used at bedtime
in addition to the antibiotic eye drops prn:
Nonpharmacologic Interventions erythromycin 5mg/1g (B class drug), hs
• Supportive care and good hygiene for both
forms of infectious conjunctivitis These treatments should not be used for
• Cleansing of eyelids qid by application of gonorrheal or herpetic eye infections, for which
compresses of saline or plain water consultation is required.
• Public health measures that support good
hygiene (e.g. frequent hand-washing, use of Viral Conjunctivitis
separate clean face cloth and towels), because Antibiotics are not helpful and are not indicated.
the condition is highly contagious
Normal saline washes often provide excellent
Client Education symptomatic relief.
• Counsel parents or caregiver about appropriate
use of medications (dose, frequency, instillation) Monitoring and Follow-Up
• Advise parents or caregiver to avoid Follow up appropriately in 2 or 3 days, or sooner
contamination of the tube or bottle of medication if symptoms worsen.
with the infecting organisms
• Suggest ways to prevent spread of infection to Referral
other household members Referral is indicated under the following
• Instruct parents or caregiver (and child, if of a circumstances:
suitable age) about proper hygiene, especially of • The diagnosis is in doubt and significant ocular
hands and eyes infections (e.g. uveitis) cannot be ruled out
• For bacterial form: child may need school or • There is associated trauma
daycare restrictions for 24-48 hours after • Visual acuity is decreased
treatment is initiated • There is significant associated ocular pain
• For viral form: contagious for 48-72 hours, but • The child's condition deteriorates or the
condition may last for 2 weeks symptoms persist despite treatment
• Adenovirus is contagious for 2 weeks • The condition recurs frequently
• For allergic form: recommend that child avoid
going outside when pollen count is high and that
protective glasses be worn to prevent pollen
from entering the eyes
• Do not use a patch for conjunctivitis

Allergic Conjunctivitis
See "Conjunctivitis" (allergic type), in chapter 1, "The Eyes," in the NWT Clinical Practice Guidelines for
Primary Care Nurses (Adult) 2003

Ophthalmia Neonatorum
Definition
Severe conjunctivitis in newborns (<28 days of Differential Diagnosis
age). • Infectious conjunctivitis
• Trauma
This condition must be differentiated from the • Nasolacrimal duct obstruction (dacryostenosis)
more common mild conjunctivitis, which has the
same causes; see "Conjunctivitis," above, this
chapter.
Complications
• Gonorrheal conjunctivitis (also known as GC
conjunctivitis) may be fulminant, leading rapidly
Causes to extensive orbital infection and possibly
• Generally acquired from the maternal genital blindness
tract
• Systemic infections, including blood, joint and
• Bacterial organisms include Chlamydia and CNS infections, may occur secondary to
Neisseria gonorrhoeae N. gonorrhoeae infection
• Chlamydial infection is a very common STI in
North America and is thus the more common
Diagnostic Tests
cause of neonatal conjunctivitis
• Swab drainage for culture and sensitivity,
• Less commonly, Hemophilus strains, N. gonorrhoeae and Chlamydia
Staphylococcus aureus, Streptococcus
pneumoniae and other gram-negative organisms
It is important to rule out chlamydial infection by
may be involved
means of a Chlamydia antigen swab.
History Management
• Depends on causative organism Goals of Treatment
• Treat infection
Gonorrhea
• Generally presents early (day 3-5 of life)
• Should be considered in any infant who presents Appropriate Consultation
with conjunctivitis at less than 2 weeks of age Consult a physician immediately, before
commencing treatment, especially if you suspect
Chlamydial Infection gonorrheal or chlamydial infection. See also
• Children present with a history of eye redness "Conjunctivitis," above, this chapter.
and discharge after incubation period of
1-2 weeks Nonpharmacologic Interventions
• Should be considered in any child who presents • Prevention of perinatally acquired infections
with conjunctivitis in the first 3 months of life through prenatal clinics and screening and
and who does not respond to usual topical through STI control
antibiotics for mild conjunctivitis • Appropriate follow-up of infected mother and
her partner
Physical Findings
The child may appear severely ill, but the physical Pharmacologic Interventions
findings are generally limited to the eye Prevention
examination: Routine prophylaxis with erythromycin ointment
• Edema or erythema of the conjunctiva 5mg/1g (B class drug) for all newborns at birth.
• Purulent secretion
• Eyelids may be stuck together secondary to the
purulent secretions

Treatment of Chlamydia Infection Referral

erythromycin ethylsuccinate suspension (A class Refer all suspected cases of gonorrheal ophthalmia
drug), 40 mg/kg daily, divided qid, PO for 14 days to a physician immediately. The child must usually
be admitted to hospital for IV administration of
Topical erythromycin ointment alone is not antibiotics
effective in eliminating nasopharyngeal
colonization. Refer all cases of Chlamydia infection to a
physician if there is no improvement after
2 or 3 days of oral treatment.

Nasolacrimal Duct Obstruction (Dacryostenosis)

Definition • Mucocele: a bluish, subcutaneous mass below
A congenital disorder of the lacrimal system the medial canthal tendon
characterized by blockage of the nasolacrimal duct • Periorbital cellulitis: inflammation around the
and resulting in excessive tearing and ipsilateral eye (this is an eye emergency)
mucopurulent discharge from the affected eye.
Diagnostic Tests
The condition occurs in approximately 2% to 6% • Eye swab for culture and sensitivity (if purulent
of newborns. Onset is usually within the first few discharge present)
weeks of life.
Management
Cause In 90% of cases, the condition resolves, with
Persistence of a membrane at the lower end of the conservative management, once the child reaches
nasolacrimal duct results in incomplete 1 year of age.
canalization of the duct and its consequent
obstruction. Goals of Treatment
• Observe, to monitor for and prevent
History And Physical Findings complications
• Usually unilateral but may be bilateral
• Conjunctival erythema and irritation minimal Nonpharmacologic Interventions
• Tearing within the affected eye • Provide reassurance to parents or caregiver
• Pooling or puddling of tears • Offer support and encouragement, as condition
• Epiphora (frank overflow of tears) may take many months to resolve
• Accumulation of mucoid or mucopurulent • Recommend nasolacrimal massage two or three
discharge in the affected eye, which results in times daily, followed by cleansing of the eyelid
crusting (usually evident upon awakening) with warm water
• Erythema or maceration of the skin under the • Suggest gentle massage of lacrimal sac toward
eye the nose, to clear the passage
• Expression of clear fluid or mucopurulent • Teach parents or caregiver the signs and
discharge when the area of the nasolacrimal sac symptoms of complications, and instruct them to
is massaged, which may be intermittent or report any that occur
continuous over several months
• URTI may exacerbate the condition Topical antibiotics for mucopurulent drainage:
erythromycin 5mg/1g eye ointment
Differential Diagnosis (B class drug), hs
• Early signs of congenital glaucoma
• Photophobia Referral
• Cloudy cornea Refer to a physician if the condition has not
• Excessive lacrimation responded to conservative management by the
time the child reaches 6 months of age or any time
Complications there are complications (e.g. dacryocystitis,
• Dacryocystitis: inflammation of the pericystitis or periorbital cellulitis, an eye
nasolacrimal sac, accompanied by edema, emergency).
erythema and tenderness of the skin over the
A surgery consult may be necessary for lacrimal
area of the affected duct (acute or chronic)
probing, which may be repeated once or twice.
• Pericystitis: inflammation of the tissues Definitive surgery is indicated if lacrimal probing
surrounding the affected duct (performed up to three times) fails to resolve the
problem.

Strabismus (Squinting)
Definition • Alternating: child uses either eye for fixating
Any abnormality in the alignment of the eyes. and the other eye deviates; vision develops
normally in both eyes because there is no
The classification of strabismus is complex. On an preference for fixation
etiologic basis, it may be paralytic or non- • Consistent: one eye is used consistently for
paralytic, but it can also be classified as congenital fixating, and the other eye consistently deviates;
or acquired, intermittent or constant, or convergent child is prone to defective development of vision
or divergent. in the deviating eye (because of constant
suppression of the visual image)
Pathogenesis
When the eyes are positioned so that an image Causes
falls on the fovea (the area of best visual acuity) of Paralytic
one eye, but not the other, the second eye will • Weakness or paralysis of one or more ocular
deviate so that the image falls on its fovea as well. muscles
This deviation may be up, down, in or out and • Deviation is asymmetric
results in strabismus. • Congenital: secondary to developmental defect
in muscle or nerves or to congenital infection
• Esotropia: both eyes converge medially • Acquired: due to extraocular nerve palsies;
(crossed eyes) indicates a serious underlying problem (e.g.
• Esotrophia: one eye deviates medially fracture of facial bone, CNS tumor,
• Exotrophia: one eye deviates laterally neurodegenerative disease, myasthenia gravis,
• Hypertrophia: one eye deviates upward CNS infection)
• Hypotrophia: one eye deviates downward
Non-paralytic
Early recognition and treatment are important for • Most common type of strabismus
the development of both normal binocular vision • Extraocular muscles and the nerves that control
and good cosmetic results. Persistent, untreated them are normal
strabismus may lead to decreased visual acuity of • Occasionally, this form may be secondary to
the deviating eye. For best results, strabismus must underlying ocular or visual defects such as
be treated before the child reaches 5 years of age. cataracts or refraction errors
• Overall, seen in 3% of children
Main Types
Heterophoria Pseudostrabismus
Intermittent (latent) tendency to misalignment. Young infants have a broad nasal bridge;
• Eyes deviate only under certain conditions (e.g. therefore, less of the inner eye is seen, which may
stress, fatigue, illness) give the impression of squinting.
• Common
• May be associated with transient double vision, Intermittent eye convergence (crossed eyes) in
headaches, eye strain infants 3-4 months of age is usually normal but
should be monitored. If it persists, the child should
Heterotropia be evaluated by a physician.
Constant misalignment of eyes.
• Occurs because normal fusional mechanisms are History
unable to control eye deviation • Family history (about 50% of cases are
• Child is unable to use both eyes to fixate on an hereditary)
object and learns to suppress the image in the • Constant or variable squint in one or both eyes
deviating (non-fixating) eye • Squinting worse with fatigue or stress

• Child tilts head or closes one eye (compensatory Fig. 8-2: Cover-Uncover Test (what
mechanisms for weak eye) practitioner sees when facing child)
Physical Findings
First assess the following:
• Extraocular eye movements (by having child
visually follow an object): watch for asymmetry
of movement
• Visual acuity (with Snellen or similar chart)
Then assess alignment with the following two

main techniques.
Corneal Light Reflex Test (Hirschberg

Test) Complications
Direct a small, focal light toward the child's face, • Amblyopia
and observe the reflections in each cornea. If the
eyes are aligned, the reflection should be on
symmetric points of the corneas.
Diagnostic Tests
None.
Cover-Uncover Test
Child is asked to fix gaze on an object. Management
Goals of Treatment
Examiner alternately covers each eye, after • Prevent complications
allowing time for the eyes to drift.
• Normal alignment: no movement of either eye Monitoring and Follow-Up
• Phoria: when deviating eye is covered, it tends A young infant with intermittent, non-paralytic
to move; therefore, when the deviating eye is strabismus may be kept under observation until he
uncovered, the examiner can observe the eye as or she reaches 6 months of age, when referral may
it resumes its former position (Fig. 8-2), i.e. become necessary.
movement is seen on uncovering the deviating
eye Referral
• Tropia: when fixating eye is covered, the • Refer all children with suspected strabismus to a
deviating (uncovered) eye moves, i.e. movement physician for evaluation
is seen on covering the deviating eye • All children with fixed (paralytic) strabismus
need more urgent referral, particularly if the
paralytic strabismus is acquired
Early referral and treatment give the best chance

for good vision in both eyes and good ocular
alignment.
Hordeolum Or Stye
Chalazion
See "Hordeolum or Stye," and "Chalazion" in chapter 1, "The Eyes," in the NWT Clinical Practice
Guidelines for Primary Care Nurses (Adult) 2003

Emergency Problems Of The Eye

Orbital Cellulitis
Definition • Conjunctivitis
Bacterial infection of the deep tissues of the • Dacryocystitis
posterior orbital space. • Eczematoid dermatitis
• Rhabdomyosarcoma
Orbital cellulitis and periorbital cellulitis (see next
section) may coexist in the same person.
Complications
Causes • Intracranial cavernous sinus thrombosis
Usually a serious complication of acute sinusitis or (associated with signs of CNS irritation,
other facial infection or trauma. puffiness of the face, deterioration in level of
consciousness)
• Streptococcus pneumoniae
• Orbital or subperiosteal abscess
• Hemophilus influenzae (non-typable)
• Branhamella catarrhalis • Infection of other orbital structures
• Staphylococcus (less common) • Meningitis
• Intracranial abscess
History • Blindness
• Preceding history of acute sinusitis (although
such a history is not often present in young Diagnostic Tests
children, <6 years old) • Swab any discharge for culture and sensitivity
• Often no obvious antecedent event in children before starting antibiotics
• Low- to high-grade fever
• Mild or marked swelling and pain on movement Management
of the eye Goals of Treatment
• Mild to marked visual impairment • Treat infection
Physical Findings
• Inflammation and swelling of the surrounding Appropriate Consultation
orbital tissues and eyelids Consult a physician immediately.
• Exophthalmos (proptosis) may be present in
severe cases Adjuvant Therapy
• Mild to moderate ophthalmoplegia (inability to • Start IV therapy with normal saline to keep vein
move eye) open
• Mild to significant decrease in visual acuity
Client Education
• Child may appear mildly ill to moribund,
• Explain to the parents or caregiver the nature,
depending on severity of infection
course, expected treatment and outcomes of
disease
Assess for any neurologic complications and level
of consciousness (see pediatric Glasgow coma Pharmacologic Interventions
scale, Table 15-1, in chapter 15, "Central Nervous • IV antibiotics should be started urgently, before
System").
transport
Differential Diagnosis • Discuss choice of antibiotics with a physician.
Antibiotic of choice: cefuroxime (B class drug)
• Periorbital cellulitis
• Insect bite
Referral
• Allergic reaction Medevac to hospital.

Periorbital Cellulitis (Preseptal)

Infection of the tissues anterior to the orbital • Orbital cellulitis
septum.
Complications
Periorbital cellulitis and orbital cellulitis (see • CNS infection
previous section) may coexist in the same person. • Meningitis
Bacteria gain access to the tissues around the orbit
• Swab any discharge for culture and sensitivity
through trauma, skin pustules, insect bites, URTIs,
before starting antibiotics
infections of the teeth and occasionally sinusitis.
• Hemophilus influenzae (type B) - very important Management

in children <5 years old Appropriate Consultation
Consult a physician for all cases of suspected
• Staphylococcus aureus
periorbital cellulitis.
• Streptococcus pyogenes
Client Education
History • Explain to parents or caregiver the nature,
• May be a preceding history of trauma or insect course, expected treatment and outcomes of the
bites to the eye area, but frequently there is no disease
antecedent history • If child is being treated on an outpatient basis,
• Child may have other systemic features, such as counsel parents or caregiver about appropriate
fever and irritability use of medications (dose, route, side effects)
• Parents or caregiver may have noticed that the
eyes are swollen to the point of shutting Pharmacologic Interventions
• Examination of the child may be very difficult, Discuss with a physician. If the infection is
because of edema, pain and anxiety extensive, IV antibiotics may have to be started
before transfer to hospital. If the infection is mild
Physical Findings or moderate, the physician may decide to treat the
• Child febrile, ill-looking child as an outpatient, using oral antibiotics (e.g.
• No pain on movement of the eye amoxicillin/clavulanate )
• Visual acuity usually normal (if it can be
assessed) Referral
• Orbital edema and erythema Medevac for admission to hospital and treatment
• Discharge from the eyelid and surrounding with IV antibiotics may be needed for more severe
tissues infections.
Unless other complications have occurred, the

child should show no evidence of neurologic
problems.

Corneal Abrasion
Conjunctival, Corneal Or Intraocular Foreign Bodies
Acute Angle-Closure Glaucoma
Chemical Burns
Blunt Or Lacerating Ocular Trauma
Uveitis (Iritis)
For the above emergency problems of the eye see Chapter 1, "The Eyes," in the NWT Clinical Practice
Guidelines for Primary Care Nurses (Adult) 2003

Chapter 9 – Ears, Nose And Throat (ENT)

Assessment Of The Ears, Nose And Throat.................................................................................................... 1
Examination Of The Ears, Nose And Throat.................................................................................................. 2
Common Problems Of The Ears, Nose And Throat ...................................................................................... 3

Otitis Externa .................................................................................................................................................. 3
Acute Otitis Media.......................................................................................................................................... 3
Chronic Otitis Media (Purulent Draining Ear)................................................................................................ 5
Serous Otitis Media (Otitis Media With Effusion) ......................................................................................... 6
Foreign Body In The Nose.............................................................................................................................. 7
Stomatitis ........................................................................................................................................................ 8
Pharyngotonsillitis ........................................................................................................................................ 10
Bacterial Pharyngotonsillitis......................................................................................................................... 10
Viral Pharyngotonsillitis ............................................................................................................................... 12
Sinusitis......................................................................................................................................................... 12
Emergency Problems Of The Ear, Nose And Throat .................................................................................. 13

Retropharyngeal And Peritonsillar Abscess ................................................................................................. 13
Epistaxis........................................................................................................................................................ 15
Common Dental Problems In Infants............................................................................................................ 17

Eruption Cyst ................................................................................................................................................ 17
Epstein's Pearls ............................................................................................................................................. 17
Neonatal Teeth.............................................................................................................................................. 17
Normal Tooth Development ......................................................................................................................... 18
Common Oral And Dental Problems In Older Children ............................................................................ 19

Ankyloglossia (Tongue-Tie)......................................................................................................................... 19
Migratory Glossitis (Geographic Tongue).................................................................................................... 19
Thumb Sucking............................................................................................................................................. 19
Congenital Absence Of Teeth (Anodontia) .................................................................................................. 19
Partial Absence Of Teeth (Oligodontia) ....................................................................................................... 20
Other Common Abnormalities Of The Teeth ............................................................................................... 20
Common Malocclusions ............................................................................................................................... 20
Dental Caries................................................................................................................................................. 20
Milk Caries ................................................................................................................................................... 21
For more information on the history and physical examination of the ears, nose and throat in older children
and adolescents, see Chapter 2, "Ears, Nose and Throat (ENT)," in the NWT Clinical Practice Guidelines for
Primary Community Care Nursing (Adult) 2003
For otitis externa, chronic otitis media (purulent draining ear) and sinusitis, clinical presentation and
management are the same in adults and children. For information on these conditions, see chapter 2, "Ears,
Nose and Throat (ENT)," in the NWT Clinical Practice Guidelines for Primary Community Care Nursing
(Adult) 2003

Assessment Of The Ears, Nose And Throat

General • Oral lesions
The following characteristics of each symptom • Bleeding gums
should be elicited and explored: • Sore throat
• Onset (sudden or gradual) • Dysphagia (difficulty swallowing)
• Chronology • Hoarseness or recent voice change
• Current situation (improving or deteriorating)
• Location Neck
• Radiation • Pain
• Quality • Swelling
• Timing (frequency, duration) • Enlargement of glands
• Severity
• Precipitating and aggravating factors Other Associated Symptoms
• Relieving factors • Fever
• Associated symptoms • Malaise
• Effects on daily activities • Nausea and vomiting
• Previous treatments Medical History (Specific To ENT)
• Efficacy of previous treatments • Seasonal allergies
• Frequent ear or throat infections
Cardinal Symptoms • Sinusitis
In addition to the general characteristics outlined • Trauma to head or ENT area
above, additional characteristics of specific • ENT surgery
symptoms should be elicited, as follows. • Audiometric screening results indicating hearing
loss
Ears • Prescription or OTC medications used regularly
• Recent changes in hearing
• Itching Family History (Specific To ENT)
• Earache • Others at home with similar symptoms
• Discharge • Seasonal allergies
• Tinnitus • Asthma
• Vertigo • Hearing loss
• Ear trauma
Personal And Social History (Specifc
Nose To ENT)
• Nasal discharge or postnasal drip • Feeding methods (breast or bottle), bottle
• Epistaxis propping
• Obstruction of airflow • Frequent exposure to water (swimmer's ear)
• Sinus pain • Use of foreign object to clean ear
• Itching • Insertion of foreign body in ear
• Nasal trauma • Crowded living conditions
• Poor personal hygiene
Mouth and Throat • Exposure to cigarette smoke, wood smoke or
• Dental status other respiratory toxins

Examination Of The Ears, Nose And Throat

General Appearance Clinical tip: For the best view of the eardrum in an
• Apparent state of health (e.g. appearance of infant or a child < 6 years old, pull the outer ear
acute illness) upward, outward and backward.
• Hydration status
• Degree of comfort or distress Palpation
• Colour (flushed or pale) • Tenderness over tragus or mastoid process
• Character of cry (infants < 6 months old) • Tenderness on manipulation of the pinna
• Activity level (spontaneous activity or lethargy) • Pre- or post-auricular nodes
• Mental status (whether alert and active)
• Degree of cooperation, consolability Nose
• Emotional reaction to parent (or caregiver) and Inspection
examiner • External: inflammation, deformity, discharge,
• Hygiene bleeding
• Posture • Internal: colour of mucosa, edema, deviated
septum, polyps, bleeding points
• Difficulty with gait or balance
• Transilluminate sinuses to check for dulling of
light reflex
Safety Tip
For examination, it may be necessary to restrain a
struggling child. For example, lay the child in a Palpation and Percussion
supine position and have the parent or caregiver • Check for sinus and nasal tenderness (only in
hold the child's arms extended, in a position close older children who can cooperate and provide a
to the sides of the head. This will limit side-to-side response)
movements while you are examining ENT
structures. Brace the otoscope, and guard against Mouth And Throat
sudden head movements. Inspection
• Lips: colour, lesions, symmetry
Ears • Oral cavity: breath odor, colour, lesions of
Inspection buccal mucosa
• External ear: position (in relation to eyes) - low- • Teeth and gums: redness, swelling, caries
set or small, deformed auricles may indicate • Tongue: colour, texture, lesions, tenderness of
associated congenital defects, especially renal floor of mouth
agenesis • Throat: colour, tonsillar enlargement, exudate
• Pinna: lesions, abnormal appearance or position
• Canal: discharge, swelling, redness, wax, foreign Neck
bodies Inspection
• Eardrum: colour, light reflex, landmarks, • Symmetry
bulging or retraction, perforation, scarring, air • Swelling
bubbles, fluid level • Masses
• Redness
Estimate hearing by producing a loud noise (e.g. • Enlargement of thyroid
by clapping hands) for an infant or young child
(which should elicit a blink response) or by Palpation
performing a watch or whisper test for an older • Tenderness, enlargement, mobility, contour and
child. Perform tympanography (if equipment consistency of nodes and masses
available).
• Thyroid: size, consistency, contour, position,
tenderness

Common Problems Of The Ears, Nose And Throat

Otitis Externa
See "Otitis Externa," in chapter 2, "Ears, Nose and Throat (ENT)," in the NWT Clinical Practice Guidelines
for Primary Community Care Nursing (Adult) 2003
Acute Otitis Media

Definition
Acute suppurative infection of the middle ear, Less Common Organisms
often preceded by a viral upper respiratory tract • Mycoplasma
infection (URTI). Spontaneous recovery in 80%. • Chlamydia
Occurs more frequently in the following groups Other Miscellaneous Causes

and situations: • Immunoreactivity
• Children with cleft palate • Allergic rhinitis
• Children with Down's syndrome
• Daycare environment History
• Children of Aboriginal origin • Otalgia (pain is absent in 20% of children)
• Possibly bottle-fed children, if the child is • Fever
propped up for feeding or goes to sleep with a • Irritability (in infants)
bottle of milk at night • Hearing loss
• Children who use pacifiers when sleeping at • Vomiting or diarrhea may be present
night • Non-specific sensation of tugging at ears
• Children 6 months to 3 years old • Restless sleep
• During winter months
• More common in boys than girls Physical Findings
• Children exposed to cigarette smoke • Fever
• May appear acutely ill
Causes
Viral Organisms Inspection of the tympanic membrane is the key to
• In 25% to 30% of cases diagnosis:
• Respiratory syncytial virus (RSV) • Light reflex and bony landmarks usually
• Influenza A virus disappear in acute otitis media
• Coxsackievirus • Tympanic membrane appears dull, red and
• Adenovirus bulging in acute otitis media
• Parainfluenza virus • Reduction in or lack of movement of the
tympanic membrane on pneumatic otoscopy
Common Bacterial Organisms Wax and other debris should be removed from the
• Streptococcus pneumoniae (40%) ear canal to allow a clear view of the tympanic
• Hemophilus influenzae, untypable (25%) membrane.
• Moraxella catarrhalis (10%)
• Streptococcus pyogenes Redness of the tympanic membrane in the absence
• Pseudomonas aeruginosa of other signs may be due to crying agitation, a
• Staphylococcus aureus common cold, aggressive examination or
manipulation of the external ear canal, or serous

otitis media with effusion (see "Serous Otitis

Media [Otitis Media with Effusion]," below, this Client Education
chapter). • Recommend increased rest in the acute febrile
phase
Guidelines for Pneumatic Otoscopy • Counsel parents or caregiver about appropriate
Anyone can learn pneumatic otoscopy, but use of medications (dosage, compliance,
practice is needed. This method consists of follow-up)
applying air pressure to the tympanic membrane • Explain disease course and expected outcome
and watching the resultant movement.
• Recommend avoidance of flying until symptoms
• Tools: a battery-operated bright light with a have resolved
well-charged battery and a hermetically sealed • Discourage prop feeding with bottle
otoscope with pneumatic attachment
• Client must remain still during the examination Pharmacologic Interventions
(it may be necessary to restrain a child) Antipyretic and analgesic for fever and pain:
• Apply positive pressure (by squeezing a full acetaminophen (A class drug), 10-15 mg/kg PO
bulb) and negative pressure (by releasing the q4-6h prn
bulb), and observe any movement of the
eardrum If there is any doubt about the diagnosis, and there
is a possibility that the child does not have acute
• Lack of movement implies the presence of fluid
otitis media, do not give antibiotics. In 70% of
in the middle ear or chronic stiffness of the
cases, acute otitis media resolves on its own with
tympanic membrane
supportive care only.
Differential Diagnosis Antibiotic therapy, first-line drug:
• Acute otitis externa amoxicillin (C class drug), 40 mg/kg per day,
• Pharyngitis or tonsillitis divided tid, PO for 10 days
• Non-infectious middle ear effusion
• Trauma to or foreign body in ear canal Consider second-line antibiotic therapy under the
• Referred pain from dental abscess following conditions:
• Mastoiditis (rare) • Penicillin allergy, give:
cefuroxime axetil (B class drug) 40 mg/kg/day,
Complications divided bid, PO for 10 days
• Perforated tympanic membrane
• Serous otitis media • Acute otitis media unresponsive to a 3- or 4-day
• Mastoiditis (rare) trial of amoxicillin and accompanied by
persistent fever, irritability or pain
Diagnostic Tests • Early recurrence of otitis media (< 2 months
after initial bout), which is often due to bacteria
that produce ß-lactamase and are thus resistant
to amoxicillin, pneumococci with reduced
Management susceptibility to penicillins or cephalosporin, or
Goals of Treatment organisms resistant to cotrimoxazole
• Control pain and fever • Immunocompromise (e.g. leukemia)
• Relieve infection • Infection in newborns <2 months old
• Prevent complications • Preference for alternative dosing schedule
• Avoid unnecessary use of antibiotics (e.g. working parents):
cotrimoxazole suspension (C class drug),
Appropriate Consultation 6-10 mg/kg daily, divided bid, PO for 10 days
Usually not necessary if condition is
uncomplicated.

Drug choice should be based on efficacy, cost and • If infection recurs less than 2 months after the
acceptability to the child. previous infection, use one of the second-line
antibiotics
Antihistamines and decongestants have no proven • If infection recurs more than 2 months after the
efficacy in the treatment of acute otitis media and previous infection, treat as acute otitis media
should be avoided. with amoxicillin
Monitoring and Follow-Up Antibiotic Prophylaxis Guidelines

Instruct parents or caregiver to bring the child Consider prophylaxis in children who have had
back to the clinic in 3 days if symptoms do not multiple episodes of acute otitis media (three
diminish or if symptoms progress despite therapy. episodes in 6 months). Prophylaxis is intended for
prevention primarily during the winter months.
Otherwise, follow up in 14 days: Consult with a physician before starting
• If ear is normal, do not give any treatment prophylaxis. Given increasing antibiotic
• If ear is still dull but asymptomatic (no pain or resistance, antibiotic prophylaxis is no longer
hearing loss), follow up again in 6 weeks recommended.
• If condition is unresolved, with persistent
symptoms, consider treatment with a second-line amoxicillin (C class drug), 20 mg/kg daily PO hs
antibiotic or (in older children)
cotrimoxazole (C class drug), 4-20 mg/kg daily
Look for development of serous otitis media. PO hs
Assess hearing 1 month after treatment is Monitoring and Follow-Up

complete. • Assess compliance with medication for
treatment of acute episode and for prophylaxis
In 70% to 80% of patients, effusion persists after • Observe closely for acute recurrent attacks
2 weeks, and 10% still have effusion at 3 months • Assess hearing monthly
and may exhibit conductive loss of hearing (see
"Serous Otitis Media [Otitis Media with Referral
Effusion]," below, this chapter). Refer to a physician any child with multiple
episodes of acute otitis media (more than five
Referral episodes in a single year) that are unresponsive to
Not necessary if condition is uncomplicated. medical management. An ENT consultation is
advisable.
Recurrent Acute Otitis Media
Recurrence of this condition is very common in Myringotomy with insertion of T-tubes
children. (plus adenoidectomy) may be indicated. See
"Bugs and Drugs" (2001), page 94, for list of
when to refer for myringotomy tubes.
Chronic Otitis Media (Purulent Draining Ear)

Otitis media is considered chronic or persistent in The diagnosis and management of chronic otitis
the following situations: media in children is the same as in adults. See
• Six episodes by 6 years of age "Chronic Otitis Media (Purulent Draining Ear),"
• Five episodes within 1 year in chapter 2, "Ears, Nose and Throat (ENT)," in
• Three episodes within 6 months the NWT Clinical Practice Guidelines for Primary
Community Care Nursing (Adult) 2003

Serous Otitis Media (Otitis Media With Effusion)

Presence of non-infective fluid in the middle ear Goals of Treatment
for longer than 3 months (following a bout of • Prevent hearing loss
acute otitis media) without evidence of acute
infection. Nonpharmacologic Interventions
• Observation for 2-3 months is appropriate
Cause • Ensure appropriate seating at school (e.g. close
• Unclear to front of classroom)
• Bacteria are isolated from a significant • Encourage compliance and regular follow-up
proportion of middle-ear aspirates • Encourage parents or caregiver to speak clearly
and directly to child
History • Measure hearing by audiology if effusion
• Previous asymptomatic otitis media persists at 2-3 months
• Feeling of fullness in the ear
• Tinnitus (uncommon) Pharmacologic Interventions
• Hearing reduced (as indicated by hearing None. Antihistamines, decongestants and steroids
examination) have no proven efficacy.
Physical Findings Monitoring and Follow-Up

• Tympanic membrane dull, translucent or • Check ears and hearing every 2 weeks
bulging; landmarks diminished or absent • In a young child, follow for language
• Reduction of mobility of tympanic membrane, development while effusion persists
indicated by pneumatic otoscopy (for
description of technique, see "Acute Otitis Appropriate Consultation
Media," above, this chapter) Consult a physician about antibiotic therapy if
effusion persists for more than 3 months.
• Acute otitis media Referral
Refer to a physician if the effusion persists.
• Dysfunction of eustachian tube
An ENT consultation regarding surgical
Complications management may be indicated.
• Chronic serous otitis media General indications for myringotomy and T-tubes:
• Hearing loss • Persistent effusion for more than 6 months, with
associated hearing loss
Complicating factors, such as nasal allergy, • Recurrent, acute ear infections in addition to
submucous clefts and nasopharyngeal tumors, chronic effusion and anatomic alteration of the
must be excluded. tympanic membrane (e.g. retraction pocket,
granulomas)
Diagnostic Tests • Poor language development
• Tympanography (if available) may support the
diagnosis of effusion

Foreign Body In The Nose

Children frequently put foreign bodies in their Diagnostic Tests
nostrils. Occasionally, the foreign body (anything None.
from a small pea to a small bead or toy part)
obstructs the airway or becomes embedded, Management
causing significant infection. Goals of Treatment
• Relieve obstruction
History • Prevent recurrence
• Generally unilateral
• History of purulent rhinorrhea and difficulty Nonpharmacologic Interventions
with breathing through the affected nostril Foreign bodies can usually be removed by means
• Typically, the parent or caregiver relates that a of a blunt plastic hook. The hook can be
very foul smell is emanating from the child maneuvered along the wall of the nostril beyond
• Fever and other systemic features uncommon the foreign body, then turned inward to rest behind
the foreign body, and finally pulled out.
Physical Findings
• Obvious mucopurulent discharge, generally Round, smooth, hard objects may be more difficult
unilateral to remove. If such an item has become embedded
• Nasal blockage may be so severe that adequate behind granulation tissue, consultation with an
visualization of the foreign body is impossible ENT specialist and removal under general
• Suction may be necessary to visualize the anesthesia may be necessary.
foreign body
It is not recommended to attempt removal of a
It is important to explore the opposite nostril and foreign body beyond the dictates of common
ears for other foreign bodies. sense. The child will become increasingly
frightened and the procedure increasingly difficult.
Educate the parents or caregiver about the
• Sinusitis
problems associated with foreign bodies,
particularly the risk of aspiration and the need to
Complications remove foreign bodies under general anesthetic.
• Sinus infection
• Epistaxis

Stomatitis
Ulcers and inflammation of the tissues of the • Temperature increased in infectious types
mouth, including the lips, buccal mucosa, gingiva (temperature is often very high with herpes
and posterior pharyngeal wall. infection)
• Painful lesions
Causes
For most cases in young children: Examine outside of lips first. Next, gently retract
• Herpes simplex virus the lips with a tongue depressor to examine the
• Coxsackievirus anterior buccal mucosa and gingiva. Then gently
attempt to separate teeth and depress the tongue.
History Look for the following features:
• Fever • Erythema (herpangina)
• Pain • Vesicles (early stages of all infectious types)
• Drooling • Ulcers: check distribution (confluent ulcers may
• Difficulty swallowing appear as large, irregular white areas)
• Decreased nutritional intake • Submandibular lymph nodes (most prominent in
herpes)
• Associated respiratory or GI symptoms
• Associated skin rash
See Table 9-1 for the features of common forms of
stomatitis.
Table 9-1: Features of common forms of stomatitis in children

Type of
Disease Cause Site Diameter Other features
lesions
Herpangina Coxsackievirus, Vesicles and Anterior pillars, 1 – 3 mm Dysphagia, vesicles on palms of
or hand- echovirus, ulcers with posterior palate, hands and soles of feet and in
foot-and- enterovirus 71 erythema pharynx and mouth
mouth buccal mucosa
disease
Herpes Herpes simplex Vesicles and Gingiva, buccal > 5 mm Drooling, coalescence of lesions
stomatitis virus shallow ulcers, mucosa, tongue, Duration about 10 days
which may be lips
confluent
Aphthous Unknown Ulcers with Buccal mucosa, > 5 mm Pain, no fever
stomatitis exudate lateral tongue Usually only one or two lesions
Differential Diagnosis • Dehydration

• Vincent's infection (Vincent's angina) • Secondary infection (e.g. gangrenous stomatitis)
• Lichen planus • Ludwig's angina
• Mononucleosis
• Immunologic: gingival hyperplasia Diagnostic Tests
• Systemic lupus erythematosus None.
• Congenital: epidermolysis bullosa
• Erythema multiforme Management
There are as yet no specific treatments for any of
Complications these conditions. An educated guess must be made
• Pain as to the cause.

Herpes stomatitis usually lasts 10 days and the similar food items; avoid citrus foods, such as
child can feel miserable for this period. orange juice
• Recommend local mouthwashes (1:1 hydrogen
Herpangina lasts for only a few days and has few peroxide and water), especially after eating
complications. Aphthous stomatitis requires no • To prevent spread of infection, recommend
treatment. avoidance of direct contact with infected
individuals (e.g. kissing, sharing glasses and
Do not treat this condition with antibiotics, as they utensils, hand contact)
are not indicated and are not helpful. • Provide support to parents or caregiver to help
them cope with a "cranky" child
Goals of Treatment
• Relieve symptoms Pharmacologic Interventions
• Prevent complications Antipyretic and analgesic for fever and pain:
acetaminophen (A class drug), 10-15 mg/kg PO
Nonpharmacologic Interventions or PR q4h prn
• Maintenance of hydration is important
• Increase oral intake of fluids (i.e. maintenance Monitoring and Follow-Up
requirements + fluid deficits caused by fever) Reassess the young child (<2 years of age) in
24-48 hours to ensure maintenance of hydration.
Client Education
• Counsel parents or caregiver about the expected Appropriate Consultation and Referral
duration of this illness and the signs and The disease is self-limiting, so consultation and
symptoms of dehydration referral are usually unnecessary, unless there are
• Recommend dietary adjustments: bland, non- complications.
acidic fluids (such as milk and water); older
children may eat Popsicles, ice cream and

Pharyngotonsillitis
Definition
A painful condition of the oropharynx associated with infection of the mucous membranes of the pharynx and
palatine tonsils. Peak prevalence is in children <5 years old.
The condition may be caused by a bacteria or virus, and it may be difficult to differentiate between these two
forms clinically. Viral infections are the most common cause of pharyngotonsillitis in younger children;
bacterial pharyngotonsillitis is very rare in children <3 years old, but its prevalence increases with age.
The next two sections describe bacterial and viral pharyngotonsillitis in detail.
Bacterial Pharyngotonsillitis
Causes • Erythematous "sandpaper" rash of scarlet fever
• Group A ß-hemolytic streptococci (accounting (may be present with streptococcal infection)
for 15% to 40% of cases of acute • Erythematous rash (particularly if child is
pharyngotonsillitis); unusual in children receiving amoxicillin) and lymphadenopathy
<3 years old with splenic enlargement in children with
• Mycoplasma pneumoniae (accounting for mononucleosis
10% of cases of pharyngotonsillitis in • Usually not associated with coryza
adolescents) • Cough minimal or absent (this is a helpful
• Pneumococci, anaerobic organisms of the mouth diagnostic clue)
• Staphylococcus aureus, Hemophilus influenzae
(both of which are rare) Differential Diagnosis
• Predisposing factors: previous episodes of • Viral pharyngotonsillitis
pharyngitis or tonsillitis, overcrowding, poor • Epiglottitis
nutrition • Gonococcal pharyngitis in sexually active
adolescents
Pharyngotonsillitis may be secondary to diphtheria
or infectious mononucleosis. Complications
• Peritonsillar or retropharyngeal abscess
History • Acute rheumatic fever (after group A ß-
• Acute onset hemolytic streptococcal infection)
• Very sore throat • Obstruction of the upper airway (with
• Fever diphtheria); see "Diphtheria," in chapter 18,
• Headache "Communicable Diseases"
• Abdominal pain and vomiting
• General malaise Diagnostic Tests
• Swab throat for culture and sensitivity in
Physical Findings clinically symptomatic children
• Significant fever • Rapid strep test
• Tachycardia
• Pharyngeal and tonsillar erythema Management
• Petechiae of soft palate Goals of Treatment
• Tonsillar exudate (particularly with • Relieve symptoms
streptococcal infection, diphtheria or • Prevent complications
mononucleosis) • Prevent spread of group A streptococcal
• Anterior cervical lymphadenopathy infection to others

• Decide whether to treat as viral or bacterial rheumatic fever but avoids unnecessary use of
pharyngotonsillitis - consider differential antibiotics. If the culture results are positive, the
diagnosis of mononucleosis (see child can be recalled for initiation of antibiotic
"Mononucleosis," in chapter 11, treatment.
"Communicable Diseases," in the NWT Clinical
Practice Guidelines for Primary Community Antibiotics:
Care Nursing (Adult) 2003 or diphtheria (see penicillin V (C class drug), 40 mg/kg per day,
"Diphtheria," in chapter 18, "Communicable divided tid or qid, PO for 10 days
Diseases," these pediatric clinical guidelines) or
erythromycin (C class drug), 40 mg/kg per day,
Appropriate Consultation divided qid, PO for 10 days
Consult a physician if the child has significant or (for infants)
dysphagia or dyspnea signaling obstruction of the erythromycin ethylsuccinate suspension (C class
upper airway, or if you are concerned about an drug), 30-40 mg/kg per day, divided qid, PO
underlying pathologic state, such as peritonsillar
abscess or rheumatic fever. Many children are carriers of group A ß-hemolytic
Streptococcus. However, assuming compliance
Nonpharmacologic Interventions with the antibiotic regimen, only routine follow-up
• Increased rest during febrile phase is required; culture is not indicated.
• Increase oral fluids during febrile phase
• Avoidance of irritants (e.g. smoke) Antipyretic and analgesic for fever and pain:
acetaminophen (A class drug), 10-15 mg/kg
• Warm saline gargles qid (for older children)
q4-6h prn
• Appropriate surveillance of community with
respect to complications of rheumatic fever
Follow-up is recommended in 48-72 hours.
Pharmacologic Interventions Ascertain culture results at that time.
Indications for the introduction of antibiotics:
• Child appears acutely ill Repeat culture on the completion of antibiotic
• Child has a history of rheumatic fever therapy is unnecessary, and cultures need not be
• Child has an illness that is clinically compatible obtained from asymptomatic family contacts.
with scarlet fever
• Evidence of early peritonsillar abscess (consult a Referral
physician) Children who have had five or more documented
group A ß-hemolytic streptococcal infections
In the absence of the above situations, and if the should be referred to a physician regarding an
child is relatively asymptomatic, it is appropriate ENT consultation. They may benefit from
to await culture results before administering tonsillectomy.
antibiotics, if cultures can be obtained quickly.
This approach will not increase the risk of acute

Viral Pharyngotonsillitis
• Adenovirus or enterovirus (the latter is more • Bacterial pharyngotonsillitis
common in children <3 years old) • Epiglottitis
• Influenza virus
• Parainfluenza virus Complications
• Coxsackievirus • Secondary bacterial infection
• Echovirus
• Epstein-Barr virus (mononucleosis) Diagnostic Tests
• Herpes simplex virus None.
History Management
• Acute sore throat combined with symptoms Goals of Treatment
consistent with a viral URTI (rhinorrhea, cough • Supportive care to relieve symptoms
and often hoarseness)
Physical Findings • Rest and reassurance
• Fever (low-grade to significant) • Increase oral fluids during febrile phase
• Tachycardia • Avoidance of irritants (e.g. smoke)
• Pharyngeal and tonsillar erythema and swelling • Warm saline gargles qid (for older children)
• Petechiae of soft palate
• Tonsillar exudate similar to that occurring with Pharmacologic Interventions
bacterial infection may be present, particularly Antipyretic and analgesic for fever and pain:
in adenovirus pharyngotonsillitis acetaminophen (A class drug), 10-15 mg/kg PO
• Anterior cervical lymphadenopathy q4-6h prn
• Vesicles and ulcers may be present with
coxsackievirus infection (e.g. hand, foot and Occasionally, children are unable to drink
mouth ulcers occur with coxsackievirus secondary to the pain of pharyngotonsillitis caused
A-16 infection [usually in the area of the soft by some viral infections, particularly
palate]) or herpes infection (usually in the coxsackievirus and herpesvirus. In such situations,
anterior portion of the mouth) admission to hospital may be required for IV
administration of fluids (to prevent dehydration).
Sinusitis
Sinusitis is uncommon in young children (<10-12 years old). See "Acute Sinusitis" and "Chronic Sinusitis," in
chapter 2, "Ears, Nose and Throat (ENT)," in the NWT Clinical Practice Guidelines for Primary Community
Care Nursing (Adult) 2003

Emergency Problems Of The Ear, Nose And Throat

Retropharyngeal And Peritonsillar Abscess
Definition • Stiffness of the neck and possibly refusal to flex
Retropharyngeal Abscess the neck
A collection of pus in the retropharyngeal space. • Obvious redness and swelling on inspection of
the posterior pharynx
Peritonsillar Abscess • Exudate may be seen on the tonsils
A collection of pus between the tonsil capsule and • Cervical lymphadenopathy generally present
either the anterior or posterior tonsillar pillar.
Causes • Child appears acutely ill
May be viewed as a complication of bacterial • Inspection reveals unilateral swelling of the
pharyngotonsillitis. anterior or posterior tonsillar pillar
• Tonsils displaced, with uvula shifted to the
Retropharyngeal Abscess opposite side from the infection
• Penetrating trauma to the oropharynx • May be difficult to examine children because of
trismus
• Infection spreads from superior pole of the Differential Diagnosis
infected tonsil • Epiglottitis (if there is stridor, drooling and
fever); see "Epiglottitis," in chapter 10,
History "Respiratory System"
Retropharyngeal Abscess • Diphtheria
• More common in young children than • Mononucleosis
adolescents
• Fever, drooling and refusal to swallow Complications
• May present with stridor • Obstruction of the airway
• Rule out trauma to the oropharynx • Parapharyngeal abscess
• Aspiration (if abscess ruptures)
• Much more common in adolescents than in Diagnostic Tests
younger children None.
• Previous history of sore throat often present
• Fever prominent Management
• Pain, drooling and dysphagia Goals of Treatment
• Trismus (difficulty opening mouth) may be • Relieve symptoms
present • Prevent complications
• Breathing may be difficult
Physical Findings Consult with a physician immediately. Referral to
Before examining the pharynx, consider the hospital and an ENT specialist is in order.
diagnosis of epiglottitis. If epiglottitis is suspected, IV antibiotic treatment may be instituted while
do not examine the throat. awaiting transfer, especially if the transfer is
expected to take a period of many hours.
Retropharyngeal Abscess
• Child appears acutely ill

Mild cases in an older child may be treated on an

outpatient basis, but only on the advice of a Monitoring and Follow-Up
physician. Monitor child closely to ensure that an adequate
airway is maintained.
Adjuvant Therapy
• Start IV therapy with normal saline, at a rate Referral
adequate to maintain hydration (rate depends on Medevac to hospital. Consultation with an ENT
size and hydration status of the child) specialist is usually necessary, and the condition
may require surgical intervention.
• Bed rest General Guidelines For Tonsillectomy
• If child is drooling, give nothing by mouth • Documented cases of recurrent tonsillitis (child
• Give sips of cold liquids only if the child is able symptomatic or positive culture for group A
to swallow saliva ß-hemolytic Streptococcus)--five episodes per
year for 2 years is generally considered an
Pharmacologic Interventions indication for the procedure
Antibiotics: • Throat infection complicated by peritonsillar or
penicillin G sodium (B class drug), retropharyngeal abscess requiring drainage
100,000 to 300,000 units/kg daily, divided q6h, IV • Suspected malignant lesion of tonsil
• Cor pulmonale
For children with allergy to penicillin: • Obstructive sleep apnea
clindamycin (B class drug), 20-40 mg/kg/day in 3 • Severe upper airway obstruction
or 4 divided does IV

Epistaxis
Definition • Heart rate may be elevated because of fear or if
Bleeding from the nostril. Very common in bleeding is severe enough to cause loss of
childhood. volume
• Obvious deformity or displacement may be
Causes present
• Mechanical dysfunction of the nose secondary to • Bleeding from anterior portion of septum may
mucosal drying (e.g. from wood heat or dry air), be present
trauma or inflammation • Inspect throat for posterior bleeding
• Bleeding from the anterior nasal septum (Little's • Sinuses may feel tender
area or Kiesselbach's plexus) is most common • Septum may be deviated
• Posterior bleeding (usually from the • Try to ensure that there is no foreign body,
sphenopalatine artery) is much less common in polyp or tumor
childhood
• Uncommon causes (tumor, foreign body, Differential Diagnosis
leukemia, rheumatic fever, high blood pressure • Mild infection of nasal mucosa
and bleeding disorders) must always be • Dryness and irritation of nasal mucosa
considered, but are rare in childhood • Nasal fracture
• Foreign body
History • Malignant lesion
• Bleeding may range from mild trickling of blood • Tuberculosis
to significant bleeding because of trauma or • Blood dyscrasias
neoplasm
• Usually, bleeding is almost entirely from the
Diagnostic Tests
anterior nostril
None.
• In posterior epistaxis, bleeding tends to be more
brisk and severe, and blood flows into the
nasopharynx and mouth even when the child is
Management
in a sitting position Goals of Treatment
• Ask about possibility of trauma, nose-picking, or • Stop loss of blood
blood noticed on pillow or bedding • Prevent further episodes
• Rule out possibility of underlying bleeding
disorder, ingestion of ASA or other factors that Nonpharmacologic Interventions
might increase risk of bleeding Most bleeding will be stopped by application of
• Ask about level of humidity in the house pressure to both sides of the nose, with firm
pressure against the nasal septum for 5-15
minutes.
Examine child sitting up and leaning forward so
Client Education
that the blood will flow forward. Good
illumination is essential; you will need an
• Recommend increasing room humidity (a pot of
water should be kept on the stove at all times,
appropriate flashlight, as well as suction to remove
especially in winter)
the blood and secretions; topical vasoconstrictors
may be helpful for visualization. • Counsel parents or caregiver about appropriate
use of medication, including dosage and side
• Assess ABCs and vital signs, and stabilize as
effects, as well as avoidance of overuse
required
• Blood pressure normal, unless bleeding is severe • Recommend avoidance of known irritants and
local trauma (e.g. nose-picking, forceful nose-
enough to cause loss of volume
blowing)

• Instruct parents or caregiver (and the child, if of • The bleeding is suspected to be coming from the
an appropriate age) about first-aid control of posterior nasal area
recurrent epistaxis (child should sit up and lean • The epistaxis is recurrent and there is concern
forward, applying firm, direct pressure to nasal about a serious underlying problem
septum)
• Recommend use of ice packs to control acute If bleeding persists, it may be necessary to apply
bleeding either anterior or posterior packing of the nose, a
• Recommend liberal use of lubricants such as procedure which should be done only if the
petroleum jelly in the nares to promote hydration healthcare provider has previous experience and
of the nasal mucosa only after a physician has been consulted.
• Advise parents or caregiver to keep the child's
fingernails trimmed to avoid trauma from nose Monitoring and Follow-Up
picking • Monitor ABCs if significant bleeding has
occurred or is still occurring
Pharmacologic Interventions • Follow up as necessary if current bleeding
If direct pressure alone is insufficient to stop the resolves with first-line treatment
bleeding, consult a physician regarding use of
vasoconstricting nose drops. If prescribed by Referral
physician: In rare cases, a child may require evacuation for
• Soak a cotton ball with the solution consultation with an ENT specialist, with a view
• Place the medicated cotton ball in the anterior to arterial ligation, but only if all three steps above
portion of the nose (pressure, application of medicated cotton ball,
• Press firmly against the bleeding nasal septum and packing) have failed to control the bleeding.
for 10 minutes
A telephone consultation with a physician is
For older children (>2 years of age), use mandatory before transporting any child with
procedures presented in "Anterior Epistaxis" and epistaxis.
"Posterior Epistaxis," in chapter 2, "Ears, Nose
and Throat (ENT)," in the NWT Clinical Practice If there has been trauma, it is important to rule out
Guidelines for Primary Community Care Nursing septal hematoma. Hematoma of the nasal septum
(Adult) 2003 must be managed surgically, and medevac is
necessary.
Consult with a physician if: If the problem is recurrent, electively refer child to
• The above measures fail to control bleeding a physician to rule out other pathology.
• More severe bleeding occurs

Common Dental Problems In Infants

Eruption Cyst
Small white, gray or bluish translucent eruptions Reassure parents or caregiver that this condition
on crest of maxilla or mandible. will resolve on its own and needs no treatment.
Cause
Remnants of dental lamina, which are usually shed
after birth.
Epstein's Pearls
Small, white, keratinized lesions along the midline Reassure parents or caregiver that this condition
of the palate. will resolve on its own and needs no treatment.
Cause
Remnants of epithelial tissue trapped as the fetus
grows, which usually fall off after birth.
Neonatal Teeth
Eruption of teeth in neonatal period. In 80% of Reassure parents or caregiver that this condition
cases, such teeth are lower primary incisors. They will resolve without sequelae.
tend to be hypermobile because of inadequate root
formation. Referral
Refer to a dentist. Removal is recommended to
prevent aspiration of the teeth.

Normal Tooth Development

By about 5 or 6 years of age, a child's jaws have Table 9-2: Age at eruption of permanent teeth
grown enough to make space for the permanent Tooth* Age
teeth. At 6 to 7 years of age, the first permanent Upper teeth (maxillary)
teeth (the first molars) start coming in at the back
of the mouth, behind, not under, the last baby Central incisor (1) 7 – 8 years
teeth. Table 9-2 presents the ages when the Lateral incisor (2) 8 – 9 years
permanent teeth are likely to appear (refer to Fig. Cuspid (3) 11 – 12 years
9-1 for position of various teeth on the jaw).
First bicuspid (4) 10 – 11 years
Fig. 9-1: Position of Permanent Teeth in Upper Second bicuspid (5) 10 – 12 years
and Lower Jaws
First molar (6) 6 – 7 years
Second molar (7) 12 – 13 years
Third molar (8) 17 – 21 years
Lower teeth (mandibular)
Third molar (8) 17 – 21 years
Second molar (7) 11 – 13 years
First molar (6) 6 – 7 years
Second bicuspid (5) 11 – 12 years
First bicuspid (4) 10 – 12 years
Cuspid (3) 9 – 10 years
Lateral incisor (2) 7 – 8 years
Central incisor (1) 6 – 7 years
* Numbers correspond to designations in Fig 9-1

Common Oral And Dental Problems In Older Children

Ankyloglossia (Tongue-Tie)
Definition Referral
A condition in which a short lingual frenum Very occasionally, a thick fibrous band of tissue
attaches the tongue to the floor of the mouth, interferes with the tongue's protrusion beyond the
interfering with protrusion of the tongue. lips. In such cases, consultation with an ENT
specialist is suggested with a view to possible
Management surgical release.
No treatment is warranted if the tongue can be
protruded beyond the lips. In 95% of cases,
reassurance is all that is required.
Migratory Glossitis (Geographic Tongue)

Definition Cause
Tongue demonstrates several smooth, red areas Unknown.
outlined by elevated gray margins of epithelial
tissue. Management
Reassure child and parents or caregiver.
Thumb Sucking
This generally benign activity may result in Referral
protrusion of the maxillary incisors and anterior In rare cases, the child with a severe thumb-
open bite. However, most children suffer no sucking problem may need referral to a dentist and
effects to their dentition. close follow-up for anterior open bite.
Management
Reassure the parents or caregiver. Children
entering school generally stop sucking the thumb
as a result of peer pressure.
Congenital Absence Of Teeth (Anodontia)

Very rare. Teeth usually begin to erupt by 6
months, but may be delayed until up to 12 months.

Partial Absence Of Teeth (Oligodontia)

This condition is more common with the Referral
permanent dentition, particularly the third molars, Appropriate dental referral should be made.
the mandibular second bicuspids, the maxillary
lateral incisors and the maxillary second bicuspids.
Other Common Abnormalities Of The Teeth

• Delayed eruption Referral
• Rotation of incisors Children should be assessed by a dentist by age
• Bulging of alveolar ridge 7 years if any of these common abnormalities have
• Large space between maxillary central incisors presented.
Common Malocclusions
Definition Referral
Anterior open bite (protrusion of maxillary Children with significant malocclusions should be
anterior teeth) or crossbite (maxillary teeth referred to a dentist.
positioned behind the mandibular teeth).
Dental Caries
With the introduction of fluoride into the drinking Management
water of some urban and rural communities and Prevention
most toothpaste, and with increased attention to Encourage appropriate dental hygiene: tooth-
dental health, there has been a decrease in the brushing from the time of tooth eruption, flossing
prevalence of pediatric dental caries in most from the time the child reaches school age, low
southern populations. sugar consumption.
Environmental factors (such as hygiene and diet), Where water is not fluoridated, children up to
particularly as influenced by the parents or 14 years of age may need fluoride supplements.
caregiver, are the most significant predictors of See the fluoride recommendations of the Canadian
childhood dental problems. Paediatric Society in the section "Vitamin and
Mineral Supplements," chapter 7, "Nutrition."
Check with the regional office for the local policy

regarding fluoride supplementation.

Milk Caries
Definition • Encourage good oral hygiene: cleaning of teeth
Caries of the deciduous teeth, most commonly the with gauze as soon as they erupt and cleaning of
maxillary incisors and mandibular premolars and toddlers' teeth with a soft toothbrush; to ensure
molars. May be severe enough to cause dental effective brushing, an adult must supervise the
abscess. child until 6 years of age
• Encourage parents or caregiver to take children
Very common in Aboriginal groups in Canada, for their first dental assessment by 3 years of age
often resulting in extraction of the affected teeth • Fluoride supplements may be appropriate for
and problems with permanent teeth. infants and children <14 years of age
Referral
Causes Appropriate management includes referral to a
• Secondary to prolonged nursing (either bottle or dental practitioner for dental fillings. The repair
breast) at bedtime procedure may require a general anesthetic,
• Liquid pools around the child's teeth, causing particularly for milk bottle caries. Repair involves
significant caries, particularly in the maxillary fillings that last for 8-10 years.
incisors
Management Occlusion sealants (organic polymers) that bond to
Prevention of this problem is a major public health the enamel are intended for teeth with deep
concern, and public health measures to discourage developmental grooves and help in preventing
bottle caries are of primary importance: caries. However, this method is not cost-effective
• Discourage bottle propping for primary molars.
• Discourage use of sweet fluids in bottle
• Encourage drinking from a cup by 1 year

Chapter 10 – Respiratory System

General Information ......................................................................................................................................... 1
Assessment Of The Respiratory System.......................................................................................................... 1

Examination Of The Respiratory System ....................................................................................................... 1
Common Problems Of The Respiratory System ............................................................................................ 3

Upper Respiratory Tract Infection (URTI) ..................................................................................................... 3
Croup (Laryngotracheobronchitis).................................................................................................................. 5
Bronchiolitis.................................................................................................................................................... 7
Pneumonia .................................................................................................................................................... 11
Acute Asthma ............................................................................................................................................... 14
Chronic Asthma ............................................................................................................................................ 17
Persistent Cough ........................................................................................................................................... 19
Emergency Problems Of The Respiratory System....................................................................................... 20

Epiglottitis..................................................................................................................................................... 20
Neonatal Resuscitation ................................................................................................................................. 22
Appendix 10-1: Oxygen Delivery Techniques............................................................................................... 26
For more information on the history and physical examination of the respiratory system in older children and
adolescents, see chapter 3, "Respiratory System," in the NWT Clinical Practice Guidelines for Primary
Community Care Nursing (Adult) 2003

General Information
Respiratory illnesses in children are the most common those who are exposed to cigarette or wood smoke.
cause of nursing station visits and hospital admissions Because of the contagious nature of many of the viral
among Aboriginal children. Such illnesses are more illnesses, outbreaks are common. Careful assessment is
common in children who live in crowded housing and necessary to prevent morbidity.
Assessment Of The Respiratory System

General • Stridor
The history varies according to the child's age. • Wheeze
• Onset of illness (sudden or gradual) • Cyanosis
• Symptoms (acute or chronic) • Fatigue
• Fever • Pallor
• Runny nose • Intake/output
• Sore throat • Previous similar episodes
• Chest pain (older children may complain of this • Medications
symptom) • Allergies
• Shortness of breath • Family history of respiratory ailments (e.g. asthma)
• Cough, night cough, exercise-induced cough (see
Table 10-1)
Examination Of The Respiratory System

Use the IPPA approach: • Hypotonic
- I for inspection • Unconsolable
- P for palpation
- P for percussion
• Fatigue
- A for auscultation • Pallor
• Cyanosis of nails and mucous membranes (late sign)
Some of these techniques (specifically palpation and • Nasal flaring (especially in infants)
percussion) are difficult to perform on infants and • Drooling: sign of upper airway disease
toddlers, and may not yield useful information. (e.g. epiglottitis)
• Grunting (especially in infants)
Vital Signs • Prolonged expiration (may indicate asthma or
• Respiratory rate: normally 30-40 breaths/minute in bronchiolitis)
infants, 20 breaths/minute at 6 years of age, • Symmetry of chest movements (asymmetry may
16 breaths/minute in adolescents indicate pneumonia)
• Very rapid respiratory rate suggests disease of the • Accessory muscles of breathing: use of
lower airway, not the upper airway sternocleidomastoid muscles suggests upper airway
• Respiratory rhythm and depth obstruction, such as croup or epiglottitis; use of
• Heart rate intercostal and abdominal muscles in children
• Temperature <6 years old suggests lower airway disease, such as
• Pulse oximetry pneumonia or bronchiolitis
Inspection
Signs of Distress
• Child appears acutely ill (may indicate septicemia)

Table 10-1: Types of cough and most likely illness • Pleural effusion
Nature of cough Likely type of illness • Pneumothorax
Paroxysmal Pertussis
Prolonged Expiratory Phase
Loose, productive URTI, bronchitis
• Asthma
Sharp, barky Croup, foreign body • Bronchiolitis
Tight, productive Pneumonia, bronchiolitis
Localized Crackles
Chronic Asthma, bronchiectasis,
tuberculosis
• Pneumonia
• Bronchiectasis
Signs of Chronic Disease
Diffuse Crackles
• Clubbing (may indicate bronchiectasis, cystic
fibrosis) • Severe pneumonia
• Eczema (may indicate asthma) • Bronchiolitis (also congestive heart failure)
• Hyperinflation ("barrel chest", may indicate asthma) Crackles that disappear after coughing usually have no
significance. You may not hear crackles if the child is
Palpation breathing shallowly. Try to have the child take deep
Not useful in children <3 years old, although it may be breaths.
useful in older, cooperative children. Allows further
assessment of respiratory excursion. Some children with pneumonia may not have crackles
or any signs other than tachypnea.
Percussion
Useful only in older children (>2 years old). Wheezes
• Resonance is normal • May be inspiratory or expiratory
• Dullness to percussion over areas of fluid or solid • Suggest asthma or bronchiolitis
tissue is present in lobar pneumonia, pleural effusion • Foreign body
and collapsed lung
• Increased resonance over areas of hyperinflation Pleural Rub
(sounding like percussion of a puffed-out cheek) is • Sounds like two pieces of leather being rubbed
present in bronchiolitis, asthma, foreign body with together
obstruction to lung behind and pneumothorax
• Suggests pneumonia
Auscultation
X-Rays In Children
• Quality of breath sounds (tracheobronchial, X-rays should be performed on site (when possible),
bronchovesicular, vesicular) according to regional policy only, in children who have
• Volume of air entry signs consistent with acute involvement of the lower
• Ratio of inspiration to expiration respiratory tract, including tachypnea, persistent
• Adventitious sounds: crackles, wheezes, pleural rub, crackles or high fever, if such imaging will help to
stridor, bronchial breathing clarify a diagnosis and/or affect management.
Otherwise, manage the illness on clinical grounds.
In infants and small children, the sounds may be
transmitted easily and may therefore be difficult to X-rays are not useful in the diagnosis or treatment of
localize. Breath sounds often seem louder in children asthma or bronchiolitis or for children who do not
because of the thinness of the chest wall. appear acutely ill ("happy wheezers").
Decrease in Breath Sounds Bronchiolitis is often complicated by atelectasis,

• Pneumonia important to know for prognostic value.
• Collapsed lung

Common Problems Of The Respiratory System

Upper Respiratory Tract Infection (URTI)
Viral infection and inflammation of the upper airway None.
structures. Also known as the common cold.
Management
Causes Goals of Treatment
• Viral condition • Primarily to relieve symptoms
• Many different viruses may cause symptoms of URTI
History • Rest
• Onset over 1-2 days • Adequate fluids
• Usually runs a 3-7-day course • Normal saline nose drops for infants with nasal
• Fever congestion that interferes with feeding
• Runny nose
• Cough Pharmacologic Interventions
Antipyretic for fever:
• Little distress (infants, who are obligate nose
acetaminophen (A class drug), 10-15 mg/kg PO or PR
breathers, may experience more distress because of
q4-6h prn
blockage)
• Exposure to others with URTI Decongestants and cough suppressants are symptomatic
• Decrease in appetite medications and have little proven value. They should
be used judiciously and only in older children.
Physical Findings
General Do not use decongestants or antihistamines in children
• If temperature is elevated, look for pharyngitis or <1 year old.
otitis media
• Examine ears, nose, mouth and neck lymph nodes Monitoring and Follow-Up
Follow-up is necessary only if symptoms worsen or do
• Fever unusual with simple URTI
not resolve as expected.
• Usually no respiratory distress
• May have macular rash (viral exanthem) Advise the parents or caregiver to watch for the
• Tympanic membranes may be slightly red following symptoms:
• Nares may be red and swollen with clear to purulent • Development of bronchiolitis (especially in infants)
discharge • Development of otitis media
• Pharynx, tonsils may be slightly red • Precipitation of wheezing in asthmatic children
• Development of secondary pneumonia
Lungs
• Breath sounds usually normal, with good bilateral air Referral
entry Not usually required.
• Crackles that clear with coughing may be present
Upper Airway Disorders
Differential Diagnosis Disorders of the upper airway are common clinical
• Bacterial URTI problems. Differentiation of the various disorders is
often difficult. See Tables 10-2 and 10-3 for some
helpful information on the clinical manifestations of
Complications these disorders. Several of these disorders are discussed
• Bacterial URTI (e.g. sinusitis) in detail in this chapter.
• Acute otitis media

Table 10-2: Features of upper airway disorders

Entity Usual age range Mode of onset of respiratory distress
Severe tonsillitis Late preschool or school age Gradual
Peritonsillar Usually >8 years Sudden increase in temperature, appears acutely ill, unilateral throat
abscess pain, “hot potato” speech
Retropharyngeal Infancy to adolescence Fever and appearance of acute illness after URTI, pharyngitis or
abscess penetrating injury
Croup 6 months to 6 years Gradual onset of stridor and barking cough after mild URTI
Epiglottitis 1 – 7 years Acute onset of hyperpyrexia, dysphagia and drooling
Foreign-body Late infancy to 4 years Choking episode resulting in immediate or delayed respiratory
aspiration distress
Bacterial Infancy to 4 years Moderately rapid onset of fever, appearance of acute illness,
tracheitis respiratory distress
Table 10-3: Clinical features of acute upper airway disorders

Clinical feature Supraglottic disorders (Epiglottitis) Subglottic disorders (Croup)
Stridor Quiet Loud
Voice alteration Aphonic, muffled Hoarse
Dysphagia + -
Postural preference + ±
Barky cough - +
Fever +++ ±
Appearance of acute illness ++ -
Note: +, present in mild form; ++, present in moderate form; +++, present in severe form; ±, may be present or absent;
-, absent

Croup (Laryngotracheobronchitis)
Acute upper airway illness causing subglottic Signs may be minimal to marked. First priority is
obstruction. Occurs predominantly in late fall and late assessment of respiratory function, not diagnosis. If the
spring. child shows signs of respiratory distress, avoid invasive
techniques such as taking temperature or performing
Most common cause of stridor in children. throat or ear examination.
Occurs most often in children 6 months to 6 years of • Irritability, anxiety (may indicate hypoxia)
age (peak age <3 years). Occurs more often in boys • Lethargy (may be due to hypercarbia)
than girls (ratio 3:2). • Temperature increased (fever is usually low-grade)
• Assess hydration status
May also occur in younger infants. Because of their
smaller airways, the risk of respiratory distress is much • Tachypnea
greater in this age group. • Pulse oximetry may be altered if the child is in
respiratory distress
Course is variable, with symptoms usually improving • Respiratory effort may be labored
by 3 to 5 days.
Signs of Respiratory Distress
Causes • Inspiratory stridor (at rest)
Contagious: may be contracted by direct contact or • Cyanosis
inhalation of airborne secretions. • Indrawing (suprasternal greater than intercostal),
nasal flaring
Viruses • Breath sounds usually normal, but transmitted upper
• Parainfluenza virus (most common causative airway stridor can be heard
organism) • Associated wheezing and hyperinflation
• Respiratory syncytial virus (RSV)
• Adenovirus Tripod or sniffing position suggests laryngeal or higher-
level obstruction (e.g. epiglottitis).
Bacteria
• Mycoplasma pneumoniae Differential Diagnosis
• Epiglottitis
History • Bacterial tracheitis
• Preceded by URTI (fever, runny nose) • Retropharyngeal abscess
• Sore throat • Diphtheria
• Brassy, barky, seal-like cough • Aspiration of a caustic substance
Most children are not markedly ill. Some may show • Thermal injury
symptoms of upper airway compromise: • Smoke inhalation
• Decreased drinking • Laryngeal fracture
• Drooling • Congenital problems (e.g. tracheomalacia,
• Dysphagia hemangioma of larynx)
• Loud stridor • Neurologic disease causing hypotonia
• Hoarse voice or cry, aphonia • Allergic angioedema
Symptoms most pronounced at night. Complications

• Respiratory distress
Rule out any trauma to neck, choking episode or
ingestion of a foreign body. • Respiratory failure
• Hypoxia
• Dehydration
• Pulmonary edema

Diagnostic Tests
• Pulse oximetry (if available and child is in respiratory Moderate To Severe Croup
distress) Appropriate Consultation
Consult a physician if the child shows signs of
Management respiratory distress.
Goals of Treatment
• Relieve symptoms Adjuvant Therapy
Give oxygen if there is any evidence of respiratory
• Prevent complications distress:
• 6-10 L/min or more by mask
Mild Croup • Keep oxygen saturation at >97%
There is no specific treatment for this form, in which
the child feeds well, is not acutely distressed and seems
happy, but has a barking cough. Nonpharmacologic Interventions
• Increase fluid intake to prevent dehydration
Client Education • Nurse the child in upright position
• Explain the nature, course and expected outcomes of
the illness Pharmacologic Interventions
• Warn parents or caregiver that croup may worsen at racemic epinephrine, aerosolized (D class drug),
night 0.5 mL in 3 mL normal saline
and
• Advise parents or caregiver to watch for signs of
(The following drugs must be ordered by a physician)
respiratory distress
corticosteroids, e.g. dexamethasone (B class drug),
• Recommend that child be given adequate fluids to 0.15 mg- 0.6 mg/kg PO or IM, one dose before transfer
prevent dehydration (use as first line)
• Recommend increasing humidity through use of a or other option
cool-mist humidifier, exposure to a steamy bathroom budesonide (B class drug) 2 g by nebulizer (one dose)
or going outside in the cool air
Pharmacologic Interventions Monitor ABCs and pulse oximetry (if available),
Antipyretic and analgesic for fever and sore throat: hydration, intake and output.
acetaminophen (A class drug), 10-15 mg/kg PO or PR
q4-6h prn If child appears acutely ill and has a high fever,
consider diagnosis of bacterial tracheitis
Monitoring and Follow-Up (Staphylococcus or Hemophilus influenzae) and consult
Follow up in 24-48 hours (sooner if symptoms worsen). a physician about antibiotic therapy.
Referral Referral
Refer electively to a physician any child with recurrent Medevac.
croup (even if it is mild), for evaluation of coexisting
problems
(e.g. subglottic stenosis, hemangioma of larynx).

Bronchiolitis
Definition • Tachycardia (>200 beats/minute)
Acute viral syndrome of the bronchioles characterized • Hypoxia with or without cyanosis, pallor
by wheezing and respiratory distress. This is an illness • Nasal flaring, indrawing, chest retractions
of young children (<2 years old) and occurs most often • Lethargy and apnea
in the winter and spring. The illness runs its course over
4 or 5 days, but can last longer in young infants. • Audible wheezing
• Breath sounds decreased
Acute Course • Prolonged expiratory phase
• In 80% of cases, clinical improvement will be evident • Widespread, fine end-inspiratory and early expiratory
within 3 or 4 days of initial presentation (recovery is crackles
usually dramatic)
• Radiologic changes normalize over the following Severely ill children may not have wheezes because
9 weeks they are unable to move air. Therefore, beware of the
silent chest. Such children look sick. Check hydration
status.
Prolonged Course
• In 20% of cases, the course is protracted, and the Differential Diagnosis
condition lasts from weeks to months
• Persistent wheezing and hyperinflation
• Pneumonia
• Abnormal gas exchange and lung function
• Asthma
• Some children experience lobar collapse
• Inhalation of noxious material (e.g. chemicals, fumes,
toxins)
Causes
• Gastroesophageal reflux disease (GERD)
• Respiratory syncytial virus (RSV) (most common
causative organism) • Aspiration
• Parainfluenza virus
• Adenovirus
Complications
• Influenza
Acute
• Dehydration
History • Febrile seizures
Prodrome • Respiratory distress with prolonged apneic spells
• Mild URTI for several (1-4) days • Respiratory failure
• Rhinitis (serous nasal discharge) • Death (mortality rate <1%, but among children with
underlying disease it is >1%)
• Sneezing
• Cough Chronic
• Low-grade fever (38.5°C to 39°C) • RSV bronchiolitis
• Anorexia with poor feeding • Asthma
• Irritability • Adenovirus bronchiolitis
• Bronchiolitis obliterans (chronic bronchiolitis)
Physical Findings
Various degrees of respiratory distress, from none to
severe. Diagnostic Tests
• Pulse oximetry (if available)
Mild Cases
• Gradual onset, resolves within 1-3 days Management
• Low-grade fever Goals of Treatment
• Paroxysmal wheezing, tight cough • Relieve symptoms
• Observe closely for and prevent complications
Signs of Worsening • See Fig 10-1 for treatment guidelines
• Tachypnea (60-80 breaths/minute)

Mild Bronchiolitis salbutamol (C class drug), by nebulizer and face mask,

Characterized by increased respiratory rate (but still doses of 0.03 mL/kg of 5mg/mL in 2 mL normal saline
<40 breaths/minute); child is happy although wheezy, (maximum dose 1 mL)
feeds and sleeps well. or
by MDI, 1 or 2 puffs
Contact physician for any child with mild symptoms Antibiotics
who is at increased risk: Antibiotics are not indicated unless there is evidence of
• Is unable to tolerate food secondary bacterial infection, such as clinical
deterioration with or without sepsis.
• Has an underlying illness (e.g. lung disease,
congenital heart disease, neuromuscular weakness or
immune deficiency) Antiviral Agent
Ribavirin is a synthetic antiviral agent directed against
• Was born prematurely viral DNA. This guanine analog prevents viral
• Is less than 3 months of age replication and is intended to shorten the clinical course
• Cannot be watched carefully at home for signs of of the disease. It can reduce the severity of bronchiolitis
respiratory distress if administered early in the course of the disease. It is
administered in hospital by continuous inhalation as a
Client Education small-particle mist for 12-20 hours per 24 hours for a
If the parents are able caregivers and they live near the period of 3-5 days. It is indicated for use in high-risk
healthcare facility, send the child home with the patients but rarely used these days.
following instructions:
• Child should sleep in propped-up position RSV Immunoglobulins
• Use cool-mist humidifier RSV immunoglobulins (palivizumab – Synagis®) given
monthly during RSV season to prevent illness in
• Ensure adequate fluid intake (maintenance
children at risk, see Clinical Practice Information
requirements + deficits resulting from fever or
Notice (April 24th, 2003) RSV Prophylaxis Protocol
tachypnea)
for Eligible Premature Infants
• Monitor closely for signs of respiratory distress
Monitoring and Follow-Up Monitor child closely in the healthcare facility until he
Reassess daily until symptoms have diminished or she can be transported to hospital (unless there is
(usually 3-5 days). significant improvement with bronchodilators):
• ABCs
Moderate To Severe Bronchiolitis • Oxygen saturation: monitor for hypoxia
Characterized by respiratory distress with or without
apneic spells, cyanosis or high-risk patient. • Apnea monitoring
• Hydration status: intake and output
Contact a physician immediately for any child with Referral
moderate to severe symptoms. Medevac child if he or she has any of the following:
• Signs of respiratory distress
Adjuvant Therapy • Episodes of cyanosis with apnea
• Give oxygen at 6-10 L/min • Decreased oxygen saturation
• Keep oxygen saturation at >97% • Inability to tolerate feeding
• Start IV therapy with normal saline • Underlying illness (e.g. lung disease, congenital heart
• Administer enough fluid to maintain hydration disease, neuromuscular weakness or immune
deficiency)
Pharmacologic Interventions • Was born prematurely
Bronchodilator • Less than 3 months of age
A trial of bronchodilators should be given if there is • Cannot be watched carefully at home for signs of
significant wheezing. Infants with a history of prior respiratory distress
wheezing or a family history of asthma are more likely
to respond to bronchodilators:

For transport, consider: • Administration of bronchodilator (if the child needs

• Supplemental oxygen (if the child is cyanotic, has a continuing medication en route)
markedly increased respiratory rate or appears
fatigued)
• IV therapy (if the child is severely distressed or
poorly hydrated)

Fig 10-1: Bronchiolitis treatment guidelines

Suggested approach to management of children with bronchiolitis. Decisions to treat must be individualized.
INITIAL ASSESSMENT
Level of consciousness Respiratory rate
Oral intake, hydration Heart rate
Indrawing, breath sounds Temperature
Head bobbing Oxygen saturation
MILD DISEASE MODERATE DISEASE SEVERE DISEASE

RR < 40 RR 40-60 RR > 60
Indrawing: none Indrawing: moderate subcostal Indrawing: severe
Auscultation: vesicular Auscultation: wheeze + rales/rhonchi Auscultation: faint + severe wheeze +
Skin colour: normal Skin colour: pallor pronounced rales/rhonchi
General condition: not affected General condition: moderately affected Skin colour: cyanotic
General condition: severely affected
Reassurance if SaO2 > 92% OXYGEN Same as for moderate disease
salbutamol 0.03ml/kg of 5mg/mL in

Maintain good hydration
Close follow-up
2mL NS with O2 at 5L/min. + TRANSFER
Can give x2 q30 min
Improvement?
YES NO
SaO2 >92% in RA one hour racemic epinephrine 0.05-1.0 mL/kg/dose (max 0.5mL)
after salbutamol or
epinephrine 0.5-1.0 mL/kg/dose of 1:1,000 (max 5 mL)
in 3mL NS with O2 at 5L/min x2 q30 min then q2h prn if
improving
*pallor may be expected adverse effect*
salbutamol ii puffs bid + prn

with aerochamber at home
SaO2 > 92% 1 hour post-Rx SaO2 < 92% 1 hour post-Rx
Treat with oxygen in Health Centre

x 2-8 hours
TRANSFER
Home if stable
Close follow-up
*can try salbutamol again to see if responding*

Pneumonia
Definition Causes
Inflammation and infection of the lung. Often classified • Viral form most common in children (RSV,
by anatomic location: parainfluenza virus, influenza A or B, adenoviruses)
• Lobar pneumonia: localized to one or more lobes of • Bacterial organisms in 10% to 30% of cases
the lung • Mycoplasma, Chlamydia
• Bronchopneumonia: inflammation around medium- • Inhaled toxins
sized airways, which causes patchy consolidation of
parts of the lobes
• Fungi (uncommon)
• Interstitial pneumonia: inflammation of lung tissue • Tuberculosis: still a factor in chronic pneumonia in
Aboriginal children
between air sacs, usually generalized, often viral
• Often spread from an intercurrent infection elsewhere
(e.g. otitis media)
Table 10-4: Common causes of pneumonia according to age

Age Bacterial Viral
0 – 4 weeks Group B Streptococcus, gram-negative rods, listeria CMV, herpesvirus
monocytogenes, staphylococcus aureus
4 – 16 Chlamydia, hemophilus influenzae, staphylococcus aureus, CMV, RSV, parainfluenza, influenza
weeks streptococcus pneumoniae, listeria monocytogenes virus, adenovirus
4 months to Hemophilus influenzae, mycoplasma, staphylococcus RSV, adenovirus, parainfluenza,
5 years aureus, streptococcus pneumoniae, chlamydia adenovirus, influenza virus
> 5 years Mycoplasma, streptococcus pneumoniae, hemophilus Influenza virus
influenzae
Source: Bugs and Drugs (2001), pp 103-106
History In children, there is often no history of sputum

Viral production.
• Gradual onset If there is any eye discharge, consider Chlamydia or
• Symptoms of URTI appear first adenovirus as the cause.
Bacterial
Physical Findings
• Acute onset
• Temperature elevated (more likely with bacterial
General Symptoms form in older children)
• Fever (less prominent in viral form, high in bacterial • Tachypnea
form) • Tachycardia
• Chills • Signs of URTI (e.g. runny nose, red throat)
• Malaise • Indrawing, nasal flaring
• Headache • Decreased unilateral chest excursion over area of
• Lethargy lobar pneumonia (chest excursion may be normal in
bronchopneumonia or interstitial pneumonia)
• Anorexia or poor feeding in infants
• Tactile fremitus increased in lobar pneumonia,
Respiratory Symptoms decreased in pleural effusion
• URTI symptoms, especially with viral form • Dullness to percussion in lobar pneumonia and
pleural effusion
• Chest pain (older child may complain of this
symptom) • Breath sounds decreased or absent or may be
increased over consolidation
• Shortness of breath
• Crackles may be present over affected lobes (other
• Cough
lobes normal) in lobar pneumonia

• Scattered crackles in bronchopneumonia Adjuvant Therapy

• Scattered crackles and wheezes in interstitial • Give oxygen (humidified), by mask at 6-10 L/min or
pneumonia more, to any child who is in respiratory distress
• Pleural rub (localized in lobar pneumonia) • Start IV therapy with normal saline during transport
to hospital, and run at a rate adequate to maintain
Differential Diagnosis hydration
• Bronchitis
• Asthma Nonpharmacologic Interventions
• Foreign-body aspiration or inhalation of toxin • Rest
• Tumor • Assure adequate hydration
• Pulmonary trauma • Nurse in propped-up position if child is short of
breath
• Cystic fibrosis
• Heart failure Pharmacologic Interventions
• Intra-abdominal pathology causing splinting or Choice of and route for antibiotic therapy are based on
reactive effusion age and the most likely infective organism.
Complications Neonate
• Respiratory failure and cardiovascular collapse Cover for group B Streptococcus and coliform bacteria
• Pleural effusion before transfer:
• Empyema ampicillin (C class drug), 200 mg/kg per day, divided
q8h, IV
• Lung abscess and
• Pneumothorax gentamicin (B class drug), 7.5 mg/kg/day IV q8h
• Bacteremia
• Sepsis 1-4 Months of Age
• Pericarditis Cover for Hemophilus influenzae, Staphylococcus
aureus and Streptococcus pneumoniae.
Diagnostic Tests
Chest x-ray (if available), but only if the diagnosis is in Treat "less sick" child as an outpatient:
doubt and the outcome of the x-ray will affect amoxicillin (C class drug), 40 mg/kg per day, divided
management; otherwise, treat on clinical basis. q8h, PO for 10 days
For a sick child awaiting transfer to hospital:

Management cefuroxime (B class drug), 150 mg/kg per day, divided
Management depends on the cause and severity of the q8h, IV or IM
disease and the age of the child. +
erythromycin (C class drug) 40mg/kg/day PO q6h
Goals of Treatment
• Relieve infection >4 Months to 5 Years Old
• Prevent complications Treat "less sick" child as an outpatient:
amoxicillin (C class drug), 40 mg/kg per day, divided
Appropriate Consultation q8h, PO for 10 days
Consult a physician if any of the following apply: or
• Moderate to severe respiratory distress erythromycin (C class drug) 40 mg/kg/day PO q6h
• Age less than 6 months or
azithromycin (B class drug) 10 mg/kg x one dose, then
• Underlying cardiac or lung disease 5 mg/kg x four doses
• Immunosuppression
• Failure to respond to oral antibiotics within 24-48 For a sick child awaiting transfer to hospital:
hours cefuroxime (B class drug), 150 mg/kg per day, divided
• Inability to tolerate oral antibiotics q8h, IV or IM
• Symptoms involving other systems (e.g. diarrhea) +

>5 Years Old Monitoring and Follow-Up

Treat "less sick" child as an outpatient: • Outpatient: Follow up in 24-48 hours to assess
erythromycin ethylsuccinate suspension (C class drug), progress and again when course of antibiotics is
30-50 mg/kg per day, divided q6h, PO for 10 days complete
or • Child awaiting transport to hospital:
azithromycin (B class drug) 10 mg/kg x one dose, then
5 mg/kg x four doses Monitor ABCs, pulse oximetry (if available and child is
or in respiratory distress) and hydration
clarithromycin (B class drug) 15mg/kg/day PO divided
q12h for 10-14 days
or (in an older child)
Referral
Medevac in the following situations:
erythromycin (C class drug), 250 mg, 1 tab PO q6h for
10 days • Moderate to severe respiratory distress
• Age less than 3 months
For a sick child awaiting transfer to hospital: • Underlying cardiac or lung disease
cefuroxime (B class drug), 150 mg/kg per day, divided • Immunosuppression
q8h, IV or IM • Failure to respond to oral antibiotics within 24-48
+ hours
• Inability to tolerate oral antibiotics
• Adequate care at home cannot be guaranteed

Acute Asthma
For further reading on asthma and current guidelines • Limitation of activity because of frequency of attacks
please refer to: • Number of visits to clinic or emergency department
www.asthmaguidelines.com for treatment
www.pulsus.com/Respir/08_02/guide-ed.htm
where Boulet et al (1999) Canadian Asthma Consensus
• Number of admissions to hospital or ICU
Guidelines, updates and treatment flowcharts and • Number of courses of systemic steroids needed to
checklists can be found. manage acute episodes
Definition Environmental History

Chronic diagnosis seen in adults, irreversible • Type of home
obstructive disease of the lungs characterized by • Heating source
hyperreactivity of the airways and inflammation, which • Carpeting
leads to recurrent episodes of cough and wheezing. • Pets
• Exposure to secondhand smoke
It occurs in 5% to 10% of children, and the prevalence
is increasing, for unknown reasons.
• Stuffed animals
• Feather pillow, duvet
Three major events lead to obstruction:
• Mucosal edema with inflammation Signs of Atopic Disease
• Increased production of mucus • Eczema
• Smooth-muscle hyperreactivity(bronchospasm) • "Allergic shiners" (dark circles under eyes)
• Transverse nasal crease
Causes • Frequent nose rubbing
Precipitating Factors • Watery eyes and nose
• Severe or recurrent RSV bronchiolitis in genetically
predisposed Determining Severity Of Acute
• Familial tendency Asthma Exacerbation
• History of eczema/allergy Mild Exacerbation
• Cough, wheeze, some dyspnea
Triggers • Inspiratory and expiratory wheezes
• Allergens (e.g. pollens) • Oxygen saturation >95% on room air
• Exercise • PEFR 75% of personal best
• Cold air
• Cigarette smoke Moderate Exacerbation
• Wood smoke • Abbreviated speech
• Respiratory infection • Dyspnea at rest
• Emotions (e.g. fear, anger, crying, laughing) • Cough, wheeze, dyspnea
• Intercostal indrawing, tracheal tug
History And Physical Findings • Inspiratory and expiratory wheezes
Acute Episodes • Oxygen saturation 92% - 95% on room air
• History of preceding URTI • PEFR 50% to 75% of personal best
• Exposure to known allergen (e.g. smoke) • Partial relief with ß 2-agonist and required > 4 hours
• Wheeze
• Cough Severe Exacerbation
• Dyspnea • Anxiety, confusion, fatigue, decreased level of
• Chest tightness consciousness
• Dyspnea, with inability to speak or eat
Impact of Asthma on Child • Respiratory rate greater than 2 SD above normal rate
• Number of school days missed for age

• Persistent tachycardia Diagnostic Tests

• No relief with usual dose of ß 2-agonist • Pulse oximetry (if available)
• PEFR (can be attempted in an older child, if he or she
Signs of Severe Airway Obstruction is not too distressed)
• Cyanosis • Chest x-ray (if available) to rule out pneumothorax
• Nostril flaring, tracheal tug, intercostal indrawing before medevac by air
• Supraclavicular indrawing
• Use of accessory muscles, especially Management Of Acute Asthma
sternocleidomastoid muscles Exacerbation
• Pulsus paradoxus greater than 20 mm Hg Goals of Treatment
• Breath sounds faint or absent (because of lack of air • Relieve symptoms
entry)
• Marked expiratory wheezes, prolonged expiratory
phase
• Oxygen saturation <92% on room air
• PEFR less than 50% of personal best or standard Consult a physician for:
level
• Any child with previously undiagnosed (suspected)
Beware the silent chest. A very quiet chest is common asthma
in severe asthma, because there is little movement of • Any child with known asthma who is experiencing
air. acute symptoms
• Any child receiving long-term prophylaxis whose
Risk Factors For Severe Asthma symptoms are not well controlled with the current
History of the following features: medication regimen
• Poorly controlled asthma
• Frequent asthma attacks (more than two per week) Adjuvant Therapy
• Recent severe attack • Give oxygen (6-10 L/min or more by mask) to keep
• Recent visit to emergency room or admission to oxygen saturation at >95%
hospital or ICU for asthma • Start IV therapy with normal saline in children with
• Severe present attack moderate to severe respiratory distress
• Duration of current symptoms longer than 24 hours
• More than 10 puffs of salbutamol in past 24 hours Nonpharmacologic Interventions
• Recent use of high-dose steroids • Nurse in an upright position
• Long delay in seeking medical care • Give liberal oral fluids to prevent dehydration and to
help liquefy secretions
• Pneumonia In a case of acute asthma, try to consult a physician
• Croup before giving any medication to the child.
• Bronchiolitis
• Foreign-body aspiration Aerosolized ß2-agonists:
• Cystic fibrosis salbutamol (C class drug), 5 mg/mL by nebulizer,
• Pulmonary edema q20min, for a maximum of 3 times (may be given
continuously if needed)
• GERD with recurrent aspiration
Dose is based on child's weight:
Complications <10 kg: 1.25-2.5 mg/dose, in 3 mL normal saline
• Frequent absences from school 11-20 kg: 2.5 mg/dose, in 3 mL normal saline
• Frequent admission to hospital >20 kg: 5.0 mg/dose, in 3 mL normal saline
• Restrictions in physical activity
• Psychologic impact of chronic illness If a full response is achieved, consult a physician about
continuing management at home:
• Localized bronchiectasis
• Death

salbutamol (C class drug), by MDI, 1 or 2 puffs q2-4h Criteria for Hospital Admission
prn for relief, depending on severity • Child is critically ill (moderate to severe airway
and obstruction with respiratory distress)
prednisone (B class drug), 1-2 mg/kg per day (to a
maximum of 60 mg) PO od for 5 days
• Poor response to emergency therapy: needs more
than three or four salbutamol treatments, post-
treatment PEFR is less than 40% of predicted, post-
If only a partial response is achieved:
treatment oxygen saturation <95% on room air
Continue ß2-agonist q20min as above and add the
following: • Social considerations: parents or caregiver unreliable,
ipratropium bromide (C class drug), 250 mcg q1h, by home is far from health facility
nebulizer with salbutamol (C class drug) and consult
physician about IV steroids Discharge Home after Treatment of Acute
Episode
Monitoring and Follow-Up • Provide instructions (preferably written) to the
Monitor ABCs, pulse oximetry (if available), hydration parents or caregiver on symptoms and signs of
and level of consciousness while awaiting transport. respiratory distress
• Advise parents or caregiver to bring the child back to
Referral the clinic if there is no response to ß2-agonists or the
Medevac. response lasts less than 2 hours
• Counsel about appropriate use of drugs, including
dosages, administration techniques (e.g. use of MDI
with spacer), effects and side effects
• Explain strategies to prevent further attacks
• Prophylactic medication regimen as required

Chronic Asthma
Definition • Counsel parents (or caregiver) and child about how to
• Mild chronic asthma: mild activity limitation, minimize local side effects (oral candidiasis) by
infrequent episodic illness careful rinsing of the mouth and gargling
• Mild persistent asthma: occasional night cough
relieved by ß2-agonists or exercise-induced Pharmacologic Interventions
bronchospasm regularly relieved by ß2-agonists Long-Term Prophylactic Management of
• Moderate asthma: regular use of ß2-agonists at night Chronic Asthma
for cough, activity limitations despite use of ß2- To be prescribed only by a physician.
agonists, recent emergency treatment for acute
symptoms or use of prednisone for control of Various medication regimens (some of which are non-
symptoms formulary items) may be prescribed for prophylaxis,
• Exercise-induced asthma including the following.
Bronchodilators (ß2-Agonists)
Management
• Short-acting, e.g. salbutamol (C class drug)
Goals of Treatment
• Long-acting, e.g. salmeterol (B class drug)
• Prevent symptoms (e.g. cough, shortness of breath,
wheeze that interferes with daytime activities,
Anti-inflammatory Agents
exercise, school attendance or sleep)
• Corticosteroids e.g. budesonide (B class drug) or
• Prevent need for regular use of rescue medications
fluticasone (B class drug)
(e.g. salbutamol )
• Mast cell stabilizers, e.g. sodium cromoglycate (B
• Prevent visits to emergency department or admission
class drug)
to hospital
• Theophylline (B class drug): may have a role for
• Normalize PEFR and FEV1 on pulmonary function
children receiving optimal anti-inflammatory therapy
testing
but still needing more bronchodilation than they are
obtaining from ß2-agonists
Appropriate Consultation • Leukotriene receptor antagonists, e.g. montelukast (B
Consult a physician for:
class drug): may help with exercise-induced asthma
• Any child with previously undiagnosed asthma and may have steroid-sparing properties, which allow
• Any child with known asthma who is experiencing better control of asthma at lower doses of inhaled
acute symptoms steroids
• Any child receiving long-term prophylaxis whose
symptoms are not well controlled with the current For Mild Chronic Asthma
medication regimen aerosolized salbutamol (C class drug),
100-200 mcg (1 or 2 puffs) q4-6h
Client Education
• Discuss diagnosis and expected course of illness For younger children, a home nebulizer for use with
• Counsel parents or caregiver about appropriate use of aerosol solution should be considered. If unable to
medications (dose, frequency, side effects) obtain a nebulizer, mild chronic asthma in very young
children can be managed with regular inhaler and
• Advise child about proper use of aerosol delivery spacer, such as the Aerochamber.
device, Aerochamber and spacer
• Review inhaler techniques regularly and often to For Mild Persistent Asthma
ensure optimal use
ß2-agonist prn, e.g. salbutamol (C class drug)
• Teach parents or caregiver how to monitor for and
symptoms and how to use peak flow meter (if sodium cromoglycate (B class drug)
deemed beneficial for managing symptoms) or
• Provide instruction on worsening signs of asthma inhaled steroids, e.g. budesonide (B class drug), 200-
• Provide written instruction on a plan of action that 800 mcg/day
the parents or caregiver should initiate when signs of or
worsening are first occurring (e.g. increasing need for fluticasone (B class drug), 100-500 mcg/day
usual rescue medications)

For Moderate Chronic Asthma For Night Cough

ß2-agonists prn, e.g. salbutamol (C class drug) inhaled steroids (B class drug), 200-800 mcg/day
and or
inhaled steroids, e.g. budesonide (B class drug), 200- fluticasone (B class drug), 100-500 mcg/day
800 mcg/day or
or salbutamol (C class drug), 100-200 mg (1 or 2 puffs)
fluticasone (B class drug), 100-500 mcg/day hs
and
prednisone (B class drug), 0.5-1 mg/kg per day for Monitoring and Follow-Up
exacerbations, PO (maximum 5-day course) See children with chronic asthma at least several times
a year to assess if there is adequate control of
For Exercise-Induced Asthma symptoms. Watch for growth failure in children taking
salbutamol (C class drug), 100-200 mg (1 or 2 puffs) more than 800 µg of inhaled steroids per day.
15 minutes before exercise
or Referral
long-acting ß 2 agonist Refer as needed to a physician to assess control and to
prescribe medications for long-term prophylaxis.

Persistent Cough
Definition • Dry hacking cough indicates tracheal irritation
Cough is a forceful explosive expiration and release of • Brassy cough indicates tracheal or bronchial
air, which serves to remove secretions and foreign compression
material from the respiratory tract. Chronic or persistent • Increase in cough in supine position indicates
cough is a cough lasting longer than 3 weeks. Cough is sinusitis with postnasal drip, gastroesophageal reflux
a symptom of some other specific diagnosis. • Nocturnal cough indicates asthma
Differential Diagnosis • Exercise-induced cough indicates asthma
Infection Associated Symptoms and Events
• URTI with irritation or postnasal drip (or both); may • URTI symptoms
be associated with sinusitis
• Postnasal drip
• Bronchitis caused by or related to virus, Mycoplasma, • Allergic "shiners"
pertussis, tuberculosis or (rarely) other organisms or
parasites • Exposure to infectious persons
• Pneumonia, especially that caused by Mycoplasma • Diarrhea, poor weight gain (cystic fibrosis)
Post-infection Past History

• After bronchiolitis or pneumonia • Developmental delay
• Allergy: allergic rhinitis with postnasal drip • Neuromuscular abnormalities
• Asthma: cough may predominate, rather than wheeze • Eczema (may precede asthma)
• Viral pneumonia (due to RSV or adenovirus) may be
Suppurative Lung Disease followed by airway damage, chronic cough and
• Bronchiectasis wheeze
• Cystic fibrosis
Environmental Irritants Assess for:
• Dry air • Presence of respiratory distress (respiratory rate, use
of accessory muscles)
• Fumes
• Nasal congestion
• Smoke
• Allergic "shiners"
Aspiration • Dullness over areas of lung consolidation
• Foreign body: onset of cough is usually sudden, but • Sound of cough
symptoms may be chronic if aspirated material is • Breath sounds
small • Adventitious sounds
• Gastroesophageal reflux with aspiration • Skin rash
• Neuromuscular disorders: aspiration especially • Muscle wasting
associated with feeding • Developmental delay
Anatomic Defects Management
• Compression of airways by lung or blood vessel Management depends on the diagnosis.
anomalies or tumors
Goals of Treatment
History • Identify underlying diagnosis
Nature of Cough Appropriate Consultation
• Production of sputum indicates pneumonia or Consult with a physician about the need for
bronchiectasis investigation and, in some cases, referral to tertiary care
• Presence of whoop indicates pertussis center.
• Paroxysmal nature (i.e. continuous, short coughs on a
single expiration) indicates pertussis, parapertussis, Do not use any cough medications without establishing
some viruses such as adenovirus diagnosis.

Emergency Problems Of The Respiratory System

Epiglottitis
Definition
Acute, life-threatening infection, consisting of cellulitis Differential Diagnosis
of the epiglottis and resulting in critical narrowing of • Croup (see Table 10-5)
the airway. Progresses rapidly (less than 12 hours from • Bacterial tracheitis
onset to respiratory distress). Usually occurs in children
3-7 years old. Children inadequately immunized against
• Peritonsillar or retropharyngeal abscess
Hemophilus influenzae type B may be particularly • Uvulitis
susceptible. • Diphtheria
• URTI in the presence of congenital or acquired
Causes airway disease (e.g. subglottic stenosis or laryngeal
Usually a bacterial infection: web)
• Hemophilus influenzae type B (accounted for more
than 90% of cases before vaccines were introduced, Complications
but is now rare) • Complete obstruction of airway causing respiratory
• Staphylococcus aureus arrest, hypoxia and death
• Streptococcus pneumoniae • Sepsis
• Streptococcus pyogenes, group A • Septic shock
History Table 10-5: Comparison of epiglottitis and croup
• Abrupt onset Feature Epiglottitis Croup
• Limited or no prodrome Age 2 – 8 years 6 months to 6
• High fever (>39°C) years
• Sore throat with drooling Onset Acute Gradual; child
• Dysphagia often has a cold
• No cough, runny nose or other symptoms of URTI first
Check that primary immunization series (for Temperature High (> 39°C) Low (< 38°C)
Hemophilus influenzae type B) is complete. Swallowing Difficulty; No difficulty
salivation
Physical Findings
Do not attempt to examine oropharynx, since this may Position Sitting up, variable
provoke sudden obstruction. leaning forward
Examination should be minimal to minimize distress to

the child. Diagnostic Tests
None.
• Child looks acutely ill and anxious
• High fever Management
• Cyanosis ABCs are the first priority!
• Slow, labored breathing
• Suprasternal indrawing Goals of Treatment
• Drooling • Relieve infection
• Child will not talk and sits erect in the classic • Prevent complications
"sniffing" position, leaning forward with
hyperextension of the neck Appropriate Consultation
• Stridor relatively quiet, given the degree of distress Consult a physician as soon as possible, but ensure that
the child's ABCs are stabilized first.
• Breath sounds normal, with transmitted stridor
• Air entry reduced

Adjuvant Therapy is likely to become distressed by this treatment. Discuss

• Give oxygen by mask at 6-10 L/min or more, unless with a physician.
this is distressing to the child
cefuroxime (B class drug), 150 mg/kg per day, divided
• Oxygen by nasal prongs at 2-4 L/min may be less
q8h, IV
distressing
• Start IV therapy with normal saline to keep vein Rifampin prophylaxis (20 mg/kg daily in a single dose
open, unless this is likely to distress the child and for 4 days) is recommended for the child and for
thereby to increase respiratory distress family, household and possibly daycare contacts.
Discuss prophylaxis with a physician.
• Nurse the child in the parent's or caregiver's arms Monitoring and Follow-Up
• Give nothing by mouth Monitor ABCs and pulse oximetry (if available) as
• Allow the child to assume any position that makes frequently as possible, but be discreet and try not to
him or her comfortable agitate the child.

Administration of antibiotics effective against Medevac immediately to a facility where controlled
H. influenzae should be started before transport, if intubation is possible.
possible.
A physician or paramedic skilled in intubation should
A child with epiglottitis has septicemia and should be accompany the child during transfer.
given initial doses of antibiotic therapy, unless he or she

Neonatal Resuscitation
See also Kattwinkel, J (editor) (2000) Textbook of • Maternal abnormalities: diabetes mellitus, size of
Neonatal Resuscitation, 4th edition. American pelvic outlet
Academy of Pediatrics and American Heart Association • Neonatal abnormalities: genetic, anatomic or cardiac
• Maternal drugs: prescription or illicit
Diagnosis
Try to anticipate situations in which a child may need Physical Examination and Evaluation
resuscitation. The following situations represent some The physical examination may have to be done while
of the predisposing factors. resuscitation is performed.
• Airway: Is it patent? Is foreign material (e.g.
History of Maternal Perinatal meconium) present?
Complications • Breathing effort: Present or absent?
• Preterm labor • Circulation: Is pulse present? What is heart rate?
• Placental abnormalities: placenta previa, abruptio What is infant's color?
placentae or cord compression • Disability: neurologic status, floppy tone, absence of
• Amniotic fluid abnormalities: polyhydramnios or reflex and grimace
oligohydramnios, meconium-stained • Environment: heat loss
• Infectious process: maternal fever • Apgar score: should be assessed 1 and 5 minutes after
• Infectious agents (maternal source): group B birth (Table 10-6)
Streptococcus, gram-negative bacteria, viruses (e.g.
HSV, toxoplasmosis, CMV, HIV)
Table 10-6: Determination of Apgar score

Feature evaluated 0 points 1 point 2 points
Heart rate 0 < 100 beats/min > 100 beats/minute
Respiratory effort Apnea Irregular, shallow or Vigorous, crying
gasping breaths
Colour Pale or blue all over Pale or blue extremities Pink
Muscle tone Absent Weak, passive tone Active movement

Reflex irritability Absent Grimace Active avoidance
* Sum the scores for each feature. Maximum score = 10, minimum score = 0
Procedure For Resuscitation If heart rate < 60 beats/minute:

1. Clamp and cut the cord. 9. Continue assisted ventilation (30 breaths/minute).
2. Position the airway. 10. Begin chest compressions at 90/minute.
3. Suction the mouth and nasopharynx. 11. If no improvement after 30 seconds, continue
4. Dry the neonate and keep warm with thermal blanket ventilation and compressions.
or dry towel. Cover scalp. Use heating lamp 12. If no improvement after a further 30 seconds,
5. Stimulate by drying the baby and rubbing his or her establish vascular access and give
back. epinephrine solution (1:10,000) (D class drug) at
6. Evaluate respirations. 0.01-0.03 mg/kg IV or IO or through ET tube.
7. Use blow-by method or simple facemask to deliver Subsequent doses must be ordered by a physician.
100% oxygen for neonate in mild distress. For an 13. Reassess heart rate and respirations.
infant with apnea or severe respiratory depression,
begin assisted breathing with bag-valve mask (BVM) If heart > 60 beats/minute:
and 100% oxygen; ventilate at 40-60 breaths/minute. 14. Continue assisted ventilation.
8. Check heart rate (apical beat). 15. Reassess heart rate and respirations each minute.
16. Give 100% oxygen by mask or blow-by method.

17. Reassess heart rate and respirations after 30 If heart rate > 100 beats/minute:
seconds. 20. Check skin color. If peripheral cyanosis is present,
give oxygen by mask or blow-by method.
If heart rate < 100 beats/minute: 21. Reassess heart rate after 1 minute.
18. Begin assisted BVM ventilation with 100%
oxygen.
19. Reassess heart rate after 30 seconds.
Table 10-7: Summary of steps in neonatal resuscitation: ABCDEF

A for airway
• Clear or suction airway
• Consider giving oxygen prn
B for breathing
• Support breathing with oral airway and bag-valve-mask prn
• 100% oxygen
C for circulation
• no support needed if heart rate > 100 beats/minute
• if heart rate ≤ 100 beats/minute, ventilate and observe
• If there is a response (heart rate increased to > 100 beats/minute), no further support is needed
• If response is poor (heart rate < 60 beats/minute) recheck airway; if airway and breathing are adequate, initiate
chest compressions
• If “ABC” (above) fail to produce a response, consider “D” as follows
D for drugs
• IV fluid (for volume expansion): 0.9% NS
• epinephrine solution (1:10,000) (D class drug), 0.01-0.03 mg/kg/IV, IO or ET (at slow rate of infusion)
• consider naloxone (D class drug) if there is a possibility of maternal narcotics
E for exposure
• keep infant under radiant warmer or surrounded by warmed blankets
F for final steps
• consult pediatric and neonatal departments at nearest tertiary care facility
• transfer to neonatal ICU if child needs more than simple oxygen and transient (for < 5 minutes) assisted
ventilation with bag-valve-mask
Post-Resuscitation Care • Handle gently

Signs of Continuing Perinatal Asphyxia
• Altered gaze, slack face Vital Signs
Record vital signs every 15 minutes or more frequently,
• Increasing irritability depending on situation.
• Seizures • Heart rate: normally 120-160 beats/minute (use pulse
• Decreased muscle tone oximetry, if available)
• Decreased suck, swallow or gag reflex • Respiratory rate: normally 40-60 breaths/minute
• Breathing irregularities (airway can be kept open by slightly extending the
• Stupor or coma position of the head and suctioning as necessary)
• Signs of increased intracranial pressure (e.g. bulging • Axillary temperature: normally 36.5°C to 37°C
fontanel, frequent emesis, blunted reflexes, "sunset" • Blood pressure: difficult to assess in newborns
eyes) without special equipment; signs of adequate
perfusion include good capillary refill, good colour,
Stabilization adequate urinary output and normal alertness;
Monitoring and Assessment determine capillary refill time (to assess skin
• Observe infant continuously perfusion) by blanching area with digital pressure
• Do not leave unattended (normal refill time is 2-4 seconds)

Thermoregulation • Major cardiopulmonary failure may be prevented by

Provide warmth to maintain normal body temperature. early intervention with 100% oxygen and PPV
Ambient temperature at which an infant uses the least
energy to maintain body temperature depends on the Maintenance of Circulation
infant's weight, gestational age at birth and postnatal Adequate cardiac output is essential to maintain
age. Prolonged cold stress results in increased oxygen circulation. The best way to maintain circulation is
consumption and abnormal glucose utilization, which provision of adequate fluids and electrolytes. Babies
can lead to hypoglycemia, hypoxemia and acidosis. with unstable conditions are usually given nothing by
mouth, and an IV infusion is started.
Measures to Maintain Warmth
• Dry the baby and keep the environment warm and Conditions Necessitating IV Infusion
humid • Extreme prematurity
• Maintain a warm room temperature, keep the infant • GI anomalies (e.g. gastroschisis)
away from cold windows and use double-walled • Cardiac anomalies
incubators or radiant heaters (if available)
• Respiratory distress syndrome
• Warm linen in contact with the baby and change wet
• Dehydration
linen
• Shock
Maintenance of Oxygenation and
Fluid Administration Guidelines for
Ventilation Newborns
Signs of Respiratory Distress • Term infant: 80-100 mL/kg every 24 hours
• Periodic breathing • Preterm infant: 100-140 mL/kg every 24 hours
• Tachypnea (respiratory rate > 60 breaths/minute)
• Grunting Maintenance of Homeostasis
• Chest wall retractions The most common problem is hypoglycemia, which
• Nasal flaring occurs in a variety of situations:
• Prematurity
Common Causes of Respiratory Distress • Restricted intrauterine growth
in Newborns • Asphyxia during birth
• Respiratory distress syndrome • Hypothermia
• Aspiration syndrome • Diabetic mother
• Pneumonia
• Pulmonary air leak Use a reagent strip or blood glucose monitor to assess
blood glucose level every hour.
In these situations, consult a physician.
Maintain glucose levels at greater than 2 mmol/L.
Respiratory Failure and Mechanical
IV administration of a 10% dextrose solution
Ventilation (approximately 3-4 mL/kg each hour) is usually
• Progressively increased oxygen demands and adequate to correct transient hypoglycemia. Persistent
respiratory distress hypoglycemia should be treated with a bolus of D5W or
• If there is evidence of respiratory failure, take steps D10W (2-3 mL/kg). Discuss with a physician.
immediately to provide positive pressure ventilation
(PPV) Abnormalities such as hypocalcemia, hypomagnesium,
• Maintain oxygen saturation in the range of 90% to hyponatremia and hyperkalemia can complicate
95% by pulse oximetry (if available) homeostasis, especially if resuscitation and stabilization
• Initiate PPV with infant resuscitation bag at 40-60 processes are prolonged.
respirations/minute and pressure of 20-30 cm H2O
• Effectiveness of ventilation judged by infant's clinical Infection
response, symmetric chest movement and If sepsis is suspected, obtain swabs from ear canal,
auscultation of air entry to both lungs umbilicus and tracheal secretions. Obtain blood for
culture if possible. IV administration of antibiotics
should not be delayed. Discuss with a physician.

Usual antibiotic dosages: Seizures

ampicillin (C class drug), 200 mg/kg/day IV divided Administer anticonvulsants to control seizure activity:
q6h lorazepam (D class drug), 0.05 mg/kg per dose IV
and
gentamicin (B class drug), 2.5 mg/kg q8h by slow IV Shock
push or IM If shock is suspected, volume expansion is indicated
(e.g. 20 mL/kg bolus of normal saline or Ringer's
Management of Special Conditions lactate).
Aspiration of Meconium
Suction mouth and nose at perineum, when head just Exposed Abdominal or Neural Contents
out. Treat infant with sterile technique. Wrap defect in
warm, sterile saline dressing and cover with plastic
Pneumothorax wrap to prevent drying. Position so that no pressure is
Depending on respiratory compromise, needle applied to the defect.
aspiration of pneumothorax (if tension) may be
necessary. Keep infant in oxygen-rich environment x 1 Gastrointestinal Obstruction
hour. Examples include duodenal atresia, ileal atresia and
anal atresia. Give nothing by mouth. Insert an
orogastric tube to remove gastric contents and prevent
abdominal distension. Establish IV infusion with
normal saline.

Appendix 10-1: Oxygen Delivery Techniques

Appendix 10-1: Oxygen delivery techniques
Device Flow (L/min) Oxygen (%)

Nasal prongs 2–4 24 – 28
Simple face mask 6 – 10 35 – 60
Face tent 10 – 15 35 – 40
Venturi mask 4 – 10 25 – 60
Partial rebreathing mask 10 – 12 50 – 60
Oxyhood 10 – 15 80 – 90
Nonrebreather mask 10 – 12 90 - 95

Chapter 11 – Cardiovascular System

Explanatory Note .............................................................................................................................................. 1
Assessment Of The Cardiovascular System.................................................................................................... 1

Examination of the Cardiovascular System.................................................................................................... 2
Common Problems Of The Cardio-Vascular System .................................................................................... 3

Heart Murmurs................................................................................................................................................ 3
Innocent Heart Murmur .................................................................................................................................. 4
Emergency Problems Of The Cardio-Vascular System ................................................................................ 5

Cyanosis In The Newborn (Birth To 6 Weeks) .............................................................................................. 5
Rheumatic Fever (Carditis)............................................................................................................................. 7
Cardiac Failure................................................................................................................................................ 9
For more information on the history and physical examination of the cardiovascular system in older children
and adolescents, see chapter 4, "Cardiovascular System," in the NWT Clinical Practice Guidelines for
Primary Community Care Nursing (Adult) 2003.

Explanatory Note
Cardiovascular disease is uncommon in childhood. Functional or innocent heart murmurs are
The major problems seen include congenital heart common.
disease (usually septal defects but also
abnormalities of the great vessels, hypoplastic Congestive heart failure at birth is rare and usually
heart, pulmonary or aortic atresia, and tetralogy of suggests severe valvular deformities. Symptoms of
Fallot), cardiac failure, rheumatic fever carditis ventricular septal defect, including heart failure,
and myocarditis. usually occur at approximately 6 weeks of age.
Assessment Of The Cardiovascular System

Symptoms of cardiovascular disease vary with the Excessive Perspiration
age of the child. • Infant's head described as "always wet"
• Infant perspires freely and easily, especially with
General excretion and feeding
Ask about:
Slow Growth
• Rapid or noisy breathing
• Child usually exhibits slow weight gain, relative
• Cough
to height gain
• Cyanosis
• Difficulty in feeding may contribute to this
• Sweating problem
• Sleeping patterns • Metabolic demands increased
• Exercise tolerance: indicated in a young child by
ability to feed and in an older child by ability to Respiratory Infections
keep up with peers during play • More common with congestive heart failure
• More severe with increased pulmonary flow
In Infants In Children
Cyanosis • Slow growth
• An abnormality of oxygen transport related to • Respiratory infections
heart, lungs or blood
• Chest pain
• Causes bluish discoloration of mucous
membranes, nail beds and skin and is a
• Palpitations
significant clinical finding • Dizzy spells or blackouts
• Exercise intolerance
Exercise Intolerance • Squatting with cyanotic episodes ("tetralogy
• Eats slowly spells")
• Tires during feeding Medical History (Specific To
• Cyanosis appears with feeding Cardiovascular System)
• Often described by parents or caregiver as a • Prematurity (associated with a higher prevalence
"good baby": always quiet, sleeps a lot of congenital cardiac malformation)
• History of illnesses related to heart disease (e.g.
Difficulty Breathing strep throat)
• Tachypnea • "Flu-like" illness
• Retractions • Joint pains or swelling
• Anxious appearance • Down's syndrome, FAS (associated with a
• Grunting higher prevalence of congenital heart disease)

Examination of the Cardiovascular System

An examination of the cardiovascular system • Apical beat may be laterally displaced, which
involves more than just examining the heart. The indicates cardiomegaly
examination generally covers two systems: the • Thrills or heaves may be palpable through chest
central cardiovascular system (head, neck and wall; check supraclavicular area for thrills (in
precordium [anterior chest]) and the peripheral children with a thin chest wall, normal heart
vascular system (extremities). Examination of the movements can be easily palpated and should
cardiovascular system must also include a full not be confused with true thrills and heaves)
assessment of the lungs and neuromental status • Hepatomegaly
(for signs of confusion, irritability or stupor). • Pulses: brachial, radial, femoral, popliteal,
posterior tibial, dorsalis pedis (also check for
Vital Signs synchrony of radial and femoral pulses)
• Heart rate • Check for presence, rate, rhythm, amplitude and
• Respiratory rate equivalence of peripheral pulses, especially
• Blood pressure (in both an upper and a lower femoral pulses (which are bounding in patent
limb, if possible) ductus arteriosus, absent in coarctation of aorta)
• Temperature (may be elevated with myocarditis • Edema: pitting (rated 0 to 4) and level (how far
or acute rheumatic fever) up the feet and legs the edema extends); sacral
• Cardiovascular problems may present as failure edema
to thrive (weight and height below percentiles • Skin: temperature, turgor
for age) or as a sharp decline in the growth curve
across a major percentile line Auscultation
• S1 and S2 heart sounds
Inspection • Physiologic splitting of S2 heart sound
• Respiratory distress • Added heart sounds (S3 and S4): determine their
• Cyanosis: central and peripheral location and relation to respiration
• Hands and feet: cyanosis, clubbing • Murmurs: determine location (where murmurs
• Precordium: visible pulsations are best heard), radiation, their timing in cardiac
• Edema cycle, intensity grade (see Table 11-1) and
quality
Palpation • Bruits: may occur in carotid arteries, abdominal
• Apical beat is located at fourth intercostal space, aorta, renal arteries, iliac arteries, femoral
lateral to the mid-clavicular line in infants, and arteries
at fifth intercostal space, lateral to the mid- • Crackles in lungs: may indicate heart failure (in
clavicular line in older children infants and children, this usually occurs as a late
• Brief, localized apical tap is normal sign)
Table 11-1: Characteristics of heart sounds of various grades

Grade Characteristic
I Very quiet, barely audible
II Quiet but audible
III Easily heard
IV Thrill can be felt, murmur is easily heard
V Thrill can be felt and loud murmur can be heard with stethoscope placed lightly on chest
VI Thrill can be felt and very loud murmur can be heard with stethoscope held close to chest
wall

Common Problems Of The Cardio-Vascular System

Heart Murmurs
General Timing within Cardiac Cycle
Most murmurs are innocent flow murmurs, which • Systolic ejection murmurs occur after the first
are present in up to 50% of children; see "Innocent sound. They are caused by turbulence in the
Heart Murmur," below, this chapter. blood as it leaves the heart.
• Pansystolic murmurs begin with the first heart
A heart murmur may signify congenital anatomic, sound and end with the second. They most often
infectious or inflammatory damage to valves and occur in association with ventricular septal
outlets of the four chambers of the heart. defects.
• Diastolic murmurs begin with the second heart
Physical Findings: Auscultation sound. They are always abnormal.
Auscultation helps to distinguish significant
murmurs from innocent murmurs. Location on the Thorax
There are four general auscultatory areas:
Murmurs must be recognized in relation to other • Aortic: left ventricular outflow murmur (usually
physiologic and pathologic sounds of the cardiac ejection)
cycle. • Pulmonary: right ventricular outflow murmur,
patent ductus arteriosus
• The first heart sound is caused by the closure of • Tricuspid: tricuspid murmurs increase on
the mitral and tricuspid valves, which usually inspiration; ventricular septal defects are heard
occurs simultaneously. The first sound is best best in this area
heard at the cardiac apex. • Mitral: murmur at the cardiac apex
• The second heart sound occurs with the closure
of the aortic and pulmonary valves. Because the
Radiation
Radiation of the murmur to the back, sides and
closure of these two valves is somewhat
neck should be carefully auscultated.
asynchronous, what is known as the second
Radiation of the murmur may give important
heart sound actually consists of two sounds. The
diagnostic clues (e.g. aortic stenosis radiates to the
separation of the two component sounds is often
neck).
difficult to detect in young children, although it
is more pronounced during inspiration. Wide Intensity of Murmur
separation of the second heart sound is often a • Intensity expressed as a fraction of 6 (e.g. 1/6,
significant pathologic finding. The second heart 2/6), where a very loud murmur = 5/6 or 6/6, a
sound is best heard in the second and third left loud murmur = 3/6 or 4/6, and a soft murmur =
intercostal spaces. 1/6 or 2/6.
• A third heart sound may occur after the second • Intensity (loudness) does not necessarily
heart sound. This may be found in healthy correlate with the severity of the condition. Soft
children. It is a sign of heart failure in a murmurs may be dangerous, whereas loud
symptomatic child. The third heart sound is best murmurs are not necessarily so. A murmur
heard when listening at the apex of the heart (in associated with a thrill has an intensity of at least
the fourth and fifth intercostal spaces); a left 4/6.
side-lying position may accentuate the sound. • Intensity may also increase with increased blood
Use the bell part of the stethoscope. flow, as with exercise, fever.
• Ejection "clicks" may be present in certain
conditions; they are always abnormal. Quality
• Blowing
If a murmur is present, several characteristics • Rumbling
should be determined. • Clanging

Innocent Heart Murmur

Definition ejection murmur), are less than 3/6 in intensity and
Heart murmur that occurs in the absence of are never diastolic.
anatomic or physiologic abnormalities of the heart
and therefore has no clinical significance. Clinical Features
Innocent heart murmurs are asymptomatic and are
Such murmurs occur in 50% of children. usually found on routine physical examination.
The age at onset is most frequently 3-8 years. Diagnostic Tests

• ECG
Pathophysiology • Echocardiography (only as ordered by a
Most innocent heart murmurs are produced by the physician)
forward flow of blood, which creates turbulence in
the chambers of the heart or the great vessels. Management
Because the intensity of the murmur parallels the • No treatment necessary
ejection velocity of blood from the ventricles, • Reassure the parents or caregiver
innocent murmurs usually occur during early to
mid-systole, are short in duration, have a Referral
crescendo-decrescendo contour (especially an Refer child electively to a physician for
assessment when a murmur is found.

Emergency Problems Of The Cardio-Vascular System

Cyanosis In The Newborn (Birth To 6 Weeks)
Definition • Cyanosis when feeding or active (e.g. while
Bluish discoloration of the skin and mucous crying)
membranes secondary to hypoxia. • Perspiration on face or forehead, especially
when feeding or active
Causes • Rapid, noisy breathing
Congenital Heart Disease
Cardiac cyanosis is due to left-to-right shunting, so Physical Findings
that systemic venous blood bypasses the • Lethargy
pulmonary circulation and enters the arterial • Cyanosis, initially of the oral mucosa; in severe
systemic circulation. cases, the cyanosis becomes generalized
• Tachypnea
Settings of increased risk of congenital heart • Poor perfusion (e.g. pallor or gray, ashen
disease: appearance; extremities cool; capillary refill
• Genetic syndromes (e.g. Down's syndrome) diminished; peripheral pulses diminished)
• Certain extracardiac anomalies (e.g. • In coarctation of aorta, pulse quality and blood
omphalocele) pressure may differ in different extremities
• Maternal diabetes that is poorly controlled in the • Heart sounds may be loud
first trimester • Precordium may appear hyperdynamic (heaves
• Exposure to a cardiac teratogen (e.g. lithium, or thrills may be present)
isotretinoin) • Heart murmur may be present
• Family history of significant congenital heart • Hepatomegaly (if infant is in heart failure)
disease
• Fetal alcohol syndrome Differential Diagnosis
• Pulmonary causes as listed above
Non-cardiac Causes
• Sepsis
• Pulmonary infection (e.g. group B streptococcal
infection)
Complications
• Aspiration of meconium
• Cardiac failure
• Pulmonary hypoplasia
• Failure to thrive
• Respiratory distress syndrome (e.g. in premature
infants) • Death
• Hypoventilation (e.g. neurologic depression)
• Persistent fetal circulation: seen in post term Diagnostic Tests
infants with perinatal distress or those with • Pulse oximetry (if available)
pulmonary disease
• Diaphragmatic hernia Management
Clinical Features Of Infants With • Consult a physician immediately and prepare to
medevac
Cyanotic Heart Disease
The clinical features usually present in the first
week of life but may present later: Adjuvant Therapy
• Difficulty feeding; infant appears to tire easily • Give oxygen 6-10 L/min (more, if necessary) by
mask
• Lethargy

• Consider IV therapy with normal saline if infant Monitoring and Follow-Up

is feeding poorly or is in significant clinical • Monitor level of consciousness, vital signs, heart
distress. Do not overload with fluid. and lung sounds, perfusion, pulse oximetry (if
available), and intake and output
Nonpharmacologic Interventions • Watch for signs of cardiac failure (see "Cardiac
• Nurse in an upright position Failure," below, this chapter)
• Feed small amounts frequently
Referral
• Medevac as soon as possible

Rheumatic Fever (Carditis)

Definition Cardiovascular Signs
A diffuse inflammatory disease of the connective • Dyspnea, cyanosis, edema and hepatomegaly if
tissues, which involves the heart, joints, skin, CNS the child is in heart failure
and subcutaneous tissue. It tends to recur. The • Thrill or heave may be present
disease arises from immune complications of • New heart murmurs, often pansystolic
group A ß-hemolytic streptococcal infection. • Rubs may be audible with inspiration and
expiration if disease is associated with
Rheumatic fever is much more common in pericarditis
Aboriginal children and those living in lower • Decrease in intensity of heart sounds
socioeconomic circumstances. It may occur at any
age but is most common in school-age children. Musculoskeletal Signs
The risk is higher in families in which there is a • Joints hot, tender and swollen at several sites
history of the disease.
Skin
Causes • Rash (erythema marginatum)
• Precedent group A streptococcal infection • Nodules may be palpated in subcutaneous tissue,
(pharyngitis) and subsequent immune response usually on extensor surfaces of limbs
History Other Symptoms
The disease is nearly always preceded by • Emotional lability
streptococcal pharyngitis (occurring 2-5 weeks
• Involuntary, purposeless muscular movements
earlier).
(Sydenham's chorea)
The presenting symptoms are variable, but may
The diagnosis is based on a complicated collection
include the following:
of signs known as Jones' criteria (Table 11-2).
• Fever
• Joint pain, redness and swelling (a constellation Table 11-2: Jones' criteria for diagnosis of
of symptoms known as migratory arthritis, rheumatic fever*
typically involving the large joints) Major criteria Minor criteria
• Emotional lability Carditis Fever
• Involuntary, purposeless muscular movements
(known as Sydenham's chorea) Polyarteritis Arthralgia
• Shortness of breath, edema, cough, fatigue Chorea Previous rheumatic fever
(representing heart failure) Erythema marginatum Laboratory findings
• Rash (erythema marginatum)
Subcutaneous nodules
• Subcutaneous nodules along tendon sheaths
* Any combination of two major criteria or one major
Physical Findings and two minor criteria is indicative of the diagnosis
The physical findings are variable and depend on
the degree of involvement of various parts and Differential Diagnosis
systems of the body. • Congenital heart disease (previously
• Low-grade fever undiagnosed)
• Tachycardia (increase in resting heart rate) • Viral carditis
• Tachypnea • Rheumatoid arthritis
• Tics (which may mimic chorea)

Complications salicylates (ASA) (A class drug), 100-120 mg/kg

• Carditis per day
• Rheumatic heart disease (valvular damage, If carditis is present, the following is sometimes
usually to the mitral valve) used:
prednisone (B class drug), 2-3 mg/kg per day,
max. 60 mg/day
Diagnostic Tests
None.
Monitor for signs of cardiac failure.
Management If child is in cardiac failure, see "Cardiac
The diagnosis and treatment of rheumatic fever Failure," below, this chapter.
require evacuation to hospital.
Referral
Emergency treatment of congestive heart failure Medevac.
may be necessary; see "Cardiac Failure," below,
this chapter.
Post-Acute Phase
Goals of Treatment Pharmacologic Interventions for
• Identify the disease early Prophylaxis
Because of the risk of recurrence, continual
• Prevent complications penicillin prophylaxis must be maintained.
Primary Prevention The risk of recurrence is greatest in the first 5
• Aggressive treatment of group A streptococcal years after the initial bout. A physician would
throat infections with a complete course of initially prescribe prophylaxis, usually one of the
antibiotic medications following commonly used drug regimens:
penicillin G benzathine (B class drug), 1.2 million
Acute Phase units per month IM
Consult a physician immediately and prepare to Oral penicillin should be used only in exceptional
medevac. cases, as ensuring compliance is difficult.
Nonpharmacologic Interventions For children with allergy to penicillin:

• Bed rest erythromycin (C class drug), 250 mg PO q12h
Pharmacologic Interventions Prophylaxis for children without carditis should be

Medications should not be started until the maintained for at least 5 years and preferably
diagnosis has been clearly established. throughout childhood.
Medications are prescribed only by a physician. If valvular disease results, lifetime prophylaxis is
recommended or at least to 21 years of age.

Cardiac Failure
The inability of the heart to pump blood • Respiratory disease (e.g. bronchiolitis or
commensurate with the body's needs. The pneumonia)
symptoms and signs correlate with the degree of • Metabolic abnormality (e.g. hypoglycemia;
failure. poisoning, as with salicylates)
• Sepsis
Causes
• Congenital abnormality of cardiac structures Complications
• Inflammatory (e.g. rheumatic fever) • Decreased cardiac output (shock)
• Infectious (e.g. viral cardiomyopathy, subacute • Death
bacterial endocarditis)
• Severe anemia (i.e. hemoglobin < 40 g/L) Diagnostic Tests
• Other high-output states (e.g. thyrotoxicosis, • Pulse oximetry (if available)
arteriovenous malformation)
• Extracardiac disease (e.g. chronic pulmonary Management
disease, pulmonary hypertension) Goals of Treatment
• Improve hemodynamic function
History • Prevent complications
The history varies according to the child's age.
• Difficulty with feeding Appropriate Consultation
• Shortness of breath Consult with a physician regarding emergency
• Excessive sweating treatment.
• Poor weight gain
• Anxious appearance Nonpharmacologic Interventions
• Nurse the child in head-elevated position (do not
Physical Findings allow neck to become kinked)
• Tachycardia • Restrict oral fluids to no more than the quantity
• Tachypnea required to maintain hydration
• Blood pressure usually normal but may be
reduced (if so, this is cause for concern, as it Adjuvant Therapy
may indicate cardiogenic shock) • Start IV therapy with normal saline to keep vein
• Temperature: if higher than normal, consider open
inflammatory or infectious cause • Give oxygen 6-10 L/min or more by mask
• Irritable
• Anxious Pharmacologic Interventions
• Fontanel full Diuretics to decrease volume:
• Nostrils flared furosemide (D class drug), 1 mg/kg IV stat
• Cyanosis
The following drug, to increase contractility, must
• Peripheral swelling (in older children)
be ordered by a physician:
• Increased venous distension
pediatric digoxin (B class drug), 0.04 mg/kg IV or
• Heave or thrill PO
• Gallop rhythm (with extra S3 heart sound)
• Increased murmurs Total dose usually divided as follows: half dose
• Crackles in lung fields given stat, quarter dose given 6 hours later and
• Hepatomegaly quarter dose given 12 hours after first dose (i.e. 6
hours after second dose)


Acute Phase
Monitor ABCs, vital signs, pulse oximetry (if
available), heart and lung sounds, intake and
output until child is transferred to hospital.
Over the Long Term

Children with cardiac illness should be monitored
regularly within the community to ensure normal
growth and development and to watch for
complications. Frequency of follow-up depends on
the severity of the condition.
Referral
Medevac immediately.

Chapter 12 – Gastrointestinal System

Assessment Of The Gastrointestinal System................................................................................................... 1
Examination Of The Abdomen....................................................................................................................... 1
Common Problems Of The Gastro-Intestinal System ................................................................................... 3

Gastroenteritis................................................................................................................................................. 3
Inguinal Hernia ............................................................................................................................................... 6
Umbilical Hernia............................................................................................................................................. 7
Constipation.................................................................................................................................................... 8
Gastroesophageal Reflux Disease (GERD) .................................................................................................. 11
Emergency Problems Of The Gastrointestinal System................................................................................ 14

Abdominal Pain (Acute) ............................................................................................................................... 14
Appendicitis .................................................................................................................................................. 17
Bowel Obstruction ........................................................................................................................................ 19
Intussusception.............................................................................................................................................. 21
For more information on the history and physical examination of the gastrointestinal system in older children
and adolescents, see chapter 5, "Gastrointestinal System," in the NWT Clinical Practice Guidelines for

Assessment Of The Gastrointestinal System

Abdominal Pain • Presence of blood
• Site • Pain before, during or after defecation
• Frequency
• Duration Other Characteristics And Symptoms
• Character (e.g. crampy or constant, sharp or • Growth history (when possible, obtain actual
stabbing) measurements)
• Radiation • Appetite
• Onset (sudden or gradual) • Food and fluid intake since onset of illness
• Progression • Usual nutrition and food habits: type of foods
• Aggravating and relieving factors eaten, variety of foods in diet, quantity of food
• Associated symptoms eaten, dietary balance, fiber content of diet
• Dysphagia
Vomiting Or Regurgitation • Unusual weight loss or weight gain
• Frequency • Colour (e.g. presence of jaundice)
• Volume • Skin (e.g. pruritis, rash)
• Force (e.g. projectile) • Activity level
• Colour • History of previous GI diseases or abdominal
• Hematemesis surgery
• Relationship to food intake • Medications (e.g. iron)
• Allergies, especially known allergies to food
Bowel Habits (e.g. lactose intolerance)
• Frequency, quantity, colour and consistency of
stool
Examination Of The Abdomen

General protuberant; in early childhood the abdomen is
• Apparent state of health still protuberant, but flattens when the child is
• Appearance of comfort or distress lying down)
• Colour (e.g. flushed, pale, jaundiced) • Peristaltic waves
• Nutritional status (obese or emaciated) • Visible masses
• State of hydration (skin turgor) • Guarding and positioning for comfort
(child's behavior can also give very good clues
as to the severity of any abdominal pain)
Vital Signs
• Temperature may be elevated in infection
• Blood pressure usually normal Auscultation
Auscultation, to listen for bowel sounds, should be
• Tachycardia may be present done before palpation.
• Respiratory rate usually normal
Increase in bowel sounds alone is not significant,
Inspection because this can occur with anxiety or mild
Observe abdomen from a distance: gastroenteritis. However, it may also be a sign of
• Size, shape and contour; note any distension or obstruction.
asymmetry (in infancy, abdomen is typically

Absence of bowel sounds indicates ileus, which quadrants in succession. If there is pain, start with
can be due to a variety of factors, including the painless areas, and palpate the painful area last.
metabolic problems, infection or peritoneal Palpation should be light at first, with progression
irritation. to deep palpation by the end of the examination.
Percussion Light Palpation

• General percussion in all four quadrants for • Assess tenderness, guarding, superficial masses
normal tympany • Watch the child's facial expression
• Increased tympanitic sound in a distended
abdomen indicates gas, which may be a result of Deep Palpation
obstruction, perforation, ileus or swallowed air • Feel for organs (liver, spleen, bladder and
• Dullness in association with abdominal kidneys) and masses
distension indicates fluid • Assess for rebound tenderness (pain that occurs
• Delineate outline of liver; upper border is in the upon suddenly releasing the hand after deep
mid-clavicular line, between the fourth and sixth palpation), which indicates peritoneal irritation
intercostal spaces; upper limit of liver span • Assess for referred tenderness (pain that is felt in
ranges from 8 cm at 5 years of age to 13 cm at an area distant to the area being palpated), which
puberty can be a clue to the location of the underlying
• Determine spleen size disease
• If ascites is present, there will be dullness to
percussion on the dependent side when the child Rectal Examination
is in a side-lying position; the border of the • Anal patency (check this feature only in
percussion note will change to a new position newborns)
several moments after the child assumes a • Skin tags
supine recumbent position • Sphincter tone
• Fissures
Palpation • Tenderness
Ideally, palpation is performed with the child lying • Masses
supine, with hands by the sides and relaxed. In • Occult blood
reality, it must sometimes be done on the run. Be
sure your hands are warm. The child's abdomen
must be completely exposed. Examine all four

Common Problems Of The Gastro-Intestinal System

Gastroenteritis
Definition History
Inflammatory process (usually infectious) • Onset and duration of symptoms
involving the GI tract and resulting in diarrhea and • Vomiting: frequency, colour, amount
vomiting. It is very common, especially among • Stool pattern: frequency, quantity (record
infants. The danger of dehydration from diarrhea amount in cups), consistency (formed or
is much greater in children than adults because of watery), colour, presence of blood or mucus
high body water content and large surface area for • Thirst
weight. Significant diarrhea and vomiting must be • Oral intake from all sources
taken seriously in small children.
• Voiding: frequency and duration, number of wet
diapers and their degree of saturation
Causes • Alertness and activity level
Numerous organisms can cause gastroenteritis,
• Alterations in mental state (e.g. irritability,
including bacteria, viruses and parasites. These
lethargy)
organisms can be categorized according to the
mechanism by which they produce diarrhea
• Diet history, focusing on water source and
intake of poultry, milk and fish
(secretory, cytotoxic, osmotic or dysenteric
mechanism). • Family history: other family members or close
contacts with similar symptoms
Viruses • Exposure to infected contacts at daycare center
• Rotavirus: most common cause in children • Past medical history, including other recent
6-24 months of age illness, recent antibiotic use (which may lead to
• Norwalk virus: affects older children infection with C. difficile), GI surgery
• Enteric adenovirus: common in children • Recent travel to an area where diarrheal illness
<2 years old is endemic
Bacteria Physical Findings

• Salmonella Weight (with child unclothed) must be recorded
for future comparison.
• Shigella
• Escherichia coli
Vital Signs
• Campylobacter
• Temperature elevated in infectious
gastroenteritis
Parasites
• Tachycardia if febrile or in compensated shock
• Giardia
• Respiration normal, unless in shock
• Blood pressure normal, unless in shock from
Other Causes
dehydration
• Food poisoning
• Colour: pale, mottled skin may indicate
• Adverse reaction to antibiotic therapy causing
dehydration
Clostridium difficile infection
• Hyperthyroidism Hydration Status
• Hirschsprung's disease (congenital megacolon) • Mucous membranes: check for dryness
• Overfeeding (in newborns) • Fontanel sunken in dehydration
• Skin turgor decreased in dehydration; skin may
be doughy; when pinched, skin may remain in a

tent shape for several seconds before slowly • Fluid therapy is based on assessment of degree
resuming its normal shape of dehydration
• Mental state (e.g. irritability, listlessness) • Therapy should include the following elements:
• See Table 4-3, "Clinical Features of rehydration, maintenance of fluids and
Dehydration," in chapter 4, "Fluid replacement of ongoing losses
Management" • To determine degree of dehydration, calculate
fluid deficit, and calculate daily maintenance
Abdominal Examination requirements, see Tables 4-1, 4-2, 4-3, 4-4 in
• Distension chapter 4, "Fluid Management"
• Bowel sounds: high-pitched, rushing sounds in
secretory or dysenteric gastroenteritis; may be Mild Diarrhea without Dehydration
decreased with ileus in dysenteric or • Breast-feeding and normal dietary intake should
malabsorptive conditions continue at home, with fluid intake dictated by
• Mild, diffuse, generalized tenderness is usual thirst
• Maintenance oral replacement solution (e.g.
Differential Diagnosis Pedialyte®) should be offered ad libitum
See "Causes," above, this section. • High-osmolality fluids (e.g. undiluted juices or
• Viral gastroenteritis: 80% of cases in children soda pop) and plain water should be avoided
<2 years old
• Bacterial gastroenteritis: 20% of cases in Mild Dehydration (<5%)
children <2 years old • Assessment and treatment under close
observation is recommended
Infections outside the GI tract can also cause • Rehydration phase: oral replacement solution
diarrhea and vomiting, especially in younger (e.g. Pedialyte®), 10 mL/kg per hour, with
children. Otitis media, pneumonia and urinary reassessment q4h
tract infections are among the most frequent non- • Rehydration should be achieved over 4 hours
GI infections associated with diarrhea and • Breast-feeding should continue
vomiting. • For bottle-fed children, usual formula should be
re-started within 6-12 hours
Management • Extra oral replacement solution (at 5-10 mL/kg)
Goals of Treatment may be given after each diarrheal stool
• Maintain adequate hydration
• Rehydrate if dehydrated Moderate Dehydration (5% to 10%)
• Prevent complications • Rehydration phase: oral replacement solution
(e.g. Pedialyte®), 15-20 mL/kg per hour, under
Appropriate Consultation direct observation
Consult a physician in the following situations: • Frequent reassessment, including weight and
• Any infant or child who shows signs of state of hydration, is required during the
dehydration on initial presentation rehydration phase (q1-2h)
• Any infant or child who does not improve on • Rehydration should be achieved over 4 hours
home therapy • If dehydration is corrected, continue fluid
• Any infant or child whose diarrhea increases therapy for maintenance and to make up for
with re-introduction of cow's milk formula ongoing losses
• Bloody diarrhea • Extra oral replacement solution (at 5-10 mL/kg)
may be given after each diarrheal stool
Nonpharmacologic Interventions • If dehydration persists, repeat rehydration phase
See "Dehydration in Children," in chapter 4, • Breast-feeding should continue
"Fluid Management" • For bottle-fed children, usual formula should be
re-started within 6-12 hours

Severe Dehydration (>10% or Signs of Pharmacologic Interventions

Shock) Antispasmodic and antidiarrheal agents should not
Requires IV therapy, in addition to oral be used. It should be explained to the parents or
rehydration. caregiver that it is best to consider the diarrhea as
• Start IV therapy with normal saline or Ringer's a purging process, to rid the intestinal tract of
lactate organisms, and that the most important part of
• Give a bolus of 20 mL/kg over 20 minutes managing diarrhea is the replacement of lost
• Reassess status and repeat bolus (to a maximum fluids. There is also a very limited role for
of three boluses in 1 hour) if shock or other antiemetic agents.
signs of severe dehydration persist
Specific antimicrobial agents are usually not
• Once a response occurs, calculate the remaining indicated, even for bacterial infection. An
deficit; replace 50% of the deficit over 8 hours exception is gastroenteritis caused by Giardia
and remainder over the next 16 hours; be sure to lamblia, which is usually treated as follows:
include maintenance requirements in total IV metronidazole (C class drug), 15-20 mg/kg per
therapy day, divided tid x 5 days
• Intraosseous infusion should be used if an IV
line cannot be established (see "Intraosseous Monitoring and Follow-Up
Access," in chapter 2, "Pediatric Procedures") Gastroenteritis without Dehydration
Re-evaluate the child with mild symptoms (treated
Fluid and Feeding Guidelines at home) within 24 hours. Ensure that the parent or
• Fluids may be given by nasogastric tube if caregiver is aware of the signs and symptoms of
necessary dehydration, and instruct him or her to return
• Oral replacement solution should be given immediately if dehydration occurs or worsens or if
slowly but steadily in small aliquots the child cannot ingest an adequate quantity of
(to minimize vomiting) fluid.
• Oral replacement solution alone should not be
given for more than 24 hours Gastroenteritis with Dehydration
Record vital signs, clinical condition, intake and
• Encourage the mother to administer the fluid by
output, and weight frequently when rehydrating a
syringe or spoon in small frequent doses
child with dehydration, and keep child under
• Breast-feeding should continue during
observation at the clinic.
rehydration
• Regular feeding (breast or bottle) should begin
Referral
within 6-12 hours
• Infants or children with mild dehydration who
• Full diet should be re-instituted within respond after 4 hours of rehydration may be sent
24-48 hours, if possible home on maintenance therapy; if dehydration
persists and there are continuing fluid losses,
There is evidence that diarrhea lasts longer if child should be medevaced
starvation occurs.
• The decision to continue home management
should be made in consultation with a physician
If the reintroduction of formula exacerbates
and depends primarily on the ability of the
diarrhea, consider the possibility of lactose
parents or caregiver to provide adequate care
intolerance, which may be secondary to loss of the
and on other factors, such as the distance of their
GI brush border (see "Lactose Intolerance," in
home from the treatment facility
chapter 17, "Hematology, Endocrinology,
Metabolism and Immunology"). If this adverse • Most children with significant dehydration
reaction to formula persists for more than 2 days, (>5%) should be evacuated to hospital
consult a physician about switching to a lactose- • Many children with 5% to 10% dehydration can
free formula (e.g. Prosobee® or Isomil®) for be rehydrated substantially in the nursing station
5-7 days. while awaiting transport

Inguinal Hernia
Definition • If the hernia proves difficult to reduce, do not
Protrusion of part of the abdominal contents into force abdominal contents back, because this can
the inguinal canal. internalize or incarcerate the hernia, and the
child remains at risk for all the complications of
This type of hernia is common in children, hernias (see "Complications," below, this
affecting more boys than girls and occurring on section)
the right side more often than the left.
Cause • Hydrocele
• Embryologic failure of closure of the processus • Undescended testis (cryptorchism)
vaginalis • Scrotal trauma
• Seminoma, teratoma
History • Lymphadenopathy
• Mass may be present in the groin at birth or may
appear anytime after birth Complications
• Mass that can be pushed back inside the • Incarceration of hernia
abdomen wall (termed "reducible") • Strangulation of hernia
If the hernia becomes incarcerated: • Testicular infarction
• Pain may occur
• Mass becomes impossible to reduce Cryptorchism is associated with inguinal hernia.
If incarceration lasts long enough to cause Diagnostic Tests

infarction of the bowel, there may be signs of None.
intestinal obstruction. See "Bowel Obstruction,"
below, this chapter.
Management
Goals of Treatment
Physical Findings
• Observation until surgery (within 2 weeks of
• Vital signs usually normal, unless bowel diagnosis, ideally)
infarction has occurred
• Mass visible in the inguinal area, especially
when the baby is crying
• If the mass is not visible, feel the inguinal canal Consult a physician and prepare to medevac if the
by invaginating the upper part of the scrotum or hernia is not reducible and there are signs of
labia with a finger; if the inguinal canal admits a complications. If the hernia is not incarcerated
finger it is too large (and is reducible), this is not an emergency
• Gentle palpation of the lower inguinal area near situation.
the pubis may give a feeling like rubbing two
layers of silk together Nonpharmacologic Interventions
• During transillumination of scrotum (by shining Reassure the parents or caregiver.
a flashlight behind the scrotum), hernial contents
will not be transilluminated because they contain Client Education
viscera Teach the parents or caregiver the following:
• Try to reduce the hernia with the child in a • How to check and reduce the hernia
supine or head-down position, so that gravity
• Signs and symptoms of complications
will assist the procedure (e.g. incarceration, strangulation, bowel
obstruction)

Emphasize the need to have the child assessed Monitoring and Follow-Up
immediately if the hernia becomes difficult to Assess the size and reducibility of the hernia every
reduce. 3 months while awaiting surgical consultation and
surgery.
None. Referral
Refer all asymptomatic children electively to a
physician for assessment. A surgical referral will
be necessary. Because of the risk of incarceration,
surgery is recommended for all infantile inguinal
hernias.
Umbilical Hernia
Protrusion of abdominal contents through the None.
diastasis recti, causing an out-pouching of the
umbilicus. Very common in First Nations children. Management
In spite of the size of umbilical hernias, they
Cause almost never become incarcerated, and surgery is
• Weakness of the diastasis recti muscles of the not required. They usually disappear by the time
abdomen the child reaches 2 or 3 years of age. All that is
necessary is to reassure the parents or caregiver.
• Enlargement and protrusion of the umbilicus Strapping and taping are not of clinical value but
may help to ease parental concerns and are usually
not harmful.
Complications
Complications are rare.
• Incarceration or strangulation of hernia

Constipation
Definition without a bowel movement is one of the best
Infrequent passage of hard, often dry stool. indicators of this condition
• Consistency of stool is usually hard
In 99% of cases, the cause of the constipation is • In severe constipation, stools may be very thick
never proven definitively. The condition is • Pain on defecation
common in children, and often (in 60% of cases) • Blood on stool
occurs during the first year of life. • Straining at stool
• Intermittent, crampy abdominal pain
Constipation is a symptom, not a diagnosis. In all • Constipation present since birth (in this
cases, the underlying cause must be sought, as situation, consider Hirschsprung's disease)
many of the causes are correctable.
• Dietary history, specifically low fiber content
(the best sources of fiber are whole wheat bread
Causes and flour, bran, whole grain cereals, vegetables
Dietary and some fruits)
• Introduction of cow's milk, too much of it. • Family history of constipation
• Inadequate fluid intake • Drugs that are constipating (e.g. iron)
• Under-nutrition • Concurrent bladder incontinence or abnormal
• Diet high in carbohydrates or protein (or both) anal tone (neurologic)
• Low-fiber diet • Hypothyroidism (dry skin, lethargy, slow
growth of hair and nails)
Organic
• Diseases causing abnormally dry stool Physical Findings
• Diabetes insipidus or diabetes mellitus • Assess height for short stature and weight
• Fanconi's syndrome
• Idiopathic hypercalcemia Abdominal Examination
• Fecal masses can usually be felt along the
Gastrointestinal Anomalies descending colon or in the suprapubic area
• Hirschsprung's disease (congenital megacolon)
• Anorectal stenotic lesion, stricture or fissure Rectal Examination
• Masses (intrinsic or extrinsic) • Rectum may be large, dilated and full of stool
• Anterior anal displacement • Normal tone of external sphincter
• Reflex contraction of anus on gentle scratching
CNS Lesions of the perianal skin with a sharp object (anal
• Hypotonia (benign congenital hypotonia) wink reflex)
• Hypertonia (cerebral palsy) • Anal placement should be midline and midway
• Infectious polyneuritis or poliomyelitis between posterior fornix and coccyx
• Myelodysplasia • Evidence of precipitating event (e.g. anal
fissure)
Other Causes
• Hypothyroidism Differential Diagnosis
• Prune-belly syndrome See "Causes," above, this section.
• Coercive toilet training
In infancy, the possibility of Hirschsprung's
History disease causes the greatest concern. This diagnosis
is most likely in a baby who has been severely
• Frequency of bowel movements: in children
constipated from birth and in whom passage of
older than infancy, a period of more than 3 days
meconium was delayed (i.e. >24 hours after birth).

During rectal examination of a child with this Client Education

disease, the examining finger can usually be • Explain pathophysiology to family (and child, if
inserted a long way before dilatation of the rectum old enough): draw a diagram of GI system and
is encountered; in contrast, in functional explain how stool is formed and the mechanism
constipation, the rectum is dilated right down to of constipation.
the external sphincter. • Encourage high-fiber diet. Most children eat a
diet very low in fiber. A commitment on the part
Occasionally, short-segment Hirschsprung's of the whole family is usually required to change
disease may present later in life as constipation. this aspect of the diet. A good rationale for
promoting a high-fiber diet for all family
Complications members is that high fiber intake may reduce the
• Overflow incontinence (encopresis) with fecal risk of cancer in later life and also smoothes out
soiling (may be incorrectly characterized as carbohydrate absorption.
diarrhea) • Stress importance of follow up.
• Impaction with chronic dilatation • Educate about proper toilet training for toddlers:
• Urinary tract infection with or without vesico- regular attempts just after meals, proper position
ureteral reflux (hips flexed, feet flat).
• Intestinal obstruction
Constipation also seems to be related to enuresis. Medication is used only if organic pathology has
been ruled out.
Diagnostic Tests
• Check urine (culture and sensitivity) to exclude Infants (if distressed):
UTI, which can complicate chronic constipation infant glycerin suppository (A class drug),
1.5 g; give one suppository and repeat as
Management necessary
Goals of Treatment
Older children:
• Relieve symptoms magnesium hydroxide (Milk of Magnesia)
• Establish regular bowel function (A class drug), 6.5-15 mL PO hs (2-6 years) or
• Rule out any underlying cause 15-30 mL PO hs (6-12 years)
• Prevent or treat complications or
• Encourage wise use of laxatives, to prevent mineral oil (A class drug), 5-20 mL PO hs
dependence on these drugs (usually 30 mL/10 kg)
Nonpharmacologic Interventions Limit the use of these agents to 3 or 4 days at most

Interventions depend on age and severity of for acute constipation, unless complications such
constipation. as encopresis are present.
• Newborns: add brown sugar to formula or water
(1 tsp in 4-8 oz. or 5 mL in 125-250 mL) Monitoring and Follow-Up
• Infants: as solid foods are introduced, gradually If you treat the child for acute functional
increase fruits and vegetables as proportion of constipation, reassess in 2 or 3 days to see if the
the diet condition has resolved.
• Older children: prunes or prune juice may be
effective Referral
• Increase dietary fiber if low The following factors may alert you to the need
• Increase fluids for referral:
• Reduce milk intake if more than recommended. • History: failure to pass meconium in the first 24
hours of life in an infant now presenting with
difficulty passing stool

• Rectal examination: rectum empty, despite stool • Clinical indications of intestinal obstruction
in colon (as revealed by abdominal exam) (e.g. vomiting, abdominal pain, decrease in
• Abnormal size and location of anus (ectopic or bowel sounds)
imperforate) • Clinical indications of Hirschsprung's disease
• Abnormal findings on neurologic examination of (e.g. delayed passage of meconium at birth,
the lower extremity fever, pain, distension, bloody diarrhea)
• Evidence of sexual abuse • Clinical indications of acute surgical abdomen
(e.g. fever, abdominal tenderness, mass)
The following factors may indicate the need for
emergency medevac:

Gastroesophageal Reflux Disease (GERD)

Definition History And Physical Findings
Physiologic or pathologic reflux of an abnormal Infants
quantity of gastric contents into the esophagus, Gastrointestinal Manifestations
which results in GI, respiratory or neurobehavioral • Failure to thrive
manifestations. • Malnutrition
• Esophagitis
The prevalence is unknown. In children, the peak • Feeding problems
age at onset is 1-4 months of age.
• Irritability
• Hematemesis
Physiologic Regurgitant Reflux
Reflux occurs occasionally in all infants and • Anemia
children, and brief episodes of reflux (small
quantities) after meals are normal. It is important Respiratory Manifestations
to differentiate physiologic from pathologic reflux. • Apnea (obstructive)
• Chronic cough
Pathologic Regurgitant Reflux • Wheeze
Pathologic reflux differs from physiologic reflux • Pneumonia (chronic or recurrent)
in two ways: • Cyanotic spells
• Abnormally large quantity of material refluxed • Others (e.g. stridor, hiccups, hoarseness)
• High frequency or long duration of episodes (or
both) Reflux with respiratory manifestations is more
likely to be observed in association with certain
Causes disorders in both infants and children (e.g.
Disturbance of the normal functioning of the esophageal atresia, cystic fibrosis,
esophagus and related structures results in a bronchopulmonary dysplasia and tracheo-
defective anti-reflux barrier. esophageal fistula).
Gastric Dysfunction Neurobehavioral Manifestations

• Large volume of gastric contents • Arching and stiffening of back
• High abdominal pressure (because of obesity or • Hyperextension of the neck or marked flexion of
tight clothes) the neck to one side (torticollis)
Dysfunction of Lower Esophageal Children and Adolescents

Sphincter (LES) Gastrointestinal Manifestations (Esophagitis)
• Transient relaxation of LES (major cause of • Chest pain (heartburn)
reflux) • Dysphagia (difficulty swallowing)
• Basal relaxation of LES (minor cause of reflux) • Halitosis (due to refluxate in mouth)
• Odynophagia (painful swallowing)
Esophageal Dysfunction • Water brash (flow of sour saliva into mouth)
• Impairment of esophageal clearance of refluxate • Hematemesis
• Anemia (iron-deficient form)
Predisposing Factors
• Supine position Respiratory Manifestations
• Certain foods and medications (see • Recurrent or chronic pneumonia
"Management," below, this section) • Recurrent wheeze
• Chronic cough
• Others (e.g. stridor, hoarseness)

Differential Diagnosis • Avoid large meals (i.e. smaller but more

• Infection as a cause of vomiting (e.g. frequent feedings)
gastroenteritis) • Diet for weight loss may be considered in an
• Neurologic problem (e.g. hydrocephalus, brain older child, if he or she is overweight or obese
tumor) • Avoid foods that decrease LES pressure or
• Metabolic problem (e.g. phenylketonuria, increase gastric acidity (e.g. carbonated drinks,
galactosemia) fatty foods, citrus fruits, tomatoes)
• Food intolerance (e.g. milk allergy, celiac • Avoid tight-fitting clothes
disease) • Avoid exposure to tobacco smoke
• Anatomic malformations (e.g. pyloric stenosis,
esophageal atresia, intussusception) Appropriate Consultation
Consult a physician in the following
Complications circumstances:
• Esophagitis • You think that diagnostic tests are necessary to
• Esophageal stricture confirm the diagnosis, or you think that
• Failure to thrive medications are needed
• Recurrent aspiration pneumonia • Conservative measures fail to control reflux
• Reactive airways disease, asthma • There is evidence of complications (e.g. failure
to thrive)
• Apnea, near-miss SIDS
• Anemia
Pharmacologic Interventions (for Older
Children and Adolescents)
Diagnostic Tests Medications for an infant or young child must be
• Hemoglobin level (if there is a concern about ordered by a physician.
anemia)
• Chest x-ray (if available), to rule out aspiration The medications presented here are for older
or recurrent pneumonia children and adolescents (>12 years old).
Management Acid-Reducing Agents

Goals of Treatment Used more often in older children who have pain
• Eliminate detrimental effects of reflux (GI, associated with esophagitis:
respiratory and neurobehavioral manifestations) aluminum-magnesium-simethicone suspension
(A class drug), 0.5-1.0 mL/kg PO 3-6 times per
Client Education day
Discuss diagnosis with parents or caregiver and
explain difference between physiologic and Histamine Antagonists
pathologic reflux. ranitidine (C class drug), 2 mg/kg PO tid
Positioning Prokinetic Agents

• Place child in upright positions Mechanism of action of prokinetic agents is to
• Avoid supine or semi-seated position raise the basal LES pressure, improve esophageal
• Elevation of head of bed onto 6-inch (15-cm) clearance and increase the rate of gastric
blocks may be useful emptying. Such an agent is usually started on a
trial basis for 8 weeks and prescribed by a
Feeding physician.
• Thicken infant foods (add 1 tbsp [15 mL] dry dopamine antagonist (e.g. domperidone)
rice cereal for each ounce of formula) (B class drug), as first-line therapy, before feeding
• Fasting for a few hours before child goes to
sleep

Monitoring and Follow-Up • Severe or intractable detrimental effects (e.g.

Reassess monthly while the child is symptomatic. failure to thrive, recurrent pneumonia, peptic
Watch carefully for signs of complications (e.g. stricture)
failure to thrive, recurrent pneumonia, asthma, • Neurologically impaired children with or
erosive esophagitis or anemia). Monitor growth without gastrostomy tube
and development, hemoglobin level and lung
sounds. Prognosis
• Most infants with mild or moderate reflux
Referral become asymptomatic and can discontinue
Refer any infant with suspected GERD to a medical therapy by 1 year of age
physician in the following situations: • Of infants with severe reflux, 60% to 65%
• Simple measures fail to relieve the problem become asymptomatic without therapy by
• There are symptoms of complications 2 years of age
(e.g. failure to thrive, recurrent pneumonia) • Children more resistant to complete resolution
have good response to medical therapy but
Surgery may be necessary in severe cases. experience relapse when medications are
Indications for surgery: discontinued
• Failure of medical management

Emergency Problems Of The Gastrointestinal System

Abdominal Pain (Acute)
Abdominal pain is a common symptom in History
children. In very young children, it may be Characteristics of Pain
difficult to verify that the pain is abdominal, as the Use the following mnemonic to characterize the
child cannot describe the pain. In younger pain:
children, abdominal pain may be a non-specific O for onset
symptom of disease in almost any system. In older P for progression
children, the symptoms become more specific, but Q for quality
can still be caused by a wide variety of more and R for radiation
less serious conditions. S for site
T for timing
Abdominal pain is often categorized as acute, A for aggravating factors and associated
chronic or recurrent. The latter is usually defined symptoms
as pain that recurs at least monthly over a 6-month
period. Pain that requires surgical intervention is Review of Systems and Medical History
almost always acute. • Respiratory system
• Urinary system
Causes • Diet
Infants • Sexual history (in female adolescents)
• Infant colic • Trauma
• Hernia • Medications
• Intussusception (in children 3 months to 2 years
old) Physical Findings
• Volvulus • Temperature
• Duplication of bowel • Heart rate
• Blood pressure
Pre-school Children
• Pneumonia
• Hydronephrosis, Ureteral-pelvic junction (UPJ) General Observations
obstruction
• Colour
• Pyelonephritis
• Sweating
• Appendicitis (especially in children >3 years
• Distress
old)
• Facial expression
Abdominal Examination
6-18 Years Old
• Abdominal distension (may be caused by
• Appendicitis
organomegaly, infection, obstruction or ascites)
• Mittelschmerz (pain at the midpoint of
• Peristaltic waves present in obstruction
menstrual cycle, presumably related to
(e.g. pyloric stenosis in small infants)
ovulation)
• Guarding with or without decrease in activity
• Tonsillitis
level
• Involuntary guarding
• Functional cause
• Bowel sounds: high-pitched, rushing (may
indicate obstruction) or absent (may indicate
ileus)

• Tympany increased with severe distension or • Urinalysis (for blood, protein, nitrates and
perforation WBCs)
• Tenderness (generalized or localized) • Pregnancy test for all reproductive-age females
• Muscle rigidity (voluntary or involuntary) • Chest x-ray (upright), to rule out pneumonia
• Localized rigidity may indicate peritoneal
irritation Management
• Masses, pulsation, hernia Specific management is based on the most likely
• Rebound tenderness (pain on sudden release of cause of the abdominal pain.
palpation pressure) may indicate peritoneal
irritation; cough or jumping also may elicit Initial Decision
rebound tenderness Decide whether to admit and observe, discharge,
• Obturator sign (pain on internal and external or refer for surgical opinion.
rotation of hip)
• Psoas sign (pain on raising straight leg by means Goals of Treatment
of obturator muscle) may indicate abscess • Identify or rule out urgent causes of pain
• Referred pain (pain felt in an area different from • Refer child with an urgent cause to a center
that palpated) may indicate site of lesion where surgery is available
• Board-like abdomen may indicate perforation • Treat treatable conditions
• Murphy's sign (pain in right upper quadrant • Provide relief and reassurance for conditions
when child is breathing in and examiner is that are not serious
applying pressure over the liver)
• Enlargement of liver or spleen Appropriate Consultation
• Tenderness of costovertebral angle Consult a physician if the diagnosis is unclear, if
the presentation looks at all serious (e.g. surgical
Rectal Examination abdomen) and before administering any analgesia.
• Indicated if you suspect a surgical problem (e.g.
appendicitis) Nonpharmacologic Interventions
• Feel for hard stool • Give nothing by mouth until the diagnosis is
• Palpate for tenderness in the area of the clear
appendix • Insert nasogastric tube if there is vomiting,
bleeding or suspected bowel obstruction
Pelvic Examination • Insert Foley catheter as necessary
• Bimanual pelvic exam (optional), to feel uterus
and adnexa in sexually active adolescent females Adjuvant Therapy
Differential Diagnosis • Determine expected fluid losses and current
See "Causes," above, this section. level of hydration, and hydrate accordingly
The lists of causes given above are by no means Pharmacologic Interventions

comprehensive, but most of the urgent conditions Unless the diagnosis is clear, do not administer
are listed there. Once urgent conditions have been any analgesia until you have consulted a
ruled out, the child can often be treated physician.
symptomatically until a physician has been able to
Although classic surgical teaching has been that
make an assessment.
medication for pain may confuse the diagnosis of
abdominal pain in the emergency setting, this is
Diagnostic Tests (If Available) not supported by the literature. In fact, if anything,
• Hemoglobin the diagnosis may be clarified by pain relief,
• WBC count which may result in fewer unnecessary surgical
procedures.

Monitoring and Follow-Up Keep child under observation if you are unsure of
Monitor pain, ABCs, vital signs and any the diagnosis. For any child with acute abdominal
associated fluid losses closely. Serial exams over a pain who has been sent home, the parents or
few hours may clarify the diagnosis. caregiver should be warned that it is difficult to
diagnose appendicitis early in the course of this
Referral condition and that if the pain increases in severity
Medevac for evaluation if the diagnosis is or becomes constant or fixed in one spot
uncertain and the child's condition warrants urgent (especially the right lower quadrant), they should
evaluation. bring the child back to the clinic.

Appendicitis
Definition experiences pain on movement or avoids any
Inflammation of appendix. movement or activity
This condition is rare in children <3 years old. It Abdominal Examination

can be very difficult to diagnose, especially in • Bowel sounds variable: hyperactive to normal in
younger children. Therefore, the index of early stages, reduced to absent in later stages
suspicion should be high. • Localized tenderness in right lower quadrant
• Muscle guarding in right lower quadrant
Cause • Rebound tenderness may be present
Obstruction of the opening of the appendix by • Psoas stretch test positive
stool. Infection may occur later.
Another test for peritoneal irritation is to have the
History child jump off the examining table. If the child can
The following outlines the classic pattern of acute do this without pain, he or she probably does not
appendicitis. However, in younger children, this have appendicitis.
history is less likely. If the child is older and has a
retrocecal or retroperitoneal appendix, the Rectal Examination
presentation may be confusing, with pain radiating • Tenderness in right lower quadrant if tip of
to the back or bladder, or the presence of bowel appendix is near the rectum
irritation.
• Vague, diffuse periumbilical or epigastric pain Appendicitis is known as the "great mimic." The
• Pain shifts within hours to right lower quadrant actual signs and symptoms depend on the location
• Anorexia of the appendix within the abdomen.
• Nausea • Gastroenteritis
• Vomiting usually occurs a few hours after onset • Crohn's disease
of pain, but may not be present • Stone in ureter
• Low-grade fever may be present • Mittelschmerz
• Urinary frequency, dysuria and diarrhea may • Ruptured follicular cyst
develop if tip of appendix irritates the bladder or • Ectopic pregnancy
bowel • Pelvic inflammatory disease
• In adolescent girls, date of most recent normal • Twisted ovarian cyst
menstrual period and any recent menstrual • Pyelonephritis
irregularity should be noted • Biliary colic
• Cholecystitis
Physical Findings
Presentation is variable, depending on whether the
Complications
child presents early or late in the evolution of the
disease process. • Abscess
• Temperature mildly elevated • Localized peritonitis
• Tachycardia (although heart rate may be normal • Perforation
in early stages) • Generalized peritonitis
• Most children are pale and appear to be in pain • Sepsis
• Variable level of distress
• Body position and gait are useful in diagnosis: in Diagnostic Tests
many full-blown cases, the child is bent over and • WBC count (if available)
• Urinalysis


Goals of Treatment Although classic surgical teaching has been that
• Maintain hydration medication for pain may confuse the diagnosis of
• Prevent complications abdominal pain in the emergency setting, this is
not supported by the literature. In fact, if anything,
Appropriate Consultation the diagnosis may be clarified by pain relief,
Consult a physician as soon as possible. which may result in fewer unnecessary surgical
procedures. Nonetheless, do not administer
Nonpharmacologic Interventions analgesia until you have consulted a physician.
• Bed rest
If the diagnosis is clear, the physician may
• Nothing by mouth recommend that broad-spectrum antibiotics be
• Insert a nasogastric tube if abdomen is distended started before transport to hospital. For example,
for suspected gangrenous or perforated appendix:
Adjuvant Therapy ampicillin (C class drug), 200 mg/kg per day,
• Start IV therapy with normal saline divided q6h, IV
• Adjust IV rate according to age and state of and
hydration gentamicin (B class drug), 7.5 mg/kg per day,
divided q8h, IV
and
clindamycin phosphate (B class drug), 40 mg/kg
per day, divided q6-8h, IV

Monitor vital signs and general condition
frequently.
Referral
Medevac as soon as possible; surgical consultation
is required.

Bowel Obstruction
Blockage of small or large bowel. Most common • General observations of colour, hydration and
in newborns. Less common in older children, facial expression
unless they have a specific risk factor. • Temperature normal or mildly elevated
• Tachycardia
Causes • Blood pressure normal, unless child is in shock
Newborns • Capillary refill normal, unless child is in shock
• Atresia: duodenal (often associated with Down's
syndrome), jejunal or ileal Abdominal Examination
• Imperforate anus • Abdominal distension, unless the obstruction is
• Malrotation located very high in the GI tract
• Duplication of bowel • Peristaltic waves may be visible
• Volvulus • Bowel sounds may be increased in early stages
and disappear later
Infants • Diffuse tenderness
• Atresia: duodenal (often associated with Down's • Shifting dullness can help to distinguish
syndrome), jejunal or ileal distension caused by ascites from obstruction
• Imperforate anus
• Malrotation Differential Diagnosis
• Duplication of bowel See "Causes," above, this section.
• Volvulus
• Pyloric stenosis Complications
• Post-surgical adhesions • Perforation
• Intussusception (most common in children • Peritonitis
3 months to 2 years of age) • Strangulation of bowel segment
• Sepsis
Older Children • Hypotension, shock
• Post-surgical adhesions • Death
• Intussusception (unusual but possible)
• Malrotation Diagnostic Tests
• Duplication of bowel • Examination of stool for occult blood
• Tumor • Urinalysis
History Management
• Vomiting: often with sudden onset; may be Goals of Treatment
stained with bile if obstruction is below ligament Treatment is directed to cause and is thus usually
of Treitz; may be projectile if obstruction is high surgical.
in the GI tract; may be stained with feces if • Relieve distension
obstruction is very low in the GI tract • Maintain hydration
• Diarrhea: bloody or colour of red currant jelly • Prevent complications
(indicates intussusception)
• Abdominal pain: severe and initially crampy Appropriate Consultation
• Bowel movements decreased or absent Consult a physician and prepare to medevac.
• Abdominal distension
• History of GI surgery
• History of similar pain

Adjuvant Therapy
• Start a large-bore IV (14- or 16-gauge) with Pharmacologic Interventions
normal saline Analgesia may be necessary or prudent if transfer
• Give enough fluid for maintenance or more, is delayed. Discuss with a physician first.
according to state of hydration
• If there is evidence of hypovolemia or shock, meperidine (D class drug),
give a bolus of IV fluid (20 mL/kg) over
20 minutes; repeat as necessary until dosage depending on age and weight of child
hypovolemia is corrected (up to three times in 1
hour) Monitoring and Follow-Up
Monitor ABCs, vital signs, intake and output,
See "Shock," in chapter 20, "General Emergencies abdominal findings and general condition
and Major Trauma." frequently while awaiting transfer.

• Bed rest Medevac as soon as possible.
• Insert a nasogastric tube and attach to low
suction or to straight drainage
• Insert urinary catheter; measure hourly urinary
output

Intussusception
Definition In children who are extremely lethargic, a clinical
Telescoping of one section of bowel into another. history, physical examination and high index of
In children, the most common form of suspicion are needed to rule out conditions such as
intussusception is prolapse of the terminal ileum meningitis, various metabolic conditions,
into the colon. (Some clinicians suspect that this is enterocolitis caused by coxsackievirus and trauma.
less common in Aboriginal children, but there is
no proof of such a difference.) Complications
• Bowel necrosis
Cause • GI bleeding
Unknown. Associated with Henoch-Schönlein • Bowel perforation
purpura and previous gastroenteritis, both cause • Sepsis
hyperplasia of Peyer's patch. • Shock

• Usually starts with crampy abdominal pain, None.
which is manifested as regular, intermittent
episodes of colic during which the baby draws Management
his or her feet up to the knee-chest position Goals of Treatment
• Vomiting • Identify the condition early (keep a high index
• "Currant jelly" stool: almost pathognomonic of suspicion)
when present • Maintain hydration
• Other signs of obstruction, including abdominal • Prevent complications
distension, may be present
• Lethargy: may become extreme, very similar to Appropriate Consultation
coma Consult a physician and prepare to medevac.
Physical Findings Adjuvant Therapy

• Pale looking, lethargic between crampy episodes • Start IV therapy with normal saline and run at a
• Vital signs usually normal in the early stages rate sufficient to maintain hydration
• If there is evidence of hypovolemia or shock,
Abdominal Examination give a bolus of IV fluid (20 mL/kg) over 20
• Careful palpation may reveal an empty feeling in minutes; repeat as necessary until hypovolemia
the right lower quadrant and a sausage-shaped is corrected (up to three times in 1 hour)
mass in the area of the transverse colon
See "Shock," in chapter 20, "General Emergencies
Rectal Examination and Major Trauma."
• May reveal bloody or currant jelly stool
Differential Diagnosis • Nothing by mouth
• Infection • Insert nasogastric tube
• Parasitic infestation (e.g. Enterobius)
• Tumor Pharmacologic Interventions
• Hirschsprung's disease (congenital megacolon) None.
• Obstruction of the bowel
• Meckel's diverticulum
• Incarcerated hernia
• Malrotation of the gut with incarceration


Monitor ABCs, vital signs, intake and output, and
abdominal findings frequently while awaiting
transfer.
Referral
• Once this diagnosis is suspected, the child must
be transferred to a center where pediatric surgery
and radiology can be carried out.
• If the intussusception has been present for less
than 18 hours and there is no free air on x-ray of
the abdomen, a barium enema with hydrostatic
pressure can be attempted to reduce the
intussusception. This procedure is successful in
up to 70% of cases and avoids the need for a
surgical procedure.
• If the attempted reduction of the intussusception
is unsuccessful or if there appears to be a lead
point (e.g. tumor), surgery is required
immediately.

Chapter 13 – Genitourinary System

Assessment Of The Genitourinary System ..................................................................................................... 1
General............................................................................................................................................................ 1
Common Problems Of The Genitourinary System ........................................................................................ 3

Urinary Tract Infection (UTI)......................................................................................................................... 3
Hydrocele (Physiologic) ................................................................................................................................. 6
Prepubescent Vaginal Discharge .................................................................................................................... 7
Glomerulonephritis ......................................................................................................................................... 9
Balanitis ........................................................................................................................................................ 10
Emergency Problems Of The Male Genital System..................................................................................... 10

Testicular Torsion ......................................................................................................................................... 10
For more information on the history and physical examination of the genitourinary system in older children
and adolescents, see chapter 6, "Urinary and Male Genital Systems," and chapter 13, "Women's Health and
Gynecology," in the NWT Clinical Practice Guidelines for Primary Community Care Nursing (Adult) 2003.
For balanitis and testicular torsion (a medical emergency), clinical presentation and management are the same
in adults and children. For information on these conditions, see chapter 6, "Urinary and Male Genital
Systems," in the NWT Clinical Practice Guidelines for Primary Community Care Nursing (Adult) 2003.

Assessment Of The Genitourinary System

General
The genitourinary (GU) system may be affected abnormalities and diseases of the kidneys. Some of
by infection, external problems, congenital the more common problems are discussed below.

The following symptoms are those most The following symptoms are associated with
commonly associated with urinary tract infection nephrotic syndrome and glomerulonephritis:
(UTI) in children: • Swelling (e.g. ankles, around eyes)
• Fever • Headaches
• Unexplained crying • Nosebleeds (an occasional symptom of
• Holding of genitals hypertension, but nosebleeds also occur
• Enuresis (bed-wetting) frequently in normal children)
• Constipation (chronic) • Hematuria
• Toilet-training problems • Decreased urinary output
• Dysuria
• Frequency A complete history of the GU system should
• Urgency include questions related to the following topics:
• Change in colour of urine • Sexual activity (for adolescents)
• Abdominal pain and back pain • Problems related to inappropriate touching by
• Scrotal or groin pain, vaginal discharge others (i.e. sexual abuse)
• Genital sores, swelling, disation
Children must be asked such questions with
• Jaundice in young infants sensitivity and without the use of leading
questions. The parents or caregiver can be asked
about these topics directly.
Vital Signs Percussion
• Temperature • Liver span (may be increased in
• Heart rate glomerulonephritis)
• Blood pressure • Ascites (dull to percussion in flanks when child
is supine; location of dullness shifts when child
Urinary System (Abdominal changes position)
Examination) • Tenderness over costovertebral angle
For full details, see "Examination of the
Abdomen," in chapter 12, "Gastrointestinal Palpation
System." • Size of liver and any tenderness because of
congestion
Inspection • Kidneys are often palpable in infants, the right
• Check specifically for any abdominal distension kidney being most easily "captured"; perform
(a sign of ascites) deep palpation to determine kidney size and
• Masses tenderness (place one hand under the back and
the other hand on the abdomen to try to
• Asymmetry
"capture" the kidney between the hands)

Male Genitalia For information about examining the adolescent

Perform examination with the child supine and, if male, see "Physical Examination of the System," in
possible, in the standing position. chapter 6, "Urinary and Male Genital Systems," in
the NWT Clinical Practice Guidelines for Primary
Penis Community Care Nursing (Adult) 2003.
Inspection
• Position of urethra (e.g. epispadias, Female Genitalia
hypospadias) • Child should be in supine frog-leg position for
• Discharge at urethra (sign of urethritis) examination
• Inflammation of foreskin or head of penis (sign • Do not perform an internal vaginal examination
of balanitis) in a prepubescent child or an adolescent who is
not sexually active
Palpation • Spread labia by applying gentle traction toward
• Foreskin adherent at birth examiner and slightly laterally to visualize
• In 90% of uncircumcised male children, the introitus
foreskin becomes partially or fully retractable by
3 years of age Inspection
• Inability to retract foreskin (phimosis) • Vulvar irritation
• Inability of retracted foreskin to return to normal • Erythema (in prepubescent girls, the labia
position (paraphimosis) normally appears redder than in adult women,
because the tissue is thinner)
Scrotum and Testicles • Urethral irritation (sign of UTI)
Inspection • Vaginal discharge (may indicate vaginitis or
• Scrotum may appear enlarged sexual abuse)
• Check for edema (a sign of glomerulonephritis), • Bleeding (may indicate vaginitis or sexual abuse
hydrocele (transillumination should be possible), in a prepubescent girl)
hernia or varicocele • Enlargement of vaginal orifice (may indicate
sexual abuse)
Palpation
• Cremasteric reflex (absent in testicular torsion) For information about examining the adolescent
• Testicular size, consistency, shape and descent female, see "Examination of the Female
into scrotum Reproductive System," in chapter 13, "Women's
Health and Gynecology," in the NWT Clinical
• Testicular tenderness: consider torsion or
Practice Guidelines for Primary Community Care
epididymitis (pain is actually in the epididymis,
Nursing (Adult) 2003.
not the testicle)
• Swelling in inguinal canal: consider hernia or
hydrocele of spermatic cord

Common Problems Of The Genitourinary System

Urinary Tract Infection (UTI)
Definition Younger Children (<3 Years Old)
Bacterial invasion of the GU tract with resulting • More abdominal complaints than GU complaints
infection. • Fever
• Abdominal pain
• Cystitis: infection affecting only the lower GU • Vomiting
tract (e.g. the bladder) • Frequency, urgency, dysuria, enuresis, strong-
• Pyelonephritis: ascending infection involving smelling urine
the upper GU tract (e.g. the ureters and kidneys) • Urinary retention
UTI is the most common genitourinary disease in Older Children (>3 Years)
children. It occurs more frequently in girls than in • Frequency
boys, except in infancy. In fact, UTI is unusual in • Dysuria
boys, and further investigation of the GU tract is
• Urgency
appropriate when it occurs.
• Enuresis
• Flank or back pain (this probably indicates
Causes
pyelonephritis, not cystitis)
Bacterial invasion by one of the following
organisms: • Fever
• Escherichia coli • Vomiting
• Klebsiella
• Enteric Streptococcus Physical Findings
• Staphylococcus • Fever (may be absent in simple cystitis)
• Proteus • Suprapubic tenderness (in cystitis)
• Predisposing factors: congenital GU tract • Tenderness of abdomen, flank and
abnormalities (e.g. short urethra), although most costovertebral angle (more likely with
children with UTI have normal GU tract; pyelonephritis)
perineal fecal contamination because of
inadequate hygiene; infrequent voiding; perianal Be sure to assess hydration status.
infections; sexual activity
History Distinguish between cystitis and pyelonephritis.
The history depends on the child's age.
Infection of the Lower GU Tract
Neonates and Infants • Urethral irritation (e.g. bubble bath)
• Primarily non-specific, non-urinary symptoms • Urethral trauma
• May present with septicemia • Diabetes mellitus
• Fever • Masses adjacent to bladder
• Irritability ("colic")
• Poor feeding Infection of the Upper GU Tract
• Vomiting, diarrhea • Gastroenteritis
• Jaundice (particularly in neonates) • Pelvic inflammatory disease (PID)
• Hypothermia • Tubo-ovarian abscess
• Failure to thrive • Appendicitis
• Decreased activity, lethargy • Ovarian torsion

Complications • Neonatal infections, for which medevac is

• Recurrent UTI required; these are often associated with
• Sepsis, especially in neonates and infants bacterial sepsis, so more aggressive treatment is
<6 months of age needed
• Renal damage leading to adult hypertension, • Suspected pyelonephritis, for which child may
renal failure be admitted to hospital (depends on age and
severity of illness)
Diagnostic Tests
Bag urine specimens are usually contaminated and Cystitis
cannot be relied upon to diagnose UTI. If Nonpharmacologic Interventions
negative, then UTI is absent. If positive, it must • Increased rest if febrile
be confirmed with a proper specimen BEFORE • Increased oral fluids
antibiotics.
In young children who are to receive antibiotic Do not treat as UTI unless results of urine dipstick
therapy a catheter urine specimen is recommended are indicative of such a diagnosis (e.g. positive for
if UTI is suspected. (Bugs and Drugs, 2001, p 116) nitrates or WBCs).
Urinalysis for routine and microscopy (midstream Antibiotics:

specimen for children, catheter specimen for cotrimoxazole (C class drug), 6-10 mg/kg per day,
infants): divided bid, PO for 10-14 days
• WBCs or
• Bacteriuria amoxicillin-clavulanate (B class drug), 40 mg/kg
• Some hematuria (blood in urine) per day, divided tid, PO for 10-14 days
• Positive for nitrates (although UTI can occur or
with organisms that do not produce nitrate) nitrofurantoin (C class drug) 5-7 mg/kg per day,
divided qid, PO for 10-14 days
Urine for culture and sensitivity:
• Preferable to use first morning specimen Pyelonephritis (Suspected)
• If multiple organisms present on culture, suspect Adjuvant Therapy
contamination, not true infection • IV therapy with normal saline may be necessary
for children with pyelonephritis (before transfer)
Management • Run at a rate sufficient to maintain hydration
Lower GU infections (e.g. cystitis) are generally
less severe and can be managed safely on an Pharmacologic Interventions
outpatient basis. Pyelonephritis is more severe and IV antibiotics may be started before transfer, on
may require hospital care for IV antibiotics. The the advice of a physician:
decision about hospitalization depends on the
child's age and the severity of the clinical ampicillin (C class drug), 100-200 mg/kg per day,
condition. divided q6h, IV
and
Goals of Treatment gentamicin (B class drug), 2.5 mg/kg per dose tid
• Relieve infection IV
• Identify underlying factors Monitoring and Follow-Up
• If treating as an outpatient, follow up in 24-48
Appropriate Consultation hours. Check sensitivity of organisms to
Consult a physician for any of the following: antibiotics when urine cultures are available.

• If no response to oral antibiotics after 48-72 • Refer to a physician (for evaluation) any child
hours or if symptoms are deteriorating, consult with culture-proven UTI who has been treated
with a physician about changing the antibiotic or on an outpatient basis
the need for IV antibiotic therapy
• Perform follow-up urinalysis and culture 1 week Radiologic evaluation may be indicated in any girl
after completion of treatment and then monthly who has had more than two or three culture-
for 3 months (if anatomy of the GU tract is proven lower UTIs, in any boy who has had one
normal) culture-proven lower UTI and in any child who
has had pyelonephritis; such evaluation includes
Referral renal ultrasonography and voiding
• Medevac all neonates cystourethrography (VCUG).
• Older infants and children with suspected
pyelonephritis may require medevac, depending
on their age and clinical condition

Hydrocele (Physiologic)
Definition
In infant boys, a mild scrotal swelling, resulting Complications
from a collection of fluid around the testicle • Slight increase in risk of inguinal hernia
(unilateral or bilateral). It may be confused with a
groin node. Usually present from birth and usually Diagnostic Tests
due to patency of the processus vaginalis. None.
Occurs only rarely in infant girls, in whom it Management

presents as a firm swelling in the groin.
Goals of Treatment
• Observe until condition resolves spontaneously
Cause or surgical referral becomes necessary
Unknown.
History Consult physician in the following circumstances:
• Painless swelling in scrotum, of variable size • Diagnosis is unclear
• Congenital or acquired • There are signs of complications (e.g. infection)
• Most cases resolve by age 1 year • There is an associated inguinal hernia
• Swelling may fluctuate in size
Physical Findings • Explain to parents or caregiver the
• Should be able to palpate an upper border of the pathophysiology of the defect
swelling • Reassure the parents or caregiver
• Testis is usually felt behind the mass, but may • Advise parents or caregiver to return to the
be difficult to feel clinic if the mass enlarges
• Transillumination of the swelling should be
possible Monitoring and Follow-Up
• Inguinal hernia may also be present Reassess every 3 months until resolution occurs or
referral becomes necessary.
Hydrocele of the spermatic cord may also be seen:
• Painless cystic swelling along the inguinal canal Referral
• Swelling may transilluminate Referral to a physician may be necessary if there
are signs of complications (e.g. if there is an
Differential Diagnosis associated inguinal hernia) or resolution does not
• Enlargement of groin node occur when expected (by 1 year of age).
• Inguinal hernia
• Trauma Surgical treatment is considered in the following
circumstances:
• Cystic lesion
• No signs of resolution by age 1 year
• Hematoma
• Hernias are associated with the hydrocele
• Neoplasm

Prepubescent Vaginal Discharge

For vaginal discharge in adolescents, see • Possible sexual abuse
"Vulvovaginitis," in chapter 13, "Women's Health
and Gynecology," in the NWT Clinical Practice Physical Findings
Guidelines for Primary Community Care Nursing Do not perform a vaginal speculum examination.
(Adult) 2003.
• Suboptimal general or perineal hygiene
Definition • Signs of URTI or skin disease
Physiologic discharge:
• Mucoid Labial Irritation
• Non-malodorous • Consider problems with perineal hygiene
• Seen in newborns and premenarchal girls • Candida
(Tanner stage II and III); (for definition of • Sexual abuse
Tanner stages, see "Puberty," in chapter 19,
"Adolescent Medicine") Marked Erythema
• Normal vaginal secretions are often increased • Consider Candida
midcycle in adolescents
Vaginal Discharge
Any other discharge is a symptom of underlying
• May be fairly non-specific
problems.
• Thick, white, cheesy: Candida
Vaginal discharge is uncommon in girls <9 years • Frothy, green: Trichomonas
old.
Foreign Body
Causes And Associated Organisms • May be visualized better if child is in knee-chest
position
• Poor hygiene (Escherichia coli)
• May be able to palpate a foreign body while
• Autoinoculation from associated URTI
doing a rectal examination
(Hemophilus influenzae, group B Streptococcus)
or skin infections (Staphylococcus)
• Pinworms (E. coli) Differential Diagnosis
• Foreign body (associated with E. coli) Non-infectious
• Specific infection: Candida, Chlamydia, • Poor hygiene
Neisseria gonorrhoeae, Trichomonas • Chemical irritation (e.g. from bubble bath)
(uncommon), bacterial vaginosis • Foreign body
• Trauma
If N. gonorrhoeae or Chlamydia is the cause of the
discharge and the child is underage for consensual Infectious
sex (i.e. <14 years), sexual abuse must be • Group A Streptococcus infection
considered. • Non-specific bacterial infection
• Pinworms
History • Candida (less common)
• Various degrees of perineal discomfort or • STI (consider sexual abuse)
itching
• Dysuria
• Frequency
• Associated illnesses (e.g. URTI, skin problems,
pinworms)
• Hygiene

Complications • Wipe from front to back, but avoid scrubbing

The complications depend on the underlying genitalia
cause.
• Localized perineal irritation For Foreign Body
• UTI In an older child who can cooperate, remove the
• Abdominal pain (with pinworms or UTI) foreign body, if possible; otherwise consult a
• Vaginitis physician about removal.
• Bleeding (from trauma)
Give:
amoxicillin (C class drug), 40 mg/kg per day,
Diagnostic Tests divided tid, PO for 7-10 days while awaiting
If child is cooperative, attempt to swab vaginal
removal of foreign body
orifice (using small swab i.e. similar size to naso-
pharyngeal type swab); avoid touching the
For Pinworms
hymenal edge. Swab for Chlamydia, N.
See "Pinworms," in chapter 18, "Communicable
gonorrhoeae, culture and sensitivity, and hanging
Diseases."
drop, in that order.
For Candidal Infection
Management nystatin cream (A class drug), PV od for 6 days
Management depends on cause.
For Trichomonal Infection
Goals of Treatment metronidazole (C class drug), 1-2 g PO stat
• Identify and correct underlying cause
For Bacterial Vaginosis
Appropriate Consultation metronidazole (C class drug), 1-2 g PO stat
Consult a physician if child is febrile or has
abdominal pain, or if you suspect sexual abuse. For Sexually Transmitted Infection
Consult a physician if you suspect an STI in a
If the child is <14 years old and there was sexual preadolescent child. Refer to and follow the
activity involving an adult partner, the legal Canadian STD Guidelines (Health Canada 1998).
definition of sexual abuse specifies that legal (e.g.
police) and child protection authorities must be If the cause of the discharge is uncertain, send
notified. samples for culture (according to child's age), as
above, and treat with amoxicillin pending results
Nonpharmacologic and Pharmacologic of culture.
Interventions
For Poor Hygiene Report as suspected sexual abuse all cases of
• Improve perineal hygiene (e.g. use of clean gonorrhea and Chlamydia infection in girls <14
cotton panties, frequent changing of underwear, years old who have been sexually active with an
regular bathing) adult (in accordance with the legal definition of
• Avoid bubble baths sexual abuse). Other cases of vaginitis may be
reportable, depending on the circumstance.

Glomerulonephritis
Definition • Proteinuria
Disease in which there is immunologic or toxic • Oliguria
damage to the glomerular apparatus of the • Renal failure (to variable degree)
kidneys. It can occur acutely, or it may have a • Congestive heart failure
chronic or insidious onset. • Encephalopathy (rare)
Some types of glomerulonephritis are self- Edema, hypertension and hematuria are the most
limiting, and others may go on to cause permanent common and most worrisome symptoms.
kidney damage.
The most common type in northern Canada is
• Other forms of glomerulonephritis, which have
post-streptococcal glomerulonephritis, described
many similar features (distinguished by
below. Any suspected glomerulonephritis should
laboratory tests, renal biopsy and other
be fully investigated.
diagnostic methods)
• Acute hemorrhagic cystitis (no edema,
Causes hypertension, renal failure; does involve dysuria,
• Usually secondary to previous streptococcal frequency, urgency)
infection (e.g. of the throat or skin) • Acute interstitial nephritis
• Follows pharyngitis by 1-3 weeks
• Lag time after skin infections is variable, but Complications
most frequently 2-4 weeks
• Acute renal failure
History • Hyperkalemia
• Acute onset • Hypertension
• Usually history of pharyngitis or impetigo about
• Chronic renal failure
10 days before the abrupt onset of dark urine
• Acute phase lasts about 1 week
Diagnostic Tests
The diagnosis is made on a clinical basis and is
Systemic Symptoms
confirmed by the following tests:
• Anorexia
• Urinalysis (hematuria, proteinuria)
• Abdominal pain
• Hemoglobin decreased (mild anemia), WBC
• Fever count increased
• Headaches • Recent throat swab positive for Streptococcus A
• Lethargy infection
• Fatigue, malaise
• Weakness Management
• Rash, impetigo Goals of Treatment
• Joint pain • Prevent, if possible, by early treatment of all
• Weight loss streptococcal infections (skin and pharyngeal)
• Prevent or treat complications
Physical Findings
The physical findings are variable and may Appropriate Consultation
include the following: Consult a physician immediately if you suspect
• Edema (in about 75% of cases) this disorder.
• Hypertension (in about 50% of cases)
• Hematuria (two-thirds of children have gross
hematuria)

Nonpharmacologic Interventions abnormalities, fluid overload, pulmonary edema,

While awaiting transfer: congestive heart failure, acute hypertension
• Bed rest
• Fluid restriction (to 60 mL/kg per day +urine Monitoring and Follow-Up over the Long
losses) Term
• Will depend on cause and type of condition
Pharmacologic Interventions • Post-streptococcal glomerulonephritis usually
None, unless complications develop. Treat has no long-term sequelae, but other types of
complications only on physician's instruction. glomerulonephritis may have long-term
complications, including recurrence and chronic
Monitoring and Follow-Up while renal failure
Awaiting Transfer • Consulting specialist will provide instructions
• Fluid restriction (to 60 ml/kg per day + urine for surveillance
losses)
• Monitor blood pressure and vital signs Referral
• Monitor intake and output Medevac.
• Watch for major life-threatening problems, such
as acute renal insufficiency with electrolyte
Balanitis
See "Balanitis," in chapter 6, "Urinary and Male Genital Systems," in the NWT Clinical Practice Guidelines
for Primary Community Care Nursing (Adult) 2003.
Emergency Problems Of The Male Genital System

Testicular Torsion
See "Testicular Torsion," in chapter 6, "Urinary and Male Genital Systems," in the NWT Clinical Practice
Guidelines for Primary Community Care Nursing (Adult) 2003.

Chapter 14 – Musculoskeletal System

Assessment Of The Musculoskeletal System................................................................................................... 1
Common Problems Of The Musculo-Skeletal System ................................................................................... 3

Limb Pain........................................................................................................................................................ 3
In-Toeing ........................................................................................................................................................ 5
Congenital Dislocation Of Hip (Developmental Hip Dysplasia).................................................................... 6
Limp................................................................................................................................................................ 8
Growing Pains................................................................................................................................................. 9
Osgood-Schlatter Disease ............................................................................................................................. 10
Patellar Femoral Syndrome........................................................................................................................... 11
Emergency Problems Of The Musculo-Skeletal System.............................................................................. 13

Musculoskeletal Injury ................................................................................................................................. 13
Fractures........................................................................................................................................................ 13
Dislocation Of A Major Joint ....................................................................................................................... 16
For detailed information on the clinical presentation, assessment and management of other musculoskeletal
problems occurring in children, see chapter 7, "Musculoskeletal System," in the NWT Clinical Practice

Assessment Of The Musculoskeletal System

History varies with age and type of condition. Muscles
• Pain
General • Weakness
The following characteristics of each symptom • Wasting
should be elicited and explored: • History of previous injuries and treatment
• Onset (sudden or gradual) received
• Acuity or chronicity (subacute, acute or chronic)
• Chronology Neurovascular Structures
• Location • Paresthesia
• Radiation • Paresis
• Quality • Paralysis
• Timing (frequency, duration) • Skin: look for signs of physical abuse (e.g.
• Whether intermittent or constant bruises, welts, cigarette burns)
• Severity
• Precipitating and aggravating factors Functional Assessment
• Relieving factors • Inability or refusal to use limb or to bear weight
• Associated symptoms, weight loss, decreased (especially in a young child)
energy • Self-care deficits (e.g. in bathing, dressing,
• Effects on daily activities and play toileting, grooming)
• Previous diagnosis of similar episodes • Mobility and use of mobility aids
• Previous treatments
• Efficacy of previous treatments Medical History (Specific To
• Ask about fever Musculoskeletal System)
• Family history • Recent infection, such as URTI (may be
associated with septic arthritis), diarrhea,
Bones And Joints pharyngitis
• Pain • Recent immunization (specifically if vaccine
• Swelling was administered in a limb)
• Redness • Previous trauma (to bones, joints, ligaments)
• Heat • Arthritis (juvenile rheumatoid arthritis)
• Stiffness • Recent immobilization of an extremity
• Time of day when symptoms are most • Medications (e.g. those used to treat
bothersome musculoskeletal symptoms)
• Relation of symptoms to movement • Obesity
• Limitation of movement
• Change of gait (e.g. limp) Family History (Specific To
• Deformity Musculoskeletal System)
• Extra-articular findings (e.g. rash) • Rheumatoid arthritis
• Trauma (obtain accurate description of exact • Diabetes mellitus
mechanism of injury) • Lupus erythematosus

Personal And Social History (Specific • Risk behaviors for injuries, especially in
To Musculoskeletal System) adolescents (e.g. snowmobiling, illicit drug use,
• Absenteeism from school (multiple days) alcohol abuse [specifically drinking and
• Sports activities (e.g. contact sports involving driving])
repetitive motion) • Dietary calcium and vitamin D intake
• Smoking
• Exercise habits
Although the musculoskeletal and neurologic Compare corresponding paired joints and bones
systems (see chapter 15, "Central Nervous for the following characteristics.
System") are discussed separately in this set of Swelling:
guidelines, they are usually examined together. • Around joint area (may indicate arthritis:
chronic, acute or infectious)
Vital Signs • Over bony area (may indicate trauma, fracture or
• Temperature may be elevated in inflammatory tumor)
or infectious disease • In soft tissue (may indicate trauma or infection)
• Tachycardia from pain or shock if major trauma
is involved Redness:
• Blood pressure normal, unless child is in shock • Implies inflammatory process or infection
from major trauma • Note any induration and extent of redness
• Rash
Inspection
The inspection is perhaps the most important part Palpation
of the exam, so take your time. • Swelling and induration (e.g. tissues feel tense,
• Apparent state of health (child may look acutely "boggy")
ill) • Presence of heat implies inflammatory process
• Appearance of comfort or distress or infection (if an area feels hot to the touch,
• Child may look acutely ill because of an compare with uninvolved joints or skin)
infectious or inflammatory process • Subcutaneous nodules
• Distress (related to pain) is usually evident if • Swelling around joints (may indicate joint
there is an infectious, inflammatory or fracture- effusion or infection)
related cause • Crepitus may be palpable with joint movement
• Significant trauma to an extremity may result in or in soft tissue overlying bony fractures
shock-like appearance • Range of motion of joints (active and passive)
• Colour (e.g. flushed, pale) • Resistance to or pain on movement of joint
• Nutritional status (obese or emaciated) • Degree of joint movement achieved
• Stability and integrity of ligaments
Observe: • Tendon function
• Mobility, gait and posture, presence of limp or
unwillingness to bear weight Neurovascular Function
• Pallor
Determine ability to perform activities of daily
living (e.g. sitting, standing, walking, dressing,
• Limb temperature (especially coolness)
playing). • Paresthesia
• Peripheral pulses
• Paralysis

Common Problems Of The Musculo-Skeletal System

Limb Pain
Often presents as an alteration of activity or gait or • Trauma (e.g. hemarthrosis)
an unwillingness to bear weight or use a limb. • Post-immunization arthritis (especially after
immunization for rubella)
The affected joint may not be the one the child • Bleeding disorder (e.g. hemophilia)
complains about; for example, pain may be • Henoch-Schönlein purpura (look for abdominal
referred from disease of the hip joint to the knee, pain and rash)
and the child presents with knee pain. • Sprain or strain
• Slipped capital femoral epiphysis
History • Legge-Calvé-Perthes disease
• Trauma: acute or subacute • Growing pains
• Infection (pain may be related to URTI or skin • Rickets
infection)
• Malignant lesion
• Distress variable, from significant (as in septic
• Rheumatic fever
arthritis) to mild (as in chronic juvenile
rheumatoid arthritis, in which stiffness is
The diagnosis of limb pain is difficult and should
predominant)
be undertaken with the help of a physician. Septic
• Fever (high in cases of septic joints) arthritis and osteomyelitis can be life threatening,
• Variable degree of limitation of activity as can fractures to large bones and joints.
(e.g. child with septic joint or significant trauma
is less likely to be able to bear weight)
Diagnostic Tests
Discuss with a physician.
Physical Findings
Physical findings are variable, depending on the
Management
specific underlying cause. Look for:
Goals of Treatment
• Fever or change in vital signs (distress may
• Ensure proper diagnosis
cause increase in heart and respiratory rates)
• Minimize risk of further injury (e.g. by
• Heat, redness, swelling, obvious deformity
immobilization)
• Decrease in mobility
• Bone tenderness Appropriate Consultation
Consult a physician if there is acute pain with
Perform a general physical examination to look for significant compromise in function, if you are
signs of other illnesses (e.g. rash with Henoch- unsure of the diagnosis, if there is significant
Schönlein purpura or heart disease with rheumatic trauma or if there is a possibility of joint or bone
fever). infection.
Differential Diagnosis Adjuvant Therapy
• Cellulitis (of the overlying areas only; no If the child appears acutely ill, if infection is
involvement of bones or joint spaces) suspected (e.g. cellulitis, septic arthritis), or if
• Septic arthritis (this is an emergency situation) there is significant trauma:
• Transient viral arthritis • Start IV therapy with normal saline and run at a
• Juvenile rheumatoid arthritis rate sufficient to maintain hydration
• Transient toxic synovitis (commonly seen in the
hip); related to previous URTI For daily maintenance fluid requirements and
• Osteomyelitis signs of dehydration, see chapter 4, "Fluid
Management."

Nonpharmacologic Interventions While awaiting transfer, the physician may order

• Bed rest antibiotics, such as the following:
• Immobilize extremity to prevent damage, ease cefuroxime (B class drug), 150 mg/kg per day,
pain divided q8h, IV
or
Pharmacologic Interventions cefazolin (C class drug), 75-100 mg/kg per day,
Antipyretic and analgesic for fever and pain: divided q8h
q4h prn Monitoring and Follow-Up
Monitoring and follow-up vary, depending on the
Acute inflammation of a joint in association with diagnosis.
fever but no obvious cause for the inflammation
should be treated as an infection (with the advice Referral
of a physician). Most cases of acute limb pain require medevac.
Cases of mild, non-acute limb pain can be referred

electively to a physician for evaluation.

In-Toeing
Definition normally rotates externally with age (about 2° at
Inward pointing of toes. If mild, may resolve on its about 1 year of age, about 20° at 15 years of age).
own; if extreme, treatment is required. In tibial torsion, this angle is smaller.
Causes Fig. 14-3: Measuring Rotation in Femoral

• Metatarsus varus: adduction of forefoot on Anteversion
hindfoot (lateral border of foot is curved instead
of straight); presents in infancy
• Tibial torsion: in-turning of entire foot (medial
twisting of tibia); presents in early childhood
• Femoral anteversion: in-turning of leg (medial
twisting at hip); presents in early childhood
History
• May be associated with stumbling Decreased external rotation of the hip; if external
• Sleeping with feet tucked underneath legs (tibial rotation is less than 20°, in-toeing may result.
torsion)
• Sitting in the W-position, with knees together Differential Diagnosis
and feet spread laterally (femoral anteversion) More severe congenital deformity with clubfoot
(rigid deformity of whole foot, evident at birth)
Physical Findings
Fig. 14-1: Metatarsus Varus Complications
• Gait difficulties if left unattended
Management
Goals of Treatment
• Improve foot position
• Metatarsus Varus: usually requires no treatment
if the condition is mild. Reassure the parents or
Forefoot is turned medially on the hindfoot. Ankle caregiver and follow up closely. See "Referral,"
joint has normal dorsiflexion and plantar flexion. below, this section.
Physiologic metatarsus varus can lead to adduction • Tibial Torsion: discuss with a physician or
of forefoot past midline (no treatment needed). advise change in sleeping position
• Increased Femoral Anteversion: change sitting
Fig. 14-2: Tibial Torsion position to tailor position. Most children require
no other intervention

Monitor gait every 3 or 4 months.
Referral
• Metatarsus varus: Refer to a physician if the
condition persists for more than 3 months or if
there is a non-flexible deformity at birth.
• Tibial torsion: Refer to a physician. May require
orthopedic consult.
Measured by angle between foot and thigh with
ankle and knee positioned at 90°. The foot

Congenital Dislocation Of Hip (Developmental Hip Dysplasia)

Failure of femoral head to rest in acetabulum of Inspection of the Newborn
pelvis (Fig. 14-4). There are three presentations: • Asymmetric fat folds in thigh
hip may be dislocated, dislocatable or subluxated. • Extra skin folds on involved side
This condition is commonly seen in some First Inspection of the Older Child
Nations communities, but is almost never seen in • Legs unequal in length
Inuit people. • Limp
• Trendelenburg sign: lurching toward affected
A check for congenital problems of the hip is part
side
of routine neonatal screening. This condition is
best diagnosed before the child begins walking.
Palpation
See section on the musculoskeletal system in • Examine child in supine position (on back)
"Physical Examination of the Newborn," in • With thighs flexed, should be able to abduct to
chapter 1, "Guidelines for Pediatric Health 90° in each hip; diagnosis should be suspected if
Assessment." abduction is limited to 60° to 70°
Fig. 14-4: Hip Joint Ortolani-Barlow hip examination for screening

newborns:
• Place middle fingers over greater trochanters
(outer upper legs)
• Position thumbs on medial sides of knees
• Abduct the thigh to 90° by applying lateral
pressure with thumb
• Move knee medially and then replace knee in
starting position
• If there is a "clunk," the hip may be dislocatable
• If there is a "click," the hip may be subluxable
• Congenital short femur
• Synovial click
Causes • Congenital adduction contraction
• Congenital • Fixed dislocation in arthrogryposis
• Condition exacerbated by use of tikanagans
(cradle boards) or other means of swaddling Complications
• Often able to identify other affected family • Long-term disturbance of the gait if left
members undiagnosed and untreated
• Breech birth • Osteoarthritis
History Management
• If diagnosed after the child is walking, presents Goals of Treatment
as a limp with or without pain • Develop improved or normal femoral insertion
into acetabulum
• Normalize gait

Nonpharmacologic Interventions Definitive treatments:

Early detection is important. Hence, the hip exam • Splint (e.g. Pavlik harness for children from
is an essential part of newborn screening. In birth to 8 months of age)
addition, infants should be screened several times • Casting
by nurse and physician during the first year of life, • Surgery
as the problem may not be evident at birth.
Referral
Educate community about potential treatments, Refer child as soon as possible for assessment by a
such as decreased use of tikanagan. physician.

Limp
Gait abnormality. Look for:
• Heat
This complaint should always be taken seriously.
A limp may arise from problems in joints, bones,
• Swelling
ligaments or soft tissues. In diagnosing a limp, it is • Redness
difficult to distinguish bone pain from muscle and • Pain on movement
joint pain. Younger children (toddlers) may refuse • Decrease in ability to bear weight
to bear weight. Severe illness involving bone, joint • Decrease in active and passive range of motion
or muscle may present as a limp. • Pinpoint pain on palpation (may indicate
fracture, osteomyelitis, tumor)
Causes
Joint Perform abdominal and general examinations if
• Infection: the cause is not evident on limb examination
• Bacterial (septic arthritis) (e.g. incarcerated hernia may present as a limp).
• Viral Differential Diagnosis
• Inflammatory: See "Causes," above, this section.
• Juvenile rheumatoid arthritis or rheumatic
fever Complications
• Reactive synovitis Depends on the cause of the limp.
• Trauma
Diagnostic Tests
Bone None.
• Trauma
• Fracture Management
• Osteomyelitis Goals of Treatment
• Tumor • Diagnose accurately
• Treat underlying cause
Muscle • Maintain a high index of concern about possible
• Sprains pathology
• Strains
• Inflammatory process Appropriate Consultation
Consult with a physician if you are unsure of the
Ligaments (Soft Tissue) diagnosis or the symptoms are significant.
• Trauma
• Infection (cellulitis) Nonpharmacologic Interventions
• Post-immunization Immobilization may be required to rest the limb,
reduce pain and prevent further damage.
Limp may develop with spinal or abdominal
involvement or injury.
Analgesic for pain:
History q4h prn
• Trauma
• Fever Monitoring and Follow-Up
• Viral URTI in preceding week Depends on the diagnosis.
• Pain Referral
• Inability to bear weight Refer to a physician or to hospital as indicated by
• Decreased mobility severity of symptoms and possible diagnosis.

Growing Pains
An idiopathic symptom complex that affects 10% Goals of Treatment
to 20% of school-age children. Pain usually occurs • Rule out more severe disease or pathology
in shins or thigh muscles. Joint pain is rare. The
pain is intermittent, usually occurring at night, and Nonpharmacologic Interventions
lasts from 30 minutes to several hours. • Reassure child and family
Causes Client Education

Unknown, although probably related to over- • Explain course of the condition and prognosis
exertion and fatigue. Emotional factors may also • Counsel parents or caregiver about appropriate
play a role. home management with rest, heat and analgesia
• Advise that heating pad or moist hot packs prn
History may help
• Usually non-articular
• Calves or thighs usually involved Pharmacologic Interventions
• Deep aching, usually worse at night Analgesic for pain (for children >6 years old):
• May waken the child at night acetaminophen (A class drug), 325 mg, 1-2 tabs
• May be relieved with massage, rubbing PO q6h prn
Physical Findings Monitoring and Follow-Up

No physical signs. Reassess the child if attacks become more frequent
or increase in severity, or pain persists during
Differential Diagnosis daytime.
• Acute infection or inflammation
• Trauma Referral
Referral to a physician is not usually needed,
unless the diagnosis is unclear or incorrect, or the
Complications symptoms are worsening.
None.

Osgood-Schlatter Disease
Traction apophysitis of the tibial tubercle. None.
Considered an overuse syndrome in which Management

repetitive microtrauma causes partial avulsion of Nonpharmacologic Interventions
the patellar tendon at its insertion on the tibia. It • Reassure child and parents or caregiver as to the
occurs during the pubertal growth spurt. benign cause and favorable prognosis
• Rest the limb
Risk Factors • Apply ice packs prn
• Male gender • Decrease activities that aggravate symptoms
• Active in sports (e.g. football, soccer) • Knee immobilization (e.g. via splint), but for
• Recent growth spurt short-term use only (e.g. a few days)
Cause use of medications, including dosage and side
• Activity (e.g. sports and running), which causes effects
microtrauma
History And Physical Findings Anti-inflammatory and analgesic:
• Knee pain around the tibial tuberosity acetaminophen (A class drug), 325 mg, 1-2 tabs
• Swelling PO q6h prn for 7-10 days
• Limp or
• Tenderness and prominence of the tibial tubercle ibuprofen (A class drug), 200 mg, 1-2 tabs PO
q6h prn for 7-10 days
Symptoms increase with activity (e.g. running,
jumping, going up and down stairs, kneeling) and Monitoring and Follow-Up
are relieved by rest. Follow up in 1-2 weeks. The condition is usually
self-limiting and resolves over several months.
• Patellar tendinitis Referral
Refer to a physician for evaluation if symptoms do
• Osteomyelitis
not improve with conservative measures in 6-8
• Knee sprain weeks.
• Ligamentous strain
• Patellar femoral syndrome The condition becomes chronic in 5% to 15% of
• Osteosarcoma cases, with persistent tenderness, swelling and
formation of ossicles, which may need surgical
Complications removal.
• Detachment of cartilage fragments from the
tibial tuberosity
• Decrease in capacity for physical activity
• Osteoarthritis

Patellar Femoral Syndrome

Definition • Degeneration of patella
Osteochondritis involving the patella, resulting in • Chondromalacia patellae
knee pain and swelling. It is considered an overuse • Patellar osteoarthritis
syndrome not involving avascular necrosis or an • Anatomic variation, such as increased angle
inflammatory process, and as such it develops over between femur and tibia (Q-angle; note that
a period of time. females more often have larger Q-angle) or
shallow outer patellofemoral groove (patella
Usually unilateral, but sometimes bilateral. prone to sublux or dislocate laterally)
Onset during adolescence. History

• Acute or chronic anterior knee pain and pain on
Most of those affected show a mild degree of underside of patella
patellar femoral malalignment, which, with
• Gradually progressive, general aching or grating
activity, causes instability of the patella and
pain
gradual destruction of the patellar cartilage.
• Sensation of the knee "giving out" and
instability (reflex response to pain); child is
Risk Factors
unable to keep knee in flexed position for any
• Female gender length of time
• Physical activity • Grinding, popping or clicking sound on knee
flexion
Causes
Soft Tissue Provocative Factors
• Prepatellar bursitis • Going up or down stairs or going down hills
• Patellar tendinitis • Running
• Meniscal tear • Prolonged sitting with knee bent
Articular Physical Findings
• Chondromalacia patellae • No knee effusion
• Patellar osteoarthritis • No decrease in range of motion of affected knee
• Osteochondritis dissecans of the knee • Tenderness of undersurface of medial or lateral
• Chondral fracture patella
• Grinding, popping or clicking sound on knee
Functional flexion, detected on manipulation of patella
• Patellar instability • Positive patellar inhibition test: child refuses to
• Synovium caught between patella and femur actively extend knee when patella is compressed
against the femoral condyles; patella is displaced
Referred Pain with knee extension
• Back pain • Chronic pain may result in disuse atrophy of the
• Hip pain quadriceps
• Ankle pain • Crepitation when determining range of motion
of knee
Mechanism • Q-angle increased
• Overuse syndrome in athletes • Abnormal patellar alignment
• Sports involving running, jumping, or quick
stops and turns (pivots) Apprehension Sign
• Contact sports (e.g. football) • Hold patella as child lies with knee in extension
• Direct impact to patella • Ask child to tense quadriceps muscle

• Positive result: child experiences pain Exercises to Stretch Lower Extremity

• Child may refuse to do the test in anticipation of • Quadriceps stretches
pain • Hamstring stretches
• Iliotibial band stretches
Differential Diagnosis • Ankle stretches
• Knee sprain • Gastrocnemius muscle stretches
• Ligamentous strain • Soleus muscle stretches
• Osgood-Schlatter disease
Complications Anti-inflammatory agents (NSAIDs) for short
• Interference with daily activities course (1-2 weeks):
Diagnostic Tests or
None. naproxen (C class drug), 125 mg, 1-2 tabs PO bid
to tid
Management
Reassess every 1-2 weeks during the acute stage.
• Rest; child can continue most activity, but for a Ascertain adherence to exercise program, and
short period in the acute stage (1-2 weeks),
provide support and encouragement.
activities that require flexion of the knee should
be limited
Surgical arthroscopy may be needed (in 5% to
• Ice packs prn 10% of cases) to remove bony or cartilaginous
• Tensor bandage may provide some comfort fragments or to shave the underside of the patella.
(should be worn only while child is awake)
Referral
Exercises to Strengthen Quadriceps Refer to a physician for assessment if there is no
• Isometric progressive resistance exercises improvement with conservative management after
• Leg-sled press (45°) 6-8 weeks.

Emergency Problems Of The Musculo-Skeletal

System
Musculoskeletal Injury
Trauma to the musculoskeletal tissue may cause for comparative information on the common
damage that ranges from minor (e.g. sprain) to symptoms of musculoskeletal injury.
major (e.g. fracture or dislocation). See Table 14-1
Table 14-1: Symptoms of musculoskeletal injury

Symptom Fracture Dislocation Sprain Strain
Pain Severe Moderate to severe Mild to moderate Mild to moderate
Swelling Moderate to severe Mild Mild to severe Mild to moderate
Bruising Mild to severe Mild to severe Mild to severe Mild to severe
Deformity Variable Marked None None
Function Loss of function Loss of function Limited Limited
Tenderness Severe Moderate to severe Moderate Moderate
Crepitus Present Absent Absent Absent
Fractures
Definition • Osteogenesis imperfecta
A break in the continuity of the bone. • Rickets
• Scurvy
The fracture line through the bone may be • Bony cyst
transverse, oblique or spiral. • Malignant lesion
Clavicle fracture is one of the most common types In the case of a fracture in an infant or toddler, the
of fracture in children. possibility of abuse should be considered.
The most serious bony injury of the upper limb is Types of Fractures
supracondylar fracture of the elbow. • Closed (simple) fracture: fracture that does not
communicate with the external environment
Fractures involving the epiphysis of a bone are
• Open (compound) fracture: fracture that
serious, as they may damage the epiphyseal plate
communicates with the external environment
so much that growth is arrested.
(through laceration of skin)
• Comminuted fracture: fracture involving three
Fractures of the pelvis, hip, femur and epiphyseal
or more fragments
separations about the knee are all major injuries
requiring prolonged care in a hospital situation. • Avulsion fracture: fracture in which fragment of
bone is pulled from its normal position by
muscular contraction or resistance of a ligament
Causes
Trauma is the most common cause.
• Greenstick fracture: incomplete angulated
fracture of a long bone, seen most often in
children
Occasionally, pre-existing pathologic conditions
may predispose to fractures: • Undisplaced fracture: fractured bone stays in
alignment

• Displaced fracture: fractured bone goes out of Differential Diagnosis

alignment • Severe sprain
• Severe contusion
History • Dislocation
Usually a history of trauma, except if there is pre-
existing bone pathology (including osteopenia, Complications
which is seen in children with cerebral palsy, Immediate (within First Few Hours)
among other conditions). • Hypovolemia from blood loss
• Shock
The fracture site and type can usually be linked to
the description of the injury. • Damage to arteries, neurovascular bundle and
surrounding soft tissues
• Determine exact mechanism of injury
Early (within First Few Weeks)
• Pain
• Wound infection
• Swelling
• Fat embolism
• Loss of function
• Respiratory distress syndrome
• Possible numbness distal to fracture site
• Chest infection
In cases of abuse, classic features of the history • Disseminated intravascular coagulopathy
may not be present or may not fit the reported • Osteomyelitis (if fracture is compound)
injury. • Malunion and compartment syndrome may
result from casting
Physical Findings
• Respiratory rate, heart rate and blood pressure Late (Months or Years Later)
increased (because of pain) • Deformity
• If there is significant associated blood loss, • Osteoarthritis of adjacent or distant joints
blood pressure may drop • Aseptic necrosis
• In older children, fracture of tibia, femur or • Traumatic chondromalacia
pelvis may be associated with traumatic shock • Reflex sympathetic dystrophy
• Child is distressed because of pain
• Skin lacerations with protruding bones may be Diagnostic Tests
present if fracture is compound • X-ray, if available and only if result will affect
• Bruising and swelling clinical decision to transfer child to hospital
• Range of motion decreased • If no fracture is seen on x-ray, but there is bony
• Visible deformity if displaced tenderness, it is prudent to treat as a fracture
• Affected part may be pale if blood flow to the • Type I fractures (growth plate fractures) often
area is compromised appear normal on x-ray
• Limb cool, pulses absent and sensation
decreased if blood supply has been Management
compromised Most bones join in 4-6 weeks; lower-limb bones
• Check temperature of area and presence of may take longer, and some greenstick fractures in
pulses distal to site of injury children may take less time.
• Test sensory function (to sharp and dull stimuli)
distal to site of injury Goals of Treatment
• Affected area extremely tender • Stabilize fracture
• If bones are displaced, crepitations may be • Relieve pain
felt • Prevent or manage complications

Appropriate Consultation • Do not attempt to reduce a displaced fracture.

Consult physician for all suspected or confirmed • For child with displaced fracture, give nothing
fractures. by mouth, as surgery may be needed
Adjuvant Therapy Pharmacologic Interventions

If there is a history of or clinical findings Analgesia may be necessary for significant
indicating significant trauma, and for all major fractures. Consult with a physician if at all
fractures (e.g. femur, pelvis, hip): possible before using narcotic analgesics.
• Start IV therapy with normal saline and run at a
rate sufficient to maintain hydration, unless meperidine (D class drug), IM
hypotension is present
The dose depends on the age and size of the child.
If hypotensive, treat for shock: Check the Compendium of Pharmaceuticals and
• Give oxygen at 10-12 L/min using a non- Specialties for guidance.
rebreather mask to obtain highest oxygen
concentrations Antibiotics are necessary if the fracture is
• Keep oxygen saturation >97% compound. Consultation with a physician is
• Start 2 large-bore IVs with normal saline (or required. IV or IM antibiotics are to be given only
Ringer's lactate) or establish intraosseous access on the advice of a physician.
if IV access cannot be established within 60-90
seconds; see "Intraosseous Access," in chapter cefuroxime (B class drug), 50-100 mg/kg per day,
2, "Pediatric Procedures" divided q8h, IV
• Deliver bolus of 20 mL/kg over 20 minutes or
• Repeat bolus as necessary until there is a ceftriaxone (B class drug), 50-75 mg/kg per day,
response in one dose, IM or IV (maximum dose 2 g)
See also "Shock," in chapter 20, "General Tetanus toxoid should be given if required. Refer
Emergencies and Major Trauma." to Canadian Immunization Guide, 6th edition
(Health Canada 2002) for recommendations.
• If spinal injury is suspected, keep child Monitoring and Follow-Up
Monitor ABCs, vital signs, pain control and
recumbent and use backboard with neck brace
neurovascular status of area distal to the fracture
for transport
site while awaiting transfer to hospital.
• Immobilize fracture site with a splint extending
across joint, above and below site of injury
After emergency treatment, take the opportunity to
• Use a back slab cast or sling (for upper follow up with the child and parents or caregiver
extremities) as appropriate to offer guidance about accident prevention.
• Apply traction for displaced femoral fracture
(use Sager Traction splint, if available) Referral
• For compound fracture, wrap skin wound with Medevac.
sterile dressing and protect by splinting
• Do not cast a fracture.

Dislocation Of A Major Joint

Displacement of a bone from normal anatomic Consult a physician. If a larger joint is dislocated,
insertion or attachment. medevac will probably be needed.
Cause Nonpharmacologic Interventions

• Trauma is the most common cause • Give nothing by mouth, in case surgery is
required
Specific Childhood Issues • Immobilize the site with a back slab cast or sling
Dislocations and fractures in infants and toddlers (for upper extremities), as appropriate
should be examined with consideration of the
possibility of an abusive situation. Pharmacologic Interventions
Analgesia may be necessary for significant injury.
Pulled elbow is common in toddlers. It is caused Consult with a physician if at all possible before
by a sudden pull or jerk (trauma), during which the using narcotic analgesics.
radial head is pulled out of the attached ligament
(subluxation). meperidine (D class drug), IM
Dislocation of the knees and elbows are true The dose depends on the age and size of the child.
emergencies because of the potential for Check the Compendium of Pharmaceuticals and
neurovascular problems. Specialties for guidance.
History Monitoring and Follow-Up

• Associated trauma consistent with site and type Monitor for control of pain and to determine the
of injury neurovascular status of the involved limb.
• If history is not consistent with injury, consider
the possibility of abuse Referral
• Pain, often aggravated by movement Medevac for orthopedic consult and definitive
treatment.
• Loss of function
Dislocation Of A Smaller Joint
Physical Findings
The physician may advise that small joints
• Tachycardia and tachypnea (related to pain) (e.g. fingers) be realigned by gentle traction.
• Swelling (mild)
• Bruising (mild to severe) Once relocated, immobilize the joint to allow for
• Marked deformity of affected joint healing. The duration of immobilization will
• Tenderness (moderate to severe) depend on the joint involved and should be
determined by a physician. Fingers should never
Differential Diagnosis be immobilized for more than 3 or 4 days.
• Fracture
• Soft-tissue injury
Complications
• Vascular or nerve damage
Management
Goals of Treatment
• Control pain
• Realignment

Chapter 15 – Central Nervous System

Assessment Of The Central Nervous System.................................................................................................. 1
Common Problems Of The Central Nervous System .................................................................................... 3

Hypotonia ("Floppy Infant")........................................................................................................................... 3
Emergency Problems Of The Central Nervous System................................................................................. 4

Seizure Disorders............................................................................................................................................ 4
Head Trauma................................................................................................................................................... 8
Headache....................................................................................................................................................... 11
Appendix 15-1: Example Of A Form To Record Headaches And Seizures............................................... 15
For more information on the history and physical examination of the central nervous system in older children
and adolescents, see chapter 8, "Central Nervous System," in the NWT Clinical Practice Guidelines for

Assessment Of The Central Nervous System

It is important to obtain a complete history and • Abnormal muscle tone (hypertonia [increased
details of all presenting symptoms, including tone] or hypotonia [decreased tone])
information about onset (sudden or gradual), • Abnormal changes in sensation (e.g. tingling,
duration and progression. numbness)
• Detailed description of any seizures, fainting or
• Change in level of consciousness (e.g. lethargy, other spells: skin colour, respiration,
stupor) precipitants, duration, associated limb and eye
• Irritability movements, level of consciousness, behavior
• Changes in cry (in infants <6 months old) before and after the seizure, breath-holding
• Changes in feeding patterns • Chronology of attainment of normal
• Presence of headache and its characteristics: site, developmental milestones
duration, alleviating factors, association with • Previous history of neurologic disorder
vomiting or visual disturbance • Family history of neurologic disorder (many
• Visual disturbance (e.g. double vision [diplopia] disorders are familial)
indicates involvement of cranial nerves) • Details of mother's pregnancy, labor, delivery
• Changes in hearing, smell or taste in older child and neonatal period (especially for children
• Vertigo (indicates inner ear disturbance) <2 years old)
• Muscle weakness or wasting
• Involuntary motor movements (e.g. tics, chorea)
A general physical examination, as well as a • Sinus of lower back and hair tuft
detailed neurologic examination, is important. • Tone, strength and reflexes of limbs
• Observation of child with respect to
Assess the following: achievement of major age-appropriate
• Level of consciousness (can be quantified by developmental milestones (e.g. crawling,
means of the pediatric Glasgow coma score - walking, playing with toys)
Table 15-1) • Observation of gait while child is walking
• Mental status • Meningeal signs (e.g. neck stiffness, Kernig's
• Speech sign [pain with passive knee extension and hip
• Eye examination: full-range extraocular flexion], Brudzinski's sign [spontaneous hip
movements, PERRLA (pupils equal, round and flexion with passive neck flexion])
reactive to light; accommodation normal), • Respiratory examination: look for underlying
funduscopy for clarity and vascularity of optic pneumonia
disk • Cardiac examination: listen for murmur (which
• Head shape and size, fontanel and suture size could indicate embolic stroke or cerebral
• Facial dysmorphism (may indicate a genetic abscess)
syndrome) • Abdominal examination: check for enlargement
• Cutaneous birthmarks (may indicate a of liver or spleen (which could indicate a liquid
neurocutaneous disorder) storage disorder)
• Cranial bruit (may indicate an intracranial
vascular malformation)

Table 15-1: Scoring for the pediatric Glasgow Coma Score*

Feature Score Age group and response
Eyes opening > 1 year < 1 year
4 Spontaneously Spontaneously
3 To verbal command To shout
2 To pain To pain
1 No response No response
Best motor response > 1 year < 1 year

6 Obeys NA
5 Localizes pain Localizes pain
4 Flexion withdrawal Flexion normal
3 Flexion abnormal Flexion abnormal
(decorticate rigidity) (decorticate rigidity)
2 Extension (decerebrate Extension (decerebrate
rigidity) rigidity)
Best verbal response > 5 years 2-5 years Birth to 23 months

5 Oriented and converses Appropriate words and Smiles, coos, cries
phrases appropriately
4 Disoriented and converses Inappropriate words Cries
3 Inappropriate words Cries and/or screams Inappropriate crying and/or
screaming
2 Incomprehensible sounds Grunts Grunts
1 No response No response No response
* Score is obtained by determining the score for each of the three criteria and summing them.
Note: NA = not applicable

Common Problems Of The Central Nervous System

Hypotonia ("Floppy Infant")
Definition • Maternal health problems (e.g. hypertension,
Lower-than-normal muscular resistance to passive diabetes mellitus)
movement of a joint. Muscle strength is a key • Maternal use of neurotoxic drugs
component of this resistance.
Physical Findings
Causes • Vital signs
• Static encephalopathy related to perinatal or • General physical examination to rule out any
prenatal insult (e.g. hypoxia, ischemia at birth, underlying cause
intracranial hemorrhage) • Complete CNS exam (see Examination," above,
• Direct CNS injury (e.g. spinal cord transection) this chapter)
• Muscular atrophy of the spine • Assessment of developmental milestones for age
• Myasthenia gravis • Assessment of primitive reflexes of the newborn
• Congenital myopathy (see "Physical Examination of the Newborn," in
• Myotonic dystrophy chapter 1.)
• Muscular dystrophy • Muscle tone decreased (hypotonia)
• Systemic illness (e.g. congenital heart disease,
hypothyroidism, celiac disease, inborn errors of Differential Diagnosis
metabolism) See "Causes," above, this section.
• Infantile botulism
• Benign congenital hypotonia Complications
• Chromosomal abnormality (e.g. Down's • Long-term disability
syndrome)
Diagnostic Tests
History None.
• Onset (acute or gradual)
• Duration Management
• Past history of any acute illness (e.g. meningitis) Management depends on the cause of the
• Family history of myopathy hypotonia.
• Social history: infant-parent interaction, siblings'
history (many babies are "floppy" because of Goals of Treatment
lack of stimulation) • Identify underlying cause early
• Minimize long-term disability
Associated Symptoms
• Respiratory and feeding difficulties Appropriate Consultation
• Fasciculations Consult a physician immediately to discuss the
• Ptosis case.
• History of any delays in reaching milestones
• Inappropriate weight gain for age Referral
A hypotonic child should be evacuated for
evaluation and investigation. The urgency of
Prenatal Symptoms
evacuation depends on the child's clinical
• Physiologic insults during pregnancy or birth
condition and possible causes of the hypotonia.

Emergency Problems Of The Central Nervous System

Seizure Disorders
Definition Febrile Seizure
Neurologic manifestations of involuntary and • Associated with temperature >38°C
excessive neuronal discharge. • Occurs in children <6 years old (prevalence is
2% to 4% among children <5 years old)
The symptoms depend on the part of brain that is • No signs or history of underlying seizure
involved and may include any of the following: disorder
• Altered level of consciousness • Often familial
• Tonic-clonic movements of some or all body • Uncomplicated and benign if seizure is of short
parts duration (<5 minutes)
• Eye movements • Involves tonic-clonic movements
• Visual, auditory or olfactory disturbance • Bilateral
Most seizures in children involve loss of Other complex seizures (not covered by categories
consciousness and tonic-clonic movements, but listed above) may require more complete tertiary
auditory, visual or olfactory disturbance, assessment.
behavioral change or absences in attention may
also occur. History
• Previous episodes (i.e. known seizures)
Seizures must be differentiated from other "spells"
(e.g. fainting, arrhythmia, vertigo, tic). Nature of Current Seizures
• Onset (sudden or gradual)
Types
• Date and time of onset
Generalized Seizure
• Whether consciousness has been regained since
• Affects both hemispheres onset of seizure activity
• Characterized by change in level of • Duration of seizure
consciousness
• Sequence of seizures
• Bilateral motor involvement
• Type of seizure (generalized or partial)
• Examples: absence seizure or grand mal seizure
with tonic-clonic movements of all four limbs
• Association with fever
• Association with head injury
Simple Partial Seizure • Ingestion of poisonous substance or other
• Affects only part of brain (focal, motor or poisoning (e.g. lead encephalopathy)
sensory) • Associated with breath-holding spell
• Formerly called focal seizures
• May progress to generalized seizures Other Factors
• Compliance with anticonvulsant therapy in child
The history is important, because the known to have epilepsy
anticonvulsants used for partial seizures differ • Other chronic disease
from those used for generalized seizures. • Medication use
• Allergies to medications
Complex Partial Seizure • Symptoms of intercurrent illness (e.g. fever,
• Partial seizure with affective or behavioral malaise, cough)
changes

Physical Findings
Acute Seizure Complications
• Temperature normal unless underlying infection • Hypoxia during seizures
is present • Status epilepticus
• Heart rate elevated and may be irregular • Arrhythmia
• Respiration irregular (absent during seizure, • Injury during seizure (e.g. from a fall)
present between seizures) • Brain damage
• Blood pressure elevated or low • Death
• Oxygen saturation may be decreased
• Loss of consciousness Diagnostic Tests
• Skin pale or cyanotic Acute Seizure
• Evidence of loss of bowel and bladder control • Random glucose stick test
• Repeated episodes of tonic-clonic movements • Pulse oximetry (if available)
• Foaming at mouth may be present
• Blood around or in mouth if child has bitten Management
tongue See Canadian Paediatric Society position
• Abnormalities suggesting underlying cause (e.g. statement "Management of the paediatric patient
stiff neck and bulging fontanel would suggest with generalized convulsive status epilepticus in
meningitis) the emergency department” Paediatrics and Child
• Focal neurologic findings (e.g. hemiparesis or Health 1996. 1(2): 151-155
abnormal deep tendon reflexes would be of http://www.cps.ca/english/statements/EP/ep95-
specific concern) 01.htm
Always consider meningitis in a child with an Acute Seizure (Status Epilepticus)

apparent simple febrile convulsion. Meningitis can Goals of Treatment
usually be diagnosed on clinical grounds alone, • Protect airway
but if in doubt, contact a physician. • Stabilize cardiorespiratory function
• Stop seizures and prevent recurrence
For any child who is having a generalized grand
mal seizure on arrival and for whom the exact time ABCs are the first priority:
of onset of the convulsion is unknown, manage as •Ensure airway is clear and patent
you would for status epilepticus (a condition
•Suction secretions as necessary
lasting longer than 30 minutes and characterized
by continuous seizure activity or intermittent
•Insert oropharyngeal airway
convulsive activity with failure to regain •Assist ventilation as needed by means of Ambu-
consciousness between convulsions). See bag with oxygen
"Management," below, this section.
Consult a physician as soon as possible after
emergency care.
• Epilepsy
• Drugs (non-compliance with prescription, Adjuvant Therapy
withdrawal syndrome, overdose, multiple drug
• Give oxygen 6-10 L/min by mask or more to
abuse)
keep oxygen saturations >97%
• Hypoxia
• Start IV therapy with normal saline, adjusting
• Brain tumor
rate according to state of hydration
• Infection (e.g. meningitis)
• Metabolic disturbances (e.g. hypoglycemia,
uremia, liver failure, electrolyte disturbance)
• Head injury

Nonpharmacologic Interventions • Monitor vital signs, ABCs, pulse oximetry (if

• Nurse child in side-lying position available)
• Keep child warm • Monitor closely for continued seizure activity
• Give nothing by mouth until child has fully
recovered Referral
• Medevac for diagnostic work-up is indicated if
Pharmacologic Interventions this is a previously long-lasting undiagnosed
lorazepam (D class drug), 0.05-0.10 mg/kg IV seizure or you suspect meningitis or another
(maximum 4 mg per dose), repeat q10min for 2 underlying metabolic cause
more doses (administer slowly over 5 minutes, • First afebrile seizures should be referred for
maximum rate 2 mg/min) investigation
or • Benign febrile seizures can usually be handled in
diazepam (D class drug), 0.3 mg/kg IV (maximum the community. Investigation is required only if
5 mg per dose for child =5 years old, 10 mg per the seizures are of long duration >15 minutes) or
dose for child >5 years old), repeat q5min for 2 they are complicated (e.g. focal, residual
more doses (administer slowly over 5 minutes, paralysis)
maximum rate 2 mg/min)
It is important that seizures be controlled before
If unable to achieve IV access, diazepam can be transport. If at all possible, obtain the assistance of
given effectively by the rectal route, as follows. an experienced critical care pediatric professional
Use IV solution without dilution and administer by in stabilizing and transferring the child to hospital.
inserting the smallest possible syringe or a small
catheter affixed to the end of a syringe (if the dose Chronic Seizure Disorder
is less than 5 mg, a tuberculin syringe is ideal): Management depends on underlying cause and
severity of symptoms.
diazepam (D class drug), 0.5 mg/kg per dose PR
(maximum dose 10 mg), repeat q5-10min for total Goals of Treatment
of 2 doses (maximum rate 2 mg/min) • Control seizures
The medication should be placed a distance of 4
cm into the rectum, adjacent to the rectal mucosa.
• Allow child to return to a normal lifestyle
The buttocks should be elevated and squeezed • Achieve good adherence to treatment regimen
together for 5 minutes to avoid evacuation of the over a long period
rectal contents after administration of the drug. • Discontinue medications eventually, with
Two doses may be given, 5-10 minutes apart. continued control of seizures
The patient with status epilepticus (convulsion Nonpharmacologic Interventions

lasting longer than 30 minutes) should receive a Provide reassurance.
loading dose of a long-acting anticonvulsant after
the first dose of benzodiazepine. Contact Client Education
physician for long-acting anticonvulsant order. • Explain prognosis
• Emphasize importance of adhering to
Risks of Drug Therapy medication regimen
• Hypotension • Emphasize importance of good lifestyle habits
• Respiratory depression (e.g. regular meals, adequate sleep) to prevent
recurrences
Monitoring and Follow-Up • Counsel about first aid during seizures
• Identify focal neurologic deficits • Advise supervision during swimming
• Observe for return to normal level of • Advise that the child be treated as a normal child
consciousness would be

• Advise about possible teratogenic effects of Monitoring and Follow-Up

medications (e.g. phenytoin) for sexually active • Follow up every 6 months if seizures are well
females controlled, more frequently if child is having
breakthrough seizures
Pharmacologic Interventions • Assess adherence to medication regimen
Anticonvulsants are tailored to the specific type of • Monitor serum drug levels every 6 months if
seizure. Monotherapy is ideal, but 10% to 15% of stable, more frequently if necessary
patients need two or more medications. Poor
compliance is the major cause of seizure Referral
recurrence. • Refer electively for review by a physician at
least annually if seizures are well controlled
Commonly Used Anticonvulsants • Refer urgently if child is having breakthrough
(B Class Drugs) seizures
• carbamazepine • Consider neurologic follow-up if symptoms are
• phenobarbital not controlled on current medications
• phenytoin
• valproic acid

Head Trauma
See Canadian Paediatric Society position • Irritability
statement "Management of children with head • Visual disturbance
trauma" Canadian Medical Association Journal • Disorientation
1990. 142(9): 949-952. Reaffirmed January 2002 • Abnormal gait
http://www.cps.ca/english/statements/EP/epp90- • Lethargy, pallor or agitation may indicate severe
01.htm injury
• Vomiting
Head trauma is common among children and
results in a significant number of visits to
• Symptoms of increased intracranial pressure
(vomiting, headache, irritability)
emergency clinics.
Many children will vomit two or three times after
Children are more predisposed than adults to head
even a minor head injury. However, protracted
injury because their head to body ratio is greater,
vomiting and retching, associated with other
their brains are less myelinated and thus more
symptoms or signs, indicates a more severe head
prone to injury, and their cranial bones are thinner.
injury.
Although the incidence of mass lesions is lower
among children than among adults, children are
The child's complete medical history must be
more likely to suffer from a unique form of brain
obtained. Evidence of conditions such as a
injury called malignant brain edema. In addition,
predisposition to seizures or bleeding problems is
children may lose relatively large amounts of
important and will affect the clinical management.
blood from scalp lacerations and subgleal
hematomas and may present in hemorrhagic
shock. Physical Findings
Severity of intracranial injury can be assessed
from a variety of characteristics
History
(see Table 15-2 below).
Head trauma may be due to child abuse or serious
neglect by a parent or caregiver. In all cases, a
thorough history should be obtained of past Vital Signs
injuries and of the circumstances surrounding the • Temperature usually normal
present injury. It may be impractical to review old • Tachypnea: rapid heart rate may signify blood
records for all children with head injuries, but in loss, in which case evidence of other injuries
suspicious cases these records must be reviewed should be sought
and appropriate follow-up arranged. • Bradycardia with hypertension (Cushing
response): usually a late response in children
Ascertain the following: with increased intracranial pressure and
• Mechanism of injury therefore not very reliable
• Time of injury • Hypertension: late sign of increased intracranial
• Loss of consciousness (a brief seizure at the time pressure
of injury) may not be clinically significant • Hypotension signifies shock: look for other
• Loss of memory injuries, since shock is not a usual sign of brain
• Amnesia injury

Table 15-2: Classification of severity of intracranial injury

Mild Moderate Severe
Asymptomatic Progressive lethargy Focal neurologic signs present
Mild headache Progressive headache
No evidence of skull fracture, facial Signs of basal skull fracture; possible Penetrating skull injury, palpable
injury or other trauma penetrating injury or depressed skull depressed skull fracture or compound
fracture; serious facial injury, skull fracture; serious facial injury or
multiple trauma multiple trauma
Three or fewer episodes of vomiting Vomiting protracted (more than three
episodes) or associated with other
symptoms
Glasgow coma score 15 Glasgow coma score 11-14 Glasgow coma score ≤ 10; a decrease
of 2 or more points in serial Glasgow
coma scores, not clearly caused by
seizures, drugs, decreased cerebral
perfusion or metabolic factors
Loss of consciousness for < 5 Loss of consciousness for ≥ 5 Unconscious
minutes
minutes
Post-traumatic amnesia or seizure

Adapted, with permission, from Canadian Paediatric Society, Emergency Paediatrics Section, 1990. Management of
children with head trauma (Ref No EP90-01; approved by CPS Board of Directors 1990). Canadian Medical
Association Journal 142(9):949-952. Reaffirmed January 2002.
Also available: http://www.cps.ca/english/statements/EP/ep90-01.htm
Signs of Skull Fracture Injuries to other areas such as the thorax or

• Hematotympanum abdomen should be sought and treated promptly,
• Periorbital or post-auricular ecchymosis since they may contribute to morbidity and death.
• Cerebrospinal fluid otorrhea or rhinorrhea
• Depressed fracture or penetrating injury Clues to increased intracranial pressure:
• Decrease in Glasgow coma score of 2 points or
Palpate scalp hematomas and contusions for more
underlying depressions, which signify depressed • Abnormality or changes in pupillary size and
skull fracture. Before suturing, explore all full- reaction to light
thickness skull lacerations to ensure that the • Respiratory abnormalities
underlying bone is intact. • Development of paresis in absence of shock
• Hypoxia
Neurologic Examination • Seizures
• Pediatric Glasgow coma scale • Elevation of blood pressure
• Papilledema (increased intracranial pressure) • Decrease in heart rate
• Pupillary light reflexes (PERRLA) • Decrease in respiratory rate
• Cranial nerve examination
• Movement of extremities Maintain a high index of suspicion for child abuse.
• Abnormal posture (decorticate or decerebrate)
• Muscle flaccidity, spasticity Management
• Plantar responses Mild Injury
Children with mild intracranial injury may be
discharged home. An instruction sheet should be

given to the parents or caregiver concerning Suture scalp lacerations, as major blood loss can
observation and precautions (Table 15-3) occur from such lesions.
Table 15-3: Instructions to parents or Appropriate Consultation

caregivers for observation at home of children For any loss of consciousness, investigation and
with head trauma treatment should be discussed with a physician.
Bring child back to clinic immediately if any of Adjuvant Therapy

the following signs and symptoms appear within • Start IV therapy with normal saline to keep vein
the first 72 hours after discharge: open (unless the child is in shock from other
• Any unusual behavior injuries)
• Disorientation as to name and place • Give oxygen at 6-10 L/min or more, as
• Inability to wake child from sleep necessary
• Increasing headache
• Seizures Nonpharmacologic Interventions
• Unsteadiness on feet • Elevate head of bed by 30° to 45°
• Unusual drowsiness and sleepiness • Place head and neck in midline position
• Vomiting more than two or three times • Minimize stimuli (e.g. suctioning and
movement)
• Restrict fluids to 60% of normal intake (except
Moderate To Severe Injury in cases of shock)
ABCs must be assessed before any detailed • To control increased intracranial pressure: above
history-taking or neurologic examination. measures plus establish controlled
hyperventilation
Instability of the cardiorespiratory system may be
due to severe intracranial injury, intracranial Pharmacologic Interventions
hypertension or injury to other areas, such as the Medications should be given only if prescribed by
thorax or the abdomen. Prompt ventilatory support a physician.
and treatment of shock are mandatory, since these
factors, if left uncorrected, will result in secondary Diuretics if intracranial pressure is increased (and
intracranial trauma. there is documented deterioration) despite
measures outlined above:
See "Shock," in chapter 20, "General Emergencies mannitol (B class drug), 0.5-1 g/kg IV
and Major Trauma."
Stabilizing Head and Cervical Spine Monitor ABCs, vital signs, pulse oximetry (if
Manual in-line stabilization must be maintained available), level of consciousness (with serial
until injury to the cervical spine has been excluded pediatric Glasgow coma scores), intake and
or the neck is properly immobilized on a flat, hard output.
surface with weights on either side of the neck.
Referral
Medevac.

Headache
Definition Infection
Acute • Brain abscess
Pain in the head involving blood vessels, • Dental infection
meninges, and bony and soft-tissue components of • Encephalitis
the head. • Meningitis
• Sinusitis (chronic)
Chronic or Recurrent
Pain in the head occurring on a chronic basis with Trauma
three broad categories of causes: vascular cause • Neck injury
(migraines), muscle contraction (tension • Post-concussion syndrome
headaches) and organic cause. Occurs in 20% of • Subdural hematoma
school-age children. Onset may occur at any age.
Toxic Effects
Causes • Carbon monoxide
Vascular causes (leading to migraine) and muscle • Heavy metal poisoning (e.g. lead)
contraction (leading to tension headaches) are the • Non-medicinal agents
most common causes of headache in children. • Excess intake of vitamins
Vascular Lesions Psychogenic
• Arteriovenous malformation • Conversion
• Berry aneurysm • Depression
• Cerebral infarction • Factitious
• Intracranial hemorrhage
Other Causes
Migraine • Food allergy or sensitivity
Vascular headaches (migraine) are common in • Refractive error
children, who often have incomplete
• Ocular muscle imbalance
manifestations of this condition. This type of
headache should be considered in any recurrent
• Temporomandibular joint (TMJ) dysfunction
problem with headache.
Traction
• Classic • Brain tumors
• Common • Hydrocephalus
• Cluster • Hypertension
Complicated Migraine
History
• Basilar artery Gather history from many sources, including the
• Hemiplegic affected child and his or her parents (or caregiver)
• Ophthalmoplegic and teachers. It is best to get a description of both
the initial and the most recent headaches. Children
Variants of Migraine >4 years old may be able to give a good
• Acute confusional state description of their symptoms.
• Benign paroxysmal vertigo
• Cyclic vomiting Onset
• When headache began
Muscle Contraction • Conditions associated with initial headache (e.g.
• Tension trauma, drug ingestion)
• Aura: visual, auditory

Location In the absence of other symptoms, recurrent

• Unilateral or bilateral headaches of more than 3 months' duration are
rarely due to an organic cause.
Radiation
• Where headache starts Headaches of relative recent onset (<3 weeks) that
• Where headache hurts the most are increasing in frequency and severity are
• Whether headache spreads to other areas worrisome.
• Occipital radiation: neck problems, occipital
neuralgia, basilar migraine Physical Findings
• Facial radiation: sinus, dental or TMJ Physical findings are usually minimal with
headaches.
Quality • Blood pressure usually normal
• Sharp, dull or tight • Temperature may be elevated with infectious
process (e.g. meningitis)
• Throbbing or pounding (characteristic of
vascular headaches) • Height and weight
• Whether character of pain changes over time
HEENT (Head, Eyes, Ears, Nose and
Severity Throat)
• Severity of the headache on a scale of 1 to 10, • Pained facies
with 10 representing the worst pain ever felt • Nuchal rigidity
• Whether pain is increasing or decreasing in • Funduscopic examination (disks, blood vessels);
intensity over time results usually normal
• Whether headache interferes with child's day-to- • Spasm or tenderness of neck muscle, tenderness
day activities of TMJ
• Deficits of cranial nerves
Timing • Purulent rhinorrhea
• Constant or intermittent • Halitosis, dental abscesses
• Frequency per day, week and month • Cephalic bruits: use bell of stethoscope over the
• Whether frequency is increasing over time frontotemporal areas and orbits
• Association with particular time of day, week,
month or season Neurologic Examination
• Duration and whether duration is increasing over • Level of consciousness
time • Mental status: general demeanor, confusion,
depression, stress
Associated Symptoms (Functional • Cutaneous lesions (café au lait spots)
Inquiry) • Focal abnormalities (e.g. tics, limb paresis)
• Nausea and vomiting with or without abdominal • Sensory deficits
pain (typical of migraine) • Abnormal deep tendon reflexes
• Photophobia, facial pain, fever • Mental confusion
• Transient neurologic signs
• Acute confusion, hemiplegia, ophthalmoplegia, Clinical Characteristics of Specific Types
syncope, vertigo, paresthesias, phonophobia of Headaches
• Depression Traction
• Anorexia, declining school performance, • Headaches increase rapidly in frequency and
insomnia, weight loss severity
• Other medical problems • Headache worst upon awakening in the morning,
• Past medical history diminishes during the day
• Family history of headaches • Headache wakens child from sleep
• Aggravated by coughing or valsalva maneuver

• May be relieved by vomiting Differential Diagnosis

• Associated symptoms: focal neurologic findings; See "Causes," above, this section.
altered gait; changes in behavior, personality,
cognition or learning Complications
• Recurrent or chronic headaches can be
In 88% of children with a brain tumor, abnormal debilitating and may cause absences from school
neurologic signs will be evident within the first 4 and social withdrawal
months after onset of headache. • Intracranial lesions, masses or infections are life-
threatening
Classic Migraine
• Headache pulsatile (throbbing), periodic, Diagnostic Tests
separated by symptom-free intervals and Most headaches can be diagnosed from the history
associated with at least three of the following and physical examination.
symptoms: abdominal pain and nausea or
vomiting, aura (motor, sensory, visual), family For recurrent or chronic headache, diagnostic
history of migraine information may include daily headache record,
• Unilateral see Appendix 15-1.
• Headache relieved by sleep
Management
Tension Headache Goals of Treatment
• Band-like tightness or pressure in the bifrontal, Goals of treatment depend on the cause of the
occipital or posterior cervical regions lasting for headache.
days or weeks but not disrupting regular
activities; not associated with a prodrome; seen Acute
at any age • Rule out serious organic pathology
• Associated symptoms: tight neck muscles, sore • Relieve pain
scalp; nausea, vomiting and aura are uncommon
Recurrent or Chronic
Refractive Error • Relieve pain
• Persistent frontal headache, which is worse • Prevent recurrence
while reading or doing schoolwork
• Avoid disruption of normal life tasks, such as
attending school
TMJ Dysfunction
• Temporal headache Appropriate Consultation
• Associated symptoms: local jaw discomfort, Consult a physician immediately in the following
malocclusion (crossbite), decreased range of circumstances:
motion of mouth, click with jaw movement, • Concern about an underlying organic cause for
bruxism (grinding of teeth) headaches
• Uncertainty about the diagnosis
Chronic Sinusitis
• Headaches are chronic and unresponsive to
• Frontal headache simple analgesia
• Tenderness to percussion over the frontal,
maxillary or nasal sinuses
• Associated symptoms: prolonged rhinorrhea and Supportive reassurance and education are
congestion, chronic cough and postnasal drip, appropriate for non-organic headaches only:
anorexia, low-grade fever, malaise • Advise parents or caregiver that headaches in
children are common and real
It is unusual for children <10 years old to have
• Reassure family that headache is unlikely to
recurrent headaches secondary to chronic sinusitis.
indicate brain tumor

• Explain underlying pathophysiology of vascular For migraines:

and muscle contraction headaches (which are • Avoid precipitants (triggers)
benign and have a favorable prognosis) • Simple analgesic (acetaminophen, ibuprofen)
• Counsel about avoiding factors that trigger may be given at first sign of aura or headache
headaches • Avoid narcotics
• Identify stressors and advise on how to deal with
them On the advice of a physician, migraine prophylaxis
• Counsel about use of medications (dose, may be ordered, but this is rarely necessary in
frequency, side effects) young children.
Relaxation and Imagery Therapy For information on treatment and prophylaxis of

• Abdominal breathing exercises migraines, see "Migraine Headache," in chapter 8,
• Visual imagery exercises "Central Nervous System," in NWT Clinical
Pharmacologic Interventions Nursing (Adult) 2003.
For tension headaches and mild migraines,
analgesics are useful: Monitoring and Follow-Up
acetaminophen (A class drug), 10-15 mg/kg per During follow-up visits:
dose (usually analgesic of choice) • Review headache diary if unable to identify
cause on first visit, as well as to monitor
Children >6 years old may be given 325 mg, and management
children >12 years old may be given 325-650 mg • Reinforce balanced health habits of sleep,
PO q4h prn. exercise and diet
or
Nonsteroidal anti-inflammatory drugs (NSAIDs): Referral
ibuprofen (A class drug), 5-10 mg/kg per dose PO Medevac any child with acute symptoms in whom
q8h prn, to daily maximum of 40 mg/kg organic pathology is evident or cannot be ruled out
without investigation. If symptoms are mild, refer
NSAIDs are associated with a risk of GI side the child electively to a physician.
effects.
Do not use ASA, as it is associated with Reye's

syndrome.

Appendix 15-1: Example Of A Form To Record

Headaches And Seizures
NAME CHILDREN'S CENTER
BD MONTHLY RECORD
CHART NO. OF HEADACHES/SEIZURES
WARD
MONTH JAN FEB MAR APR MAY JUNE JULY AUG SEPT OCT NOV DEC
DAY D N D N D N D N D N D N D N D N D N D N D N D N
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Totals
Note: D=day; N=night

DATE & DESCRIPTION: duration, precipitating factors, record of everything eaten in the 24
TIME hours before headache

Chapter 16 – The Skin

Assessment Of The Integumentary System..................................................................................................... 1
Types Of Lesions ............................................................................................................................................ 2
Common Problems Of The Skin ...................................................................................................................... 4

Scabies ............................................................................................................................................................ 4
Impetigo .......................................................................................................................................................... 6
Cellulitis.......................................................................................................................................................... 8
Eczema (Atopic Dermatitis) ......................................................................................................................... 10
Diaper Rash................................................................................................................................................... 12
Poison Ivy Dermatitis ................................................................................................................................... 13
Hereditary Polymorphic Light Eruption ....................................................................................................... 14
Hemangiomata .............................................................................................................................................. 15
Mongolian Spots ........................................................................................................................................... 16
Molluscum Contagiosum.............................................................................................................................. 17
Ringworm Of The Scalp (Tinea Capitis) ...................................................................................................... 18
Acne Vulgaris ............................................................................................................................................... 19
Ringworm (Tinea)......................................................................................................................................... 20
Warts (Verrucae)........................................................................................................................................... 20
Dermatological Emergencies.......................................................................................................................... 21
Pediatric Burns.............................................................................................................................................. 21
For more information on the history and physical examination of the skin in older children and adolescents,
see chapter 9, "The Skin," in the NWT Clinical Practice Guidelines for Primary Community Care Nursing
(Adult) 2003.
For ringworm (tinea), including tinea corporis and tinea pedis, and for warts (verrucae), clinical presentation
and management are the same in adults and children. For information on these conditions, see chapter 9, "The
Skin," in the NWT Clinical Practice Guidelines for Primary Community Care Nursing (Adult) 2003.

Assessment Of The Integumentary System

General • Recent or current viral or bacterial illness
The following characteristics of each symptom • Allergies to drugs, foods or other chemical
should be elicited and explored: substances
• Onset (sudden or gradual) • Sensitivity to sunlight
• Skin site involved • Medications: current and past prescription and
• Chronology OTC drugs
• Date(s) and site(s) of recurrence(s) • Immunosuppression (e.g. HIV/AIDS)
• Current situation (improving or deteriorating) • Seborrheic dermatitis
• Nature of symptom: intermittent or continuous • Dermatitis
• Influence of environmental factors • Psoriasis
• Potential causative factors • Diabetes mellitus
• Measures taken to relieve symptoms
Family History (Specific To
Cardinal Symptoms Integumentary System)
In addition to the general characteristics outlined • Allergies (e.g. seasonal hay fever, allergies to
above, additional characteristics of specific foods)
symptoms should be elicited, as follows. • Asthma
• Seborrheic dermatitis
Skin • Psoriasis
• Changes in texture, colour, pigmentation • Others at home with similar symptoms (e.g.
• Unusual dryness or moisture rash)
• Itching
• Rash Personal And Social History (Specific
• Bruises, petechiae To Integumentary System)
• Lesions • Obesity
• Changes in moles or birthmarks • Inadequate personal hygiene
• Hot or humid environment, poor environmental
Hair sanitation
• Changes in amount, texture, distribution • Exposure to new chemicals (e.g. soaps), foods,
pets or plants
Nails • Emotional disturbance
• Changes in texture, structure • History of sensitive skin
• Others at home, work or school with similar
Medical History (Specific To symptoms
Integumentary System) • Recent travel
• Allergic manifestation (e.g. asthma, hay fever,
urticaria, eczema)

General Appearance • Bruising, petechiae
• Apparent state of health • Edema (dependent, facial)
• Appearance of comfort or distress • Induration (firm to touch)
• Colour (e.g. flushed, pale) • Individual lesions (colour, type, texture, general
• Nutritional status (obese or emaciated) pattern of distribution, character of edge,
• State of hydration whether raised or flat)
• Vital signs (temperature may be elevated) • Hair (amount, texture, distribution)
• Nails (shape, texture, discoloration, grooving)
Inspection And Palpation Of The Skin • Mucous membranes (e.g. moisture, lesions)
• Colour • Skin folds (e.g. rashes, lesions)
• Temperature, texture, turgor • Joint involvement
• Dryness or moisture
Other Aspects
• Scaling
• Examine lymph nodes
• Pigmentation
• Examine area distal to enlarged lymph nodes
• Vascularity (erythema, abnormal veins)
Types Of Lesions
Lesions of the skin and mucous membranes are Fig. 16-2: Skin Lesions Greater than 1 cm in at
characterized by their size, elevation, contents and Least One Dimension
colour (Figs. 16-1 to 16-3).
Fig. 16-1: Skin Lesions Up to 1 cm in Greatest

Dimension
A: Macule, a flat, circumscribed area of discoloration of

the skin or mucous membrane up to 1 cm in its greatest
dimension.
B: Papule, a solid, elevated lesion of the skin or mucous

membrane up to 1 cm in its greatest dimension.
C: Vesicle, a fluid-filled, superficial, elevated lesion of A: Patch, a flat, circumscribed area of discoloration of
the skin or mucous membrane, up to 1 cm in its greatest the skin or mucous membrane, with at least one
dimension. dimension greater than 1 cm.
B: Plaque, a solid, elevated lesion of the skin or mucous

membrane, with at least one dimension greater than
1 cm.

C: Nodule, a solid, elevated lesion of the skin or Fig. 16-3: Skin Lesions of Variable Size
mucous membrane, with the added dimension of depth
into the underlying tissue, with at least one dimension
greater than 1 cm.
D: Tumor, a solid, elevated lesion of the skin or mucous

membrane, with the added dimension of depth into the
underlying tissue (to a greater extent than for a nodule), Wheal - an irregularly shaped, elevated, solid,
with at least one dimension greater than 1 cm. changing, transient lesion of the skin or mucous
membrane, due to cutaneous edema.
E: Bulla, a fluid-filled, superficial, elevated lesion of
the skin or mucous membrane, with at least one Other lesions of variable size include pustules (vesicle
dimension greater than 1 cm. or bulla containing pus rather than clear fluid) and
telangiectasias (fine, often irregular red lines produced
by dilatation of a capillary).

Common Problems Of The Skin

Scabies
Definition • Symptoms may take 1-2 months to develop after
Infestation of the skin with a mite parasite. contact with mite
• Symptoms are due to hypersensitivity to mite
Skin eruptions consist variably of wheals, papules, and its products
vesicles, burrows and superimposed eczematous
dermatitis. The lesions are intensely pruritic, Physical Findings
especially at night, which leads to marked • Usually affects interdigital web spaces, flexures
excoriation. of wrists and arms, axillae, belt line, lower folds
of buttocks, genitalia, areolae of nipples
In infants, the face, scalp, palms and soles are • Diffuse red rash
most commonly involved. • Primary lesions: papules, vesicles, pustules,
burrows
In adolescents, the lesions, which often appear as
• Secondary lesions: scabs, excoriations, crusts,
threadlike burrows, occur in the interdigital
nodules, secondary infection
spaces, the groin and genitalia, the umbilicus, and
the axillae and on the wrists, elbows, ankles and
• Lesions in various stages present at the same
time
buttocks.
• Secondary lesions may predominate
Cause • Burrows (gray or flesh-coloured ridges 5-15 mm
long) may be few or many
• Itch mite, Sarcoptes scabiei, which burrows
under the skin
• Burrows commonly seen on anterior wrist or
hand and in interdigital web spaces
• Usually transmitted by direct contact and
(rarely) fomites (e.g. clothes, linen)
• In infants, burrows are much less common

• Failure to recognize an infestation • Pediculosis
• Faulty application of treatment • Impetigo
• Failure to treat close contacts • Eczema (atopic dermatitis)
• Failure to eradicate mites from clothing and bed • Contact or irritant dermatitis
linen • Viral exanthem
• Exposure to someone with scabies • Chickenpox
• Drug reaction
The Aboriginal population in some areas may be
at risk from a number of additional factors, such as Complications
the following: • Impetigo
• Crowded housing, shared beds, crowded schools • Cellulitis
and daycare centers
• High pediatric population Diagnostic Tests
• Lack of running water, which may predispose to None.
poor hygiene and secondary skin infection
Management
• Severe itching • Eradicate infestation
• Itching generally worse at night • Control secondary infection
• Rash on hands, feet, flexural folds • Relieve symptoms


Consult physician if you are unsure of the Scabicide cream or lotion, applied to entire body,
diagnosis. from chin to toes. Emphasize that scabicide must
be applied in skin creases, between fingers and
Nonpharmacologic Interventions toes, between buttocks, under breasts and to
Client Education external genitalia.
• Counsel parents or caregiver (and child, if old permethrin 5% dermal cream (A class drug)
enough) about proper use of medication and its (drug of choice)
side effects
Leave on skin for 8-14 hours. A single application
Control Measures is usually curative, but medication may be re-
• Prophylactic therapy is essential for all applied after 1 week if symptoms persist.
household members, since signs of scabies may
not appear for 1-2 months after the infection is The safety of permethrin for infants
acquired <3 months old has not been established.
• Treat all household members at the same time to
prevent re-infection Pruritus may be a problem, particularly at night.
Advise the child and the parents or caregiver that
• All bed linen (sheets, pillow slips) and clothing
itching will persist for up to 2 weeks.
worn next to the skin (underwear, T-shirts,
socks, jeans) should be laundered in a hot soapy
To manage itching:
wash and dried with a hot drying cycle, as
diphenhydramine hydrochloride (A class drug)
available
5 mg/k/day PO, IM, IV maximum dose 300
• If hot water is not available, place all bed linen
mg/day
and clothing into plastic bags and store away
from the family for 5-7 days, as the parasite
Topical steroids may be useful after antiscabietic
cannot survive beyond 4 days without skin
treatment, because the rash and itching may persist
contact
for several days:
• Placing bedding outside in the cold or in hydrocortisone 1.0% (A class drug), applied od or
ultraviolet light will also help bid
• Children may return to daycare or school the day
after treatment is completed Monitoring and Follow-Up
• Healthcare workers who have had close contact • Follow up in 1 week to assess response to
with people who have scabies may themselves treatment
require prophylactic treatment • Advise parents or caregiver to bring child back
• Community education, aimed at early to the clinic immediately if signs of secondary
recognition and awareness of scabies, is infection develop
important
• In widespread scabies epidemics, prophylactic Referral
treatment of a whole community may constitute Rarely necessary if original diagnosis is correct
optimal management and adequate eradication treatment is adhered to
by the child and his or her contacts.

Impetigo
Highly contagious, superficial bacterial infection • Localized or widespread cellulitis
of the skin. • Post-streptococcal glomerulonephritis
• Invasive group A streptococcal disease (invasive
Causes GAS)
• Streptococcus, Staphylococcus or both
• Predisposing factors: local trauma, insect bites, Diagnostic Tests
skin lesions from other disorders (e.g. eczema, • Wound swab for culture and sensitivity (may be
scabies, pediculosis) confirmatory)
History Management
• More common on face, scalp and hands, but Goals of Treatment
may occur anywhere • Control infection
• Involved area is usually exposed • Prevent auto-inoculation
• Usually occurs during summer • Prevent spread to other household members
• New lesions usually due to auto-inoculation
• Rash begins as red spots, which may be itchy Appropriate Consultation
• Lesions become small blisters and pustules, Consult a physician if there is no response to
which rupture and drain therapy.
• Discharge dries to form characteristic golden
yellow crusts Nonpharmacologic Interventions
• Lesions painless • Warm saline compresses to soften and soak
• Fever and systemic symptoms rare away crusts qid and prn
• Mild fever may be present in more generalized • Cleanse with an antiseptic antimicrobial agent to
infections decrease bacterial growth

• Thick, golden yellow, crusted lesion on a red • Counsel parents or caregiver about appropriate
base use of medications (including dose, frequency
• Numerous skin lesions at various stages present and compliance)
(vesicles, pustules, crusts, serous or pustular • Offer recommendations about hygiene as
drainage, healing lesions) necessary
• Bullae may be present • Cut fingernails to prevent scratching
• Lesions and surrounding skin may feel warm to • Counsel parents or caregiver about prevention of
touch future episodes
• Local lymph nodes may be enlarged, tender • Suggest strategies to prevent spread to other
household members (e.g. proper hand-washing,
Differential Diagnosis use of separate towels)
• Infection associated with eczema, contact
dermatitis or scabies Pharmacologic Interventions
• Herpes simplex infection with blisters or crusts Apply topical antibiotic preparation after each
soaking:
• Chickenpox infection with blisters or crusts
mupirocin ointment (A class drug), qid for 7-10
• Shingles (herpes zoster) with blisters or crusts days
• Insect bites

Oral antibiotics may be necessary if there are Monitoring and Follow-Up

multiple lesions that appear infected: • Follow up in 3 to 5 days to assess response to
cephalexin (C class drug), 40 mg/kg per day, treatment
divided q6h, PO • Instruct parents or caregiver to bring the child
or back for reassessment if fever develops or
cloxacillin (C class drug), 25-50 mg/kg per day, infection spreads despite therapy
divided q6h, PO
or Referral
erythromycin (C class drug), 40 mg/kg per day, Not usually necessary unless complications
divided q6h, PO develop.
Topical antibiotics such as mupirocin may be used
alone for small areas or in conjunction with oral
antibiotics for larger areas.

Cellulitis
Definition • Redness, swelling
Acute, diffuse, spreading infection of the skin, • Advancing edge of lesion diffuse, not sharply
involving the deeper layers of the skin and demarcated
subcutaneous tissue. • Small amount of purulent discharge may be
present
Periorbital cellulitis is a special form of cellulitis • Skin surrounding lesion red and swollen, may be
that usually occurs in children. In this form of tense
cellulitis, unilateral swelling and redness of the • Edema
eyelid and orbital area, as well as fever and • Tenderness
malaise, are usually present. Be alert for any child • Induration (firm to touch)
who is unable to elevate or move the eyeball and
• Regional lymph nodes may be enlarged and
any child with forward displacement of the
tender
eyeball, which indicates that the infection has
extended into the orbit (orbital cellulitis). See
"Periorbital Cellulitis (Preseptal)," in chapter 8, Differential Diagnosis
"The Eyes." • Folliculitis
• Foreign body
Facial, periorbital and orbital cellulitis are • Abscess
particularly worrisome, as they can lead to • Contact dermatitis
meningitis.
Complications
Causes • Extension of infection
• Bacteria: most commonly Staphylococcus or • Abscess formation
Streptococcus or combination of both • Sepsis
• Predisposing factors: local trauma, furuncle,
underlying skin ulcer Diagnostic Tests
• Swab any wound discharge for culture and
If a bite was the original trauma, different sensitivity
organisms are involved. See "Skin Wounds," in
chapter 9, "The Skin," in the NWT Clinical Management
Goals of Treatment
Nursing (Adult) 2003.
Facial cellulitis in children <3 years old may be • Identify abscess formation
due to Hemophilus influenzae.
Mild Cellulitis
History Treat on an outpatient basis.
• Localized pain
• Redness
• Apply warm saline compresses to affected areas
• Swelling
qid
• Area increasingly red, warm to touch, painful
• Elevate, rest and gently splint an affected limb
• Area around skin lesion also tender
• Mild fever and headache may be present Client Education
Physical Findings use of medications (dose, frequency,
• Temperature may be elevated compliance)

• Encourage proper hygiene of all skin wounds to • Cellulitis is progressing rapidly, which may
prevent future infections indicate an invasive streptococcal infection
• Stress importance of close follow-up • Condition affects hands, feet, face or a joint
• Child is immunocompromised (e.g. has diabetes
Adjuvant Therapy mellitus)
If original lesion was caused by trauma, check for • Child is febrile, appears acutely ill or shows
tetanus immunization; if not up to date, administer signs of sepsis
tetanus vaccine.
Do not underestimate cellulitis. It can spread very
Pharmacologic Interventions quickly and may progress rapidly to necrotizing
Oral antibiotics: fasciitis. It should be treated aggressively.
cephalexin (C class drug), 40 mg/kg per day,
divided q6h, PO for 7-10 days (for most cases Adjuvant Therapy
involving limbs and trunk) • Start IV therapy with normal saline to keep vein
open; adjust rate according to state of hydration
For children who are allergic to penicillin: and age
erythromycin (C class drug), 40 mg/kg per day, • If original lesion was caused by trauma, check
divided q6h, PO for 7-10 days tetanus immunization; if not up to date,
administer tetanus vaccine
Analgesic and antipyretic for pain and temperature
control: Pharmacologic Interventions
acetaminophen (A class drug), 10-15 mg/kg PO Administer IV antibiotics only as directed by a
q4-6h physician:
see Bugs and Drugs, 2001, p75
• Follow up daily to ensure that infection is Antipyretic and analgesic for fever and pain:
controlled acetaminophen (A class drug), 10-15 mg/kg per
• Instruct parents or caregiver to bring child back dose PO q4-6h prn
for reassessment immediately if lesion becomes
fluctuant, if pain increases or if fever develops Monitoring and Follow-Up
Monitor vital signs and affected area frequently
Moderate To Severe Cellulitis for progression.
Consult physician if any of the following Referral
conditions exist: Medevac.
• Cellulitis is moderate to severe (e.g. large area is
involved)

Eczema (Atopic Dermatitis)

Inflammatory skin disorder characterized by None.
erythema, edema, pruritus, exudate, crusting,
pustules and vesicles. It may be an allergic Management
phenomenon. Goals of Treatment
Eczema is a common problem in children, and • Identify and control environmental causes
those affected are predisposed to impetigo. (for allergic cases)
Eczema can begin in infancy, often becoming • Prevent secondary infection
quiescent later in childhood.
Recurrences and exacerbations are common.
• Offer support to child and family, as it can be
difficult to live with this irritating chronic
Causes condition
• Largely unknown • Assist parents (or caregiver) and child to identify
• Often a familial predisposition precipitating and aggravating factors, and
• May be associated with allergic rhinitis and encourage avoidance
asthma
Client Education
History • Counsel parents (or caregiver) and child about
• Erythema appropriate use of medications (dose, frequency,
• Weeping patches application)
• Pruritus • Encourage proper hygiene, to prevent secondary
• In infancy, cheeks, face and extensor surfaces of bacterial infection
arms and legs are involved • Recommend that child wear loose-fitting cotton
• In childhood and adolescence, flexural surfaces clothing and avoid coarse materials and wool
are common sites • Recommend that soap not be used on face
• Recommend avoidance of overheating
Physical Findings • Recommend avoidance of irritants
• Erythematous, dry, pruritic lesions • Recommend avoidance of perfumes, detergents
• In severe cases, lesions may weep and soap, as much as possible (and use of a soap
• Multiple sites substitute, such as Aveeno®)
• Purulent scabs and crusts, indicating • Suggest that greasy lubricants be applied within
superinfection, may be present minutes of leaving shower or bath to "lock in"
• Lesions may be indurated moisture (e.g. Lubriderm®, Sofsyn®,
Dermabase®, creamy Vaseline®)
Differential Diagnosis • Advise parents or caregiver to stop application
• Seborrheic dermatitis of steroid preparations once acute lesions have
• Scabies healed, as steroids do not have any preventive
• Allergic dermatitis effect and can further irritate and damage the
skin
• Hereditary polymorphic light eruption
Wet Lesions
Complications Promote drying and cooling:
• Drying and thickening of skin (lichenification) normal saline compresses, qid prn

Dry Lesions Monitoring and Follow-Up

Promote lubrication: Follow up in 1-2 weeks to assess response. Advise
Glaxal® base, Nivea® cream or petroleum jelly parents or caregiver to bring child back to the
bid (i.e. after bathing and prn) clinic sooner if there are signs of infection
developing.
Reduce inflammation if itch is moderate or severe: Appropriate Consultation
hydrocortisone 1% cream or ointment Consult a physician if there is no response to
(C class drug), bid or tid for 1-2 weeks therapy after a 1- to 2-week trial. Higher-potency
steroids, if necessary, must be ordered by a
Steroids should be used only sparingly on the face physician.
and then only for brief periods.
Referral
Gels and creams are used for acute, weeping Arrange elective follow-up with a physician if
eruptions. Ointments are used for dry or there is no response to treatment outlined above.
lichenified lesions. Lotions are used for hairy
areas.

Diaper Rash
Inflammation of skin over area covered by diaper; None.
may include erythema, papules, vesicles and
occasionally bullae. Management
Goals of Treatment
Causes • Reduce exposure to irritants
• Reaction to friction and prolonged contact with • Treat any secondary infection
urine and feces
• Candidal dermatitis Nonpharmacologic Interventions
• Frequent diaper changes
History • Washing with warm water and mild soap and air
• Sore, red rash in diaper area drying at each change
• Candidal infection may be associated with oral • Exposure of child's bottom to air for longer
antibiotics being given for other reasons periods
• Candidal infection may be seen in other creased • Application of topical protection (e.g. zinc oxide
areas, such as neck and axillae, and may be cream) at each change
associated with thrush • Family and caregiver education about bathing,
diaper changing and skin maintenance
Physical Findings
Contact Diaper Dermatitis Pharmacologic Interventions
• Erythematous rash over area covered by diaper Contact diaper dermatitis may require mild
• Creases usually spared in cases of simple contact steroids:
dermatitis associated with exposure to urine hydrocortisone 1% ointment (C class drug),
applied bid until rash resolves (5-7 days)
Candidal Infection
• Erythematous rash with sharply demarcated For candidal diaper dermatitis:
edges nystatin cream (A class drug), applied qid until
• Weepy, red rash of diaper area rash resolves
• Satellite pustules outside demarcated edge
For severe cases of candidal diaper dermatitis:
• Rash often involves creases nystatin cream (A class drug), applied qid until
rash resolves
Differential Diagnosis and
• Irritative contact dermatitis hydrocortisone 1% cream (C class drug), bid
• Candidal infection
• Staphylococcal infection Monitoring and Follow-Up
• Seborrheic dermatitis Advise follow-up in 1 week if the rash has not
improved, or sooner if there are signs that the
Complications infection is worsening.
• Secondary infection with other bacteria
Referral
Not usually necessary, unless the condition is
recurrent or unresponsive to therapy.

Poison Ivy Dermatitis

A type of contact dermatitis, secondary to Consult a physician for advice if the rash is severe
exposure to poison ivy. or widespread.

• Exposure to poison ivy oleoresin • Cleanse the skin to prevent further eruption
• Wash hands, cleaning especially well under nails
History • Wash clothing contaminated by the oleoresin
• Recent work or play in the bush
• Intensely pruritic, erythematous, weeping rash Client Education
• Counsel parents (or caregiver) and children
Physical Findings about appropriate clothing to be worn for outside
• Erythema (bush) activities (e.g. long sleeves, long pants)
• Vesicular, bullous lesions
• Weeping rash For mild to moderate cases:
• Linear streaks hydrocortisone 1% cream (C class drug), applied
• Edema of affected tissue tid to affected area
Differential Diagnosis For intense pruritus:

• Eczema (atopic dermatitis) diphenhydramine hydrochloride (A class drug)
• Psoriasis 5 mg/k/day, PO, IM, IV, maximum dose 300
• Other contact dermatitis mg/day
or
Complications hydroxyzine (C class drug)
• Secondary bacterial skin infection Children <6 years old: 50 mg/day, divided q6h
Children >6 years old: 50-100 mg/day, divided
q6h
Diagnostic Tests
None.
Occasionally, a tapering course of oral steroids
(prednisone) is required (1-2 mg/kg per day for
Management 14-21 days). Steroids should be given only on the
Goals of Treatment order of a physician.
• Prevent infection
• Relieve itch Monitoring and Follow-Up
Reassess as necessary in 2 or 3days.
Referral
Usually a self-limiting problem.

Hereditary Polymorphic Light Eruption

Skin lesions occurring in areas exposed to the sun, • Secondary infection
without other cause. Commonly seen in • Lichenification
Aboriginal people throughout North and South • Depigmentation
America.
Diagnostic Tests
Causes None.
• Hypersensitivity to sunlight
• Hereditary condition Management
• Probably an immunologic phenomenon Goals of Treatment
History • Decrease exposure to sunlight
• Erythematous, vesicular, bullous rash and
papules in exposed areas, usually occurring in Nonpharmacologic Interventions
late winter through summer • Use of high-level (>30 SPF) sunscreens
• Recurrence common • Coverage of exposed parts (with clothing, wide-
• Often pruritic brimmed hats, etc.)
• Family education about dress and sunscreen use
Physical Findings
• Erythematous rash on face, hands and other Pharmacologic Interventions
exposed surfaces Topical steroids may be tried, starting with:
• Often involves cheilitis (inflammation of the hydrocortisone 1% cream (C class drug), applied
lips) od or bid for 1-2 weeks
• Distribution is a significant clue to diagnosis
Fluorinated steroids (e.g. betamethasone) may be
Differential Diagnosis necessary on body parts other than the face. Such
• Eczema (atopic dermatitis) drugs must be ordered by a physician.
• Contact dermatitis
• Impetigo Referral
Refer child to a physician for evaluation if the
• Seborrheic dermatitis
treatment is unsuccessful.

Hemangiomata
Definition Cavernous Hemangioma
Vascular nevi, which may be superficial or deep, • Capillary (strawberry) hemangioma
capillary or cavernous. Often most visible in
infancy, tending to diminish in size with age. Complications
Capillary (Strawberry) Hemangioma
Cause • Secondary infection or breakdown with
• Congenital vascular defect with genetic involution
propensity • Trauma
• Small scars may remain after involution
History
• Visible vascular lesion Cavernous Hemangioma
• Usually from birth or early infancy • Secondary infection
• Lesion changes over time • May involve underlying structures, including
bone
Capillary (Strawberry) Hemangioma • Large cavernous hemangioma may be associated
• Usually presents between birth and 2 months of with hemorrhage or thrombocytopenia
age
• Most common on face, scalp, back or chest Diagnostic Tests
• Expands rapidly initially None.
• Involuted by 5 years of age in 60% of cases
• Involuted by 9 years of age in 95% of cases Management
Goals of Treatment
Cavernous Hemangioma • Reassure child and parents or caregiver
• Red hemangioma • Treat secondary infection
• Deeper, not as well defined or demarcated as
strawberry hemangioma Nonpharmacologic Interventions
• Period of growth followed by period of • Reassurance of family
regression
Physical Findings For cavernous hemangioma, steroids
Capillary (Strawberry) Hemangioma (e.g. prednisone [B class drug], 1 mg/kg per day)
• Red, protuberant, compressible and sharply may be useful. However, steroids can be
demarcated lesion prescribed only by a physician.
Cavernous Hemangioma Referral

• Poorly defined red hemangioma • Refer child electively to a physician for
• Lesion may be compressible assessment
• Lesion may be completely covered with skin • More urgent evaluation may be necessary if
there is significant secondary infection, if the
hemangioma obscures a vital organ (e.g. the
eye), or if the lesion is large enough to trap
Capillary (Strawberry) Hemangioma
platelets
• Cavernous hemangioma
• Some children require plastic surgery
consultation

Mongolian Spots
Benign lesions, presenting as bluish black • Bruising from trauma
discoloration of the skin. Commonly seen in black,
oriental, Inuit and First Nations children. They These lesions are sometimes confused with
diminish or disappear during childhood. bruising and can be inaccurately interpreted as
evidence of child abuse.
Cause
• Unknown Complications
None.
History
• Bluish discoloration Diagnostic Tests
• Asymptomatic None.
• Lesions fade with age
Management
Physical Findings Goals of Treatment
• Bluish spots of various sizes • Make accurate diagnosis
• May occur anywhere on the body, but most
common in lumbosacral areas and on back, Nonpharmacologic Interventions
shoulders and legs • Reassurance of family

Molluscum Contagiosum
Viral condition of the skin, with firm, round, None.
translucent papules.
Management
Cause Goals of Treatment
• Viral infection • Make accurate diagnosis
• Prevent secondary infection
History
• Clusters of papules occurring anywhere on the Nonpharmacologic Interventions
body • Benign neglect is the treatment of choice (most
of the lesions disappear within 2 years)
Physical Findings • Reassure child and parents or caregiver as to
• Discrete, skin-coloured, dome-shaped papules of benign nature of lesions
various sizes • Advise against scratching or picking at lesions,
• Central umbilication to prevent secondary infection
• Occurring anywhere on the body, but with
predilection for face, eyelids, neck, axillae and Pharmacologic Interventions
thighs Podophyllin, silver nitrate or trichloroacetic acid
can be used to eradicate the lesions, if necessary.
Differential Diagnosis Do not use unless ordered by a physician.
• Warts
Referral
Refer child electively to a physician regarding
Complications
definitive treatment if the parents (or caregiver)
• Rare are concerned and desire such treatment.
• Scarring, if papule becomes infected

Ringworm Of The Scalp (Tinea Capitis)

Superficial infection of the scalp by the fungus Goals of Treatment
Microsporum or Trichophyton. • Make accurate diagnosis
• Relieve infection
Cause
• Fungal infection, usually acquired through direct Appropriate Consultation
contact with an infected person Consult a physician about treatment if you confirm
this diagnosis, since topical antifungal agents are
History ineffective on the scalp.
• Alopecia
• Other family members with same condition Nonpharmacologic Interventions
• Provide reassurance to parents or caregiver
Physical Findings • Offer support, as therapy is long and arduous
• Alopecia or patchiness of hair
• Gray scaling There is no need to shave the head.
• Broken hairs
• Lesion usually well demarcated Pharmacologic Interventions
Topical antifungal agents are ineffective on the
scalp.
• Seborrhea Consult a physician to order:
• Trichotillomania (hair-pulling) griseofulvin (B class drug), 15 mg/kg per 24 hours
• Psoriasis for 8-12 weeks
• Alopecia areata
This drug is not on the nurses' formulary.
Complications Griseofulvin can have many side effects, including
• Damaged hair follicles GI disturbances, hepatotoxicity and leukopenia,
• Spread of infection but it is generally well tolerated by children.
Diagnostic Tests Monitoring and Follow-Up

• Take scrapings of skin or hair for fungal Follow up every 2 or 3 weeks while the child is
examination receiving medication, to assess adherence, to
determine whether there are signs of improvement
• Wood's lamp test
and to offer support to the parents or caregiver.
• Potassium hydroxide (KOH) wet prep
It may be necessary to monitor CBC, creatinine
level and liver function. Discuss with a physician.

Acne Vulgaris
Definition Papules
Chronic inflammatory disease of the skin with an • Develop from obstructed follicles that become
eruption of papules or pustules. inflamed
Most common skin disorder in adolescents and Pustules

seen to some degree in all adolescents. • Larger lesions, more inflamed than papules;
superficial or deep
Although not life-threatening, acne may have
serious psychological effects on self-conscious Nodules and Cysts
adolescents. • Nodules: Formed when deep pustules rupture
and form abscesses
Causes And Pathogenesis • Cysts: End product of pustules or nodules
Acne involves the sebaceous follicles, which are • Seen in more severe cases
sebaceous glands emptying into hair follicles. • Prone to re-inflammation
Found mainly on the face, chest and back, these • May scar on healing
follicles are stimulated at puberty by increasing
levels of androgen.
The follicles produce greater amounts of sebum • Fungal infection
(oil), which combines with keratin from the lining • Acne rosacea
of the follicle to form plugs (comedones). Bacteria • Flat warts
(specifically Propionibacterium acnes) invade the
comedones and produce lipases, which break Complications
down the sebum into free fatty acids. These • Scarring
compounds cause inflammation and subsequent • Hyper-pigmentation of affected areas of the skin
rupture of the follicle.
Diagnostic Tests
History None.
• Rash, lesions on face
• Psychological effects, including embarrassment Management
and social withdrawal Goals of Treatment
• Control symptoms
Physical Findings • Prevent complications
Comedones
• Blocked follicle Client Education
• Open comedo (blackhead): epithelium-lined sac • Encourage regular use of non-irritating soaps,
filled with keratin and lipids with a widely since strong soaps may cause irritation and lead
dilated orifice, cylindrical, 1-3 mm in length; to increased production of sebum
black colour because of melanin pigment in • Recommend mild soaps containing sulfur and
dermis and exposure to air (which causes salicylic acid
discoloration of lipids and melanin); colour is • Affected areas should be cleansed two or three
not due to dirt times daily
• Closed comedo (whitehead): precursor to • Encourage persistence with medication (e.g.
inflammatory lesion; small, flask-shaped, skin- tretinoin), even if condition worsens temporarily
coloured, slightly elevated papule just beneath after 2-3 weeks of treatment
the surface of the skin • Provide education about the "myths" of acne
(e.g. not related to junk food or poor hygiene)

• Recommend avoidance of oily hair products and Oral Antibiotics

make-up tetracycline (C class drug), 250 mg tid for 3
weeks, tapering to once a day
Benzoyl Peroxide (non-formulary) This drug may be given over the long term, until
• Decreases sebum production and comedo acne resolves.
formation
• Has antibacterial effects Monitoring and Follow-Up
• Available in 2.5% to 10% gels See adolescent every 2 or 3 weeks at beginning of
treatment.
• Preferred application: 5% gel bid
• Side effects: dryness and irritation
Referral
• Consult physician for prescription
Refer any adolescent to a physician electively if
there is failure to respond to first-line therapies or
if the person has severe nodulocystic disease.
Ringworm (Tinea)
See "Ringworm (Tinea)," in chapter 9, "The Skin," in the NWT Clinical Practice Guidelines for Primary
Community Care Nursing (Adult) 2003.
Warts (Verrucae)
See "Warts (Verrucae)," in chapter 9, "The Skin," in the NWT Clinical Practice Guidelines for Primary
Community Care Nursing (Adult) 2003.

Dermatological Emergencies
Pediatric Burns
Definition Open flames and hot liquids are the most common
Tissue injuries resulting from thermal injury to cause (heat usually 15°C to 45°C or greater).
skin (epidermis) or mucosal surfaces. May include
injury to the underlying dermis, subcutaneous Risk Factors
tissue, muscle or bone. The extent of injury (the • Excess sun exposure
depth of the burn) depends on the intensity of heat • Hot water heaters set too high
(or other exposure) and the duration of exposure. • Exposure to chemicals or electricity
• Young children with thin skin are more
Burns are common in children and can cause susceptible to injury
significant morbidity and mortality. They • Carelessness with burning cigarettes
constitute the leading cause of accidental death in • Inadequate or faulty electrical wiring
children.
Specific Pediatric Issues
Types Of Burns • Body surface area is proportionately high for
First-Degree weight in younger children
• Affects epidermis only • The relative contribution of various body parts
• Painful and erythematous to body surface is different in children than in
adults (e.g. head relatively larger, legs relatively
Second-Degree smaller)
• Superficial: Affects epidermis and outer half of • In children <3 years old, scald burns from
dermis; hairs are spared spilled hot liquids are the most common type of
• Deep: Affects epidermis, with destruction of burn
reticular dermis; can easily convert to full- • Electrical burns to the mouth can occur in
thickness burn if secondary infection, toddlers who chew electrical cords
mechanical trauma or progressive thrombosis
occurs Intentional Burn Injuries
A form of child abuse that can sometimes be
Third-Degree recognized by specific burn patterns. It can be
• Tissue dry, pearly white, charred, leathery difficult to diagnose. Accurate diagnosis requires a
• Healing occurs by epithelial migration from the careful history, physical examination and
periphery and by contracture assessment of the child's developmental
• May involve adipose, fascia, muscle or bone capabilities, as well as consultation with a
physician or admission to hospital for assessment.
Causes
• Sunlight • Consider child abuse when a child presents with
• Hot fluids hot-water burns
• Steam • Observe distribution of burns
• Flame • Pay attention to straight-line burns, especially if
• Contact with hot objects bilateral
• Caustic chemicals or acids (there may be few
signs or symptoms for the first few days after History
exposure) Defer history until ABCs have been assessed and
• Electricity (may result in significant injury with stabilized.
very little damage to overlying skin) • Obtain accurate description of exact mechanism
of injury

• Inquire about any treatment given at home Goals of Treatment

(e.g. cooling, application of oils) • Promote healing and restoration of tissue
• Obtain medical history (but only when time • Prevent complications
permits) • Prevent recurrences
• Determine medications (but only when time
permits) First Aid Measures for All Burns
• Determine allergies (but only when time • Thermal burn: Cool the area if it is still warm to
permits) the touch. Burns caused by liquid should be
• Determine tetanus immunization status cooled rapidly, and any clothing in contact with
the area should be removed rapidly, to decrease
Physical Findings contact time. Immerse the body part briefly in
• Assess ABCs cool water to reduce heat and prevent extension
• Temperature may be elevated if wounds are of burn. Do not immerse or apply cold water if
infected the burns involve more than 10% of the body
• Heart rate may be elevated because of pain surface area.
• Blood pressure may be low if child is in shock • Chemical burn: Irrigate. If dry powder is still
• Determine depth (Table 16-1) and extent (Tables visible on the skin, brush it away before
16-2 and 16-3) of the burn irrigating the skin with water. Irrigate with
copious amounts of water for at least 15
• Determine nature of the burn according to injury
(preferably 30) minutes after powders have been
pattern (Table 16-4)
removed. This process should be started at the
accident scene if possible. Alkali burns should
Differential Diagnosis be irrigated for 1-2 hours after injury. Call the
• Toxic epidermal necrolysis poison control center for specific instructions.
• Scalded skin syndrome • Tar burn: Cool, clean gently and apply a
petrolatum-based antibacterial ointment (e.g.
Complications Polysporin®) or other petroleum-based
• Hypoglycemia (may occur in children because products. Do not attempt to scrape tar off the
of limited glycogen storage) skin surface, as this can cause further damage.
• Burn wound sepsis (usually gram-negative Avoid chemical solvents, which may cause
organisms) additional burns. After 24 hours the tar can be
• Decreased mobility, with possibility of future washed away and the injury treated as a thermal
flexion contractures burn.
• Gastroduodenal ulceration (Curling's ulcer) • Electrical burn: Be cautious and observe the
• Pneumonia child closely. Watch for cardiac arrhythmias.
Cardiac monitoring for 24 hours is essential if
Diagnostic Tests there was significant exposure to electrical
• Glucose level (hypoglycemia may occur in current. Apply a cervical collar. Look for long
children because of limited glycogen storage) bone fractures secondary to muscle contraction.
An electrical burn may cause thrombosis of any
• For electric burns, electrocardiogram
vessel in the body. Clean and dress as for a
thermal burn (see below).
Management
Management is based on the depth of the burns
and an accurate estimate of total body surface area
(see Tables 16-2 and 16-3).

Table 16-1: Assessing Depth of a Burn

Characteristic First degree Second degree Third degree
Blisters None Present None
Colour Red Red White, charred
Moisture Dry Wet Dry
Sensation Present Present Absent
Pain Moderate Severe Absent
Table 16-2:Assessing extent of burns in children

% of child’s body surface area by age
Area Birth to 11
1 year 5 years 10 years 15 years
months
Head 19 17 13 11 9
Neck 3 3 3 3 3
Trunk 26 26 26 26 26
Buttocks 4 4 4 4 4
Genitals 1 1 1 1 1
Arm 7 7 7 7 7
Hand 2.5 2.5 2.5 2.5 2.5
Thigh 5.5 6.5 8.5 8.5 9.5
Leg 5 5 5.5 6 6.5
Foot 3.5 3.5 3.5 3.5 3.5
Table 16-3: Classification of burns by severity (surface area involved)
Minor
• < 10% surface area in second-degree burn
• < 1% surface area in third-degree burn
Moderate
• 10% to 20% surface area in second-degree burn
• 1% to 10% surface area in third-degree burn
Severe
• > 20% surface area in second-degree burn
• > 10% surface area in third-degree burn
• any burns on hands, feet, face, eyes, ears, perineum
• any inhalation injury

Table 16-4: Classification of burns by injury pattern
Sunburn
• Areas exposed to sun
Splash or scald burns

• Maximal burns at location of impact, with lesser burns in dependent areas where fluid has cooled and dropped
• Multiple small satellite areas of burned skin may occur around scalded areas of skin
Electrical burns
• Burns of the mouth and lip, mucosal swelling and coagulation
• May have minor entrance and exit wounds, with severe underlying tissue destruction along route of current
Forced immersion burn

• Indicative of abuse
• Areas of severe burn in immersed areas usually separated from normal skin by sharp demarcation, without
splash marks
• May be in a stocking distribution or may involve trunk
• Spared sharp-edged areas may be present in dependent areas where part of the body is in contact with
immersion container
Contact burns
• Burned areas bear patterns of specific hot object in contact with the skin (e.g. grate, stove element)
• May be accidental or intentional
Flame burns
• Associated inhalation damage may cause acute respiratory failure
Cigarette burns
• Usually discrete circular lesions, well circumscribed
• May be a form of child abuse and can be confused with impetigo
Adapted with permission from Ludwig, S; Fleisher, G. 1988. Textbook of Pediatric Emergency Medicine. 2nd ed.
Willliams and Wilkins, Baltimore, MD. p902-3
Treatment Of Less Severe Thermal require antimicrobial ointment or impregnated

Burns (<10% Body Surface Area) dressings; instead, apply non-adherent porous
Nonpharmacologic Interventions mesh gauze dressings (e.g. Jelonet®)
First degree burns • Elevate a burned extremity to reduce swelling
• Cleanse with normal saline or sterile water • Increase fluid intake over the next 24 hours
• Dressings: Cover area lightly with clean, dry
gauze dressing Client Education
• Counsel family about appropriate use of
Second degree (Superficial or Deep) Burns medications (dose, frequency)
• Remove any attached clothing and debris • Suggest that analgesics be taken 1 hour before
• Cleanse with normal saline or sterile water dressing changes
• Gently debride using sterile technique • Recommend that dressing be kept clean and dry
until the area has healed
• Small blisters may be left intact
• Recommend use of sunscreen
• Remove larger blisters with forceps and scissors
(blister fluid is an excellent culture medium) • Recommend that child's access to electrical
cords and outlets be prevented
• Dressings: Small, less severe second-degree
burns (superficial partial-thickness burns) do not • Suggest that household chemicals be placed out
of child's reach

• Suggest low temperature setting for hot water • Re-evaluate depth and extent of injury
heater • Monitor for healing and development of
• Recommend that household smoke detectors be infection
installed, with special emphasis on maintenance • Cleanse and debride prn; tub soaks can help
• Recommend a family and household evacuation loosen coagulum and speed separation of
plan in case of fire necrotic debris
• Recommend proper storage and use of • Reapply bacitracin or silver sulfadiazine and dry
flammable substances sterile dressing
Adjuvant Therapy Absolute sterility is not mandatory during dressing

Check whether tetanus immunization is up to date; changes; however, cleanliness and thorough
give tetanus vaccine as needed (refer to the cleansing of hands, sinks, tubs and any
Canadian Immunization Guide, 6th edition. instruments used is emphasized. Acetic acid
Health Canada 2000) (0.25%) can be applied for pseudomonal
prophylaxis.
Analgesic for pain: Treatment Of Major Burns
acetaminophen (A class drug), 10-15 mg/kg per Appropriate Consultation
dose, PO q4h prn (for children >6 years old, Consult a physician as soon as the child's
325 mg, 1-2 tabs PO q4h prn) condition is stabilized, and prepare to medevac.
Larger, more severe, deep partial-thickness burns Primary Survey

require topical antibiotic ointment or impregnated • Stabilize ABCs
dressings (ointments can make evaluation of • Establish airway and assist ventilation as
drainage difficult). required
• Oxygen to keep oxygen saturation >97%
Apply:
bacitracin ointment (A class drug), od or bid
or
Fluid Resuscitation
bactigras dressing (A class drug), od
Calculate fluid resuscitation from time of burn, not
or
from time treatment begins.
silver sulfadiazine (A class drug), od or bid
• Start IV therapy with normal saline or Ringer's
lactate
Relative contraindication to silver sulfadiazine:
possible cross-sensitivity to other sulfonamides. • Initiate IV therapy if more than 10% of child's
body surface area has been burned
Prophylactic antibiotics should rarely be required • Replace fluid losses
but may be considered for: • Rule of thumb for fluid replacement in children
• immunocompromised children with major burns: 4 mL × body weight
• any child at high risk of endocarditis (kilograms) × % of body surface area burned
• Half of this volume is given in the first 8 hours,
Broad-spectrum coverage with first-generation a quarter in the second 8 hours and the last
cephalosporin or with a penicillinase-resistant quarter in the third 8 hours
penicillin plus an aminoglycoside may be used if • This quantity is given in addition to maintenance
necessary. fluids and is adjusted according to urine output
Discuss choice with a physician. and vital signs
Monitoring and Follow-Up Burn shock usually takes hours to develop. If

• Follow up in 24 hours and daily until the burn is shock is evident on initial presentation, look for
healed other causes of volume loss, such as major injury

elsewhere in the body. See "Shock," in chapter 20, • Wrap child in clean sheet and cover with
"General Emergencies and Major Trauma." blankets to conserve heat and prevent
hypothermia
Special Considerations for Resuscitation
• Restlessness may be secondary to hypoxia Referral
• Assume smoke inhalation; see "Inhalation of Medevac (using criteria in Table 16-5).
Toxic Material," in chapter 3, "Respiratory
System," in the NWT Clinical Practice Table 16-5: Criteria for transfer of burn
Guidelines for Primary Community Care patient to hospital
Nursing (Adult) 2003
• Monitor for respiratory distress or failure Second degree burns over 10% body surface
area
Any third degree burn
Secondary Survey Burns of hands, feet, face or perineum
• Identify associated injuries Electrical or lightening burns
• Insert urinary catheter Inhalation injury
• Insert nasogastric tube Chemical burn
• Assess peripheral circulation if child has Circumferential burn
circumferential burns on extremities
• Monitor colour, capillary refill, paresthesia and
deep tissue pain
Wound Care
• Cover burns with clean wet dressings
• Do not break blisters
• Do not immerse or apply cold water if burns
involve more than 10% of body
For analgesia, consult a physician first, if possible;
otherwise give:
morphine (D class drug) in small, frequent doses

(0.1 mg/kg per dose), IV
Be alert for respiratory depression with narcotics.
There is no indication for prophylactic antibiotics.

• Monitor ABCs and vital signs frequently
• Watch for signs of shock (it usually takes hours
for burn shock to develop)
• In circumferential burns, extensive extremity
burns or electrical burns, watch for vascular or
neurologic compromise, which indicates a
developing compartment syndrome; immediate
escharotomy is required
• Elevate extremities to minimize swelling

Chapter 17 – Hematology, Endocrinology,

Metabolism And Immunology
Explanatory Note .............................................................................................................................................. 1
Common Hematologic Problems ..................................................................................................................... 1

Iron Deficiency Anemia In Infancy ................................................................................................................ 1
Common Endocrine And Metabolic Problems............................................................................................... 3

Failure To Thrive ............................................................................................................................................ 3
Diabetes Mellitus In Aboriginal Children....................................................................................................... 6
Common Immunologic Problems .................................................................................................................. 10

Allergies........................................................................................................................................................ 10
Urticaria (Hives) ........................................................................................................................................... 11
Milk Protein Sensitivity ................................................................................................................................ 13
Lactose Intolerance ....................................................................................................................................... 14
Obesity.......................................................................................................................................................... 15

Explanatory Note
For this chapter, history and examination of the hematologic, endocrine, metabolic and
system are not discussed as such, because immunologic disorders commonly manifest in
hematologic, endocrine, metabolic and these systems.
immunologic disorders often manifest symptoms
and signs in more than one body system. The See individual chapters for information on history
cardiovascular, GI, neurologic, endocrine and and physical examination relevant to each of these
integumentary systems in particular should be systems.
evaluated, as problems or symptoms of
Common Hematologic Problems

Iron Deficiency Anemia In Infancy
See also "Iron Deficiency Anemia," in chapter 10, Predisposing Factors
"Hematology, Metabolism and Endocrinology," in • Low birth weight, prematurity
NWT Clinical Practice Guidelines for Primary • Fetal and/or neonatal blood loss
Community Care Nursing (Adult) 2003. • Low hemoglobin concentration at birth
• Insufficient absorption from mother in utero
Definition • Chronic hypoxia
Abnormally low quantities of circulating RBCs,
• Frequent infections
hemoglobin and hematocrit.
• Intake of non-iron fortified cow's milk for
> 4 months without other foods
Iron deficiency anemia is most common in
infancy, and in some communities up to 65% of • Frequent and excessive tea intake
Aboriginal infants have iron deficiency between 6 • Low Vitamin C or meat intake
and 24 months of age. • Breast-feeding for > 6 months without
The peak age is 10 to15 months supplemental iron
• Ethnic practices
Normal mean hemoglobin levels vary according to • Nutritional deficiencies (e.g. folic acid)
the age of the child (Table 17-1).
History
Table 17-1: Normal hemoglobin levels in • Diet consisting almost exclusively of milk
children • Child 6-24 months of age (usually)
Age Hemoglobin level (g/L) • Symptoms of irritability or lethargy may be
1 month 115 – 180 present
2 months 90 – 135 • Prematurity
3 – 12 months 100 – 140
1 – 5 years 110 – 140 Physical Findings
6 – 14 years 120 – 160 • Obesity
• Pallor
Causes • Tachycardia
• Inadequate iron intake • Systolic murmur
• Excess blood losses • In severe cases, signs of heart failure maybe
• Defects in hemoglobin structure present (e.g. hepatomegaly, gallop rhythm); see
• Bone marrow failure "Cardiac Failure," in chapter 11,
"Cardiovascular System"

Differential Diagnosis • For any child with obvious symptoms of

• Anemia of chronic disease anemia; this is especially urgent if there is
• Hemolytic anemia evidence of heart failure
• Anemia of acute hemorrhage
• Aplastic anemia Nonpharmacologic Interventions
• Thalassemia • Encourage appropriate intake of iron-rich foods,
• Vitamin B12 deficiency such as cereals and meats
• Folate deficiency • Encourage use of iron-fortified infant formula
• Failure to thrive because of decreased nutritional • Children with extremely severe anemia may
intake need transfusion initially
Complications
For mild anemia without heart failure:
• Frequent infection ferrous sulfate (C class drug), 5 mg/mL solution,
• Side effects of iron therapy 6 mg/kg od, for 3 months
• Cardiac failure (only if the anemia is severe)
• Poor weight gain, anorexia, blood in stools, The Canadian Task Force on the Periodic Health
malabsorption, irritability, decreased attention Examination recommends that high-risk infants be
span, exercise intolerance, decreased physical screened for iron deficiency at 9 months of age.
activity Prophylactic iron supplementation of infants
weighing less than 2500 g at birth and those
Diagnostic Tests receiving excessive amounts of evaporated milk
• CBC formulas:
• Blood smear: small, pale RBCs ferrous sulfate drops, (C class drug) 2 mg
• Ferritin level: decreased elemental iron per kilogram of body weight per
• Serum iron level: decreased day, from birth
• Hemoglobin level: decreased for age (<110 g/L)
• Serum iron-binding capacity: increased Monitoring and Follow-Up
Reassess at monthly intervals to check adherence
to treatment plan and to re-check hemoglobin
Management
level.
Goals of Treatment
• Prevent dietary deficiencies of iron Referral
• Reverse anemia and increase iron stores Refer the child to a physician if there is no
response to iron therapy after 1 month of
Appropriate Consultation treatment.
Consult a physician:
• For medication orders once anemia has been
identified

Common Endocrine And Metabolic Problems

Failure To Thrive
Definition • Renal disease
A sign (rather than a diagnosis) characterized by • Prenatal causes (e.g. intrauterine infection)
failure to gain weight commensurate with gain in
height. Length or height and head circumference Normal, Small-Statured Children
are affected in severe cases. • About 10% of cases
• This is not true failure to thrive
This sign may extend through a range of situations
from inexperience on the part of the parents or Risk Factors
caregiver to neglect and abuse. It is recognized • Undiagnosed diseases
that the parent-child relationship may play a role • Parent(s) or caregiver with psychosocial
in failure to thrive (Bennett 1996). problems
• Child born prematurely or sick at birth
The prevalence of failure to thrive is unknown.
However, 3% to 5% of pediatric inpatient • Infant with physical deformity
admissions are for evaluation of this common, yet • Unstable, dysfunctional family unit
difficult-to-diagnose problem. Most affected • Poverty
children are 6 to 12 months of age, and almost all
are <5 years old. Boys and girls are equally History
affected. • Parents or caregiver may describe child as
having a difficult personality
Causes • Sleep problems
Environmental Deprivation of Food • Previous weight, height and head circumference
• About 70% of cases for comparison (for premature infant, adjust
• One-third of these cases involve simple expected values to correct for gestational age at
educational problems, such as incorrect feeding birth)
techniques, incorrect formula preparation and
substitution with too much fruit juice Feeding History
• Other causes are poor maternal-child bonding • Dietary intake
and child neglect • Psychosocial events associated with feeding
time
Organic Causes • Food preparation
• Less than 20% of cases • Quality and quantity of food
• Usually a GI or neurologic condition preventing • Consider detailed 1- to 3-day diary of dietary
sufficient caloric intake (e.g. cleft palate or intake
choanal atresia)
• Defect in food assimilation (e.g. giardiasis, Nursing and Breast-Feeding
protein-losing enteropathy such as celiac • Infrequent, brief feedings
disease) • Maternal ingestion of milk suppressants (e.g.
• Excessive loss of ingested calories (e.g. through alcohol, diuretic drugs)
chronic diarrhea, pediatric gastroesophageal • Inadequate milk supply
reflux disease) • Nipple problems
• Immunodeficiency • Inadequate let-down, poor sucking reflex
• Pediatric AIDS • Maternal malnutrition, exhaustion or depression
• Malignant lesion
• Cyanotic heart disease

Psychosocial History educational deficiencies and personality disorders;

• Interference with adequate care-taking only one-third ultimately develop normally.
• Lower scores on intelligence testing
Family History • Poor language development and reading skills
• Height/weight of parents • Social immaturity, more frequent behavior
• Inherited diseases problems
• Developmental delay Source: Oates (1985)
Risk Factors Diagnostic Tests

• Economic stress Careful, detailed history and physical examination
• Dysfunctional family are the most valuable diagnostic tools.
• Social isolation
• Parental depression • Observation of infant and his or her interaction
with caretakers and environment
Growth Patterns • Careful plotting of growth curves, including
Expected weight gain: weight, height and head circumference
0-3 months of age: 26-31 g/day
3-9 months: 13-18 g/day Plotting of growth curve should be done at every
9-14 months: 10-11 g/day visit; observe the growth curve carefully.
15-24 months: 7-9 g/day
Routine laboratory work-up should be kept to a
minimum and should be done only if, after
Physical And Environmental Findings
consultation with a physician, it is decided to
• Weight low for age (below third percentile) on manage the case initially on an outpatient basis:
more than one occasion, or weight < 80% of
• CBC
ideal weight for age
• Urinalysis
• Growth chart shows significant deceleration of
weight gain (line recording weight gain on • Urine culture
growth chart crosses two major percentile lines) • Chemical profile, including BUN, calcium,
• Child apathetic and withdrawn or watchful and phosphorus
alert • Erythrocyte sedimentation rate
• Poor hygiene • Other studies as dictated by results of history
• Signs of inflicted trauma and physical examination (e.g. thyroid activity
profile if there are GI symptoms such as
• Primary caregiver characteristics: psychosocial
diarrhea; stool samples for culture and
problems, commonly depressed
sensitivity and occult blood)
• Family characteristics: unstable, dysfunctional
• Signs of neurologic disorders such as fetal
Management
alcohol syndrome
Goals of Treatment
• Identify the cause of failure to thrive
• Protect child from permanent sequelae
• Any condition of sufficient severity to cause
failure to gain adequate weight, including child
• Improve parenting skills of caregivers
abuse and neglect
Complications
The long-term prognosis for children with failure
Admission to an inpatient setting is often the first
to thrive due to environmental deprivation is not
step in sorting out the cause of this condition.
encouraging: many of these children remain small,
and most demonstrate developmental and

Other Measures
Nonpharmacologic Interventions • Provision of stimulation, cuddling and affection
Diet to both inpatients and outpatients
• Provision of balanced, high-calorie diet on both
a scheduled and ad lib basis Pharmacologic Interventions
• Intake should be 150-200 kcal/kg per day • Routine infant vitamin supplementation
• During observation period, discontinue all solids
with fewer calories per ounce than formula or Monitoring and Follow-Up
milk • When the cause is organic, follow-up depends
on the particular disease involved.
Client Education • When environmental deprivation is established,
• Depends on cause (e.g. provide information extremely close follow-up (weekly, both at
about preparing formula if inadequate dietary home and in the clinic) is essential. If the family
intake is the suspected cause) fails to comply with necessary measures, child
• When environmental deprivation is established, protection authorities must be notified, and
attempts to re-educate the family in a non- foster care may be necessary.
punitive way are essential
Referral
Behavioral and Family Treatment Referral for investigations to rule out organic
• Involve parents or caregiver actively in causes is advisable. The urgency of such referral
investigation and therapy depends on the particular situation. Protection of
• Recognize that parents or caregiver may the child from further harm is the most compelling
experience frustration and guilt factor.
• Restore adequate caregiving
• Modify child's maladaptive learned feeding Long-term multifaceted intervention is necessary
responses for non-organic failure to thrive:
• Address interactional difficulties between • Support and encourage positive parenting skills
parents (or caregiver) and child • Psychiatric and social services
• Developmental stimulation
• Community infant-stimulation programs

Diabetes Mellitus In Aboriginal Children

For more detailed information, see "Diabetes Causes
Mellitus," in chapter 10, "Hematology, • Genetic
Metabolism and Endocrinology," in the NWT • Autoimmune disorder
Clinical Practice Guidelines for Primary
Community Care Nursing (Adult) 2003, as well as Risk Factors
the 2003 Canadian diabetes guidelines (Meltzer et • Family history
al. 2003).
• Central obesity
• High-fat diet
Definition
Disorder of carbohydrate metabolism
characterized by hyperglycemia, which is due to History
reduced insulin secretion, increased tissue • Polyuria (excessive urination), bedwetting
resistance to insulin action or both. • Polydipsia (excessive thirst)
• Polyphagia (excessive ingestion of food)
Classification • Fatigue
There are two main types of diabetes, both • Irritability
associated with serious long-term complications, • Blurred vision
including cardiovascular diseases, hypertension, • Nausea and vomiting
kidney failure, retinopathy leading to blindness • Fu-like symptoms that do not resolve
and neuropathy. • Family history of diabetes
Type 1 Past History

• Near complete loss of insulin production • Large-birth-weight infant of a diabetic mother
• Onset may occur anytime during childhood or • Recurrent urinary tract infections or yeast
early adulthood infections (or both)
• Without insulin, ketosis develops and death may
occur Current Health
• Extremely rare (almost non-existent) in • Eating habits (food choices, meal patterns)
Aboriginal children • Physical activity
• Smoking
Type 2 • Alcohol use
• Previously known as non-insulin-dependent
diabetes mellitus Screening For Type II Diabetes In
• Relative lack of insulin or blunted response to Aboriginal Children
insulin The College of Physicians and Surgeons of
• Often associated with obesity Manitoba recommends offering yearly screening
• Ketosis is unusual for Type II diabetes to at risk asymptomatic
aboriginal children > 7 years.
In recent years, more and more cases of type 2
diabetes have been recognized in First Nations Particular risk factors include female gender,
teenagers and young children. obesity and positive family history. Recent
research has revealed aboriginal adult prevalence
Other Disorders of Carbohydrate rates of 19 to 26 percent and in a Manitoba
Metabolism community-based study a prevalence rate of
• Impaired fasting glucose tolerance 8.3 percent in aboriginal females age 10 to 19
• Impaired glucose tolerance years. Note that "aboriginal" in these studies will
The focus here is on type 2 diabetes. relate differently to First Nations than to Inuit.

Physical Findings treatment is not necessarily urgent. The diagnosis

• Vital signs normal unless there are is more likely to constitute a medical emergency if
complications there are moderate to large quantities of ketones in
• Weight changes (child may have a history of the urine and other clinical signs of ketoacidosis
weight gain over the years before onset and may (e.g. dehydration). However, ketoacidosis is rarely
lose weight after onset) seen in type 2 diabetes.
• Obesity (most commonly truncal obesity) may
be present in association with type 2 diabetes Nonpharmacologic Interventions
• Some children may show signs of dehydration Diet is the main focus of diabetes management. It
(e.g. sunken eyes, dry mucous membranes) is usually advisable to completely restructure the
diet of the entire family.
• Most affected children look normal, but may
appear ill if the diabetes is of sudden onset
A diabetic child's diet should be low in raw
carbohydrates, moderate in complex carbohydrates
Diagnostic Tests (starches) and high in fiber. A system of dietary
• Urinalysis for glucose, ketones, protein exchanges, as recommended by the Canadian
• In type 1 diabetes, there may be large amounts Diabetes Association, is useful.
of ketones, but these compounds are not usually
present in type 2 diabetes Both the parents (or caregiver) and the child
should participate in a diabetes education program,
Diagnostic Blood Glucose Levels including nutritional and lifestyle counseling.
Guidelines for diagnosis of diabetes mellitus on
the basis of serum blood glucose level: Calorie reduction for weight loss is recommended
• Random blood glucose level >11.0 mmol/L for obese children.
• Fasting blood glucose level >7.0 mmol/L
• 2-hr pc blood glucose level >11.0 mmol/L Exercise reduces blood glucose and facilitates
• For impaired fasting glucose tolerance: fasting entry of glucose into the cells. Regular exercise
blood glucose 6.1-6.9 mmol/L also decreases the risk of cardiovascular disease
• For impaired glucose tolerance: 2-hour pc blood and assists in weight loss. All children with type 2
glucose level after oral glucose load diabetes should be encouraged to develop a
7.8-11.0 mmol/L regular exercise program. All community
resources (e.g. a physical education teacher at the
In the presence of persistent symptoms, only one school and a community recreation director, if
abnormal glucose result is required for diagnosis. there is one) should be asked to help in this effort.
Without symptoms, two abnormal values are
needed for the diagnosis. Prevention
Although it is unproven that diabetes can be
Management prevented, there is fairly good evidence that
Goals of Treatment diabetes was rare among Aboriginal people 40
years ago. Changes in diet and lifestyle have
• Improve carbohydrate metabolism
probably contributed to the increasing prevalence
• Reduce symptoms
of this condition.
• Prevent long-term complications
It makes sense to try to prevent diabetes by
Appropriate Consultation increasing community knowledge of nutrition,
An urgent consultation with a physician is reducing consumption of sugar (e.g. candy,
advisable for all children with newly diagnosed chocolate bars and soft drinks), teaching about
diabetes mellitus. diabetes in the schools, and encouraging regular
exercise and development of recreation programs
If a diagnosis of type 2 diabetes is confirmed, and and facilities.
the symptoms and signs are not severe, medical

Pharmacologic Interventions Neuropathy

The two main types of drug treatment are insulin • Type 2 diabetics should be assessed annually for
and oral hypoglycemic agents. These treatments peripheral neuropathy (loss or decrease in
should not be started without a trial of vibration sense, loss of sensitivity to a 10-g
nonpharmacologic management and may be monofilament at the big toes or loss of ankle
ordered only by a physician, preferably one who reflexes, or any combination of these)
will be following the child over the long term.
Foot Care
Monitoring And Follow-Up • Assess at least annually for structural
Children with type 2 diabetes need close, regular abnormalities, neuropathy, peripheral vascular
medical follow-up. The most useful features are disease, ulcers and evidence of infection
weight and general health.
Cardiovascular Disease and Hypertension
Fasting blood glucose and HbA1c (glycosylated • Monitor blood pressure at every visit
hemoglobin) levels can serve as indicators of • Fasting lipid profile should be done for all type 2
diabetes control, but the focus should be on diabetics >15 years old, repeated every 1-3 years
lifestyle, weight loss and exercise. as clinically indicated
Monitoring for complications should include Referral
blood pressure, eye examination, urinalysis (for Medevac if there is evidence of ketonuria or
protein and microalbuminuria), glucose and renal ketoacidosis.
function, sensory function in extremities and lipid
profiles. Otherwise, the child should be evaluated by a
physician as soon as feasible. Once the child's
The Canadian Diabetes Association has made the condition has been stabilized by means of a
following recommendations for screening for diabetic regimen, the case should be reviewed by a
complications of diabetes. physician every 3-6 months, including a yearly
retinal examination. More frequent follow-up with
Retinopathy a physician is advisable if the diabetes is not well
• Type 2 diabetics >15 years old should be controlled or there is evidence of complications.
screened for retinopathy by an ophthalmologist
at the time of diagnosis The long-term management of type 2 diabetes is a
• Those with little or no retinopathy should then collaborative effort between physicians, nurses,
be screened every 2 years CHRs, nutritionists, educators and others.
• Those with retinopathy on initial screening
should be followed appropriately by an Type 2 Diabetes In Adolescent
ophthalmologist according to severity of Pregnancy
retinopathy There are special considerations for the
management of diabetes in pregnant adolescent
Nephropathy girls. Good control of blood glucose is desirable to
• Type 2 diabetics >15 years old should be reduce the risk of a large baby with congenital
screened annually for urinary microalbuminuria malformations or stillbirth.
if dipstick urine shows trace or negative protein
• Recommended screening: albumin to creatinine Careful monitoring of glucose and regular care by
ratio in a random, daytime urine sample a physician are indicated.
• If ratio > 2.8 mmol/L for females or
> 2.0 mmol/L for males, test should be repeated Pharmacotherapy is often indicated. Oral
and possibly confirmed with a 24-hour urine to hypoglycemic agents are contraindicated because
determine microalbuminuria rate of their potential teratogenic effect.

Many of these girls must be treated with insulin For detailed information on diabetes in pregnancy,
during pregnancy and require specialized prenatal see "Gestational Diabetes," in chapter 12,
care. "Obstetrics," in the NWT Clinical Practice
Guidelines for Primary Community Care Nursing
(Adult) 2003.

Common Immunologic Problems

Allergies
Definition • Respiratory symptoms: wheezing, difficulty
Any untoward physiologic event caused by an breathing, cough (especially at night)
immunologically mediated response. • GI symptoms: cramps, loose stools
Atopy is an allergic condition based on an IgE- Physical Findings

mediated mechanism, with a strong genetic • Vital signs change only with severe reactions
predisposition; may manifest as urticaria, (respiratory rate increases, heart rate increases,
anaphylaxis, eczema, asthma, insect sting allergy, blood pressure declines)
food allergy or allergic rhinitis. • Allergic facies: dark circles under eyes, folds
below eyes, transverse crease over bridge of
History nose, adenoid facies caused by chronic mouth
• Age at onset breathing, deep nasolabial folds, high arching of
• Progression of symptoms palate, enlargement of tonsils and adenoids
• Seasonality (e.g. if allergy occurs in early • Skin: dry, follicular prominence, scaling,
spring, it is probably related to trees; if in early thickening and darkening of skin in flexor
summer, to grass; if in fall, to ragweed) creases of elbows and at back of knees
• Exposure to animals • Rash: when present, includes urticaria and
• Exposure to dust eczema
• Exposure to mold in damp places • Growth: growth failure and failure to thrive may
• Complete history of environment (both indoor occasionally result from food allergies or from
and outdoor) inadequate control of asthma
• Record of activities, eating habits • Lungs: wheezing from bronchospasm
• Complete review of systems, since allergic
symptoms may involve any system Specific Conditions
The following specific allergic conditions are
Most Common Symptoms presented in this chapter:
• Skin: itch, rash, dryness • Urticaria (hives)
• Swelling of lips, eyes, ears • Milk protein sensitivity
• Nasal symptoms: clear discharge, coryza, • Lactose intolerance
sneezing, snoring

Urticaria (Hives)
Definition If swelling of the lips and subcutaneous tissues
Red, blotchy wheals of the superficial skin or occurs or there is respiratory difficulty or
mucous membranes, which blanch with pressure wheezing, emergency treatment is required. See
and are usually very itchy. "Anaphylaxis," in chapter 20, "General
Emergencies and Major Trauma."
Acute urticaria is common among children
(approximately 10% to 15% will experience at Differential Diagnosis
least one episode). • Insect bites
• Erythema multiforme
Causes • Vasculitis
Mechanism is release of vasoactive peptides • Viral exanthem
(e.g. histamine, prostaglandins, leukotrienes and
platelet-activating factor), which cause dilatation Complications
of the blood vessels in the skin and leakage of None related to urticaria.
fluid into the surrounding tissue.
If urticaria is associated with anaphylaxis,
The following are frequent causes of urticaria: respiratory failure and death could ensue. If
• Drug reactions urticaria is due to an underlying disease, treatment
• Foods must be directed to the specific disease.
• Infections (viral, streptococcal)
• Inhalants (e.g. pollen, animal dander) Diagnostic Tests
• Insect bites and stings None. In an older child, allergy testing may be
• Systemic diseases (e.g. rheumatoid disease, useful. Consult a physician about such testing.
malignant lesions, endocrine problems)
• Hereditary causes Management
• Physical causes (e.g. exercise, cold, heat, Goals of Treatment
exposure to sun) • Eliminate cause
• Provide symptomatic relief
History
• Onset Appropriate Consultation
• Duration Consult a physician if urticaria is extensive and
• Frequency (if recurrent) acute respiratory symptoms are involved.
• Diet
• Exposure to inhalants Nonpharmacologic Interventions
• Family history Avoid contact with anything that appears to be
• Fever related to the onset of urticaria
• Sore throat
• Other systemic symptoms
If symptoms are mild, some degree of
• Exposure to drugs symptomatic relief can be obtained from common
antihistamines:
Physical Findings
• Temperature normal diphenhydramine hydrochloride (A class drug)
• Heart rate normal or increased 5 mg/k/day, PO, IM, IV, max 300mg/day
• Blood pressure normal or decreased
• Rash is usually the only symptom For urgent treatment of anaphylaxis, see
"Anaphylaxis," in chapter 20, "General
Emergencies and Major Trauma."


Follow up in 24 hours to ensure that symptoms are Prepare for possible medevac if symptoms are
diminishing. severe or anaphylaxis is involved.
Otherwise, refer child electively to a physician for
evaluation.

Milk Protein Sensitivity

Abnormal GI response related to the protein in Outpatient care is acceptable except in cases of
cow's milk formula. Manifests in the first 2 malnutrition.
months of life. More common in boys and in
children with a family history of allergies. Goals of Treatment
• Primary prevention
Most children who are allergic to milk protein lose • Reduce symptoms
this sensitivity by 2 or 3 years of age. • Prevent complications
• Unknown Allergy avoidance strategies:
• Predisposing factors: significant family history • Identify the at-risk infant early (prenatally or
of allergies soon after birth; document highly atopic
families)
History And Physical Findings • Breast-feeding should be advocated as a means
• Vomiting of preventing food allergy, especially in atopic
• Diarrhea families
• Abdominal pain • Delay introduction of cow's milk (i.e. not before
• Steatorrhea 12 months of age)
• Respiratory symptoms (e.g. wheezing) • Calcium-fortified juices now available for those
• Eczema who cannot drink milk
• Poor weight gain • Awareness of different labeling terms for milk
• Edema proteins and the types of common foods which
may contain milk
Up to 25% of children with cow's milk protein
• Lactose intolerance sensitivity may also be allergic to soy protein, so
• Malabsorption syndrome switching to a soy-based formula may not help.
• Gastroenteritis
Complications • Monitor as necessary until symptoms are under
• Obstruction of gastric outlet control
• GI blood loss leading to anemia • Monitor growth to ensure that child is gaining
• Protein malabsorption leading to growth weight
retardation (e.g. failure to thrive)
• Edema secondary to hypoproteinemia Referral
Refer to a physician for evaluation if symptoms
Diagnostic Tests are not controlled by dietary measures or if you
• Serum immunoglobulin E (IgE) elevated are concerned about another underlying pathologic
(specific to milk) condition, such as inflammatory bowel disease, or
if the child is not thriving.

Lactose Intolerance
Definition Causes
Inability to digest lactose (the primary sugar in Primary Form
milk) into its constituents, glucose and galactose, • Normal decline in lactase activity in the
because of low levels of lactase enzyme in the intestinal mucosa after weaning
brush border of the duodenum. • This decline is genetically controlled and
permanent, so primary lactose intolerance is also
Congenital Lactose Intolerance permanent
• Very rare
Secondary Form
Primary Lactose Intolerance • Associated with gastroenteritis in children
• Occurs after weaning, usually beginning in late • Usually temporary, although it may persist for
childhood several months after the inciting disease has
• Age at presentation usually teenage or adult been cured
• Symptoms are experienced after consumption of • Also associated with non-tropical and tropical
milk sprue, regional enteritis, abetalipoproteinemia,
• Intolerance varies with amount of lactose cystic fibrosis, ulcerative colitis and
consumed immunoglobulin deficiencies in both adults and
• Prevalence varies according to ethnic children
background: 100% among aboriginal people in
the United States, 80% to 90% among blacks, History And Physical Findings
Asians, Jews and those of Mediterranean • Bloating
extraction, and less than 5% among descendants • Cramping
of northern and central Europeans • Abdominal discomfort
• Diarrhea or loose stools
Secondary Lactose Intolerance • Flatulence
• Caused by any condition injuring the intestinal • Rumbling (borborygmus)
mucosa (e.g. diarrhea) or a reduction of
• Vomiting common in children
available mucosal surface (e.g. because of
resection)
• Frothy, acidic stool occurs in children
• Usually transient, with duration of intolerance • Malnutrition may occur (see Table 7-4,
determined by the nature and course of the "Physical Signs of Nutritional Deficiency
primary condition Disorders," in chapter 7, "Nutrition")
• 50% or more of infants with acute or chronic • Inadequate weight gain
diarrhea (especially those with rotavirus disease)
have lactose intolerance Degree of symptoms varies with lactose load and
with other foods consumed at the same time.
• Also fairly common with giardiasis and
ascariasis, inflammatory bowel disease and
AIDS malabsorption syndrome Differential Diagnosis
• Age at presentation varies with underlying • Sucrase deficiency
condition • Diseases mentioned under "Secondary Lactose
Intolerance," in "Definition," above, this section
Breast milk contains a large quantity of lactose but • Cystic fibrosis
does not seem to worsen diarrhea associated with • Failure to thrive
viral or bacterial diseases.
Complications
Lactose Malabsorption • Calcium deficiency
• Inability to absorb lactose
• Does not necessarily parallel lactose intolerance

Diagnostic Tests • Lactose-intolerant children may tolerate whole

• Stool samples: low fecal pH and low quantity of milk or chocolate milk better than skim milk
reducing substances in stool; such results are • Lactose is tolerated better when it is consumed
valid only when stool has been collected fresh with other food products than when it is
and assayed immediately, and even in these consumed alone
circumstances, the test is fairly insensitive
• Lactose breath hydrogen test is especially useful Pharmacologic Interventions
in children (to be ordered only by a physician) Lactase (e.g. Lactaid, Lactrase), 1 or 2 capsules
or tabs before ingestion of milk products (or may
Management be added to milk before ingestion)
Outpatient care, except in severe cases of
malnutrition. These products are not in the nurses' drug
formulary.
Dietary Adjustments These agents vary in effectiveness at preventing
• Reduce or restrict dietary lactose to control symptoms. In some areas, milk with added lactase
symptoms is available.
• Yogurt and fermented products such as hard
Supplementary calcium (calcium carbonate) may
cheeses are tolerated better than milk
become necessary if dietary intake is too low.
• Prehydrolyzed milk (Lactaid) is effective
• Calcium-fortified juices for children > 1 year old Monitoring and Follow-Up
who cannot drink milk Monitor as necessary until symptoms are under
• Lactose-free formulas (e.g. Prosobee®) control. Monitor growth to ensure that the child is
gaining weight.
Client Education
• Recommend avoidance of lactose in large Referral
quantities, to relieve symptoms Refer to a physician for evaluation if symptoms
• Suggest that parents (or caregiver) and child are not controlled by dietary measures or if you
learn what level of lactose is tolerable are concerned about another underlying pathologic
• Stress that parents or caregiver must read labels condition, such as inflammatory bowel disease, or
on commercial products, because milk sugar is if the child is not thriving.
used in many products, which therefore may
cause symptoms
Obesity
See "Obesity," in chapter 7, "Nutrition."

Chapter 18 – Communicable Diseases

Common Communicable Diseases................................................................................................................... 1
History Of Present Illness And Review Of Systems....................................................................................... 1
Acquired Immunodeficiency Syndrome (AIDS) ............................................................................................ 2
Botulism.......................................................................................................................................................... 3
Exanthems (Rash) ........................................................................................................................................... 5
Rubeola (Measles) .......................................................................................................................................... 6
Scarlet Fever ................................................................................................................................................... 8
Rubella (German Measles) ........................................................................................................................... 10
Erythema Infectiosum (Fifth Disease) .......................................................................................................... 12
Roseola Infantum.......................................................................................................................................... 14
Chickenpox (Varicella)................................................................................................................................. 16
Diphtheria ..................................................................................................................................................... 18
Parotitis (Mumps) ......................................................................................................................................... 20
Pertussis (Whooping Cough) ........................................................................................................................ 22
Pinworms ...................................................................................................................................................... 24
Hepatitis........................................................................................................................................................ 25
Tuberculosis.................................................................................................................................................. 25
Mononucleosis .............................................................................................................................................. 25
Communicable Disease Emergencies ............................................................................................................ 26

Meningitis ..................................................................................................................................................... 26
The clinical presentation and management of infectious mononucleosis are the same in adults and children.
For information on this condition, see chapter 11, "Communicable Diseases," in the NWT Clinical Practice

Common Communicable Diseases

History Of Present Illness And Review Of Systems
When a communicable disease is suspected, a • Sore throat
thorough history is essential. Because • Drooling
microorganisms can affect every system, a • Vomiting
thorough review of systems is indicated. The • Diarrhea
following points should be emphasized: • Level of consciousness
• Onset (date and time) and duration of illness • Irritability
• Fever, chills or rigors • Seizures
• Pain • Contact with a person with similar symptoms or
• Rash: site, colour, consistency known communicable disease
• Involvement of mucous membranes or • Travel history (specifically, recent travel to an
conjunctiva area where a communicable disease is endemic)
• Coryza
• Cough
Vital Signs Palpation
• Temperature • Fontanel (in infants): size, consistency
• Heart rate • Neck rigidity
• Respiratory rate • Tactile characteristics of rash
• Blood pressure prn • Lymphadenopathy
• Hepatosplenomegaly
Inspection • Joint movement
• Colour • Skin turgor and hydration
• Coryza
• Pharynx: redness, lesions Auscultation (Heart And Lungs)
• Mucous membranes: moistness, lesions • Breath sounds
(e.g. Koplik's spots) • Crackles
• Skin: rash or petechiae • Wheezing
• Joints: swelling and mobility • Heart sounds
• Anal excoriation in diarrheal illnesses • Pleuritic or cardiac rubs
• Murmurs

Acquired Immunodeficiency Syndrome (AIDS)

AIDS is still rare among children in Canada. • Cryptococcus infection
However, it may result from neonatal vertical • Tuberculosis
transmission (from mother to newborn) and can
occur in adolescents who are involved in Alternatively, the person may have unusual
prostitution or drug abuse. Adolescents engaged in cancers:
such activities constitute the child population at • Kaposi's sarcoma
greatest risk for AIDS. • Primary brain lymphoma
Clinical Characteristics Other conditions associated with AIDS:
• Insidious onset of illness • Wasting syndrome
• Fever • Encephalopathy
• Diarrhea
• Fatigue Refer to HIV Infection and AIDS: Information for
• Weight loss Health Professionals. NWT H&SS August 1999.
• Lymphadenopathy Health Canada's First Nations and Inuit Health
Branch (formerly Medical Services Branch) has
The person may present with opportunistic prepared a manual on HIV infection and AIDS,
infections, sometimes severe and life threatening: which contains detailed information about this
• Pneumocystis carinii pneumonia complicated condition (Medical Services Branch
• Cryptosporidiosis 1995). The reader is also encouraged to refer to the
• Toxoplasmosis Canadian STD Guidelines (Health Canada 1998).

Botulism
Definition ingestion of improperly home-canned meats,
Illness produced by neurotoxins associated with such as salmon on the west coast.
Clostridium botulinum infection, which cause an • Vomiting
acute, descending, flaccid paralysis. • Diarrhea, followed initially by constipation
• Weakness
There are three forms of botulism: • Dry mouth
• Visual problems (e.g. blurring of vision, loss of
Classical (food-borne): occurs after ingestion of
accommodation, diplopia)
food containing pre-formed toxins; common in the
North • Dysphagia
• Dysarthria
Infantile: suspected to occur when ingested
organisms produce toxin in the gut; rare Within 3 days, onset of the following symptoms:
• Descending symmetric paralysis
Wound: occurs after contamination of a wound in • Cranial nerves affected first
which anaerobic conditions develop; rare
• Mentation clear, except for fear and anxiety
Causes Infantile Botulism
Any one of five neurotoxins produced by • Constipation often the first symptom
Clostridium botulinum.
• Weakness
• Progressive lethargy
Transmission
• In infants (infantile botulism): probably through • Poor feeding
ingestion of C. botulinum spores; honey
A history of constipation followed by progressive
frequently contains such spores, and corn syrup
weakness and decreased activity in an afebrile
has also been identified as a source of spores
infant should prompt consideration of botulism as
• In older children and adults: ingestion of food the diagnosis.
contaminated by toxin
Occasionally, the onset and progression of
Incubation lethargy and weakness is rapid, but the usual
• Food-borne: 12-36 hours after eating improperly duration of symptoms before presentation is 1-20
processed food days.
• Infantile: unknown
• Wound: 4-14 days after contamination of wound Wound Botulism
• Fever may be present but is not a diagnostic
Contagion criterion
Botulism is not known to be contagious; however, • Constipation
the precise mechanism by which infantile botulism • Purulent discharge from wound
is acquired is still unknown.
• Unilateral sensory changes
Communicability
Not applicable. Physical Findings
• Fever may be present
History • Ptosis
Food-Borne Botulism • Blurring of vision
• Exposure to home-prepared foods or honey. • Dysphagia (due to bulbar paralysis)
Botulism has occurred in Inuit communities in • Hypotonia and weakness
the Far North after ingestion of contaminated • Respiratory insufficiency
fermented seal flipper; it may also follow • Neuromuscular respiratory failure

Differential Diagnosis Discourage use of honey or corn syrup in formula

• In older children, various infections (e.g. and on pacifiers.
bacterial sepsis, meningitis, poliomyelitis, tic
syndrome); however, absence of fever and clear Appropriate Consultation
sensorium make sepsis and meningitis less likely A physician should be contacted immediately if
• Guillain-Barré syndrome, which usually presents this condition is suspected.
with ascending paralysis
Adjuvant Therapy
The descending and symmetric nature of the • Start IV therapy with normal saline, and run at a
paralysis, a history of ingestion of home-processed rate sufficient to maintain hydration
foods and early, more severe involvement of the • Give oxygen if there are signs of respiratory
cranial nerves are clues to the diagnosis. complications
Complications Nonpharmacologic Interventions

• Dehydration • Nothing by mouth
• Aspiration pneumonia
• Paralysis Control
• Respiratory failure • Notify medical health officer immediately in
• Death outbreaks of food-borne disease
• Identify food suspected of causing the outbreak,
Diagnostic Tests as antitoxin is recommended for all others who
None. have ingested this food
Management
Antitoxin, which is given when the botulism has
Goals of Treatment been caused by food-borne or wound infection,
• Provide supportive care may be used in older children but is not usually
used in infants.
Prevention
Provide instruction in the proper preparation of The antitoxin, if available, is administered only on
foods. In particular, boiling of contaminated the order of a physician.
home-processed foods for a period of 3 minutes
destroys the toxins. Arrangements may be made to have the antidote
delivered in an emergency situation.
In the Arctic, botulism seems to have increased
with the introduction of plastic bags, which are Antibiotics for wound infection may be instituted
now used by many Inuit for caching seal flipper on the advice of a physician before transfer:
and walrus for fermentation, perhaps because penicillin G sodium (B class drug),
Clostridium grows best in an anaerobic 250,000 units/kg per day, divided q6h
environment. Conversely, there is a suggestion
that botulism is less likely if porous material is Monitoring and Follow-Up
used for fermentation, because the bacteria grow Monitor ABCs, vital signs, airway protective
poorly in an aerobic environment. Education reflexes, lung sounds, pulse oximetry (if
should be provided to those who wish to continue available), intake and output.
this traditional means of food preservation.
Referral
Medevac.

Exanthems (Rash)
Definition • Fourth disease: Duke's disease (probably
A rash that "bursts forth or blooms" in association coxsackievirus or echovirus); this condition is
with some infections. difficult to distinguish as a diagnostic entity;
therefore it is not specifically covered in these
Characteristically widespread, symmetrically guidelines
distributed on the child's body, and consisting of • Fifth disease: erythema infectiosum
red, discrete or confluent flat spots (macules) and (coxsackievirus)
bumps (papules) that (at least at first) are not • Sixth disease: roseola infantum (herpes virus 6
scaly. infection, exanthem subitum)
Diseases that begin with exanthem or rash may be Many viral infections of childhood are
caused by bacteria, viruses or reactions to drugs. characterized by a rash occurring toward the end
of the disease course. Often, the rash starts on the
Some exanthems are accompanied by oral lesions, head and progresses down the body and out on to
the most well known of which are the Koplik's the extremities. About the time the rash appears,
spots of rubeola and the oral lesions found in the fever associated with the infection usually
hand-foot-and-mouth disease. disappears and the child starts to feel a lot better.
Several viral illnesses are associated with rashes
Exanthems were previously numbered according that are reliable for diagnosis (e.g. rubeola,
to their chronological appearance in the child: rubella, erythema infectiosum, roseola infantum,
• First disease: rubeola (measles) chickenpox), but the rashes of most viral illnesses
• Second disease: scarlet fever (group A are too variable to allow accurate diagnosis. That
streptococcal infection) is why healthcare professionals often tell the client
• Third disease: rubella (German measles) simply "It's a virus."

Rubeola (Measles)
Definition • After 3 or 4 days, the rash disappears, leaving a
Exanthematous disease with a relatively brownish discoloration and fine scaling
predictable course. • Conjunctivitis, pharyngitis, cervical
lymphadenopathy and splenomegaly may
Cause accompany rash
• Measles virus
Transmission • Unspecified viral exanthem
• Airborne droplets • Rubella (German measles)
• Direct contact with secretions • Adverse drug reaction
• Sensitivity to sunlight
Incubation • Roseola infantum
• About 10 days (range 8-12 days) from exposure • Coxsackievirus infection
to onset of illness • Kawasaki disease (rash much like rubeola; fever
lasts 7-10 days; characterized by inflammation
Contagion of mucous membranes and swelling of cervical
• High lymph nodes; cause unknown)
• Lifelong immunity is likely after a person has • Erythema infectiosum (fifth disease) ("slapped-
this disease. cheek" appearance and "lacy" rash on limbs and
trunk, which often comes and goes over several
Communicability weeks; not usually associated with high fever);
The disease may be transmitted during the see "Erythema Infectiosum (Fifth Disease),"
prodrome and from 1 or 2 days before up to 4 days below, this chapter
after appearance of the rash. • Scarlet fever
• Stevens-Johnson syndrome
History
• Exposure to an infected person Complications
• Fever • Otitis media
• Cough • Pneumonia
• Coryza • Encephalitis
• Malaise
• Pink eye with discharge Diagnostic Tests
• Red rash on face and trunk • Blood sample for serum IgG or IgM: a fourfold
rise in serum antibody IgG between acute and
Physical Findings convalescent serum samples or the presence of
• Fever (up to 40°C) measle-specific IgM in cases with compatible
• Koplik's spots (white spots on buccal mucosa clinical features is diagnostic
early in disease process) • Urine for viral culture
• Nasopharyngeal swab for viral culture
Rash
• Appears on day 3 to 7 Management
• Erythematous, maculopapular Prevention and Control
• Often starts on face and nape of neck, but then • Immunize children at 12 months of age or as
becomes generalized soon thereafter as possible
• Spreads from head to feet • Measles vaccine (as measles-mumps-rubella
• Lesions may become confluent (blotchy) [MMR]) is given in two doses: first dose after
child's first birthday, second dose at 18 months

• Unimmunized contacts should be given gamma • Advise families to receive no visitors, especially
globulin (0.25 mL/kg IM) within 6 days of unimmunized children and pregnant women, for
exposure or measles vaccine within 72 hours of 5 days after rash starts
exposure • Notify public health officer
Goals of Treatment Pharmacologic Interventions

• Provide supportive care Antipyretic for fever:
• Prevent spread of disease to others acetaminophen (A class drug), 10-15 mg/kg PO
q4h prn
Consult a physician if you are unsure of the Antibiotics are to be used only if bacterial
diagnosis. Rubeola is not frequently seen in a complications occur.
properly immunized population and can be
difficult to diagnose. Monitoring and Follow-Up
Advise parents or caregiver to bring the child back
Nonpharmacologic Interventions to the clinic if there are signs of complications.
• Rest
• Fluids in adequate amounts to prevent Referral
dehydration This is usually a self-limiting illness, and referral
• Keep children home from school for 5 days after is usually not necessary. Be alert for complications
rash starts such as pneumonia, and refer as needed.

Scarlet Fever
Definition • Tender anterior cervical lymphadenopathy
Syndrome caused by a group A streptococcal
toxin. It is characterized by the scarlatina form Characteristics of Scarlatina Rash
rash. • Appears 12-24 hours after the onset of the
illness, first on the trunk and then extending
Cause rapidly over the entire body to finally involve
• Erythrogenic toxin produced by group A the extremities
streptococci (which are normal flora of the • Usually spreads from head to toe
nasopharynx) • Diffusely erythematous
• Usually associated with pharyngitis but, in rare • In some children, rash is more palpable than
cases, follows streptococcal infections at other visible
sites • Usually has the texture of coarse sandpaper
• Infections may occur year-round, but prevalence • Erythema blanches with pressure
of pharyngeal disease is highest among school- • Skin may be pruritic but is not usually painful
age children (5-15 years of age), in the winter • A few days after the rash becomes generalized
and spring, and in settings of crowding and close over the body, it becomes more intense along the
contact skin folds and produces lines of confluent
petechiae, known as Pastia's lines (which are
Transmission caused by increased capillary fragility)
Person-to-person spread by respiratory droplets is • Three or four days after the onset of the rash, it
the most common method of transmission. begins to fade, and the desquamation phase
begins, with peeling of flakes from the face;
Incubation peeling from the palms and around the fingers
• 12 hours to 7 days occurs about 1 week later; desquamation lasts
for about 1 month after the onset of the disease
Contagion
• Those affected are contagious during both the Appearance of Tongue
acute illness and the subclinical phase • During the first 2 days of the disease, the tongue
• Occurs predominantly in school-age children has a white coating through which the red,
(5-15 years of age) edematous papillae project; this phase is referred
to as white strawberry tongue.
History • After 2 days, the tongue also desquamates,
Prodrome which results in a red tongue with prominent
• Fever papillae, called red strawberry tongue
• Sore throat
• Headache Differential Diagnosis
• Vomiting • Exfoliative dermatitis
• Abdominal pain • Erythema multiforme
• Mononucleosis
Physical Findings • Erythema infectiosum (fifth disease)
• Child appears moderately ill • Kawasaki disease
• Face flushed, with circumoral pallor • Rubeola (measles)
• Fever • Pharyngitis
• Tachycardia • Pneumonia
• Tonsils edematous, erythematous and covered • Rubella (German measles)
with a yellow, gray or white exudate • Pityriasis rosea
• Petechiae on the soft palate • Scabies

• Staphylococcal scalded skin syndrome Client Education

• Syphilis • Instruct parents or caregiver that child must
• Toxic epidermal necrolysis complete the entire course of antibiotics, even if
• Toxic shock syndrome symptoms resolve
• Drug hypersensitivity • Warn parents or caregiver of generalized
• Unspecified viral exanthem exfoliation over the next 2 weeks
• Emphasize the warning signs of complications
Complications of the streptococcal infection, such as persistent
• Cervical adenitis fever, increased throat or sinus pain, and
generalized swelling
• Otitis media or otitis mastoiditis
• Ethmoiditis
• Sinusitis Antipyretic for fever:
• Peritonsillar abscess acetaminophen (A class drug), 10-15 mg/kg PO
• Pneumonia q4-6h prn
• Septicemia
• Meningitis Antibiotics:
• Osteomyelitis penicillin V (C class drug) 40 mg/kg/day PO for
• Septic arthritis 10 days
• Rheumatic fever or
• Acute renal failure from post-streptococcal penicillin G benzathine (A class drug)
glomerulonephritis
Children <12 years old:
Diagnostic Tests 25,000 to 50,000 units/kg IM (one dose only;
• Throat swab for culture and sensitivity maximum dose of 1.2 million units)
Children >12 years old: 1.2 million units IM (one
dose only)
Management
Goals of Treatment For children allergic to penicillin:
• Eradicate infection erythromycin (C class drug)
• Prevent complications Children <12 years old: 40 mg/kg per day, divided
• Prevent spread to others tid, PO for 10 days
Children >12 years old: 250 mg PO qid for 10
Appropriate Consultation days
Consult a physician if you are unsure of the
diagnosis or there are complications. Monitoring and Follow-Up
Follow up in 1 or 2 days. Monitor for signs of
Nonpharmacologic Interventions complications.
• Rest
• Fluids in adequate amounts to maintain Referral
hydration Usually not necessary unless complications arise.
Prognosis for recovery is excellent with treatment.
Prevention
Children should not return to school or daycare
until the first 24 hours of antibiotic therapy is
complete.

Rubella (German Measles)

Definition • Erythema infectiosum (fifth disease)
Viral exanthematous illness, often mild and • Mononucleosis
subclinical. Rarely seen in an adequately
immunized population. Complications
In Fetus
Cause Congenital rubella syndrome may result in any of
• Rubella virus the following fetal anomalies:
• Deafness
Transmission • Cataracts
• Airborne spread of respiratory droplets • Microcephaly
• Direct contact with nasopharyngeal secretions • Mental retardation
• May also be passed through the placenta to the • Cardiac lesions
fetus • Hepatosplenomegaly
• Jaundice
Incubation The risk is highest in the first trimester.
• 14-23 days
In Children
Contagion • Thrombocytopenia
• High
In Adolescents
Communicability • Arthritis
• 1 week before to 14 days after rash erupts • Encephalitis
• Mild illness None.
• Up to 50% of cases are asymptomatic
• Low-grade fever Management
• Mild systemic signs (e.g. headache, malaise) Prevention of Congenital Rubella
• Arthralgia (joint pain), more common in Syndrome in Fetus
adolescents • All female adolescents and women of
childbearing age should be given measles-
Physical Findings mumps-rubella (MMR) vaccine unless they have
• Low-grade fever documented proof of immunity
• Conjunctivitis • Women immunized against rubella are advised
• Macular rash, which starts on face and not to become pregnant for at least 1 month after
progresses to trunk and then the extremities receiving the vaccine
• Rash does not coalesce and lasts about 3 days • The vaccine-type virus can cross the placenta;
• Lymphadenopathy (especially post-auricular, however, no case of congenital rubella has ever
posterior cervical and suboccipital nodes) occurred in newborns of women who were
• Arthritis (in adolescents) inadvertently immunized while pregnant
• The fetal risk in women "accidentally"
Differential Diagnosis immunized during pregnancy is minimal and
• Rubeola (measles) does not mandate automatic termination of the
• Unspecified viral exanthem pregnancy
• Adverse drug reaction
• Scarlet fever

• If a pregnant woman is exposed to rubella Goals of Treatment

(native disease, not associated with vaccine), an • Treat the symptoms of the illness
antibody titer should be obtained immediately; if • Prevent spread to others
antibody is present, the woman is immune and
not at risk Nonpharmacologic Interventions
• If antibody is not detectable, a second titer • Rest
should be obtained 3 weeks later; if antibody is • Fluids in adequate amounts to maintain
present in the second specimen, infection has hydration
occurred and the fetus is at risk for congenital • Parents or caregiver should be advised to limit
rubella syndrome new visitors to the home, especially pregnant
• If antibody is not detectable in the second women, for 14 days after appearance of rash
specimen, a third titer should be obtained 3 • Report all cases to the public health department
weeks later (i.e. 6 weeks after exposure); a
negative result at this time means that infection Pharmacologic Interventions
has not occurred, whereas a positive result Antipyretic and analgesic for fever and pain:
means that infection has occurred, and the fetus acetaminophen (A class drug), 10-15 mg/kg q4h
is at risk for congenital rubella syndrome prn
• Consult a physician about use of immune
globulin for prophylaxis during pregnancy, as it Antibiotics are to be used only if bacterial
predictably and reliably prevents rubella and complications occur.
congenital rubella syndrome
For further information, see the Canadian • Advise parents or caregiver to bring the child
Immunization Guide, 6th edition (Health Canada back to the clinic if there are signs of
2002). complications
• Complete recovery usually occurs in 1-2 weeks
Prevention and Control of Disease in
Children
Referral
• Rubella vaccine (as measles-mumps-rubella This is usually a self-limiting illness, so referral is
[MMR]) is given in two doses: first dose after usually not necessary. Be alert for complications
child's first birthday, second dose at 18 months such as encephalitis, and refer as needed.
of age

Erythema Infectiosum (Fifth Disease)

Definition Prodrome
Usually a benign viral childhood illness • Prodromal symptoms (especially joint
characterized by a classic "slapped-cheek" symptoms) occur more typically in adults;
appearance and lacy exanthem. children remain active and relatively
asymptomatic
Slightly more females than males are affected. • Prodromal symptoms usually mild, beginning
Approximately 70% of all cases occur in children approximately 1 week after exposure and lasting
5-15 years old, whereas infants and adults are 2-3 days
affected infrequently. Disease incidence peaks in • Headache
winter and early spring. Epidemics of infection • Fever
with the causative organism appear to occur in • Sore throat
cyclic fashion every 4-7 years. • Pruritus
• Coryza
Cause • Abdominal pain
• Human parvovirus B19 • Arthralgias
Transmission Rash
• Respiratory secretions • Typical viral rash (exanthem) occurs in three
• Possibly through fomites phases (see "Physical Findings," below, this
• Parenterally by vertical transmission from section)
mother to fetus
• Transfusion of blood or blood products Physical Findings
• Rash seen in approximately 75% of children
Fetal transmission may lead to severe anemia with human parvovirus B19 but in less than 50%
resulting in congestive heart failure and fetal of infected adults
hydrops (in fewer than 10% of primary maternal
• Begins as bright red, raised, "slapped-cheek"
infections). Recent studies have reported that the
rash with circumoral pallor (nasolabial folds
risk of fetal death in pregnant women exposed to
usually spared)
active infection with human parvovirus is 1% to
• 1-4 days later, erythematous maculopapular rash
9%, with greatest risk of fetal loss in the first
appears on proximal extremities (usually arms
trimester.
and extensor surfaces) and trunk (palms and
soles usually spared)
Incubation
• Maculopapular rash fades into classic lace-like
• Usually 7-10 days, but can range from 4 to 21
or reticular pattern as confluent areas clear
days
• Rash clears and recurs over a period of several
weeks or (occasionally) months, possibly in
Contagion
response to stimuli such as exercise, irritation or
• Once the rash appears, the person is no longer overheating of skin from bathing or sunlight
infectious
• Rash may be pruritic
• Arthritis may also occur, affecting (in order of
History frequency) metacarpophalangeal and
Usually a biphasic illness: prodrome followed by
interphalangeal joints, knees, wrists, ankles
viral rash, separated by a symptom-free period of
about 7 days.

Differential Diagnosis • Avoid excessive heat or sunlight (which can

• Hand-foot-and-mouth disease cause flare-ups of the rash)
• Rubeola (measles) • Thorough hand-washing should be encouraged
• Parotitis (mumps)
• Roseola infantum Client Education
• Rubella (German measles) • Emphasize in discussion with parents or
• Scarlet fever caregiver that otherwise healthy children are not
• Systemic lupus erythematosus infectious once the rash appears, so there is no
need to isolate or restrict the child from school
• Adverse drug reaction
or daycare
• Allergic rash
• Infected children with hemolytic disease or
• Unspecified viral exanthem immunosuppression may be quite infectious; in
these cases, respiratory isolation, especially from
Complications pregnant, chronically anemic or immuno-
• Complications most often seen in children with suppressed individuals, should be observed
underlying chronic hemolytic anemia or a
congenital or acquired immunodeficient state Pharmacologic Interventions
• Arthralgia or arthropathy occurs in up to 10% of Antipyretic and analgesic for fever and pain:
affected children acetaminophen (A class drug), 10-15 mg/kg PO
• Aplastic anemia q4h prn
Diagnostic Tests Monitoring and Follow-Up

None. Follow up as necessary if complications develop
or symptoms do not resolve in the expected period
Management of time (up to 20 days or more).
Goals of Treatment
• Provide supportive care Referral
Usually not necessary unless complications arise.
Rash is usually self-resolving, but may last several
weeks or months with exacerbations caused by
heat or sunlight.

Roseola Infantum
Definition • Non-pruritic
Acute benign disease characterized by a prodromal • Lesions blanch on pressure
febrile illness, lasting approximately 3 days and • Seizures (in 6% to 15% of cases)
followed by defervescence and the appearance of a • Diarrhea (in 68% of cases)
faint pink maculopapular rash.
Physical Findings
May present as an acute febrile illness associated • Child appears alert, not acutely ill
with respiratory or GI symptoms.
• Fever
Most cases present within the first 2 years of life,
with the peak age of occurrence between 7 and 13
• Rash
months. Roseola appears more commonly in the • Rose-pink macules or maculopapules
spring and fall. approximately 2-5 mm in diameter
• Lesions characteristically discrete, rarely
coalescing together and blanching with pressure
Cause
Human herpes virus 6 (HHV-6) was identified as • Typically involves the trunk or back, with
the etiologic agent in 1988. There are two major minimal involvement of the face and proximal
strains of this virus, A and B. Strain B is extremities
responsible for most of the primary infections in • Some lesions may be surrounded by a halo of
children. pale skin
• Nagayama's spots (erythematous papules on the
Transmission soft palate and uvula)
• Probably through respiratory secretions of • Periorbital edema, most commonly in the pre-
asymptomatic individuals exanthematous stage
• Cervical, post-auricular and post-occipital
Incubation lymphadenopathy
• About 9 days (range 5-15 days) • Splenomegaly
• Conjunctival erythema
Contagion
• Most likely to spread during febrile and viremic Differential Diagnosis
phases of the illness • Mononucleosis
• Viremia usually noted on third day of illness, • Febrile seizures
just before appearance of rash • Erythema infectiosum (fifth disease)
• By eighth day of illness, antibody activity peaks • Rubeola (measles)
and viremia resolves • Meningitis or encephalitis
• Rubella (German measles)
History • Adverse drug reaction
Roseola is classically characterized by high fever
followed by rapid defervescence and a Complications
characteristic rash. Roseola is usually a self-limiting illness with no
• Prodromal symptoms (in 14% of cases): sequelae.
listlessness, irritability • Seizures during the febrile phase of the illness
• Fever (often as high as 40°C) • Encephalitis
• Rash (usually fades within a few hours but may • Meningitis
last up to 2 days) • Hepatitis
• Maculopapular or erythematous lesions
• Rash typically begins on the trunk and may
spread to involve the neck and extremities

Fulminate hepatitis, hemophagocytic syndrome Client Education

and disseminated infection with HHV-6 are • Educate family about signs and symptoms of
extremely rare manifestations. complications
• For an older child, recommend that he or she
Diagnostic Tests cover nose and mouth when sneezing or
None. coughing

Goals of Treatment Antipyretic for fever:
• Provide supportive care acetaminophen (A class drug), 10-15 mg/kg PO
q4h prn
• Rest Monitoring and Follow-Up
• Maintain adequate fluid intake The illness is usually benign and brief. Follow-up
• Reassure parents or caregiver as to benign nature is necessary only if complications develop.
of illness
Referral
Not necessary, unless complications develop.

Chickenpox (Varicella)
Usually benign viral infection characterized by • Scabies
vesicular eruptions. • Impetigo
• Herpes
Cause • Infection with coxsackievirus
• Herpes zoster virus
Complications
Transmission • Impetigo
• Direct contact • Cellulitis
• Inhalation of airborne droplets • Encephalitis
• Pneumonia
Incubation
• Usually 13-17 days, or up to 3 weeks Management
• Chickenpox typically develops 2 weeks after Goals of Treatment
contact • Provide supportive care
Contagion Nonpharmacologic Interventions
• Very high • Calamine lotion or Aveeno® baths to control
itching and to help dry lesions
Communicability • Chickenpox is reportable in the NWT
• Most infectious 12-24 hours before the rash
appears The Canadian Paediatric Society recommends that
children with mild chickenpox be allowed to
History return to school or daycare as soon as they feel
• Slight fever well enough to participate in all activities,
• Mild constitutional symptoms regardless of the state of their rash. Practice may
• Skin lesions, possibly extensive, in successive vary in your area, depending on local school
crops policy.
• Lesions may involve mucous membranes
• There may be only a few lesions Pharmacologic Interventions
• Rash usually starts on trunk or neck hydroxyzine (C class drug), 2 mg/kg, divided bid
or tid, PO
Physical Findings or
• Fever usually mild diphenhydramine hydrochloride (A class drug)
1.25 mg/kg PO q4-6h prn, maximum 4 doses per
• Skin lesions begin as macules
day
• Skin lesions at various stages may be present
concurrently Immunocompromised children must receive
• Lesions become vesicular after 3-4 days, then varicella zoster immune globulin (VZIG) with in
break open with development of scabs 24 hours of exposure. Immune globulin is also
recommended for newborns and for mothers who
Lifelong immunity is likely, although as immunity develop chickenpox between 5 days before and
wanes with age, herpes zoster (shingles) may 48 hours after delivery. Discuss with a physician.
occur, usually in elderly people. Shingles is a local
recurrence of the same virus, and may be slightly Monitoring and Follow-Up
contagious to non-immune individuals. Follow up after 1 week.

Referral Prevention
Not usually necessary unless complications arise. A varicella vaccine was licensed in Canada in
December 1998.
Varicella vaccine is offered routinely to all infants

in the NWT at one year of age.

Diphtheria
Definition • Laryngeal diphtheria most often represents an
Acute infectious disease affecting primarily the extension of pharyngeal infection and presents
membranes of the upper respiratory tract. Occurs clinically as typical croup; acute airway
most frequently in children <15 years old who are obstruction may occur
inadequately immunized. • Cutaneous (skin) diphtheria is characterized by
non-healing ulcers with a gray membrane that
Cause may serve as a reservoir of respiratory diphtheria
• Corynebacterium diphtheria (toxigenic or non- in endemic areas
toxigenic strain) • Skin is the major reservoir of infection in
Canadian Aboriginal communities
Transmission
• Direct contact with affected person or carrier Physical Findings
through airborne respiratory droplets Findings are variable, depending on the site and
the extent of infection, but may include any of the
Incubation following:
• 1-6 days • Fever
• Tachycardia out of proportion to fever
Contagion • Child appears acutely ill
• Moderate • Ear discharge
• Nasal discharge
Communicability • Adherent nasal and/or pharyngeal gray or white
• May be transmitted until virulent bacilli have membrane
disappeared from infected person's system • Neck swollen
• Rarely, chronic carriers may shed the organism • Moderate to severe lymphadenopathy
for months • Skin lesions, which may resemble impetigo
• Cough, hoarseness
History • Stridor
• Acute onset • Respiratory distress
• Fever
• Aural discharge Differential Diagnosis
• Nasal discharge • Streptococcal pharyngitis
• Sore throat • Peritonsillar abscess (quinsy)
• Aural diphtheria presents as otitis externa with a • Vincent's infection (Vincent's angina)
purulent, malodorous discharge • Infectious mononucleosis
• Nasal diphtheria, common in infants, starts with
mild rhinorrhea that gradually becomes Complications
serosanguineous, then mucopurulent; discharge • Respiratory obstruction
is often malodorous • Toxic effects (including nerve palsies and
• Pharyngotonsillar diphtheria begins with myocarditis) 2-6 weeks after resolution of initial
anorexia, malaise, low-grade fever and sore symptoms
throat
• Nasal and/or pharyngeal membrane appears Diagnostic Tests
within 1 or 2 days • Obtain throat and/or nasopharyngeal swabs for
• Cervical lymphadenitis and edema of the culture and sensitivity to confirm diagnosis
cervical soft tissues may be severe, and
respiratory and cardiovascular collapse may
occur

Management Adjuvant Therapy

Prevention • Start IV therapy with normal saline, and run at a
Diphtheria toxoid given as diphtheria-pertussis- rate sufficient to maintain hydration
tetanus-polio (DPTP) combination vaccine for • Give oxygen prn if there are signs of respiratory
children <7 years old or as tetanus-diphtheria- distress
polio (Td-Polio) combination vaccine for children
>7 years old, according to NWT recommended Nonpharmacologic Interventions
immunization schedule; see also Canadian • Nothing by mouth
Immunization Guide, 6th edition (Health Canada • Bed rest
2002).
For Contacts of Index Cases Antibiotics may be instituted before transfer, but
Antibiotics should be given: only on the advice of a physician:
erythromycin (C class drug) for 7 days
Usual antibiotic therapy:
• If contact has been previously immunized but erythromycin (C class drug), 40 mg/kg per day,
has not had a booster in the past 5 years, give divided bid, IM or IV
booster dose of diphtheria vaccine
• If contact has never been immunized, use Carrier state may be treated with:
antibiotics as described here, obtain culture erythromycin (A class drug), 40 mg/kg per day,
before and after initiation of antibiotic, and start divided qid, PO for 7 days
an age-appropriate series of immunizations with
diphtheria vaccine Monitoring and Follow-Up
Monitor ABCs, pulse oximetry (if available),
Goals of Treatment respiratory, cardiovascular and neurologic
• ABCs are the first priority systems, hydration status, intake and output.
• Stabilize any airway difficulty
Referral
Appropriate Consultation Medevac.
Immediate consultation with a physician is
essential.

Parotitis (Mumps)
Acute viral infection characterized by painful • Sialolithiasis (parotid stones)
swelling of the parotid and other salivary glands. • Sjögren's syndrome (parotitis,
keratoconjunctivitis, absence of tears)
Cause • Purulent parotitis
• Mumps virus • Parotid tumor
• Buccal cellulitis
Transmission
• Airborne droplets Complications
• Direct contact with saliva • Orchitis
• Oophoritis
Incubation • Deafness
• 2-3 weeks • Pancreatitis
• Encephalitis
Contagion • Aseptic meningitis
• Low to moderate
Diagnostic Tests
Communicability None.
• 6 days before to 9 days after parotitis appears
Management
History Prevention and Control
• Exposure to infected person Mumps vaccine (as measles-mumps-rubella
• Inadequate immunization [MMR]) is given in two doses: see NWT
• Pain and swelling of parotid glands (may be Immunization Schedule and Canadian
unilateral or bilateral) Immunization Guide, 6th edition (Health Canada
2002)
• Dysphagia
Goals of Treatment
Prodrome
• Provide supportive care
• Fever
• Malaise
• Prevent spread to others
• Anorexia
• Headache Appropriate Consultation
• Myalgia (sore muscles) Consult a physician if you are unsure of the
diagnosis. Parotitis is not frequently seen in a
Physical Findings properly immunized population and so can be
• Swelling of parotid glands (may be unilateral or difficult to diagnose.
bilateral)
• Glands very tender to the touch Nonpharmacologic Interventions
• Ear on affected side displaced upward and • Rest
outward • Fluids in amounts adequate to prevent
• Submaxillary and sublingual glands may also be dehydration
swollen • Child may return to school 9 days after the onset
• Dysphonia of parotid swelling
• Advise parents or caregiver to limit visitors,
especially unimmunized children and pregnant
women, for 5 days after swelling starts
• Notify public health officer


Antipyretic and analgesic for fever and pain: • Advise parents or caregiver to bring the child
acetaminophen (A class drug) back to the clinic if there are signs of
Children <6 years old: 10-15 mg/kg q4h prn complications
Children 6-12 years old: 325 mg, q4h prn • Complete recovery usually occurs in 1-2 weeks
Children >12 years old: 325-650 mg q4h prn
Referral
Antibiotics are to be used only if bacterial This is usually a self-limiting illness, so referral is
complications occur. usually not necessary. Be alert for complications
such as pneumonia, and refer as needed.

Pertussis (Whooping Cough)

Acute bacterial illness of the upper respiratory • Viral infections (consider respiratory syncytial
tract. virus, adenovirus, parainfluenza virus)
• Asthma
Cause • Tuberculosis
• Bordetella pertussis
Complications
Incubation • Hypoxia
• 7-10 days • Apnea in young infants (<6 months old)
• Pneumonia
Contagion • Seizures
• High in unimmunized people
Diagnostic Tests
Communicability • CBC (high WBC count, with predominance of
• Highly transmissible in early catarrhal stage, lymphocytes)
before paroxysmal cough stage • Culture of nasopharyngeal specimens using
• Negligible after 3 weeks calcium alginate or Dacron swab and special
• Usually extends 5-7 days after onset of therapy culture media (if these culture materials are
available) should be attempted to confirm
History diagnosis
Catarrhal Stage
• 1-2 weeks The causative organism is usually cultured only in
• Symptoms of URTI: rhinorrhea, fever, the catarrhal or early paroxysmal stage.
conjunctival redness, lacrimation
Management
Paroxysmal Stage Prevention and Control
• 2-4 weeks or longer • Immunization according to standard schedule
• Paroxysmal cough, increasing in frequency and with DPTP combination vaccine (2, 4, 6 and 18
severity, with a high-pitched inspiratory whoop months and before starting school [i.e. 4-6 years
at end of paroxysm of age])
• Vomiting may occur after coughing paroxysm • See Canadian Immunization Guide, 6th edition
• Cyanotic and apneic spells common in infants (Health Canada 2002)
• Feeding difficulties
For Contacts of Index Cases
Whoop does not usually occur in young infants Close contacts <6 years old who have not received
and is not necessary for diagnosis. their primary DPTP series should be given one
dose of DPTP.
Physical Findings
• Fever Goals of Treatment
• Rhinorrhea • Treat infection
• Lacrimation (tearing) • Prevent complications
• Conjunctival redness • Prevent spread to others
• Apnea and cyanosis (may be seen during
paroxysmal stage and may be present without
the paroxysmal cough)
• Lungs normal, unless pneumonia or atelectasis
have occurred


Consult a physician if you suspect this diagnosis in erythromycin (C class drug), 40 mg/kg per day,
a younger child, especially in an infant, as this age divided qid, for 14 days
group is most at risk for complications.
If the child is allergic to erythromycin, consult a
Nonpharmacologic Interventions physician for alternatives.
• Rest
• Fluids in amounts adequate to maintain For Contacts of Index Cases
hydration erythromycin (C class drug), 40 mg/kg per day for
• Report any suspected or confirmed cases to household or daycare contacts
public health officer
Client Education The paroxysmal stage may last up to 4 weeks, and
• Educate the parents or caregiver about the signs the convalescent stage up to several months.
of complications Follow up every 1-2 weeks as necessary, to
• Counsel the parents or caregiver about monitor for complications and to provide support.
appropriate use of medications (dose, frequency,
side effects) Referral
• Advise parents or caregiver to limit new visitors Infants and older children with severe disease
to the home until 5 days after antibiotic therapy manifestations (e.g. apnea, cyanosis or feeding
is started difficulties) should be admitted to hospital for
supportive care.

Pinworms
Parasitic infestation of the cecum of the large • Perianal excoriation from scratching
bowel. More common in girls, occurring in late • Vulvovaginitis
fall and winter. Unrelated to personal hygiene.
Diagnostic Tests
Cause • Scotch Tape test: apply transparent tape to
• Enterobius vermicularis perianal region, remove tape early in the
morning and examine microscopically for eggs
Transmission
• Direct transfer of eggs from anus to mouth Management
• Contact with fomites contaminated with eggs Goals of Treatment
• Relieve infestation
Incubation • Prevent spread to others
• 4-6 weeks (duration of organism's life cycle)
Contagion • Wash bed clothes, towels and clothing
• Medium to high • Vacuum house
Communicability Client Education
• About 2 weeks (as long as eggs are laid on • Educate all members of the family about
perianal skin and remain intact) personal hygiene (hand-washing, cutting
fingernails)
History
• Anal itching, worst at night Pharmacologic Interventions
• Irritability pyrantel pamoate (C class drug), 11 mg/kg, single
• Restlessness during sleep dose, tabs or suspension
• Diffuse, non-specific abdominal pain may occur
The whole family should be given treatment
Physical Findings concurrently.
• Small white worms visible in perineal area or
stool Monitoring and Follow-Up
Symptoms should improve in several days.
Usually there is no need to re-treat, although
recurrence is common.
• Hemorrhoids
• Tapeworms Referral
None.

Hepatitis
Hepatitis A And Hepatitis B Prevention of Hepatitis B in the
See "Hepatitis" in chapter 11 "Communicable Newborn
Diseases," in the NWT Clinical Practice • If a newborn is exposed to hepatitis B (i.e.
Guidelines for Primary Community Care Nursing mother is positive for hepatitis B surface antigen
(Adult) 2003 for detailed information on the [HBsAg]), hepatitis B immune globulin (0.5 mL
clinical presentation and management of acute IM) is given within 24 hours of birth, and
hepatitis A and hepatitis B. hepatitis B vaccine (0.5 mL) is administered
within 7 days after birth and at 1 and 6 months
Control of Hepatitis A of age
immune serum globulin 0.02-0.04 mL/kg IM to • All infants in the NWT receive 3 doses of
household and daycare contacts hepatitis B vaccine at birth, 1 and 6 months of
age
Tuberculosis
See "Tuberculosis," in chapter 11, "Communicable past 20 years, the incidence of TB has decreased
Diseases," in the NWT Clinical Practice dramatically in Canada as a whole, although there
Guidelines for Primary Community Care Nursing is currently an upward trend because it occurs
(Adult) 2003, and "NWT Tuberculosis Manual" frequently in people with AIDS. In addition, TB
March 2003 for detailed information on the remains endemic among Aboriginal Canadians.
clinical presentation and management of • Most prevalent in people with crowded living
tuberculosis. conditions
• Children particularly susceptible
In addition, detailed information on the
prevention, diagnosis and treatment of pulmonary Prevention And Control Of Tb In
tuberculosis can be found in Canadian
Children
Tuberculosis Standards (Canadian Lung
BCG vaccine is routinely administered to
Association 2000).
Aboriginal newborns. It protects against TB
meningitis and disseminated (miliary) TB. It may
Tuberculosis has been a significant cause of
be less effective in preventing pulmonary TB.
morbidity and mortality among Canada's
Aboriginal peoples in the past 50 years. Over the
Mononucleosis
See "Mononucleosis," in chapter 11, "Communicable Diseases," in the NWT Clinical Practice Guidelines for

Communicable Disease Emergencies

Meningitis
Definition Incubation
Inflammation of the meningeal membranes of the • Meningitis caused by H. influenzae: 2-4 days
brain or spinal cord. Most cases (70%) occur in • Meningococcal meningitis (caused by N.
children <5 years old. May be secondary to other meningitidis): 2-10 days
localized or systemic infections (e.g. otitis media).
Contagion
Causes • Meningitis caused by H. influenzae: moderate;
Meningitis may be caused by bacteria, viruses, high risk of transmission in daycare centers and
fungi and (rarely) parasites. other crowded environments
• Meningococcal meningitis (caused by N.
Bacterial meningitidis): low; spreads most rapidly in
• In children <1 month old: group B crowded conditions
Streptococcus, Escherichia coli
• In children 4-12 weeks old: E. coli, Hemophilus Communicability
influenzae type B, Streptococcus pneumoniae, • Meningitis caused by H. influenzae: as long as
group B Streptococcus, Neisseria meningitidis organisms are present; non-communicable
(meningococcal) within 24-48 hours after treatment is started
• In children 3 months to 18 years old: • Meningococcal meningitis (caused by
Streptococcus pneumoniae (most common N. meningitidis): until organism is no longer
cause), N. meningitidis, H. influenza type B present in secretions from nose and mouth
(rare)
• Mycobacterium tuberculosis History
• Usually preceded by URTI
Viral • High fever
• Approximately 70 strains of enteroviruses
In children <12 months old the symptoms are non-
Fungal specific. The following symptoms are commonly
• Candida reported by the parent or caregiver:
• Irritability
Aseptic • Child sleeps "all the time"
• Lyme disease • Child is "not acting right"
• Child cries when moved or picked up
All cases of suspected meningitis occurring in • Child won't stop crying
northern communities should be treated as • "Soft spot bulging"
bacterial until proven otherwise. • Vomiting (often without preceding nausea)
• Poor feeding
Transmission
• Meningitis caused by H. influenzae: airborne Older children may complain of the following
droplets and secretions symptoms:
• Meningococcal meningitis (caused by N. • Photophobia
meningitidis): direct contact with droplets or
• Headache that becomes increasingly severe
secretions
• Headache made worse with movement,
especially bending forward
• Neck pain

• Back pain meningitis, to increase the chance of isolating the

• Changes in level of consciousness, progressing organism. Consultation with a physician should be
from irritability through confusion, drowsiness attempted before initiating collection of these
and stupor to coma specimens.
• Seizures may develop • One blood culture
• Rash (purple spots) • Urine for routine and microscopy, culture and
sensitivity
Physical Findings • Throat swab for culture and sensitivity
Perform a full head and neck examination to
identify a possible source of infection. Management
• Temperature elevated Goals of Treatment
• Tachycardia or bradycardia with increased • Control infection
intracranial pressure • Prevent complications
• Blood pressure normal (low if septic shock has
occurred) Appropriate Consultation
• Child in moderate-to-acute distress Consult a physician immediately. Do not delay
• Flushed starting antibiotics if this diagnosis is suspected. If
• Level of consciousness variable you are unable to contact a physician, follow the
• Possible enlargement of the cervical nodes guidelines below for IV antibiotics.
• Focal neurologic signs: photophobia, nuchal
rigidity (in children >12 months old), positive Nonpharmacologic Interventions
Brudzinski's sign (spontaneous hip flexion with • Bed rest
passive neck flexion; in children >12 months • Nothing by mouth
old), positive Kernig's sign (pain with passive • Foley catheter (optional if the child is conscious)
knee extension and hip flexion; in children >12
months old) Adjuvant Therapy
• Petechiae with or without purpura may be • Start IV therapy with normal saline, and adjust
present in meningococcal meningitis rate according to state of hydration
• Shock (septic)
Do not overload with fluids, as this could lead to
Differential Diagnosis brain edema.
• Bacteremia
• Sepsis Pharmacologic Interventions
Antipyretic for fever:
• Septic shock acetaminophen (A class drug), 10-15 mg/kg q4h
• Brain abscess prn
• Seizures
Consult a physician before initiating antibiotic
Complications therapy, if you are able to do so. Give initial
• Seizures antibiotic dose as soon as possible. These may
• Coma include: ampicillin, gentamicin, a cephalosporin
• Blindness and vancomycin
• Deafness Bugs and Drugs (2001) p 120
• Death
• Palsies of cranial nerves III, VI, VII, VIII Monitoring and Follow-Up
Monitor ABCs, vital signs, level of consciousness,
Diagnostic Tests intake and hourly urine output, and watch for focal
It is important to culture several specimens before neurologic symptoms.
initiating antibiotic therapy in cases of suspected

Referral
Prevention and Control

Meningitis caused by Hemophilus influenzae
A vaccine is now routinely given to infants as part
of the usual childhood immunizations. In the NWT
the vaccine is usually given at 2, 4, 6 and 18
months of age, along with the DPTP vaccine.
Chemoprophylaxis for household contacts

(including adults) in homes where there are
children <4 years old:
rifampin (B class drug), 20 mg/kg per dose od for
4 days (maximum dose 600 mg)
Meningococcal Meningitis
Vaccines for certain subtypes are available and are
sometimes used in epidemics.
Vaccine for Meningococcal disease, type C, is

now being offered to all chidlren in the NWT and
has been added to the routine immunization
schedule for infants. (February 2004)
Chemoprophylaxis for household contacts:

rifampin (B class drug)
Infants <1 month old: 5 mg/kg bid for 2 days
Children: 10 mg/kg bid for 2 days
Adults: 600 mg bid for 2 days

Chapter 19 – Adolescent Health

Introduction ....................................................................................................................................................... 1
Adolescent Development................................................................................................................................... 1
Characteristics Of Developmental Stages....................................................................................................... 1
Adolescent Health Care .................................................................................................................................... 2

History-Taking................................................................................................................................................ 2
Comprehensive Physical Examination ........................................................................................................... 2
Puberty............................................................................................................................................................ 3
Sexuality ......................................................................................................................................................... 4
Teen Pregnancy: Testing And Counseling ..................................................................................................... 5
Contraception.................................................................................................................................................. 5
Sexually Transmitted Infections ..................................................................................................................... 6
Suicide ............................................................................................................................................................ 7
Injury Prevention ............................................................................................................................................ 7
Alcohol, Nicotine, Drug And Inhalant Abuse ................................................................................................. 8

Factors Associated With Higher-Risk Behaviors ........................................................................................... 8
Risk For Substance And Alcohol Abuse ........................................................................................................ 8
Alcohol............................................................................................................................................................ 8
Nicotine........................................................................................................................................................... 9
Marijuana........................................................................................................................................................ 9
Inhalants.......................................................................................................................................................... 9
Interventions In Substance Abuse................................................................................................................... 9
For information about injury prevention, see "Injury Prevention Strategies," in chapter 3, "Prevention," these
pediatric clinical guidelines.
For information about the clinical presentation and management of STIs, see "Sexually Transmitted
Diseases," in chapter 11, "Communicable Diseases," in the NWT Clinical Practice Guidelines for Primary
Community Care Nursing (Adult) 2003. In addition, refer to and follow the Canadian STI Guidelines (Health
Canada 1998).
For information about suicide, see "Suicidal Behavior," in chapter 15, "Mental Health," in the NWT Clinical
Practice Guidelines for Primary Community Care Nursing (Adult) 2003.

Introduction
Adolescence is a unique time in human Another unfortunate characteristic of adolescence
development, both physiologically and is a propensity for risk-taking behaviors, such as
psychologically. Adolescents in modern society abuse of drugs and alcohol, which cause premature
face many health issues, particularly in the areas morbidity and death within this age group.
of mental, emotional and social health. Among adolescents, 77% of deaths are caused by
Unfortunately, adolescence is also a period of life accidents, violence and suicide.
when there is little or no contact with healthcare
professionals.
Adolescent Development
Requirements for healthy development: Other factors assisting in healthy development:
• Supportive environment over the long term • Mutual positive engagement between
• Graded steps toward autonomy adolescents and adults
• School and community programs
Characteristics Of Developmental Stages

Early Adolescence Late Adolescence
• Preoccupation with body changes • Adult appearance
• High levels of physical activity and mood • More capable of orienting activities toward the
swings future, of mutual caring and of internal control
• Uncertainties about sexuality, future
Mid-Adolescence relationships and work possibilities
• Independence
• Peer group dominates social life
• Risk behaviors more prevalent
• Sexual matters are of most interest

Adolescent Health Care

An acute medical need is the most frequent reason S for sexuality issues
for an adolescent to seek medical care. It is A for affect (e.g. depression) and abuse (e.g.
important to take this opportunity to discuss other drugs)
topics important to adolescent health. The F for family (function and medical history)
mnemonic SAFE TIMES is one way of E for examination (sensitive and appropriate)
remembering appropriate topics for discussion: T for timing of development (body image)
I for immunizations
M for minerals (nutritional issues)
E for education and employment (school and
work issues)
S for safety (e.g. vehicle)
History-Taking
Consider the following points when interviewing (e.g. "How would you compare your school
an adolescent: performance with that of others? Better, worse
• Ensure that the adolescent is the prime historian. or the same?").
It is preferable to interview the adolescent
without his or her parents or caregiver, although Functional Inquiry
it may be necessary to obtain collateral history A complete history of the health status of the
from parents, caregivers, teachers and others. adolescent should be undertaken whenever an
Assure the adolescent that all important opportunity to do so presents itself. A record of
problems will be kept strictly confidential (there pubertal changes and, for young women, a
are some obvious exceptions, including suicide complete menstrual history, are essential
intention and other high-risk, potentially components of this history.
destructive activity).
• Sensitively explore with the adolescent any Psychosocial Evaluation
problems with sexuality, drugs, alcohol, school Issues related to sexuality, drug or alcohol use, and
and family. family and school problems should be
• Try to elicit information about the activities in systematically reviewed. Questions about school
which the adolescent participates and what his or attendance and performance and future plans for
her peer group is doing. Peer group activities school and employment should be part of a
generally reflect the individual's activities. complete evaluation.
• If the adolescent is uncommunicative, a
multiple-choice approach can be used
Comprehensive Physical Examination

Emphasis should be placed on common adolescent Skin
concerns. Height, weight and blood pressure Obvious problems, particularly acne, should be
should be measured yearly in adolescents. Sexual noted and treated.
maturation (according to Tanner stages; see Table
19-1) should be noted.

Eyes adolescence. Routine screening for scoliosis is of

Visual acuity should be screened, as myopia questionable value.
commonly develops during the adolescent growth
spurt. Genitalia
Assess development of pubic hair to allow Tanner
Mouth staging (see Table 19-1).
Dental decay and periodontal disease can be
significant problems in adolescence. Boys should be examined with respect to normal
growth and development of the external genitalia.
Breasts
Development and symmetry of the breasts should Girls who are sexually active should undergo a
be assessed, and girls should be taught how to pelvic examination and Pap smear with
perform breast self-examination. appropriate STI screening at least once yearly.
General indications for pelvic examination would
Cardiovascular System also include menstrual irregularities, severe
Functional murmurs are common in adolescence, dysmenorrhea, vaginal discharge, unexplained
but look for other forms of cardiac pathology abdominal pain or dysuria.
(e.g. mitral prolapse).
Rectal Examination
Musculoskeletal System At some point during the health maintenance
Sports injuries, knee problems and other problems program, a rectal examination should be
of the musculoskeletal system are common in performed on all adolescents, but this can be
deferred to the late teens if necessary.
Puberty
Female IV (see Table 19-1), and during this period she
In the female, puberty begins between the ages of will grow an average of 8 cm per year.
8 and 14 years and is usually complete within 3
years. Menarche usually occurs 2.5 years after the Male
onset of puberty; in North America, the mean age Puberty usually begins 1.5-2 years later in the
at menarche is 12.5 years. At menarche the male than in the female, and it takes twice as long.
adolescent female has generally attained 95% of The male adolescent growth spurt occurs during
her adult height. The female adolescent growth Tanner stage V (see Table 19-1). The average
spurt usually occurs between Tanner stages II and increase in height during this period is
approximately 10 cm per year.

Table 19-1: Tanner staging of adolescent development*

Pubic hair †
Testes and penis in Breast development
Stage Male Female
male in female
I No pubic hair No pubic hair present Appearance of testes, Juvenile breast with elevated
(pre- present; some fine scrotum and penis papilla and small, flat areola
adolescent) villous hair covers identical with that of
the genital area early childhood
II Sparse distribution of Sparse distribution of Enlargement of testes Breast bud forms; papilla and
long, slightly long, slightly and scrotum; reddish areola elevates to form small
pigmented hair at the pigmented, straight coloration and mound
base of the penis hair bilaterally along enlargement of penis
medial border of
labia
III Pigmentation of Pigmentation of Continued growth of Continued enlargement of

pubic hair increases, pubic hair increases, testes in scrotum and breast bud and areola; no
and hair begins to and hair begins to continued separation of breast contours
curl and spread curl and spread lengthening of penis
laterally sparsely over mons
pubis
IV Pubic hair becomes Pubic hair begins to Testes and scrotum Papilla and areola separate from
coarser in texture and curl and becomes continue to grow; the contour of the breast to form
takes on adult coarse in texture; scrotal skin darkens; a secondary mound
distribution number of hairs penis grows in width,
continues to increase and glans penis
develops
V Mature pubic hair Mature pubic hair Mature adult size and Mature areolar mound recedes
chains and adult chains; adult shape of testes, into general contour of breast,
distribution, with feminine triangle scrotum and penis papilla continues to project
spread to surface of pattern, with spread
the medial thigh to surface of medial
thigh
*Adapted with permission, from Tanner J M, 1962. Growth at Adolescence, 2nd ed. Oxford: Blackwell Scientific Ltd.
† Distribution and coarseness of pubic hair may differ according to ethnic background (e.g. an Aboriginal adolescent
may not have the same distribution of coarse hair as a Caucasian adolescent).
Sexuality
Recent estimates suggest that approximately 70% community. Questions about sexual activity and
of North American teenagers are sexually active the adolescent's peer group may help to identify
by 17 years of age. This may occur earlier among problems.
Aboriginal teens in some communities. Given this
prevalence of sexual activity, it is obvious that Homosexuality
adolescence is an important time for a person to Complex physical and social issues arise for all
determine his or her sexual identity and attitudes homosexual adolescents. Seventeen percent of
toward sexual orientation. boys and 11% of girls report having had at least
one homosexual experience by the age of 19 years.
In addition, the prevalence of STIs and unplanned It is estimated that half of these adolescents will be
pregnancies are high among adolescents. These homosexual in adulthood.
are very important public health concerns for the

Teen Pregnancy: Testing And Counseling

A high index of suspicion is necessary. Consider Follow-Up
the possibility of pregnancy when an adolescent • Nutritional status and weight gain by the
presents with any of the following somatic adolescent mother constitute one of the most
complaints: important features of good prenatal care for this
• Irregular menses age group
• Unusual vaginal bleeding • Because the prevalence of STIs is higher among
• Acute or chronic abdominal pain adolescents, the potential of passing such
• Unreliable menstrual history infections to the baby must be stressed; initial
• Amenorrhea and follow-up cultures, as indicated, should be
routine
Urine Pregnancy Testing • Assessment for immunity to rubella virus
Highly specific monoclonal antibody techniques • Long-term planning with respect to adoption
yield positive results in early pregnancy. A urine placement or, more commonly, with respect to
pregnancy test usually has a positive result by 2 support for the adolescent mother once her baby
weeks after conception. is delivered
• Assessment and counseling for drug and alcohol
Counseling abuse
Counseling the adolescent about her options
related to pregnancy is an important role for Community Health Aims And
nurses. Options include carrying the fetus to term Interventions
and keeping the infant, carrying the fetus to term • Repeat pregnancy within 2 years after the first
and placing the child for adoption, or therapeutic child is born to an adolescent female is a
termination of the pregnancy. The pregnant recognized problem
adolescent will have to decide which option she • Counseling and interventions with respect to
will pursue, and referral should be available for all appropriate postpartum contraception are key
options. • Ongoing surveillance of the adolescent's coping
and parenting skills is of prime importance
Factors Of Teenage Pregnancy • Community education programs to prevent
Associated With Risks To Infant unplanned teenage pregnancies, particularly
• Poor prenatal care (reluctance to seek care) those aimed at school-age children, are also
• Poor nutrition, leading to intrauterine growth important
retardation
• Smoking (one-third of pregnant teens)
• Use of illicit drugs
• Associated STIs
• Poor parenting skills
Contraception
Hormonal Contraception • The main problem with oral contraception as a
• The most effective non-surgical methods of form of birth control is poor compliance and
preventing pregnancy in adolescents are oral discontinuation of therapy (which occurs in 25%
contraception and Depo-Provera injection (every to 50% of North American teenagers for whom
3 months) this form of contraception has been prescribed)

• Discontinuation is usually secondary to adverse contraceptive use. Thereafter, condom use, to

effects or to family or community pressures prevent STIs, should be recommended.
regarding childbearing
• Adolescent growth is not affected by the use of For detailed information about contraceptive
hormonal contraceptives methods and choices for oral contraception, see
"Contraception," in chapter 13, "Women's Health
Management Of Adolescent Females and Gynecology," in the NWT Clinical Practice
Requiring Contraception Guidelines for Primary Community Care Nursing
• Detailed history and physical examination, (Adult) 2003.
including blood pressure
• Pelvic examination and Pap smear (if the Other Issues
adolescent is not yet sexually active, these tests Compliance
can be deferred until she becomes sexually Compliance is a significant problem in
active) adolescents, and lack of compliance is a major
factor in the failure of oral contraception.
Contraceptives And Counseling
The nursing profession has a vital role in The adolescent should understand that initially
educating and counseling adolescents about the there is a high likelihood of spotting or break-
risks associated with sexual activity. Use of through bleeding and missed menses with use of
contraception by sexually active adolescents hormonal contraceptives. These side effects
should be encouraged. usually diminish or disappear within 3-6 months.
Appropriate counseling addresses the various Rubella

methods of contraception, presenting both their Adolescent females without documented evidence
advantages and their disadvantages. The use of of rubella immunization should undergo rubella
condoms must be heavily emphasized. Both titer testing; if negative, measles-mumps-rubella
contraceptives and condoms should be made vaccine should be given. Alternatively, those
readily available at the nursing station, and without any recorded evidence of immunization
condoms should be available at other strategic may be immunized without first undergoing
places in the community. rubella titer testing.
Follow up at 1, 3 and 6 months after initiation of Pap Smear

contraception to ensure no significant side effects A Pap smear should be obtained for any sexually
and to monitor blood pressure. active adolescent female - at annual intervals if
results are normal or more frequently as dictated
Condoms and foam should be used as back-up by findings.
contraception during the first month of oral
Sexually Transmitted Infections

The occurrence of STIs in gay males is a See "Sexually Transmitted Diseases," in chapter
significant public health issue. Consideration 11, "Communicable Diseases," in the NWT
should be given to hepatitis B vaccination and to Clinical Practice Guidelines for Primary
HIV, VDRL and STI testing for all sexually active Community Care Nursing (Adult) 2003
adolescents.

Suicide
See "Suicidal Behavior," in chapter 15, "Mental Health," in the NWT Clinical Practice Guidelines for
Injury Prevention
See "Injury Prevention Strategies," in chapter 3, "Prevention."

Alcohol, Nicotine, Drug And Inhalant Abuse

Drug abuse is widespread in North American • Poor diet and limited physical activity
society. The use of so-called gateway drugs, such • Low socioeconomic status
as alcohol, tobacco and marijuana, usually begins • Poor relationship with parents or caregiver
in adolescence, and today's adolescents experiment
at earlier ages than adolescents of previous Risk For Substance And Alcohol
generations.
Abuse
Nicotine is the most commonly abused drug, • Family history of alcohol or substance abuse on
followed by alcohol, marijuana and then either side of the family
stimulants such as amphetamines and cocaine. In • Use of alcohol, marijuana or cocaine in early
Aboriginal communities, gas and solvent sniffing adolescence
also constitute a significant hazard. Ecstasy (a • Use of cross-dependent drugs, such as
drug used at raves) is a new drug of abuse. marijuana, sedatives, tranquilizers
Generally, adolescent boys abuse all forms of • Drug use within peer group
drugs and alcohol to a greater extent than do • Adolescents with attention deficit hyperactivity
adolescent girls. disorder, learning disability or depression
• Adolescents who are suicidal
Factors Associated With Higher-Risk • Family dysfunction: divorce, alcohol or drug
Behaviors abuse, child abuse, inconsistent or impulsive
• Drug and alcohol use stealing
• Sexual activity • Adolescents with school problems (e.g.
• Poor school performance absenteeism) or problems with the law
• Peer pressure
Alcohol
Genetic Risk Factors • Adolescents with a history of repeated accidents,
One-third of surveyed alcoholics reported that at drunk driving offenses, and other similar
least one parent was alcoholic. Biological studies problems should be considered to have a drug or
support this familial trend. alcohol problem until proven otherwise.
• Adolescents with antisocial behavior in
Preventive Measures combination with significant drug or alcohol
• Incorporate questions about alcohol, drug and dependency usually require a long-term
cigarette use during routine questioning of treatment program designed for their age group.
adolescents, beginning at an early age. Look for Finding appropriate treatment programs is
a profile consistent with drug abuse difficult, especially in remote areas, and
(e.g. the T-ACE questionnaire). reference to a social worker or a National Native
• Any adolescent with school or family problems, Alcohol and Drug Abuse Program (NNADAP)
depressive symptoms, antisocial behavior, a peer worker with knowledge of appropriate referral
group that uses drugs heavily, or a family history agencies is generally required.
of drug- or alcohol-related problems should be
assessed for drug or alcohol abuse.

Nicotine
Nicotine is one of the most addictive (and lethal) clothes, decreased athletic fitness and high
drugs known. It is estimated that 85% of financial cost
adolescents who learn to smoke cigarettes will • Provide those addicted to tobacco with smoking
become addicted. cessation counseling and support
Nursing Intervention Source: "Tobacco Use among Aboriginal Children

• Educate children early (when they are of school and Youth," (CPS, Indian and Inuit Health
age) about the risks of tobacco use Committee 1999)
• Counsel about the short-term effects: bad breath,
staining of the teeth and fingers, foul-smelling
Marijuana
This is the illicit drug most commonly used by Abuse of marijuana may be associated with
adolescents and young adults. It is associated with chronic depressive illness or abuse of alcohol or
an increase in the risk of respiratory cancer, as other drugs.
well as acute panic attacks, confessional states and
acute psychotic reactions (especially in those with
a genetic risk for mental illness).
Inhalants
Dozens of inhalants are available in stores. absorption of the inhalant, which sensitizes the
Commonly used products are liquids (such as heart to arrhythmias (generally fatal ventricular
model glue), contact cement, lacquers and aerosols arrhythmias).
(such as gasoline, cooking sprays and toiletries
[hair spray, cologne]). Inhalants are most often Long-term neurologic deficit secondary to the
used by younger adolescents. inhalation of volatile hydrocarbons such as toluene
has been documented, although much research is
Acute depression of the CNS can result, and there still needed in this category of drug abuse. Hearing
is a strong potential for accidents, such as burns or loss and other cranial nerve deficits have been
drowning. Sudden sniffing death is rare and is suggested, as well as long-term encephalopathy.
probably the result of rapid nasal or pulmonary
Interventions In Substance Abuse

Prevention progressive school-based curriculum with
Healthcare professionals need to promote developmentally appropriate modules, offered
awareness about the health hazards of substance throughout elementary school, is seen as the most
abuse to children, adolescents, parents and efficient strategy and should be implemented,
caregivers, teachers, vendors of volatile substances particularly in areas where inhalant abuse is
and community leaders. prevalent.
Education is considered the most effective Providing alternative activities, such as

prevention strategy, particularly if it is initiated recreational facilities, and promoting cultural
before the usual age of experimentation. A values encourage positive lifestyles and may

diminish the risk of inhalant abuse and other treatment programs specifically aimed at
destructive behaviors. teenagers. In remote areas, consultation with a
mental health worker or a physician may be
Treatment indicated to establish the most effective and
Adolescents with significant alcohol, solvent or practical treatment program.
other drug problems should be referred to the most
appropriate social services (e.g. NNADAP). Source: "Inhalant Abuse," (CPS, Indian and Inuit
Provincial alcoholism foundations also sponsor Health Committee 1999)

Chapter 20 – General Emergencies and Major Trauma

Assessment And Management of Pediatric Trauma...................................................................................... 1
General Comments ......................................................................................................................................... 1
Nuances Of Pediatric Trauma......................................................................................................................... 1
Spinal Cord Injury .......................................................................................................................................... 2
General Approach To The Child With Trauma .............................................................................................. 2
Primary Survey ............................................................................................................................................... 2
Resuscitation................................................................................................................................................... 3
Secondary Survey ........................................................................................................................................... 4
Definitive Care................................................................................................................................................ 7
Major Emergency Situation ............................................................................................................................. 8

Anaphylaxis .................................................................................................................................................... 8
Shock ............................................................................................................................................................ 11
Overdoses, Poisonings And Toxidromes...................................................................................................... 13
Fever Of Unknown Origin (Bacteremia And Sepsis) ................................................................................... 17
September 2004 Pediatric 20

Assessment And Management of Pediatric Trauma

General Comments
Trauma is the single largest most important cause morbidity and mortality rates in the critical early
of morbidity and mortality in all childhood age hours after trauma has occurred (the "golden period”),
groups, except the first year of life. To reduce early resuscitation and rapid transport are key.
Nuances Of Pediatric Trauma

• Multisystem injury is the rule rather than the Airway Injury
exception. The smaller the child, the greater the disproportion
• The priorities of pediatric trauma management between the size of the cranium and the size of the
are the same for children as for adults; however, midface. This produces a greater propensity for the
children's unique anatomic characteristics posterior pharyngeal area to buckle as the relatively
deserve special consideration. large occiput forces passive flexion of the cervical
• Because of smaller body mass, energy from spine.
linear forces (e.g. fenders, bumpers, falls) results
in greater force applied per unit body area. Chest Trauma
• Children have less fat, less elastic connective The child's chest wall is very compliant, which allows
tissue and close proximity of organs, which energy to be transferred to the intrathoracic soft
leads to more multisystem organ injuries. tissues, frequently without any evidence of external
• The skeleton is incompletely calcified and more chest wall injury. Consequently, pulmonary
pliable. contusions and intrapulmonary hemorrhage are
• Internal organs may be damaged without common.
evidence of overlying bone fractures.
• If bones are broken, assume that a massive The mobility of the thoracic structures makes the child
amount of energy was applied. more sensitive to tension pneumothorax and flail
• The child's ability to interact and cooperate with segments.
parents or caregivers is limited, which makes
history taking and physical examinations Head Trauma
difficult. Children are particularly susceptible to the secondary
• Children have a large body surface area in effects of brain injury produced by hypoxia,
relation to their weight, relatively thin skin and a hypotension, seizures and hyperthermia. Shock
lack of insulating fat. These characteristics lead resuscitation and avoidance of hypoxia are critically
to increased loss of water and heat. Appropriate important to a favorable outcome.
measures must be taken to ensure that injured
children do not become hypothermic Young children with open fontanels and mobile
(e.g. thermal blankets, warmed IV fluids). cranial suture lines are more tolerant of expansion of
• "Normal" systolic blood pressure can be intracranial mass lesions, and decompensation may
estimated by adding 80 to two times the child's not occur until the mass lesion has become large. A
age in years. Normal diastolic blood pressure is bulging fontanel or a widened suture is an ominous
roughly two-thirds of the systolic pressure. sign.
• Because of children's excellent capacity for
physiologic adaptation, shock may go
unrecognized in its early stages.
September 2004 Pediatric 20-1

Spinal Cord Injury

Children may sustain spinal cord injury without joints are flatter, and the relatively large size of the
radiographic abnormality (known by the acronym head allows for more angular momentum to be
SCIWORA). This situation occurs because the generated during flexion and extension, which in turn
pediatric spine is so much more elastic and mobile results in greater energy transfer. Spinal precautions
than the adult spine. The interspinous ligaments must be maintained.
and joint capsules are more flexible, the facet
General Approach To The Child With Trauma

ABCs are your first priority. Primary survey and The child with multisystem trauma may have both
resuscitation are followed by secondary survey, cardio respiratory failure and shock. A rapid
definitive care and finally transport. evaluation of the cardiopulmonary system must be
performed, along with a rapid thorax-abdominal
The primary survey and resuscitation are done examination to detect life-threatening chest or
simultaneously. During this period, a patent abdominal injuries that might interfere with successful
airway is established while control of the cervical resuscitation. For instance, ventilation and oxygen
spine is maintained. therapies may be ineffective until tension
pneumothorax is treated.
Maintenance of airway patency is obviously the
most critical factor, and cervical spine injury Common errors in resuscitation include failure to:
should be assumed in every seriously injured • Open and maintain the airway
child, until proven otherwise. • Provide appropriate and adequate fluid resuscitation
to children with head injuries
The next priorities are as follows: • Recognize and treat internal hemorrhage
• Adequate ventilation
• Treatment of shock
• Identification of life-threatening injuries
Primary Survey
The primary survey is performed to identify and Airway
simultaneously manage life-threatening Assess for signs of airway obstruction such as foreign
conditions. bodies or facial, mandibular, tracheal or laryngeal
fracture.
It consists of ABC plus D and E:
• A for airway maintenance with cervical spine The cervical spine must be protected (use chin lift or
control jaw thrust). Do not hyperextend, hyperflex or rotate
• B for breathing and ventilation the cervical spine. Cervical immobilization should be
• C for circulation with hemorrhage control achieved.
• D for disability (neuralgic evaluation)
• E for exposure and environmental control Breathing And Ventilation
Inspection, palpation, percussion and auscultation
should be performed to assess for tension
pneumothorax, flail chest, pulmonary contusions,
open pneumothorax, fractured ribs and any other
condition that might compromise breathing.
20-2 Pediatric September 2004

Circulation With Hemorrhage Control • A for alert

• Hypotension after trauma should be considered • V for responds to verbal stimuli
hypovolemic in origin until proven otherwise. • P for responds only to painful stimuli
• It is generally assumed that any child who is • U for unresponsive
hypotensive secondary to hypovolemia has lost
at least 25% of the blood volume Alteration in the level of consciousness should prompt
• Reduction in level of consciousness may be an immediate re-evaluation of oxygenation,
caused by cerebral hypoperfusion ventilation and circulation. If these are adequate,
• Ashen gray or white skin color is a sign of assume that the trauma is the cause of the decrease in
hypovolemia level of consciousness. Alcohol or drugs may also
• Rapid, thready pulses and delay of capillary reduce the level of consciousness, but they are
refill are early signs of hypovolemia diagnoses of exclusion in a person with trauma.
• Rapid external blood loss should be managed
initially by direct manual pressure on the wound Exposure And Environmental Control
Completely undress the child, but protect from
Disability (Neurolgic Evaluation) hypothermia. Warm blankets, warmed IV fluids and a
Use the AVPU method, as well as pupillary size warm environment must be provided.
and reactiveness, to assess level of consciousness.
The pediatric Glasgow coma score (see Table 20-
1, below) is always obtained during the secondary
survey.
Resuscitation
Airway Shock
A person with compromised airways and anyone See also "Shock," below, this chapter.
with ventilatory problems needs an oral airway.
The airway must be protected and maintained at Shock should be assumed to be hypovolemic in
all times, and ventilation with bag or mask should origin, since neurogenic shock and cardiogenic shock
be performed as required. are rare in children with trauma. Shock should be
treated aggressively with fluids.
Oxygen
Oxygen should be given to all children with Fluid resuscitation is generally achieved with normal
trauma, and should be freely used (10-12 L/min by saline or Ringer's lactate. A fluid bolus of 20 mL/kg is
non-rebreather mask). given over a short period of time (e.g. 20 minutes). If
normovolemia is not restored, bolus infusions of
20 mL/kg are continued until stabilization is achieved.
Intravenous Therapy
Two large-bore IV lines should be inserted. A very limited amount of time (60-90 seconds) should
Remember that if an IV line cannot be placed be spent establishing a peripheral venous line in the
promptly, an intraosseous needle should be hemodynamically unstable child. Intraosseous
inserted instead (see "Intraosseous Access," in infusion provides rapid access to the circulation and is
chapter 2, "Pediatric Procedures"). If the child is safer. See "Intraosseous Access," in chapter 2,
in severe shock, go directly to intraosseous access. "Pediatric Procedures."
Do not try to establish intraosseous access in a
fractured bone.

ECG Monitoring Contraindications to placing a Foley catheter:

If available, ECG monitoring should be used. • Blood is apparent at the urethral meatus
• Blood is apparent in the scrotum
• Dysrhythmias, tachycardia, atrial fibrillation,
premature ventricular contractions and ST Verifying adequate urinary output (1-2 mL/kg per
segment changes may all indicate cardiac hour) is important in the assessment of fluid
contusion replacement, but in the immediate time frame of
• Bradycardia, premature beats or aberrant changes associated with resuscitation, the vital signs
conduction patterns may indicate hypoxia, are more important.
hypothermia or hypoperfusion
Gastric Tube
Urinary Catheter A gastric tube should be inserted to reduce stomach
Place a urinary catheter, unless urethral transection distension and to reduce the risk of aspiration.
or injury is suspected.
If fracture of the cribriform plate is confirmed or
Genital and rectal examinations are required suspected, consult a physician about inserting a gastric
before insertion of a urinary catheter. tube.
Secondary Survey
The secondary survey begins once the primary 3. The SAMPLE mnemonic is useful in obtaining the
survey (ABCs) is completed, resuscitation has history from a conscious child:
commenced, and the child's ABCs have been • S for symptoms
reassessed. • A for allergies
• M for medications
The secondary survey serves to identify any • P for past medical history
potentially life-threatening cardiopulmonary • L for last meal time
injuries that were not immediately evident in the • E for events and environment related to the
primary survey. It consists of a head-to-toe injury
evaluation, including all vital signs, accompanied
by a complete history and physical examination, a 4. Perform a detailed head-to-toe physical
complete neuralgic evaluation and the pediatric examination. Use log roll maneuver with spine
Glasgow coma score. precautions to assess posterior chest wall, flanks,
back and rectum. If you find an impaled object, do
1. Record vital signs, including pulse oximetry not remove it. Instead, stabilize the object in place.
(if available).
2. Obtain a history of the injury. The history should Head And Neck
include especially the time and mechanisms of First, reassess ABCs.
the injury (e.g. whether it was blunt or
penetrating), the child's status at the scene of the Inspection and Palpation of Skull and Face
incident, any changes in status over time and any • Deformities, contusions, abrasions, penetration,
complaints the child may have. If the child is burns, lacerations or swelling
younger or unconscious, ask bystanders or • Tenderness, instability or crepitations
witnesses. If the child is unconscious, look for a • Battle's sign (bluish discoloration over mastoid
medical alert tag. process)
• Eyes: conjunctiva, PERRLA (pupils equal, round,
reactive to light, accommodation)
• Racoon-like eyes (which could indicate basal skull
fracture)

• Clear nasal discharge (which indicates CSF Abdomen

rhinorrhea) Inspection
• Ears: blood in canal or hemotympanum (bluish • Penetrating wounds, blunt trauma, lacerations
purple color behind eardrum, due to presence of • Bruising (anterior, sides)
blood; occurs with basal skull fracture) • Bleeding
• Check for voluntary symmetric movement of • Distension
facial muscles • Movement with respiration
Inspection and Palpation of Neck Auscultation

• Distension of neck veins (sign of tension • Bowel sounds
pneumothorax or cardiac tamponade)
• Tracheal deviation Palpation
• Deformities, contusions, abrasions, penetration, • Tenderness
burns, lacerations or swelling • Abdominal guarding, rigidity
• Check carotid pulse again • Rebound tenderness
• Assume injury to the cervical spine if trauma has • Fractures of lower ribs (ruptured spleen, possible
occurred above clavicle penetrating wound, bowel injury and intra-
• Ensure adequate immobilization of the neck abdominal hemorrhage possible)
• Apply a cervical collar if not already done
Pelvis And Genitalia
Chest Inspection
Inspection • Perineal laceration, hematoma or active bleeding
• Respiratory effort • Blood coming from urethral meatus
• Equality of chest movement
• Deformity Palpation
• Bruising • Tenderness of iliac crest and symphysis pubis
• Lacerations (indicating pelvic fracture)
• Penetrating wounds • Distension of bladder
Palpation Remember that pelvic and femoral fractures can cause

• Equality of chest movement extensive loss of blood.
• Position of trachea
• Crepitus, deformity Extremities
• Fractures of the lower ribs (splenic or kidney Inspection
injury may also be present) • Bleeding, lacerations, bruising, swelling, deformity
• Leg position: unusual external rotation of a leg may
Percussion indicate fracture of the femoral neck or the limb
• Area of dullness • Movement of limbs
Auscultation Palpation
• Air entry • Sensation
• Quality of breath sounds • Tenderness
• Equality of breath sounds • Crepitus
• Muscle tone
Cardiovascular System • Distal pulses, capillary refill
• Auscultate heart for heart sounds: presence, • Reflexes: presence, quality
quality
• Assess peripheral pulses Remember that pelvic and femoral fractures can cause
extensive loss of blood.

Back • Cranial nerves

Perform log roll maneuver with spine precautions • Pupil abnormalities: position, size, equality,
to assess back and rectum. reactivity, funduscopy
• Re-examine nose for rhinorrhea
Inspection • Motor function (voluntary movement of fingers and
• Bleeding toes)
• Lacerations • Sensation (child's ability to feel your fingers when
• Bruising: posterior chest wall, flanks, low back, you touch his or her fingers and toes)
buttocks
• Swelling Signs of Skull Fracture
• Periorbital bruising (indicates basal skull fracture)
Palpation • Clear nasal discharge (CSF) (indicates basal skull
• Tenderness fracture)
• Deformity • Bruising behind ears, blood coming from ears,
• Crepitus blood behind eardrum (indicates basal skull
fracture)
Rectum • Skull lacerations with palpable bony irregularity or
Inspection depression (indicates some form of skull fracture)
• Occult blood
Remain calm and think clearly. Try to do things in a
Palpation logical order, as outlined above
• Integrity of walls, sphincter muscle tone
Central Nervous System

Perform a neurolgic assessment to evaluate the
child's present level of function. Determine the
level of consciousness according to the pediatric
Glasgow coma score (Table 20-1).
Table 20-1: Scoring for the Pediatric Glasgow Coma Score
Feature Score Age group and response

Eyes Opening > 1 year < 1 year
4 Spontaneously Spontaneously
3 To verbal command To shout
2 To pain To pain
Best Motor > 1 year < 1 year
Response 6 Obeys NA
5 Localizes pain Localizes pain
4 Flexion withdrawal Flexion normal
3 Flexion abnormal Flexion abnormal
(decorticate rigidity) (decorticate rigidity)
2 Extension (decerebrate Extension (decerebrate rigidity)
rigidity)
Best Verbal > 5 years 2-5 years Birth to 23 months
Response 5 Oriented and converses Appropriate words and phrases Smiles, coos, cries appropriately
4 Disoriented and converses Inappropriate words Cries
3 Inappropriate words Cries and/or screams Inappropriate crying and/or screaming
2 Incomprehensible sounds Grunts Grunts
1 No response No response No response
* Score is obtained by determining the score for each of the three criteria and summing them. Note: NA = not applicable

Definitive Care
• Resuscitative measures initiated earlier are • Anytime you carry out an intervention, perform a
continued (e.g. airway, IV therapy, oxygen) reassessment survey
• Identified conditions should be managed • Monitor hourly urine output (aim for urine output
according to their priority >1 mL/kg per hour)
• Ensure that airway is protected in an
unconscious child Irritability or restlessness may be caused by hypoxia,
• Apply suction as needed bladder or gastric distension, fear, pain or head injury.
• Administer supplemental oxygen, even if However, do not assume head injury. Rule out
breathing appears adequate correctable causes first.
• Treat hypotension aggressively with IV fluid
replacement (see "Shock," below, this chapter) Head injuries are never a cause of hypovolemic shock.
• Insert nasogastric tube and apply suction (if not Look for other source of hemorrhage elsewhere.
already done), unless the child has facial
fractures or a suspected basal skull fracture; if in Checklist
doubt, do not insert the tube--consult a physician • Check airway tubes for patency
first • Check oxygen rate
• Insert Foley catheter (if no contraindications and • Check IV lines for patency and rate of infusion
not already done) • Check for patency of decompression needle for
• Contraindications to catheterization: blood at tension pneumothorax, if inserted
urethral meatus, blood in scrotum, obvious • Check splints and dressings
pelvic fracture • Check rate of hyperventilation of any child with
decreased level of consciousness
Bandaging And Splinting
• If necessary, finish bandaging and splinting Consultation
injuries • Consult a physician at transfer facility as soon as
• Angulated fractures of the upper extremities are able (e.g. when child's condition is stabilized).
best splinted as found
• Fractures of the lower extremities should be Referral
gently straightened with traction splints • Medevac as soon as possible
(e.g. Thomas splint) • Make sure that child's condition is as stable as
possible before leaving health facility
Monitoring And Follow-Up • Pressure effects on certain injuries are accentuated
• Monitor and reassess ABCs frequently in unpressurized aircraft; maximum flying altitudes
• Monitor vital signs as frequently as possible are applicable; see Patient Care in Flight Manual
until condition is stable (Medical Services Branch 1985)
• Anytime the child's condition worsens, perform
a reassessment survey

Major Emergency Situation

Anaphylaxis
Definition Severe Reaction
Rare and potentially life-threatening allergic • Severe respiratory distress (lower respiratory
reaction. The symptoms develop over several obstruction characterized by high-pitched wheezing,
minutes, may involve multiple body systems upper airway obstruction characterized by stridor)
(e.g. skin, respiratory system, circulatory system) • Difficulty speaking
and may progress to unconsciousness only as a • Difficulty swallowing
late event in severe cases. Rarely is • Agitation
unconsciousness the sole manifestation of • Shock
anaphylaxis. • Loss of consciousness
Anaphylaxis must be distinguished from fainting
(vasovagal syncope), which is a more common Physical Findings
and benign occurrence. Rapidity of onset is a key • Tachycardia
difference. When a person faints, the change from • Tachypnea, labored respiration
a normal to an unconscious state occurs within • Blood pressure low-normal (child hypotensive if in
seconds. Fainting is managed simply by placing shock)
the person in a recumbent position. Fainting is • Pulse oximetry may show hypoxia
sometimes accompanied by brief clonic seizure • Child in moderate to severe distress
activity, but this generally requires no specific • Use of accessory muscles of respiration
treatment or investigation. • Chest: air entry reduced, mild to severe wheezing
• Child flushed and diaphoretic
Causes • Generalized urticaria (hives)
• Vaccines • Facial edema
• Injectable drugs • Diminished level of consciousness
• Insect sting (e.g. bee) • Skin feels cool and clammy
• Food allergy (e.g. peanuts)

Anaphylaxis usually begins a few minutes after • Asthma
injection of the offending substance and is usually • Foreign-body aspiration
evident within 15 minutes. The symptoms may • Angioedema
include the following:
• Sneezing, coughing Complications
• Itching • Hypoxia
• "Pins-and-needles" sensation of the skin • Shock
• Flushing of the skin • Airway obstruction due to edema of upper airway
• Facial edema (perioral, oral or periorbital • Convulsions
urticaria) • Aspiration
• Nausea, vomiting • Death
• Early respiratory difficulties (e.g. wheezing,
dyspnea, tightness of the chest) Diagnostic Tests
• Palpitations • None.
• Hypotension, which may progress to shock and
collapse
• Cardiovascular collapse can occur without
respiratory symptoms.

Management vaccination site to slow absorption of the vaccine.

Goals of Treatment However, if the vaccine was given intramuscularly,
• Improve oxygenation local injection of epinephrine at the vaccination site is
• Alleviate symptoms contraindicated because it will dilate the vessels and
• Prevent complications speed absorption.
Speedy intervention is of paramount importance.
Early recognition and treatment of anaphylaxis are Failure to use epinephrine promptly is more
vital. dangerous than using it quickly but improperly.
Nonpharmacologic Interventions Epinephrine Dose

• Place the child in a recumbent position The epinephrine dose should be carefully determined.
(elevating the feet if possible) Calculations based on body weight are preferred when
weight is known. When body weight is not known, the
• Establish an oral airway if necessary
dose of epinephrine (1:1000) can be approximated
• Place a tourniquet (when possible) above the site
from the subject's age (Table 20-2).
of injection; release for 1 minute every 3
minutes
Excessive doses of epinephrine can compound a
Adjuvant Therapy
subject's distress by causing palpitations, tachycardia,
Severe Anaphylaxis flushing and headache. Although unpleasant, such
• Give oxygen by mask, 10-12 L/min by non- side effects pose little danger. Cardiac dysrhythmias
rebreather mask; keep oxygen saturations > 97% may occur in older adults but are rare in otherwise
healthy children.
open, unless severe anaphylaxis and signs of
Table 20-2: Epinephrine Dose on the Basis of Age
shock are evident (see "Shock," below, this
chapter, for details of fluid resuscitation in Age Dose in mL Dose in mg
shock) 2 to 6 months* 0.07 mL 0.07 mg
12 months* 0.1 mL 0.1 mg
18 months* to 4 0.15 mL 0.15 mg
years
Promptly administer:
5 years 0.2 mL 0.2 mg
aqueous epinephrine (D class drug), 1:1000,
6 to 9 years 0.3 mL 0.3 mg
0.01 mL/kg (maximum dose 0.5 mL) SC or IM 10 to 13 years 0.4 mL† 0.4 mg
in the limb opposite that in which the original > 14 years 0.5 mL† 0.5 mg
injection was given * Dose for children between the ages shown should be
SC epinephrine injection is appropriate for mild approximated, the volume being intermediate between the
cases or those treated early. values shown or increased to the next larger dose, depending
on the practicability.
† For a mild reaction a dose of 0.3 mL can be considered.
In severe cases, an IM injection should be given
because this route leads more quickly to
generalized distribution of the drug. A single SC Severe Anaphylaxis
injection is usually sufficient for mild or early In addition to the epinephrine, give the following:
anaphylaxis. Epinephrine can be repeated twice at diphenhydramine hydrochloride (A class drug)
20-minute intervals, if necessary. In severe 1-2 mg/kg/dose, max 50 mg/dose
reactions it may be necessary to give these repeat
doses at shorter intervals (10-15 minutes). This drug should be reserved for children who are not
responding well to epinephrine or may be used to
If the vaccine causing anaphylaxis was given maintain symptom control in those who have
subcutaneously, an additional dose of aqueous responded (since epinephrine is a short-acting agent),
epinephrine (D class drug) 1:1000 0.005 mL/kg especially if transfer to an acute care facility cannot be
(maximum dose 0.3 mL) can be injected at the effected within 30 minutes.
Oral administration of diphenhydramine is preferred

for conscious children who are not seriously ill, Monitoring and Follow-up
because pain results when the drug is given Severe Anaphylaxis
intramuscularly. This drug has a high safety Monitor ABCs, vital signs and cardiorespiratory status
margin, which means that precise dosing is less frequently.
important.
The approximate doses of diphenhydramine for Severe Anaphylaxis
injection (50 mg/mL solution) are shown in Consult a physician as soon as child's condition
Table 20-3. stabilizes; physician may recommend IV steroids and
ranitidine.
Table 20-3: Diphenhydramine Dose on the
Basis of Age Referral
Age Dose in mL Dose in mg Medevac as soon as possible. In all but the mildest
< 2 years 0.25 mL 12.5 mg cases, children with anaphylaxis should be
2 to 4 years 0.5 mL 25 mg hospitalized overnight or monitored for at least 12
5 to 11 years 1 mL 50 mg hours.
> 12 years 1-2 mL 50-100 mg
Source: Canadian Immunization Guide, 6th edition, Because anaphylaxis is rare, epinephrine vials and
Health Canada 2002 other emergency supplies should be checked regularly
and should be replaced if outdated.
For Bronchospasm
salbutamol (D class drug), by nebulizer, three
doses q20min (dose dependent on body weight)
Weight = 10 kg: 1.25-2.5 mg/dose in 3 mL NS
Weight = 11-20 kg: 2.5 mg/dose in 3 mL NS
Weight = 20 kg: 5 mg/dose in 3 mL NS

Shock
Definition • Hypoxemic shock: caused by respiratory failure
A condition that occurs when perfusion of tissue from lung injury or obstruction, or disruption of the
with oxygen becomes inadequate. As a result, the airway
cells of the body undergo shock, and grave cellular • Low-volume shock (absolute hypovolemia): caused
changes occur. Eventually cell death follows. by hemorrhage or other major loss of body fluid
• High-space shock (relative hypovolemia): caused by
Shock is categorized in many ways, for example, spinal injury, syncope, severe head injury,
according to the state of physiologic progression vasomotor injury from hypoxia
that has occurred:
• Compensated shock: vital organ perfusion is History
maintained by endogenous compensatory Infant
mechanisms • May become combative initially, then lethargic
• Uncompensated shock: compensatory • Poor feeding
mechanisms have failed; associated with • Decreased responsiveness to parents or caregivers
hypotension and impairment of tissue perfusion • History of trauma
• Irreversible shock: multiple end-stage organ • History of symptoms of an underlying illness
failure and death occur, despite occasional return (e.g. cough indicating pneumonia)
of spontaneous cardiorespiratory function
Older Child
Arterial blood pressure is often preserved by • Nausea
compensatory vasoconstrictive mechanisms until • Lightheadedness, faintness
very late in shock. Therefore, an over-reliance on • Thirst
arterial blood pressure readings can delay
• Altered level of consciousness
recognition and timely treatment of shock.
• Other symptoms depending upon underlying cause
• Trauma
Types Of Shock
• Hypovolemic shock: inadequate perfusion of Physical Findings
vital organs because of reduction in circulating Remember: ABCs are the priority.
blood volume
• Cardiogenic shock: due to the inability of the The physical findings are variable, depending on
heart to pump blood to tissues (decreased whether the child is in compensated or decompensated
cardiac output), as in congestive heart failure; shock. It is generally assumed that any child who is
rare in children hypotensive secondary to hypovolemia has lost at
• Distributive shock: due to massive least 25% of total circulating blood volume.
vasodilatation from interference with Do not rely on blood pressure readings. In children,
sympathetic nervous system or effects of blood pressure is preserved by compensatory
histamine or toxins, such as in anaphylaxis, vasoconstrictive mechanisms until very late in shock.
septic shock, neuralgic injury, spinal cord injury, Appearance, breathing and perfusion are more reliable
intoxication with some drugs (e.g. tricyclic clinical indicators of shock.
antidepressants, iron)
• Obstructive (mechanical) shock: obstruction of Prolonged capillary refill (>2 seconds) is a sign of
cardiac filling such as that caused by pericardial decreased tissue perfusion and is more beneficial as a
tamponade or tension pneumothorax sign of shock in children than in adults.
• Dissociative shock: oxygen is not released from
hemoglobin to the cells (as in carbon monoxide Persistent tachycardia is the most reliable indicator of
poisoning) shock in children.

Compensated Shock Adjuvant Therapy

• Appearance: alert, anxious • Give oxygen at 12-15 L/min by non-rebreather
• Work of breathing: tachypnea or hyperpnea mask with reservoir; keep oxygen saturation >97%
• Circulation: tachycardia, cool or pale skin, • Start 2 large-bore IV lines with normal saline (or
decreased peripheral pulses Ringer's lactate)
• Give 20 mL/kg IV fluid rapidly as a bolus over
Decompensated Shock 20 minutes
• Appearance: altered mental status, reduced level • Reassess for signs of continuing shock
of consciousness • If shock persists, continue to administer fluid in
• Work of breathing: tachypnea or bradypnea 20 mL/kg boluses, and reassess after each bolus
• Circulation: tachycardia or bradycardia, mottled • Adjust IV rate according to clinical response
or cyanotic skin, peripheral pulses absent • Ongoing IV therapy is based on response to initial
fluid resuscitation, continuing losses and underlying
Source: APLS: The Pediatric Emergency Medicine cause
Course Manual (Strange 2002) • For maintenance fluid requirements, see "Fluid
Requirements in Children" in chapter 4, "Fluid
Differential Diagnosis Management."
• Sepsis • If unable to access a peripheral vein quickly (in 60-
• Anaphylaxis 90 seconds or less), institute intraosseous infusion
• Status asthmaticus (see "Intraosseous Access," in chapter 12,
"Pediatric Procedures")
Complications
• Myocardial ischemia or infarction After Initial Resuscitation
• Cardiorespiratory failure or arrest • Insert indwelling urinary catheter
• Renal failure • Insert nasogastric tube prn
• Death
• Monitor ABCs, vital signs (including pulse
Diagnostic Tests
oximetry, if available) and level of consciousness as
• None.
often as possible until condition is stable
• Frequent reassessment for continuing blood loss is
Management important
• Remember: ABCs are the priority.
• Monitor hourly intake and urine output
• Identify and manage underlying cause of shock
Goals of Treatment
(e.g. manage sepsis with IV antibiotics)
• Restore circulating blood volume
• Assess stability of pre-existing medical problems
• Improve oxygenation of vital tissues
(e.g. diabetes mellitus)
• Prevent ongoing volume losses

• Assess and stabilize ABCs • Medevac.
• Ensure that airway is patent and ventilation is
adequate
• Insert oral airway and ventilate with Ambu bag
(using oxygen) as needed
• Control any external bleeding: use direct
pressure to control bleeding from external
wounds
• Place in head-down position

Overdoses, Poisonings And Toxidromes

Definition Determine:
Ingestion of a potentially toxic substance, • Circumstances of ingestion
including a drug, a household or industrial • What and how much was taken
chemical, plant material or waste products. • The time of ingestion
• When the symptoms began, if any
One of the unique features of poisoning during • Whether symptom intensity has decreased,
childhood is its two very different scenarios. The increased or remained the same
first involves the young child between 1 and 5
years of age who accidentally ingests a small Retrieve the container (send someone to the child's
amount of a substance that may or may not have home if necessary) and any spilled pills. If the
pharmaceutical properties. The second involves informant can reliably state how much of the
the teenager who intentionally ingests a large substance had already been used, this information can
amount of one or more substances, usually be used in the calculation:
pharmaceutical.
Initial volume or number of pills minus amount
Although the latter situation can and does result in remaining = maximum ingestion
significant morbidity, it is quite uncommon in
young children. In the younger age group, less Always assume maximum ingestion. For example, if
than 10% of those who ingest a potentially toxic two children have shared a bottle of pills, assume that
substance are actually poisoned, either because the either child could have ingested the whole amount.
ingested substance is inherently non-toxic or
because the amount ingested is too small to cause Make inquiries about the circumstances of the
toxic effects. ingestion:
• How did the child get at the container?
The management of intentional overdose by • Was the container left within easy reach?
teenagers is the same as for adults. See • Was the child-resistant closure left disengaged?
"Overdoses, Poisonings and Toxidromes," in
chapter 14, "General Emergencies and Major This information is useful for preventive counseling at
Trauma," in the NWT Clinical Practice Guidelines the end of the encounter.
for Primary Community Care Nursing (Adult)
2003 Although most childhood poisonings are accidental,
always be on guard for purposeful administration by a
Initial Evaluation parent or caregiver. This should be considered
ABCs are the first priority. especially in children <1 year old and in any child
with repeated ingestion of a potentially toxic
Ensure that the child's condition is stable. If not, substance, particularly if the various incidents involve
take steps to stabilize before obtaining the history, the same compound.
performing the physical examination and
instituting management. A careful history is the most important part of the
assessment, as there may be no clinical signs at the
History time of presentation.
Typically the young child is brought to the
healthcare provider very soon after the discovery Physical Examination
of the accidental ingestion. In most situations, • ABCs are the priority.
there has not been enough time for symptoms to
• Vital signs: temperature, heart rate, respiratory rate,
have occurred.
depth of respiration, blood pressure
• Level of consciousness

• Closely examine cardiovascular, respiratory and • Charcoal is supplied in premixed containers as 50 g

central nervous systems of charcoal in 250 mL of either water or 70%
sorbitol
Signs vary with the type of poison. The main • Dose for children <6 years old: 25 g of charcoal in
systems involved in poisoning are the water orally or, if child will not drink, by
cardiovascular, respiratory and central nervous nasogastric tube (use a 12-14 French tube, as
systems, but in certain situations there is a need to smaller ones tend to become clogged)
focus on other systems (e.g. the mouth and the • The only risk associated with charcoal therapy is
esophagus after ingestion of caustic alkali). aspiration should the child vomit; this might occur if
the child ingested theophylline or salicylates or has
Management: General Approach already been given ipecac
Opiate poisonings in northern populations are rare. • Shake the bottle thoroughly before opening because
Remember that all features of the classic opiate the charcoal tends to settle
triad (decreased level of consciousness, depressed • Before infusing the charcoal into a nasogastric tube,
respiration and pinpoint pupils) need not be verify that the tube is in the stomach (by
present for diagnosis. spontaneous return of gastric contents or
auscultation of injected air over the left upper
If you are concerned about opiate poisoning in a quadrant)
small child, ask if he or she has had access to
cough medications. Appropriate Consultation
The primary consultant for poisonings is your regional
Nonpharmacologic Interventions poison control center. This service is immediately
Stabilize ABCs as required. available at all times. Be prepared to provide the
For all children with decreased level of following information:
consciousness without apparent cause: • Product ingested
• Give oxygen, 6-10 L/min or more by mask • Approximate dose
• Start IV therapy with normal saline (if there is • Time of ingestion
evidence of compromise in circulation or • Age and weight of child
significant dehydration); run at a rate sufficient • Vital signs
to maintain vital signs and hydration • Level of consciousness
• Any pertinent symptoms or signs
Nasogastric tube may be necessary for a child who
is unconscious and who cannot or will not drink. The poison control center will advise whether the
exposure is potentially toxic, will provide treatment
Administer charcoal therapy (see "GI Tract advice and will suggest whether evacuation to a
Decontamination," below, this section). medical facility is required.
Insert Foley catheter (in child with altered level of Consult a physician to review unfamiliar management
consciousness). and recommendations for evacuation.
If opiate poisoning is suspected: Monitoring and Follow-Up
naloxone (D class drug), 0.1 mg/kg by IV push • Monitor ABCs, vital signs, level of consciousness,
cardiorespiratory function, intake and output
GI Tract Decontamination frequently if the child's condition is unstable and
Activated charcoal is now recommended as the transfer to hospital is planned
sole therapy and should be given for ingestion of • If child is discharged home, next-day follow-up is
any toxic material, except iron, hydrocarbons, recommended
alcohols and caustic agents. It is most effective
within one hour of ingestion.

Prevention of the compound or there are clinical symptoms of

Information obtained during the initial history is toxic effects.
often very helpful for post-encounter preventive
counseling. Poison prevention as well as accident Remember to obtain a blood sample before evacuation
prevention counseling should be a regular part of and to note the time that this sample was obtained.
your follow-up and a regular part of well-baby
visits beginning after the child reaches 6 months of In your letter of referral, include all of the information
age. requested above, as well as any treatment
interventions already undertaken, the interim clinical
Referral course and the time at which the blood was drawn.
The child should be medevaced if there is a
possibility that he or she ingested a toxic amount
Table 20-4: Antidotes for Poisonings

Toxins and Indications Antidotes Required Amount
Acetaminophen n-acetylcysteine Verify protocol with poison control centre and physician
Ethylene glycol, methanol Ethanol
Iron (challenge test or Deferoxamine
treatment)
Isoniazid (INH) Pyridoxine 50-75 mg
Narcotics Naloxone 0.1 mg/kg per dose or 2-4 mg for children > 5years old
Organophosphates or Atropine 0.5 mg slowly IV
carbamate insecticides; If symptoms of toxicity persist and there are no cholinergic side effects,
cholinergic crisis re-administer q5min to a maximum of 2 mg
Most oral toxins Activated charcoal 25-50 g
Specific Poisonings overdose. Although the antidote becomes less

Table 20-4 presents the antidotes for specific effective beyond 8 hours, it is still worthwhile to
poisonings likely to occur in the North. initiate therapy between 8 and 24 hours after
ingestion. In medical facilities, administration of this
Acetaminophen antidote is determined by acetaminophen blood level,
This is the most common drug overdose at all which is unavailable in the nursing station.
ages. Despite the tens of thousands of reported
ingestions by children <6 years old, there have History and Examination
been only a few cases of significant toxic effects, Although the child may be completely asymptomatic,
primarily because small children usually ingest there is frequently nausea, vomiting and abdominal
pediatric formulations. Ingestions of greater than cramps in those at risk for hepatic toxicity.
150 mg/kg should be a cause for concern, but • Obtain history of total maximum ingestion
remember that this figure also incorporates a • Verify ingestion quantity by obtaining the container
safety factor, such that significant toxic effects
actually manifest at a somewhat higher dose. The
Management
organ at risk is the liver, with toxic effects
See "Management: General Approach," above.
occurring a few days after the ingestion.
Toxic effects can be prevented if the antidote Specific Interventions

N-acetylcysteine is started within 8 hours after the All children who have ingested more than
150 mg/kg should receive activated charcoal, and
N-acetylcysteine (D class drugs) may be given

according to oral protocol, as follows: Management

loading dose: 140 mg/kg PO See "Management: General Approach," above.
subsequent doses: 70 mg/kg PO q4h for 17 doses Iron overdose is one of the few situations in which
Once N-acetylcysteine has been started, the child activated charcoal is ineffective.
should be evacuated to a medical facility.
Remember to obtain a blood sample before Specific Interventions
evacuation and to note the time at which it was If more than 20 mg/kg of elemental iron has been
obtained. ingested, administer syrup of ipecac unless there has
already been significant spontaneous emesis (three or
N-Acetylcysteine may also be administered more episodes)
intravenously or via a nebulizer mask.
Protect the airway.
Iron
Iron poisoning can be quite serious. It usually Deferoxamine is the specific antidote for iron
results from ingestion of a prenatal supplement or poisoning. It should be administered only after
other adult dosage form. The toxic effects depend consultation with a poison control center and a
on the amount of elemental iron ingested (ferrous physician.
sulfate is 20% elemental iron, ferrous fumarate is
33% elemental iron, and ferrous gluconate is 12% Remember to draw a blood sample for determination
elemental iron). Therefore, for example, a 300-mg of iron level and send it with the child on transfer. It is
tablet of ferrous sulfate contains 60 mg of especially important to obtain this sample before
elemental iron. initiating deferoxamine therapy, because the antidote
interferes with the laboratory measurement of iron
History level.
Verify maximum amount ingested.
Referral
With greater amounts ingested, degree of toxic Medevac any child:
effects also increases. At 20 mg of elemental iron, • who has symptoms of iron toxicity
expect GI symptoms, such as vomiting and
• who has been treated with deferoxamine
diarrhea, with the possibility of blood in the
• who has ingested more than 40 mg/kg of elemental
emesis or stool. At 60 mg/kg of elemental iron,
iron
there is significant risk of GI hemorrhage, shock
and acidosis.
Coma occurs late in the overdose and is a

consequence of shock and acidosis.
• ABCs
• Vital signs
• Level of consciousness
• Hydration
• Circulation

Fever Of Unknown Origin (Bacteremia And Sepsis)

Definition Most common pathogens causing sepsis in infants (>3
Fever in infants and toddlers is defined as rectal months of age):
temperature greater than 38°C. Neonates may • S. pneumoniae
present with hypothermia rather than fever as a • H. influenzae (in the unimmunized child)
manifestation of occult bacterial illness or sepsis. • N. meningitidis
• Staphylococcus aureus
In infants <2 years old, tympanic membrane • Group A ß-hemolytic Streptococcus
temperature is not as reliable, so rectal temperature • Gram-negative rods
should be used for decision making.
• Fever of unknown origin: fever in a child with Risk Factors Influencing Susceptibility to Occult
no readily identifiable source of infection, Bacteremia
despite a careful history and physical Age is a significant factor influencing susceptibility:
examination the younger the child, the greater the risk. Newborns
• Occult bacteremia: fever with no obvious focus are at greatest risk for bacterial sepsis, and this
of infection and a positive result on blood condition becomes uncommon by 2-3 years of age.
culture Older children with a serious bacterial infection are
• Sepsis: bacteremia with evidence of systemic more consistently identified by clinical examination
invasive infection (rather than by fever).
General Comments Factors contributing to increased risk in neonates:

Febrile infants and children <3 years old • E. coli, L. monocytogenes and group B
commonly present for emergency care. The Streptococcus are the most common pathogens
differential diagnosis is broad, ranging from a causing serious bacterial infections in this age group
simple URTI to occult bacteremia and sepsis. • Findings of physical examination are less reliable in
the neonate
The child's age, the clinical presentation, the • The neonate's immune system is not fully developed
likelihood of a particular diagnosis and risk factors
for sepsis or bacteremia are important In the absence of dehydration or high environmental
considerations when evaluating a young child with temperature, sepsis is a common cause of fever in the
fever. first week of life.
Causes Of Occult Bacteremia Other factors influencing susceptibility to occult

Most common pathogens causing occult bacteremia:
bacteremia in the fully immunized child: • Exposure to communicable pathogens
• Streptococcus pneumoniae (approximately 98% • Malignant lesions
of cases) • Chemotherapy
• Hemophilus influenzae type B (<2% of cases) • Immunocompromised states (e.g. hyposplenism,
• Neisseria meningitidis, Salmonella and others sickle cell disease)
(<1% of cases)
History
Most common pathogens causing sepsis in the In general, young infants (<3 months old) with serious
neonate: bacterial illness present with fever and subtle signs,
• Escherichia coli such as irritability or lethargy. Older children often
• Group B Streptococcus present with more specific clinical signs.
• S. pneumoniae • Fever documented at home by a reliable caregiver
• Listeria monocytogenes (should be considered equivalent to fever
documented in the clinic)

• Change in mental status (e.g. lethargy, In the older infant and child, look for focal findings:
somnolence or decreased level of activity) may • Meningitis in this age group sometimes presents
indicate a serious bacterial illness with nuchal rigidity, a positive Kernig's sign (pain
• Recent immunizations with passive knee extension and hip flexion) and a
• History of prematurity or lack of immunizations positive Brudzinski's sign (spontaneous hip flexion
(places the child at higher risk) with passive neck flexion)
• Recent exposure to sick contacts • The integumentary examination is often overlooked
• Recent antibiotic therapy and can sometimes provide diagnostic clues
• Recurrent illnesses (e.g. presence of petechiae and fever represents a
• Immunocompromised children are not only at broad differential diagnosis that includes
higher risk for serious bacterial illness, but they meningococcal sepsis and viral exanthems)
are also susceptible to different pathogens
• Response to antipyretics does not differentiate Differential Diagnosis
between bacterial and viral pathogens, nor does • Bacteremia and sepsis
it aid in identifying children at risk for serious • Bronchiolitis
bacterial illnesses • Chickenpox (varicella)
• Impact of environment (over bundling can • Croup (laryngotracheobronchitis)
increase the temperature by 0.4°C to 0.8°C) • Febrile seizures
• Erythema infectiosum (fifth disease)
Physical Findings • Gastroenteritis
• Vital signs may reveal hyperthermia, • Hand-foot-and-mouth disease
normothermia, hypothermia, tachycardia, • Kawasaki disease
tachypnea or hypotension • Meningitis and encephalitis
• If tachycardia is disproportionate to the degree • Otitis media
of fever, consider dehydration, sepsis and • Pharyngitis
cardiac abnormalities as potential causes • Pneumonia
• Tachypnea out of proportion to the degree of • Roseola infantum
fever may suggest the early stages of • Scarlet fever
bronchiolitis, pneumonia or laryngotracheitis • Urinary tract infections, pyelonephritis
• Hypothermia in the neonate or
immunocompromised child may be the only
diagnostic clue to a serious bacterial infection Complications
• Children with sepsis typically appear acutely ill • Serious focal bacterial infections such as meningitis
and may exhibit altered mental status • Septic shock (which can produce multiorgan system
(e.g. lethargy), hypotension (easily identified by failure)
delayed capillary refill), hypoventilation,
hyperventilation or cyanosis Diagnostic Tests
• Pulse oximetry (if available)
When evaluating infants, the following • Blood culture (if available) remains the gold
observational variables can be used as a clinical standard for identifying children with occult
guide: bacteremia: collect blood samples for culture, one
• Quality of cry blood culture will usually suffice.
• Reaction to parental or caregiver stimuli • WBC count (if available) between 15,000 and
• Level of arousal 20,000 or less than 5,000
• Color • Urinalysis and urine culture should be performed;
• Hydration status for infants and for toddlers, the most expedient and
• Response to social overtures reliable method of obtaining urine for urinalysis and
culture is by catheter

• Chest x-ray (if available) is useful only if there culture(s) have been obtained. Discuss with a
is clinical evidence of a possible respiratory physician first, if possible.
infection (e.g. tachypnea, cough, retractions, use
of accessory muscles, crackles or wheezing); The neonate with bacteremia or sepsis should be
such imaging should be done only in older treated with combination therapy such as ampicillin
infants and children who are relatively less sick and gentamicin. Third-generation cephalosporins,
and only if the result would affect the decision to such as ceftriaxone, may provide improved CNS
transfer to hospital penetration and can be substituted for gentamicin.
Older infants and children with bacteremia or sepsis
Management can be treated with ceftriaxone.
The main focus of prehospital care of the febrile
child, particularly one who appears acutely ill, Antibiotic therapy:
should be rapid transport to a hospital emergency ampicillin (C class drug)
department. Neonate <7 days and >2000 g: 75 mg/kg per day,
divided q8h, IV
Stabilization Interventions Neonate 7 days and >2000 g: 100 mg/kg per day,
• ABCs are your first priority divided q6h, IV
• Airway management and venous access are Children: 100-200 mg/kg per day, divided q4-6h, IV
indicated if the child has signs of sepsis or IM
and
Adjuvant Therapy gentamicin (B class drug)
• Start IV therapy with normal saline and run at a Neonate <7 days and >2000 g: 2.5 mg/kg per dose IV
rate sufficient to maintain hydration, unless there q12h
are signs of septic shock (see "Shock," above, Neonate =7 days and >2000 g: 2.5 mg/kg per dose IV
this chapter). q8h
• Oxygen may be necessary if there are signs of Children: 1.5-2.5 mg/kg IV or IM q8-12h
sepsis (6-10 L/min or more; keep oxygen Dose and frequency of gentamicin are based on the
saturation > 97%) child's age and renal function.
• Foley catheter (may be necessary if in septic or
shock) ceftriaxone (B class drug), 50-75 mg/kg per day,
divided q12-24h, IV or IM
Once the child's condition has been stabilized, Monitoring and Follow-Up
consult a physician according to the following Monitor ABCs, vital signs, pulse oximetry (if
guidelines: available), level of consciousness and urinary output
• All infants <1 month with rectal frequently if the child's condition is unstable.
temperature > 38°C need a full septic work up;
therefore medevac Referral
• All infants 1-3 months old • Medevac all febrile infants <1 month old and all
• All infants 3-36 months old who appear acutely children 1-36 months old who appear acutely ill and
ill or who are at increased risk for occult in whom bacteremia or sepsis is suspected
bacteremia or sepsis • Antibiotics may be administered before transfer, on
the advice of a physician.
Pharmacologic Interventions • In some settings, a pediatric transfer team (which
Antibiotics are the standard of care in the often includes a physician) is available for critically
management of children with suspected ill children
bacteremia or sepsis. The selection of the drug is
based on the child's age and the presence of risk
factors for unusual pathogens. Antibiotics should
be administered promptly after the results of

Some febrile infants and children 1-36 months old caregiver, close follow-up and an established protocol
may be managed as outpatients. Clinical studies for notification of the parents or primary caregiver of
have reported the following criteria identifying the any positive culture results.
children at lowest risk and hence appropriate for
outpatient management:
• Reliable caregivers
• Follow-up within 24 hours
• Child does not appear acutely ill
• Term gestation
• Child previously healthy
• No current antibiotics
• Normal results on urinalysis
• Normal results on chest x-ray (when indicated
and if available)
• Infants 1-3 months of age should have a CBC,
still difficult to judge clinically, WBC <15,000
should be considered for treatment (Rochester
criteria)
The febrile child 1-36 months old who has a

temperature <39°C and no obvious source of
infection and who does not appear acutely ill can
be managed as an outpatient with administration
of antipyretics and close follow-up.
No diagnostic tests are indicated, and antibiotics

are not recommended in these children. Avoidance
of antibiotics helps to distinguish viral from
bacterial meningitis and also to distinguish partial
treatment of occult bacteremia from a viral
syndrome in the event of clinical deterioration.
However, if there are concerns about reliable
follow-up or if the child is at higher risk for
serious bacterial illness (e.g. presence of
immunocompromised state), a more complete
diagnostic work-up should be considered.
The management of febrile children 1-36 months

old with a temperature >39°C, but no identifiable
source of infection and without appearance of
acute illness, is controversial.
Children in this situation are more likely to have

occult bacteremia (approximately 4%), and they
may not consistently manifest clinical signs of
serious bacterial illness. No matter how extensive
the diagnostic evaluation and therapy, these
children require close follow-up after discharge to
prevent infectious complications. Careful
outpatient management should include a reliable

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10-004_Binder Cover 10/8/04 3:05 PM Page 1

NWT Clinical Practice Guidelines for Primary

Introduction, Acknowledgements, Preface (Adult)

September 2004 Adult 1

Brenda Kolasa Jo-Anne Hubert Marilyn Lidstone

in helping to review and revise these guidelines

2 Adult September 2004

Chapter 1 - The Eyes

Common Problems Of The Eye ....................................................................................................................... 4

Emergency Problems Of The Eye.................................................................................................................. 16

September 2004 Adult 1

Assessment Of The Eyes

September 2004 Adult 1-1

General Physical Examination

Differential Diagnosis Of Eye Symptoms Or Ocular Pain

September 2004 Adult 1-3

Common Problems Of The Eye

September 2004 Adult 1-5

Pharmacologic Interventions Identify and manage underlying seborrhea (scalp,

September 2004 Adult 1-7

• Suspicion of gonorrhea or chlamydial Bacterial Conjunctivitis

September 2004 Adult 1-9

September 2004 Adult 1-11

History Post-Operative Medication Review

September 2004 Adult 1-13

Chronic Open-Angle Glaucoma

Appropriate Consultation • People > 65 years of age should be assessed

September 2004 Adult 1-15

Emergency Problems Of The Eye

Diagnostic Tests Complaints of irritation and foreign-body

Monitoring and Follow-Up Referral

September 2004 Adult 1-17

Differential Diagnosis Referral

Conjunctival, Corneal Or Intraocular Foreign Bodies

Complications Pharmacologic Interventions

gentamycin ungt (C class drug), qhs

September 2004 Adult 1-19

Acute Angle-Closure Glaucoma

September 2004 Adult 1-21

Keratitis (Snow Blindness)

September 2004 Adult 1-23

• If a corneal defect is noted on examination, Monitoring and Follow-Up

Pharmacologic Interventions Referral

September 2004 Adult 1-25

Blunt Or Lacerating Ocular Trauma

September 2004 Adult 1-27

Minor Soft-Tissue Contusion

Differential Diagnosis Steroids may be prescribed by ophthalmologist.

September 2004 Adult 1-29

Chapter 2 - Ears, Nose And Throat (ENT)

Common Problems Of The Ears And Nose .................................................................................................... 3

Common Problems Of The Mouth And Throat ........................................................................................... 21

Emergency Problems Of The Ears, Nose And Throat................................................................................. 25

September 2004 Adult 2

Assessment Of The Ears, Nose And Throat

History Of Present Illness And Review Of System

Medical History (Specific To ENT)

September 2004 Adult 2-1

Examination Of The Ears, Nose And Throat

Common Problems Of The Ears And Nose