pediatric nursing review (2)

PEDIATRIC NURSING

Review

ERICKSON’S PSYCHOSOCIAL STAGES OF DEVELOPMENT

Infancy (0 – 1 year) Toddler (1 – 3 year)

Preschool (3 – 6 years)

School (6 – 12 years)

Adolescent (12 – 18 years)

Trust vs. Mistrust Autonomy vs.

Shame and Doubt Initiative vs. Guilt Industry vs.

Inferiority Identity vs. Role

Diffusion

PIAGET’S THEORY OF COGNITIVE DEVELOPMENT

Sensorimotor Reflexes (0 – 2 years)

Pre-operational/Pre-conceptual (3 – 5 years)

Reliance on reflexes to interact with environment

Increase use of language; unable to put self in another’s place; does not understand relationship of size, weight, volume


Intuitive (5 – 7 years)

Concrete Operations (8 – 13 years)

Magical thinking; egocentric; tendency to center attention on one feature

Inductive reasoning (specific to general); conservation-ability to understand things are essentially the same even though its shape and arrangement are altered


Formal Operations (13 – 16 years)

Capable of introspection, deductive reasoning; able to formulate hypothesis

PHYSICAL ASSESSMENT

By what age should the anterior fontanel be

closed? a. 2 weeks b. 6 months

c. 12 months d. 18 months d. 18 months diamond shapedPosterior triangle in 2 monthsTells hydrationShould be sitting up

PHYSICAL ASSESSMENT

Posterior fontanel closed when?

A. 2 weeksB. 2 months

C. 8 monthsD. 12 months

PHYSICAL ASSESSMENT

Respiratory

Are young children thoracic or abdominal breathers?

Chest shapeRespiratory 1st vital signs on kids is what we do!!Boys are thoracicGirls stay abdominal

Are young children thoracic or abdominal breathers?A-p diameter is less than transverseChest shape

Infants – shape is roundChildren & adolescents – transverse diameter to anteroposterior

diameter changes to 2:1

WEIGHT

Birth weight doubles by 6 months Birth weight triples by 12 months

IQ

IQ = Mental age/Chronological age x 100

GROSS MOTOR SKILLS

2 months 3 months

4 months 5 - 6 months 6 months

6 – 8 months 12 months

Holds head up Holds head and

chest up when prone

Rolls front to back Rolls back to front Holds head steady

when sitting Sits unsupported Stands

FINE MOTOR

Circle by 3 years Cross by 4 Square by 5 Triangle by 6

Social development 2 month smile 3 month breast milk, 6 month stranger

anxiety 9 months waves bye bye 12 months comes when

called speaks one word 15 months jargon

babbles 18 month copies parents 2 yr. two words

PEDIATRICS FEEDING AND PLAY

0-1 yo breast milk 4-6 mo iron fortified 6-8 mon yellow

veggie

Play Infants solitary play Toddler parallel play Preschool

associative or cooperative play

School-age competitive play

HEALTH ASSESSMENT

Birth – 3 year old pull the pinna down and back

After 3 pull the pinna up and back

PAIN MANAGEMENT

A 10 year old child has just had an appendectomy which of following tools is appropriate a VAS visual analogue Scale

Faces for at least 3-6 year old!!!

Kindergarten count to 100, know shapes, skip jump walk backward walk a straight line

Waiting for pain management “if you let the pain get too bad, the medication will not work as well” is what a nurse says

Give pain meds around the clock

Reevaluate or evaluate the effectiveness of pain med

EXPLORE

a primary care provider prescribes 240 mg of Cefuroxme bid PO for a 3 year with OM. The medication is available in a 200mg/5 suspension

How much mLs should the child receive with each dose?

Feeding tube Check placement

first Flush tubing before

and after medication Dissolve tab in

premeasured amt. of fluid mea

Push slowly

IMMUNIZATION

Vastus lateralis site for infants and children less than 2 years

After 2 year, the ventral gluteal both of these sites can accommodate fluid up to 2 ml

The deltoid site has a smaller muscle mass and can only accommodate up to 1 ml of fluid because size

PLAY ACTIVITIES & SEPARATION ANXIETY

Birth -3 mo visual & auditory

3-6 months noisemaking objects and soft toys

6-9 months teething toys and social interaction, stack, build cause they sitting up

9-12 months push pull, popcorn popping, large blocks pull apart

Separation Anxiety Parents at hospital

are toddler Begins 9 months

and peaks at 18 months

Isolation washable toys

NUTRITION

Solids introduced to infant doubles his birth weight (5 to 6 months)

Are able to sit up at this age!!!

• First, give iron-fortified cereals.

• Next, give pureed or strained foods one at a time to assess for food allergies.

• Finally, breast milk/formula should be decreased as intake of solid foods increase.

NUTRITION

Preterm infants < 37 weeks & < 2,500 g 50-60 kcal/kg/daily parenteral 75 kcal/kg/daily orally Breast milk

NUTRITION

0 – 1 year 4 – 6 months

6 – 8 months

8 to 10 months After 12 months

Breast milk or formula

Iron-fortified cereal, such as rice cereal

Yellow vegetables, fruits

Meat While milk, eggs,

strawberries, wheat, corn, fish, and nuts

NUTRITION Toddlers—1-3 year Finger food “picky” 3 meals & 2 snacks

daily Small portions—healthy Limit fruit juice—4-6

oz/day d/t sugar Preschooler—3-5 years Certain food for a

period of time 3 meals & 2-3

snacks/daily all areas food pyramid

Schooler—5-12 years Depends on activity Balanced diet Likes to be included in

meal planning & preparation

Adolescent—12-20 years

Growth spurts Fast food healthy

difficult 2,000—3,000 kcal/daily

PLAY

Infants Toddler Preschool School-age

Solitary Play Parallel Play Associative or

Cooperative Play Competitive Play

INFANT PLAY ACTIVITIES

Birth – 3 months

3 – 6 months

6 – 9 months

9 – 12 months

Visual and auditory stimuli

Noise-making objects and soft toys

Teething toys and social interaction

Large blocks, toys that pop apart, and push and pull toys

SEPARATION ANXIETY

Begins at 9 months and peaks at 18 months.

IM MEDICATION ADMINISTRATION

The vastus lateralis site for infants and children < 2 years.

After age 2, the ventral gluteal site can be used. Both of these sites can accommodate fluid up to 2 ml.

The deltoid site has a smaller muscle mass and can only accommodate up to 1 ml of fluid.

MEDS ADMINISTRATION

MEDICATION ADMINISTRATION

A primary care provider prescribes 240 mg of Cefuroxime BID PO for a 3 year old with Otitis Media. The medication is available in a 200 mg/5 ml suspension. How many mLs should the child receive with each dose?

5ml x 240 mg = 1200 = 6 mL200 mg x 1 200 Or D/A x Q240/200 x 5 = 6

MEDS ADMINISTRATION

List 3 intervention, with rationales, that a nurse can use to decrease the risk of medication errors when administering medications

Interventions Have 2nd nurse verify dose calculation Obtain accurate weight of child Mix medication with small amounts or liquid or soft

foods Rationale

Adult meds forms may be used requiring calculation of very small doses

Dosages are usually based on weight or BSA If med is mixed in large amounts of liquid or foods, the

child may refuse to finish the dose

PAIN MANAGEMENT

Effectiveness of treatment evaluation 15 min after IV 30 min after IM 30-60 min after Orally & nonpharm. Therapy

Older children can give report Physiologic changes BP, HR, RR are temporary

changes produced by anxiety associated with pain. Initially, elevated VS will return to normal despite persistence of pain

Self report using pain scales is useful in children over 7 year

Children 3-7 can comprehend how to use pain rating scale—assess their ability & validate w/parents

PAIN MANAGEMENT

FLACC Behaviors 0-2 2-7 months 0/10 10 worst

CHEOPS 4/13 13 worst 1-5 years

FACES Use Drawing 3-older VAS Scale numbered 7-older or as

y/4.5 0-10 point to #

MEDICATION ADMINISTRATION

When administering oral medications to a child with a feeding tube, the nurse knows to:

a. Flush the tubing with NS before and after administration of the medication.

b. Dissolve tablets in a premeasured amount of fluid, measure into a syringe, and give slowly into the side of the mouth to prevent clogging the feeding tube.

c. Push slowly on the plunger of the administration syringe to gently administer the medication through the feeding tube.

d. Check tube placement, administer medication by gravity flow, flush adequately, and clamp tubing.

OTIC ADMNISTRATION

Birth to 3 years – Pull the pinna (auricle) down and back.

After 3 years – Pull the pinna (auricle) up and back.

PAIN MANAGEMENT

A 10-year-old child has just had an appendectomy following a ruptured appendix. A nurse is monitoring the child’s response to antibiotics, postoperative healing, and pain control Which of the following tools is most appropriate for assessing the child’s pain?

a. FLACC (Faces, Legs, Activity, Cry, Consolability Scale)

b. FACES pain rating scalec. Children’s Hospital Eastern Ontario Pain

Scales (CHEOPS)d. Visual Analogue Scale (VAS)

PAIN MANAGEMENT

A nurse suspects that a 15-year-old adolescent is experiencing pain. The nurse asks if the adolescent would like her pain medication. The adolescent tells the nurse that she will wait until the pain worsens. Which of the following statements by the nurse is most appropriate in response to the adolescent’s pain?

a. “If you let the pain get too bad, the medication will not work as well.”

b. “Just let me know when you are ready.”c. “You need to take your pain medication

now.”d. “Are you sure you don’t want anything

now?”

PAIN MANAGEMENT

Thirty to 60 minutes following the administration of an oral pain medication to a child, it is important that a nurse

a. Document the child’s pain on a rating scale.b. Evaluate the effectiveness of the pain

medication.c. Assess the child for bowel sounds.d. Massage the child’s painful area.

HOSPITALIZATION

Infant

Toddler

Preschooler—separation anxiety too

School-age--seeks information for a way of control, sense when not being told the truth, stress related to separation from peers and regular routine

- Adolescent--aintain composure,

embarrassed about losing control, worries about outcome, may not be compliant if it makes them appear different from peer group

Experiences stranger anxiety Experiences separation anxiety Harbors fear of bodily harm;

fears hospitalization is a punishment will ask for a bandaid!!!! They think they did something wrong

Fear loss of control

Body-image disturbance; feelings of isolation from peers

7YEAR OLD IN HOSPITAL APPROPRIATE NEEDS

Answer: provide play activities that foster a sense of normal routine

Girl like arts and craft

Boys like things to build

Toddler no small lago because choking

Friction toys not near oxygen

AGE-RELATED INTERVENTIONS

Infant

Toddler

Preschooler

School Age

Adolescent

Near nursing station, consistent caregivers

Parent to provide regular routine, appropriate choices—autonomy, consistent caregivers

Explain procedures, encourage independence—self care, validate feelings, express feelings, toys to allow for expression, “Do you want your med in a cup or spoon, younger children to handle equipment

Provide factual information, express feelings, maintain normal routine—time for school work, encourage to contact peer group

Factual information, include in planning of care for powerlessness, encourage contact peer group

HOSPITALIZATION

Which of the following nursing interventions is most appropriate for the needs of a 7-year-old child being hospitalized for an extended time?

a. Bring security items such as a toy and blanket

b. Provide play activities that foster a sense of normal routine

c. Limit choices whenever possibled. Restrict family visiting hours

DEATH AND DYING

Which of the following nursing interventions is the most appropriate when working with a school-age child who has a terminal disease?

a. Give factual explanations of the disease, medications, and procedures

b. Perform all care for the patientc. Tell the child that everything will be okayd. Reinforce that being in the hospital is not a

punishment for any thoughts or actions

HYPOXEMIA

Tachypnea Tachycardia Restlessness Pallor of the skin

and mucous membranes

Elevated blood pressure

Work of breathing

Confusion and stupor

Cyanosis of skin and mucous membranes

Bradypnea Bradycardia Hypotension Cardiac

dysrhythmias

Early Late

BRONCHIAL (POSTURAL) DRAINAGE

Schedule treatments 1 hour before meals or 2 hours after meals to decrease the likelihood of the child vomiting or aspirating.

Bronchial drainage is more effective if other respiratory treatments (e.g., bronchodilator medication and/or nebulizer treatment) are performed 30 minutes to one hour prior to postural drainage.]

Give a treatment first if they are getting a treatment and CPT

SUCTIONING

Suction should take no longer than 5 seconds.

Suction catheters should be one-half the size in diameter of the child tracheostomy tube.

It is no longer the standard of practice to instill sterile saline into the tracheostomy tube prior to suctioning.

HYPOXEMIA

When assessing a child removed from an oxygen tent, a nurse recognizes which of the following signs and symptoms as an early indication of hypoxemia?

a. Nonproductive coughb. Hypoventilationc. Nasal flaringd. Nasal stuffinessRationale: signs of hypoxemia early! Nonproductive cough, hypoventilation and nasal stuffiness are signs and symptoms of oxygen toxicity plus sub-sternal pain, N/V/Fat/H/sore throat

OXYGEN TOXICITY

Which of the following is the most appropriate nursing interventions for a child experiencing oxygen toxicity?

a. Immediately discontinue oxygen administration

b. Increase humidification of oxygenc. Use lowest possible flow rate of

oxygend. Monitor oxygenation with a pulse oximeterRationale: interventions include using lowest level necessary to maintain adequate SaO2 levels. O2 should be discontinued gradually, should be humidified.

OXYGEN SATURATION

Normal values Acceptable values Emergency value Life-threatening

value

95 to 100% 91 to 100% Less than 86% Less than 80%

OXYGEN ADMINISTRATION

A child with cystic fibrosis is hospitalized with an acute episode of pulmonary manifestations. Which of the following nursing interventions is contraindicated for this child?

a. Perform chest physiotherapy three times daily

b. Administer oxygen at an increased flow rate

c. Deliver aerosolized medication to open bronchi

d. Teach the child to use a flutter mucus clearance device

ASTHMA

Manifestations of asthma Mucosal edema Bronchoconstriction (from bronchospasm) Excessive secretion production

Expiratory wheeze Prolonged expiratory phase Nonproductive, hacking cough know if having

asthma attack you hear Wheezes can be audible Appearance may show enlarge chest wall

anteroposterior diameter

ASTHMA Treatment

Beta 2 adrenergic agonists are bronchodilators Albuterol Salmeterol Terbutaline

Glucocorticoids Prevent inflammation Suppress airway mucus production Promote use of beta2 receptor Beclomethasone QVAR use low dose, difficulty speaking, hoarseness

candidiasis Prednisone Pulmicort Flovent

Leukotriene Antagonist Singulair Mast cell stabilizer Cromolyn Sodium Monoclonal Antibodies Xolair B before C Beta agonist then Corticoid No CPT during an asthma attack.

ASTHMA

A child is exhibiting suspected clinical manifestations of asthma. The mother asks the nurse what tests will be necessary to diagnose her child. Which of the following diagnostic procedures should the nurse tell the mother is most accurate for diagnosing asthma?

a. Arterial blood gasesb. Chest x-rayc. Pulmonary function testsd. Allergy tests

ASTHMA

A child experiencing an acute asthma attack presents to the ED. Which of the following medications should a nurse prepare to administer to the child as an intervention for an acute asthma attack?

a. Terbutaline (Brethine)b. Beclomethasone dipropionatec. Prednisoned. Albuterol (Proventil) is expensive Proventil

albuterol is cheaper

INHALED STEROIDS

Side Effects Difficulty speaking Hoarseness Candidiasis

TONSILLITIS Tonsils filter viruses and bacteria. Lymph tissue. Highly vascular.

Tonsillitis caused by group A beta-hemolytic streptococci (GABHS) Chronically infected tonsils may pose a potential threat to other parts of the

body. Some children who have frequent bouts with severe tonsillitis may develop other diseases, such as rheumatic fever and kidney infection.

In younger children d/t immature immune systems Tonsillectomy pre-op – CBC (anemia & infection) RN intervention Tonsillitis (symptomatic—viral: rest, fluids, warm salt water

gargles, Tylenol or ibuprofen for pain, NPO if surgery!

Tonsillectomy – post-op Side lying position initially with HOB up when fully awake Nothing sharp in mouth, no straws, no sharp food Look for frequent swallowing, clearing throat, restlessness, bright red emesis,

tachycardia and/or pallor Provide ice collar and throat moist Clear liquid, soft, bland foods—no fruit punch Avoid red colored foods and milk initially Discourage coughing, throat clearing, and nose blowing Limit strenuous activity for 2 weeks Notify MD if bright red bleeding occurs, increase pain, lack of oral intake

TONSILLECTOMY

Discharge—must be able to tolerate oral fluids and soft foods, & void prior

Instructions Call doctor if difficulty breathing, bright red

bleeding, lack of oral intake, increase in pain and/or signs of infection

Not to put anything sharp in mouth No spicy food or hard, sharp foods like corn

chips Limit strenuous activity and physical play w/no

swimming for 2 weeks Full recovery occurs usually within 10 days – 2

weeks!

RESPIRATORY INFECTIONS

Respiratory infections are less common in infants from birth to 3 months of age because maternal antibodies offer protection.

CROUP SYNDROMES Bacterial Epiglottitis

Medical emergency Caused by Haemophilus influenzae Dysphonia, Dysphagia, Drooling Inspiratory stridor Sore throat, high fever Tripod positioning Racemic epinephrine Prepare for intubation Corticosteroids Antibiotics DO NOT EXAMINE THE CHILD’S THROAT WITH A

TONGUE BLADE OR TAKE THROAT CULTURES.

CROUP SYNDROMES Croup or Acute Laryngotracheobronchitis

(LTB) Causative agents: RSV, influenza A and B, and

Mycoplasma pneumoniae Barky cough Inspiratory stridor Low-grade fever URI Racemic epinephrine Corticosteroids Use of warm or cold mist Possible need for emergency airway DO NOT EXAMINE THE THROAT

RSV

Diagnosis of Respiratory Syncytial Virus (RSV) is accomplished througha. Collection of a sputum specimenb. A throat culturec. Nasal aspirationd. Obtaining blood for a CBC

RSV

What are nursing interventions that would be expected for a child hospitalized for pneumonia caused by RSV?

Antipyretics for fever O2 w/cool mist for comfort IV &/or oral fluid therapy Postural drainage and CPT

RESPIRATORY ILLNESS

Viral infections more common in toddler and preschooler. Incidence decreases by age 5.

GABHS and Mycoplasma pneumoniae rates increase after age 5.

RSV more common during winter and spring.

Mycoplasma pneumoniae more common in autumn and early winter.

CYSTIC FIBROSIS Hereditary; autosomal recessive trait;

both parents must carry the trait Dysfunction of exocrine glands, causing

glands to produce thick, tenacious mucus Thick mucus obstructs respiratory

passages; also, obstructs secretory ducts of the pancreas, liver, and reproductive organs

Sweat and salivary glands excrete excessive amounts of sodium and chloride

Bronchiectasis and emphysema may develop with pulmonary fibrosis (these are two most common the are sterile too reproductive wise)

CYSTIC FIBROSIS

Diagnostic Tests Sweat chloride test Absent pancreatic enzymes Stool analysis indicating steatorrhea

(undigested fat) and azotorrhea (foul-smelling from protein)

Pulmonary function Sputum C & S—infection Abdominal X-ray—detects meconium ileus

CYSTIC FIBROSIS

Interventions Bronchodilators then CPT (do 1 hour before

meals or 2 hours after meals) Flutter mucus clearance device Pulmozyme nebulizer to decrease viscosity of

mucus Pancreatic enzymes with meals and snacks High-caloric, high protein diet Multiple vitamins, including water-soluble

forms, of vitamins A, D, E, and K

CYSTIC FIBROSIS

All of the following are assessment findings seen in a child with cystic fibrosis except for:

a. Wheezy respirationsb. Clubbing of fingers and toesc. Barrel-shaped chestd. Rapid growth spurts

CHD

Key points Present @ birth because anatomic

abnormalities Result primarily in HF and hypoxemia Prevent normal blood flow Any structural lesion in heart or blood vessel

that is directly proximal to the heart = CHD Many defects spontaneously close Diagnosed in 1st yr. of life

CHANGES AT BIRTH

FIG. 25-1 Changes in circulation at birth. A, Prenatal circulation. B, Postnatal circulation. Arrows indicate direction of blood flow. Although four pulmonary veins enter the LA, for simplicity this diagram shows only two. RA, Right atrium; LA, left atrium; RV, right ventricle; LV, left ventricle.

RA3 mm Hg72-80%

RV25/0-5 mm Hg72-80%

Ao115/80 mm Hg95% PA

25/15 mm Hg72-80%

PV9 mm Hg95%LA

5-10 mm Hg95%

LV120/0-10 mm Hg95%

ATRIAL SEPTAL DEFECT

Figure 25-1 ASD

VENTRICULAR SEPTAL DEFECT

Figure 25-2 VSD

ATRIOVENTRICULAR CANAL DEFECT

Unn Figure 25-3 Atrioventricular canal defect

PATENT DUCTUS ARTERIOSUS

Figure 25-4 PDA

COARCTATION OF THE AORTA

Figure 25-5 Coarctation of the aorta

COARCTATION

Increased blood pressure in the UE. Increased saturation in the UE. Weak or absent pulses in the LE Nosebleeds Headaches Leg pain Weak or absent LE pulse (indicate decreased

CO)

AORTIC STENOSIS

Unn Figure 25-6 Aortic stenosis

PULMONIC STENOSIS

Unn Figure 25-7 Pulmonic stenosis

TETRALOGY OF FALLOT

Unn Figure 25-8 TOF

TOF Pulmonary Stenosis VSD Overriding Aorta Right ventricular hypertrophy

Polycythemia Squatting position Clubbing of fingers Murmur Severe dyspnea Hypercyanotic spells Acidosis FTT Growth retardation

TRICUSPID ATRESIA

Figure 25-9 Tricuspid atresia

TRANSPOSITION OF THE GREAT ARTERIES, OR TRANSPOSITION OF THE GREAT VESSELS

Figure 25-11 Transposition of great vessels

TOTAL ANOMALOUS PULMONARY VENOUS CONNECTION

Figure 25-12 Total anomalous pulmonary venous connection

TRUNCUS ARTERIOSIS

HYPOPLASTIC LEFT-SIDED HEART SYNDROME

Unn Figure 25-14 Hypoplastic left-sided heart syndrome

IMPLEMENTATION/ASSESSMENT

Palpate peripheral pulses, noting rhythm irregularities and decreased strength or inequality

Palpate extremities for slow cap refill Auscultate HR & rhythm, Assess for bradycardia, tachycardia, or

dysrhythmias, heart sounds, murmurs or extra sounds

Palpate and percuss abdomen for enlarged liver and/or spleen


Sign & symptoms of HF Impaired myocardial function Tachycardia Diaphoresis decreased UOP Fatigue Pale & cool extremities Weak peripheral pulses Cardiomegaly FTT Anorexia


Sign & Symptoms of Pulmonary Congestion Tachypnea Dyspnea Retractions Nasal flaring Exercise intolerance Stridor Grunting Recurrent respiratory infections


Sign & symptoms of Systemic Venous Congestion hepatomegaly Peripheral edema Ascites Neck vein distention (not seen in infants)

Signs & Symptoms of Hypoxemia Cyanosis Clubbing Polycythemia Squatting Chest deformities Hypercyanotic spells (blue or “Tet”) = acute cyanosis

and hyperpnea!

IMPLEMENTATION

Improve cardiac function Administer Digoxin (check K, double check dose with

another RN, apical for one minute) Afterload reduction

Monitor BP (before & after ACE inhibitors, assess for ↓BP, monitor electrolytes)

Decrease cardiac demands Rest, cluster care, minimize crying, etc.

Reduce respiratory distress ↑HOB, O2

Maintain nutritional status Need ↑calories d/t ↑metabolic demands

Promote fluid loss Diuretics, I & O, weight, electrolytes, hydration, fluid

restriction Support child/family

MANAGEMENT OF HYPOXEMIA

Children with heart defects can have hypercyanotic “Tet” spells which can result in severe hypoxemia.

Immediately place the child in the knee-chest position, attempt to calm the child, and call for help.

CARDIAC CATHETERIZATION

If bleeding occurs at the insertion site after the cardiac catheterization, the first action the nurse should implement is to

a. Apply pressureb. Administer vitamin Kc. Call the surgeond. Apply a tighter pressure dressing

DIGOXIN

Administer one hour before or two hours after feedings.

If the child vomits, do not re-administer the dose.

If a dose is missed by more than 4 hours, withhold the dose and do not double the next dose.

Observe for signs of digoxin toxicity: slow pulse, decreased appetite, N/V

EPISTAXIS

Have child sit up with head tilted slightly forward to promote drainage out of nose instead of down the back of the throat.

Apply pressure to the lower nose. Cotton or tissue can be packed into the nare

that is bleeding. Ice across bridge of nose. If bleeding last longer than 30 min., see

medical care.

LEUKEMIA

Most common cancer of childhood Bone marrow dysfunction Causes an increase of immature WBCs

(blasts) to be produced Deficient RBCs cause anemia Deficient mature WBCs (neutropenia)

increase risk for infection Deficient platelets (thrombocytopenia) cause

bruising Invasion of CNS causes increased ICP Invasion of bone marrow causes bone bain

LEUKEMIA NURSING INTERVENTIONS

Good oral care. Soft brushes. Avoid rectal temperatures. Soft, bland diet. High fiber diet. Stool softeners/laxatives as needed. Weigh daily. Encourage fluids. Prepare for hair loss.

LEUKEMIA Low grade fever Pallor Increased bruising and petechiae Listlessness Enlarged liver, lymph nodes and joints Constipation Headache N/Anx Low platelet & RBC Increased immature WBC Late manifestations

Hematuria Ulceration in mouth Enlarged kidneys and testicles Increased intracranial pressure

IRON DEFICIENCY ANEMIA

Most prevalent nutritional and mineral deficiency in the US.

Common in ages 6 months to 2 years and in adolescents 12 to 20 years.

Can decrease oxygen to tissues Cause growth retardation and developmental

delays. Whole milk is not a good source of iron.

NURSING INTERVENTIONS

Preterm or LBWI require iron supplements Breastfeed younger than 4—6 months Iron-fortified formula Modify diet—high iron, Vit. C & protein Allow frequent rest periods Restrict milk intake in toddlers. Give only 1 qt. per day Avoid until after a meal Don’t carry bottle or cups of milk


Restrict milk intake in toddlers. Give iron one hour before or 2 hours after milk

or antacid. Give on empty stomach. Give iron with vitamin C to help increase

absorption. Give with straw to avoid staining teeth. Rinse

mouth out with water. Stools may be tarry. Increase fluids to prevent constipation. Dietary sources: dried legumes, nuts, green

leafy vegetables, red meat, foods iron fortified Use Z track for parenteral injection—Don’t

massage

BLOOD STUDIES

2 months

6 to 12 years

12 to 18 years

Hbg: 9 to 14 g/dL Hct: 28 to 42% Hbg: 11.5 to 15.5 g/dL Hct: 35 to 45% Hbg: 13 to 16 g/dL

(male) Hbg: 12 to 16 g/dL

(female) Hct: 37 to 49% (male) Hct: 36 to 46 (female)

Age Hgb/HCT

IRON

A nurse is administering parenteral iron dextran to a child by the Z-track method. Which of the following strategies is correct when using the Z-track method to administer iron?

a. Watch the child carefully for an allergic reaction after administration.

b. Use the deltoid muscle for administration in school-age children.

c. Massage the injection site for comfort after administration.

d. Administer no more than 3 ml of iron into one site at a time.

SICKLE CELL DISEASE Autosomal recessive genetic disorder. Promote REST OXYGEN Pain management: Tylenol or ibuprofen, opioids for

severe pain. Warm packs to painful joints. Maintain fluids. Blood products/exchange transfusion. PROM to prevent venous stasis. Prevent infection—hand washing, prophylactic

penicillin Complications: SVA and Acute Chest Syndrome

Seizures, abnormal behavior, slurred speech, change in vision, vomiting, severe headache

Chest syn.—chest pain, fever 102 F or higher, congested chest, tachycardia, dyspnea, retractions, decreased O2 sat

HEMOPHILIA

X-linked recessive disorder. Hemophilia A

Deficiency of factor VIII Classic hemophilia Accounts for 80% of cases

Hemophilia B Deficiency of factor IX Christmas disease


Avoid rectal temperatures. Avoid unnecessary skin punctures. Apply pressure for 5 minutes to injection

sites. Monitor urine, stool, and nasogastric fluid for

occult blood. Rest and immobilize affected joints

(hemarthrosis). Elevate and apply ice to affected joints. Soft toothbrush. Medic Alert bracelet.

HEMOPHILIA

True or False:

Aspirin and ibuprofen are the best choices for pain relief in a child with hemophilia.

RHEUMATIC FEVER

Inflammatory disease of connective tissue which can include the connective tissue of the heart, joints, CNS, and subq tissue.

Rheumatic fever can cause RHD which can result in cardiac valve damage.

Usually occurs within 2 to 6 weeks following an untreated upper respiratory infection (GABHS).

RHEUMATIC FEVER

Major Criteria Carditis Polyarthritis Chorea – involuntary muscle movements, muscle

weakness, etc. (this is transitory & will resolve) Subq nodules Rash (erythema marginatum) – pink macular

rash on trunk and abdomen (not on face) Minor Criteria

Fever Arthralgia

NURSING INTERVENTIONS Penicillin (erythromycin if child allergic to PCN)

Assess for allergic response (hives, rash, anaphylaxis) Assess for N/V/D

Aspirin for anti-inflammatory effect (rheumatic fever is bacterial and not viral in origin) Bed rest

Assist w/ADL’s if chorea prevent the child from bathing, feeding School work arranged

Chorea is self-limiting Follow prescribed prophylactic treatment

2 daily doses of 200,000 penicillin Monthly IM of 1.2 mill units of penicillin Or Daily PO dose of 1 g of Sulfadiazine Obtain prophylaxis therapy FOR ALL DENTAL WORK & INVASIVE

PROCEDURES ARRANGE medical follow-up Q5years

Elevated or rising serum antistreptolysin-O (ASO) titre – most reliable

IMMUNIZATIONS

Contraindications Moderate to severe illness Allergies (e.g., specific medications, eggs,

gelatin, or any vaccine) Serious reaction following vaccine administration

in the past History of seizures or other neurological

condition Immunosuppression (e.g., cancer, HIV, chronic

steroid use) Blood transfusion, immunoglobulin, or recent TB

test Pregnancy

COMMUNICABLE DISEASES Varicella (Chickenpox)

No longer contagious once lesions have crusted over Contagious one day before lesions to 6 days after first lesions

appear Very itchy

Rubella (German Measles) Low-grade fever mild rash lasting 2 to 3 days Rash begins on face, spreading down trunk Prevent exposure to pregnant women

Measles (Rubeola) High fever Koplik spots Rash begins at hairline and spreads down body

Pertusis (Whooping Cough) Nighttime cough; may have mucous plug Droplet Isolation

Mumps Swollen parotid glands; earache with chewing

Infectious Mononucleosis Restrict activities for 2 to 3 months

OTITIS MEDIA

Lower incidence in breastfed infants. Hearing difficulties and speech delays if OM becomes a chronic

condition. Myringotomy and placement of tympanoplasty tubes may be indicated

for the child with multiple episodes Tubes usually come out by themselves in 6 to 12 months. IgA in breast milk—protect against infection Acetaminophen 10—15 mg/kg Q4 Ibuprofen 10 mg/kg Q6 Amoxicillin is 1st Choice 4 OM

Give high dose amoxicillin 80-90 mg/kg/day

Augmentin & azithromycin are 2nd line 10-14 days course Observe for allergic reaction (rash, difficulty breathing etc.)

Discourage use of Decongestants or Antihistamines Sit upright Avoid smoke, people w/viral or bacterial respiratory infections Up to date immunizations

WILM’S TUMOR (NEPHROBLASTOMA)

Malignancy that occurs in the kidneys or abdomen.

Metastasis is rare. Avoid preoperative palpation of Wilm’s tumor. Treatment involves:

Preop chemotherapy or radiation to decrease size of tumor

Surgical removal of the tumor and affected organs

Chemo from 6 to 15 months.

NEUROBLASTOMA

Malignancy that occurs in the adrenal gland, the sympathetic chain of the retroperitoneal area, head, neck, pelvis, or chest.

Presents as asymmetrical, firm, nontender mass in the abdomen. This mass crosses the midline.

Treatment involves: Surgical removal of tumor. Radiation in an emergency to decrease the size

of a tumor that is compressing the spinal cord. Radiation to decrease the size of the tumors and

palliation for metastasis.

BONE MARROW DEPRESSION RESULTING IN ANEMIA, NEUTROPENIA, AND/OR THROMBOCYTOPENIA

Monitor blood counts for anemia, neutropenia, & thrombocytopenia.

Monitor VS, low-grade temp. may be sign of infection. Protect from sources of infection. Avoid invasive procedures. Avoid ASA/NSAIDs. Administer filgrastim (Neupogen) to stimulate WBC

production. Administer epoetin alfa (Procrit) to stimulate RBC

formation. Administer interleukin-11 to stimulate PLATELET

formation. Soft toothbrush. Rest periods.

A CHILD WHO IS 2 DAYS POSTOPERATIVE SURGICAL REMOVAL OF A WILM’S TUMOR IS SOBBING AND REPORTING ABDOMINAL PAIN. THE CHILD WAS MEDICATED 30 MIN. AGO, AND THE NURSE OBSERVES THAT THE CHILD’S ABDOMINAL GIRTH HAS INCREASED BY 6 CM FROM 2 HR PREVIOUSLY. THE CHILD’S SKIN IS COOL AND MOIST. WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE TAKE FIRST?A. ASSESS VITAL SIGNS AND DRESSINGB. PROVIDE DIVERSION FOR 30 MORE MINUTES TO ALLOW MEDICATION TO TAKE EFFECTC. REPOSITION THE CHILD INTO THE SEMI-

FOWLER’S POSITIOND. PROVIDE THE CHILD WITH A QUIET ENVIRONMENT

HIV/AIDS

Viral infection—infects the T-lymphocytes, causing immune dysfunction.

CD4+ T-lymphocyte count determines the level of immuno-suppression.

Pregnant women with HIV are usually given antiviral medications during pregnancy.

Retrovir (Zidovudine) 14 wks. Gestation, thru out, & before onset of labor

or C-section Don’t breastfeed Give 4 6 wks. After delivery at least 30 minutes before or 1 hour after a meal

LAB: Enzyme immunoassay (antibody screen) Confirmed by + Western Blot Testing

HIV/AIDS

Which of the following infections indicates that a child with AIDS is severely ill?

a. Oral-pharyngeal candidiasisb. Otitis mediac. Pneumocystis carinii pneumonia (PCP)d. Herpes simplex virus

BURNS

First Degree Superficial Sunburn Pain

Second Degree Partial thickness Extremely painful Scalds

Third Degree/Fourth Degree Full-thickness Nerve endings destroyed = no pain Lava burn

BURNS

Signs of inhalation injury may include mouth and nose. Maintain airway.

Stop the burning process. Flush with water. Remove clothing. Cover burn with clean cloth. Provide warmth. Obtain tetanus prophylaxis. Moderate to severe burns: fluid replacement. Pain management prior to wound care. Wet dressing prior to removal.

SKIN INFECTIONS

Match the following skin disorders with their cause.

____Impetigo contagiosa A. Fungal infection____Scabies B. Bacterial

infection____Lyme disease C. Viral infection____Cold sore, fever blister D. Spirochete____Ringworm E. Burrowing mite

ECZEMA

Which of the following medications can be used for children with eczema?

CorticosteroidsAccutanePeroxideAntihistaminesCalamine lotion

HOW IS CRADLE CAP TREATED?

GASTROINTESTINAL

Rotavirus is a common cause of diarrhea in young children.

Metronidazole (Flagyl) is used for the child who is symptomatic of C. difficile.

Mild dehydration is 5% weight loss in infants. Moderate dehydration is 10% weight loss in

infants. Severe dehydration is 15% weight loss in

infants.

PINWORM (ENTEROBIUS VERNICULARIS)

Parasitic worm whose eggs when inhaled or swallowed can cause perianal itching.

To assist in diagnosis: transparent tape is placed over anus of child at night. Remove tape prior to child toileting or bathing. Tape sent to lab.

Wash bed linens and underwear in hot water and dry in hot clothes dryer daily for several days.

Cleanse toys and child care areas thoroughly to prevent further spread of disease.

ORAL REHYDRATION THERAPY (ORT)

Foods and fluids to avoid: Fruit juices, carbonated sodas, and gelatin,

which are all high in carbohydrates, low in electrolyte content, and have a high osmolality.

Caffeine, due to its mild diuretic effect. Chicken broth or beef broth, which has too

much sodium and not enough carbohydrates. Bananas, rice, applesauce, and toast (BRAT

diet). This diet carries low nutritional value, high carbohydrate content, and low electrolytes.

PICA

Pica should be considered in which of the following children presenting to the health clinic?a. 7-year-old with nausea and vomiting

for the past 3 days.b. 4-year-old with history of celiac disease

presenting with anemia and abdominal pain.

c. 2-year-old who is still drinking from a bottle and presents with anemia.

d. 4-month-old who presents with crying, irritability, and reddish-colored stools.

GI

Which of the following is the term used to describe impaired motility of the GI tract?a. Malrotationb. Obstructionc. Abdominal distentiond. Paralytic ileus

HIRSCHSPRUNG DISEASE

To confirm the diagnosis of Hirschsprung disease, the nurse prepares the child for which one of the following tests?a. Barium enemab. Upper GI seriesc. Rectal biopsyd. Esophagoscopy

GI

The passive transfer of gastric contents into the esophagus is termed:a. Esophageal Atresiab. Meckel diverticulumc. Gastritisd. Gastroesophageal Reflux

PYLORIC STENOSIS

What are features & assessments of a patient with this diagnosis?

PYLORIC STENOSIS

Olive-shaped mass in RUQ of abdomen and possible observation of peristalsis when lying supine.

Vomiting that occurs 30 to 60 minutes after a meal and becomes projectile as obstruction worsens.

Constant hungry. Weight loss, signs of dehydration. Diagnosed by ultrasound.

INTUSSUSCEPTION

Al, age 5 months, is suspected of having intussusception. What clinical manifestations would he most likely have?a. Crying during abdominal exam,

vomiting, currant jelly-appearing stools

b. Fever, diarrhea, vomiting, and lowered WBCc. Weight gain, constipation, and refusal to eatd. Abdominal distention, periodic pain,

hypotension

MECKEL’S DIVERTICULUM

Remnant of a fetal duct, which in most newborns has resolved completely.

More common in boys. Most symptoms occur in children less than 2

years, but may occur in children up to 10 years.

May have abdominal pain, bloody stools without pain, bright red mucus in infant stools.

Diagnosed using a radionucleotide scan.

OB COMPREHENSIVE FOCUSED REVIEW

Day One Review

COMPLICATIONS OF NEWBORN Complication of newborn: Hypoglyclemia Risk factors Assessment

Under 40 Get them on breast poor feeding Hypothermia Diaphoresis Weak shrill cry Lethargy Flaccid Seizures Irregular respiration Cyanosis

Labs: plasma glucose less 40 mg/dL

HYPOGLYCEMIA

Obtain blood per heel stick for glucose Provide frequent oral and gavage feeding

HYPOGLYCEMIA CONTINUES LGA

Greater than 4000 gram Above 90% tile

Risk factor Post term Maternal DM Fetal cardiovascular disorder of transposition Genetics

Assessment Weight first indication SQ fat Signs of hypoxia Birth trauma Sluggishness Hypotonia of muscles Hypoactivity Tremors from hypocalcemia

CONT’D

Monitor glucose Initiate early feeding Monitor thermoregulation Identify and treat birth injuries Surfactant for lung maturity

CIRCUMCISION PAIN MANAGEMENT

NPASS Give oral Tylenol

BREASTFEEDING

Education Feed 2-3 hrs 8-12 times in 24 hours Colostrum day 1-3 provides passive

immunity Educate on the benefits Reduces the risk of infection Promotes rapid brain growth d/t large

amounts of lactose Has water Protein and nitrogen

ATTACHMENT OF MOTHER-INFANT

Assessment: Looking at baby Comparing the baby Face to face Smiles Talks to Response Identifies characteristics

pediatric nursing review (2)

Health & Medicine