Pediatric Dermatology Final Study Guide

Final Study Guide  Peds 70 Q's on weeks 14 and 15  Week 14:  **Dermatology ** Majority of rashes in kids =viral (at end of sickness) Purpura -- bigger blotch -- doesn't blanch; Emergency (sepsis, meningitis) **Dermatitis ** - Diaper- localized - Candida - Triple paste -...

Final Study Guide  Peds 70 Q's on weeks 14 and 15  Week 14:  **Dermatology ** Majority of rashes in kids =viral (at end of sickness) Purpura -- bigger blotch -- doesn't blanch; Emergency (sepsis, meningitis) **Dermatitis ** - Diaper- localized - Candida - Triple paste - Air-dry - No baby powder - Water---no wipes - Seborrheic (cradle cap) - Does not itch - Oils; soft scalp brush  - Contact  - Irritant or allergic - Calamine vs hydrocortisone - Oatmeal bath Inflammation of skin -- General term for dermatitis Diaper rash caused by candida -- satellite lesions, will be in "cracks" - Very red (yeast rashes) Triple paste -- lotrimazole, hydrocortisone, antibiotic ointment Barrier = prevention of diaper rash (better than treating) Air = best for diaper rash NO baby powder = pneumonia r/t exposure to inhalation of powder Best to avoid rubbing Hair = more oil; more prone to seborrheic rash Oil may help crust Hydrocortisone not for large area Oatmeal bath = helps with itchiness OR baking soda bath **Eczema ** Atopic dermatitis - Chronic - Dry air (environmental causes) more prone to flare ups - Can move around body and illness may increase flare up - Creams come in a tub vs thinner lotion with a pump - Avoid bathing every day (every 2 to 3 days with daily bed baths) - Moderate/severe eczema -- hydrocortisone/topical steroids - Remission by age 3 but can be life-long - Atopey - Triple A -- asthma, atopic dermatitis, allergies **Impetigo ** - Mostly infected with normal skin flora Vesicles, honey-colored crusting when they break  Face is common, around mouth  Oral or topical antibiotics  Very contagious  Bacterial infection of the skin Vesicle -- fluid filled bump (how it starts), once vesicle breaks dries to honey colored crusting Mild -- topical antibiotic cream (ideal) Severe -- Large areas/sever infection -- oral antibiotics Contagious until on antibiotics for 24 hours Other illness and presenting with rash -- is it hand/foot/mouth? Summer has increased rate for impetigo 2-3 weeks will resolve without treatment **Head Lice** Spread by close contact  Live very close to the scalp Louse can live one month on host and 48 hours off host Nits hatch in 7-10 days Not a matter of hygiene Wash in HOT water/hot dryer Bag items for 2 weeks Needs to have blood source and warm (closer to scalp) Most lice treatment are a 2 times treatment (once for adults and again in 7-10 days for eggs that have hatched) All clothing/bedding needs to be washed in HOT water and dried in HOT dry setting - Can't be washed, close in plastic bag for 2 weeks - Vacuum carpet/mattress **Burns (she said in lecture to really know first aid for burns and prevention) ** - Thermal, chemical, electrical, sun, cold  - First, second, third degree       BSA %- p. 560  - Erythema - Blistering?   Blanches?  - Fluid replacement - Tetanus booster  - Pain medication - Avoid ice to burn - Dressing changes, debridement  - Monitor for contractures -- may need PT  Superficial, partial, full thickness BSA -- how you document burn 1. Rule of nines -- estimated/average BSA 2. Graph based on percentage of burns 3. NO BSA ON EXAM 4. Standard for burn assessment 5. Burn on face/eyes/hands/feet/genitals -- major burn in child regardless of degree, r/t to scarring and loss of function in that area → referral to specialist Blistering helps determine type of burn No blanching = loss/lack of blood flow Check about tetanus status with burns Avoid injections -- oral meds \*ideal\* Do not put ice on "fresh" burn -- cool/luke-warm water is fine Priority with burns = infection Contractures from skin tightness -- PT and ROM to prevent contractures Pg. 56? KNOW EDUCATION & Burn prevention (anticipatory guidance) Superficial (1^st^ degree) - Treated in clinic - How much of child is burned? - Is it blistering? Blanched? - No blisters/skiny skin/ heal on own in 3-7 days - Will blanch Partial thickness burns - Blisters present - Blanchable - Hair/sweat glands may be involved Small area -- Full thickness -- 3^rd^ degree No blanching Not much pain r/t nerve involvement Weeks to months to heal Respiratory distress Antibiotic Hypovolemic Hypothermia Increased metabolic need -- more calories/nutrients ↑ protein consumption Large % of burns are non-accidental (children) -- understand story to help determine if abuse is suspected **GI** **Dehydration ** - Mild, moderate (6-9% wt loss cap refill 2-4 sec, sunken fontanel, dry mucous membranes, tachy) - Severe (10% wt loss, cap refill \>4, no tears, tachy, oliguria) - Oral rehydration solution for mild to moderate  - 10mL/kg per episode  - Parenteral fluid therapy V/D more prone in children -- other illness can cause V/D which increases risk for dehydration (up to 2 weeks is acute) Vomiting -- \- Bright red blood/coffee greens or bright green (bilious vomiting) Diarrhea -- no testing/culture \- Black tarry or copious blood, mucous, pale Typically, do not stop vomiting; need to get viral infection out -- do not prescribe Zofran typically Once every 8 hours for wet diaper -- any less may need to go to ED Weight is the main way to assess dehydration Probiotics can help reduce diarrhea episodes up to 1-2 days No cow's milk -- hard on stomach, no fruit juices -- natural stool softener No meconium in 48 hours = red flag Mild - Oral hydration solution -- Pedialyte, electrolyte-based fluids (if too salty for child, okay to dilute a little) 10mL/kg/episode -- 5mL at a time - Assess how they are acting? Lethargic? Moderate \- Weight is best way to 6-9% weight change, normal cap refill, sunken fontanel, dry mucous membranes (look at mouth), increased HR Severe - IV fluid supplementation - 10% weight loss - Cap refill \>4 - No urine output - Tachycardia Dry mucous membranes **Constipation in NB ** - First meconium should be passed within 24 to 36 hours of life; if not, assess for - Hirschsprung disease - Hypothyroidism - Meconium plug or meconium ileus (cystic fibrosis) **Gastroesophageal Reflux (GER) ** - Defined as transfer of gastric contents into the esophagus - Often resolves by 1 year ; 50% of 4mth olds spit up  - Predisposition  - Neurological impairment, hiatal hernia, morbid obesity, preterm w/ BPD - Diagnosis: - Spitting up/forceful vomiting, irritable, arching of back, excessive crying, cough, sore throat, apnea - Upper GI series, pH probe study is gold standard, endoscopy with biopsy. - Management - Small/frequent meals, Thickened feeds, positioning, medications can reduce gastric HCl acid secretion and may stimulate increase in LES tone, Nissen with fundo.  - Nursing management - Identification, education, parental reassurance. - Complications: pneumonia, wt loss or FTT May need to change formula Frequent burping Meds given 30 mins before feeds GERD -- damage is done GER - Resolve by 1 year - Normal - Diagnosed by symptoms -- rarely sent for testing - Infant - Spitting up with every feed - Large volume - Forceful/projectile = concerning - Irritable \*\* during/after feeds - Arching of back - Excessive crying Toddlers/older kids - Cough - Sore throat - Apnea episodes Management is conservative at beginning Upright 30 minutes after feed Every 10 mL burp them Thicken formula -- or add rice cereal to mix with formula -- thickening agents : MD ordered Medication -- last resort Severe cases (more out than in) significant weight loss, or poor weight gain -- Nissen with fundo \- KNOW - Educate parents on conservative measures/medications (30 minutes before feeds) Reassurance this is normal until 1 year Educating/assessing for complications like aspiration/pneumonia, FTT, weight loss **Acute Appendicitis ** Can they jump? Ride in a car? Post-op- monitor for peritonitis School-age children -- more common Abdominal pain can be esophageal -- starts at base of sternum midline Fever & stomach pain Light palpation with ↑ pain in LLQ -- rebound tenderness may be present Ruptured appendix -- want to avoid, once ruptured may experience relief Catching it early is best way to avoid rupture No heat to abdomen with appendicitis, no enemas/laxatives Post-Op - Monitoring for peritonitis (tenderness with palpation) - NPO - NG tube -- low inter suction: allow for bowel rest - IV fluids - Antibiotics - Monitor BS, passing gas Kids Dx - Ultrasound **Cleft Lip and Palate (lots of slides, maybe spend most focus?) ** Otitis media -- fluid going up to sinuses and middle ear Dental -- teeth may erupt strangely, crowding Hearing -- fluid in ear and frequent ear infections \*\* Aspiration -- biggest issue DX - choking/gagging during feed Treatment - Feeding tube if significant - Do not repair for months later; parental education for specialized bottle - Fed upright to ↓ risks for Otis media, Can still breastfeed -- pump and give with specialized bottle **Hypertrophic Pyloric Stenosis ** - Constriction of the pyloric sphincter with obstruction of the gastric outlet - Pathophysiology - the pylorus muscles thicken and become abnormally large, blocking food from reaching the small intestine. Signs of pyloric stenosis usually appear within one to five weeks after birth. Pyloric stenosis is rare in babies older than age 3 months. - Diagnostic evaluation - Physical exam, abdominal ultrasound, xrays - Clinical presentation - Forceful vomiting, dehydration and weight loss. Babies with pyloric stenosis may seem to be hungry all the time. - Olive shaped mass in RUQ - Therapeutic management - Surgical intervention. IV fluid management if dehydrated.  - Nursing management Dx in 1^st^ month - Vomiting that is forceful - Large volume - Especially after feeds - See in first 28 days Past 28 days with type of vomiting -- not likely Pyloric stenosis No weight gain Palpation -- may feel an olive mass in LUQ near stomach r/t muscle (not common) KNOW: findings/who is at risk/parental report **Intussusception ** - Telescoping of one portion of the intestine into another; typically occurs from age 3 months to 3 (6?) years - Pathophysiology - Intussusception is the most common cause of intestinal obstruction in children younger than 3. The cause of most cases of intussusception in children is unknown.  - Signs: episodic abdominal pain (knees to chest) & distention, mucous/blood in stool, bilious vomiting, lethargy, diarrhea, fever.    - Diagnostic evaluation - Ultrasound, CT scan, barium or air enema (can fix problem in 90% of cases if no perforation) - Therapeutic management - Avoiding dehydration, shock, replogle/NG tube to decompress intestines. - Surgery if barium enema won't work.  - Nursing management - IV fluid management, infection prevention, family support.  Episodic and then symptom free, occurring in regular intervals Currant jelly stools- blood and mucous mixed in stool after about 12 hours Hx of intussception -- contraindicated Rotavirus Emergency r/t ischemia = bowel death Occurs from 3 months to 3 years A lot of pain in small amount of time Currant jelly stool is not an initial s/s up to 12 hours-- may not have any stool/diarrhea initially **Failure to Thrive ** - Weight for age is \ - Seizures due to hyponatremia, hypocalcemia & hypoglycemia Hypertension I & O, fluid restrictions as ordered, daily weights Maintain catheter Monitor for seizures, seizure precautions Administer diuretics, NaBicarb, insulin (hyperkalemia), HTN meds Low K., low protein diet Worst case scenario -- Dialysis ; temporary BUN ↑ Electrolytes → seizure precautions (monitor labs) r/t hyponatremia, hypocalcemia, hypoglycemia NaBicarb -- metabolic acidosis AKI -- no urine concentration, does not excrete waste products, and no electrolyte conservation **CKD (lots of slides, maybe spend most focus?)  ** - Begins when diseased kidneys cannot maintain the normal chemical structure of body fluids Irreversible and progressive Considered chronic when lasted \3 months Staged from 1-5 p. 419 Table 17-5 Most common cause in pediatrics are congenital defects Most common complication: HTN Progresses to a clinical syndrome called uremia Congenital (typically) Progresses → kidney failure \10 days; double worsening, or 3 days fever \>102 Viral most of the time -- ABX after 2 weeks → could be bacterial after 2 weeks Saline before suction to help with removal of mucus No meds for children under age 6 -- humidity, and hydration are key **Tonsilitis ** - Generally larger than in adults - Can cause difficulty breathing or swallowing: kissing tonsils (size is graded) - Tonsillectomy- removes palatine tonsils due to recurrent throat infections, sleep disordered breathing - Adenoidectomy - Cleft palate is a contraindication - [Nursing Care]: control post-op pain to aid in hydration - Do not suction; have equipment near however - Monitor for fresh bleeding; frequent swallowing - Soft foods; avoid milk products - Avoid coughing, gargles, activity **Pertussis ** - Pertussis toxin can activate pancreatic beta cells = hypoglycemia - Cough lasts 6-10 weeks...or longer - \< 6 months old may not have the "whoop" with inspiration - Treated with antibiotics **Croup ** - Inflammatory; often viral - Hoarseness, "barky" cough, possible respiratory distress, inspiratory stridor - Viral croup typical under age 3; worse at night; lasts 3-5 days - Fall & winter - Hib vaccine prevents - Tx: Airway protection, fluids, corticosteroids, humidity/cool mist, cold air Steroid for treatment Stridor may be heard on auscultation → emergency Resolve in 3-5 days **RSV/Bronchiolitis ** - Acute viral infection occurring in winter/spring (Nov-Mar) - Infancy to age 2 - Spread by exposure to contaminated secretions: droplet and contact isolation - RSV increases risk of asthma if occurs \60 mEq/L older than 6mths - DNA testing for CFTR deletion - Stool fat analysis Most common cause of death is Resp. infections **Respiratory** - Prevent & treat infection - Recurrent infections= damaged airways - Often infected with difficult pathogens to clear; MRSA or fungal; may become colonized - Airway Clearance therapies- percussion, postural drainage; often 2-4x/day - Bronchodilators; Pulmozyme; hypertonic saline \*no antihistamines - Physical exercise is encouraged - Infections are treated rapidly; aerosolized antibiotics, IV antibiotics; flu vaccine - Risk of pneumothorax due to ruptured bronchial cysts; nasal polyposis **GI** - Pancreatic insufficiency- replace pancreatic enzymes with meals and snacks - Number of capsules adjusted to regulate stools to 1-2/day - High calorie-high-protein diet; extra enzymes with high fat foods - Need fat soluble Vitamin supplements: A,D, E, K - Growth failure often correlates with poor pulmonary status - Often experience anorexia; oral supplements, tube feedings - Intestinal obstruction, constipation - Rectal prolapse - Transient or chronic GERD Osteoporosis can occur in low Vit D **Mental Health ** **Assessment ** **Stress ** **Depression ** **Anxiety ** **ADHD ** **ASD ** **Anorexia Nervosa ** **Bulimia (lots of slides) ** **Suicide ** **School-Age** **Promoting Development ** - School age is generally defined as age 5 to 12 years - Early 5-7 years - Middle 8-10 years - Late 11-12 years - Time of gradual growth and development - Progress with physical and emotional maturity - Entrance into school environment; development of relationships - School phobia - Often divided into young school age and older school age - Slow but steady pace until growth spurt at puberty - Height increases by 2-3 inches per year - Weight increases by 4-6 lbs per year - Males and females differ little in size until late childhood where girls may surpass boys - Bones mature 2 yrs earlier in girls - Slimmer, more proportionate; "thin and spindly" - Fat diminishing - Muscle strength increases, but muscle fx still immature- making them easily damaged with overuse - All deciduous teeth are lost **Motor Skills ** - Fine Motor Skills - Tie shoelaces - Play musical instruments - Can print smaller and neater - Gross Motor Skills - Smoother movements - Dance, run, jump, climb, throwing, organized sports - Increased strength and endurance **System Maturation ** - Bladder and stomach capacity increases- can have 3 meals per day - Lower caloric needs - Immune system matures - Tonsils are largest size at about age 6 - Visual maturity achieved by 6-7 years - Heart is smaller in relation to the rest of the body - Functional heart murmur - Immune system is increasingly effective- exposure to illness in school, however - Bones increase in ossification - "growing pains" - Scoliosis screening - Physical maturity is not necessarily correlated with emotional and social maturity Primarily lower extremities, usually bilateral, not often in joints- but thighs, calves, shins; achy/crampy nature, rarely limits activity or function, mostly late afternoon to night **Prepubescence ** - Defined as the 2 years preceding puberty - Typically occurs during preadolescence - Varying ages from 9 to 12 years (in girls, it occurs about 2 years earlier than in boys) - Average age of puberty is 10 years in girls and 12 years in boys **Erikson ** - Industry vs Inferiority - Need positive reinforcement and praise - Eager to develop new skills and participate in meaningful and socially useful work - Acquires a sense of personal and interpersonal competence and accomplishment - Peer approval is a strong motivator - Learn to cooperate, compete and cope with others - Inferiority and inadequacy are the potential negative outcomes - Early on- like instant gratification - May occur if incapable or unprepared to assume the responsibilities associated with developing a sense of accomplishment - All children feel some degree of inferiority regarding skill(s) they cannot master **Piaget ** - Move to Concrete operations - Develop an understanding of relationships between things and ideas - [Causation] - Steady continued reduction in egocentrism. Beginning to see perspective of others - Able to make judgments based on reason (conceptual thinking, rather than only what they see) - Use memories of past experiences to interpret the present - [Conservation]- changing shape of a substance does not alter its mass or volume - Able to classify- group and sort objects; love to "collect" - [Seriation] and [classification] - Learn to tell time, understand space - Learn to read - Increased attention span & memory Increased attention span, improved memory, problem-solving emerges *Underlined terms should be known for exam* **Kohlberg ** - Pre-Conventional level - Primarily egocentric, but empathy emerging - Development of conscience and moral standards - In a child age 6 to 7 years, reward and punishment guide choices - Older school-age child can judge an act by the intentions that prompted it; move to conventional level - Rules and judgments become more founded on the needs and desires of others - Beginning to consider different points of view - Understand "treat others as you want to be treated" - [Reciprocity]- fairness and concern for others Begins to act to please others Choices between good and bad behaviours are in their control **Spiritual Development ** - Children think in concrete terms - Interested in learning about a deity - See God as possessing human qualities - Development of conscience - Children expect punishment for misbehavior - May view illness or injury as punishment for a real or imagined misdeed - Family continues to influence their beliefs - Find comfort in rituals **Social Development ** - Importance of the peer group - Relationships often numerous and short duration - Peer pressure - Expect friends to be loyal - Identification with peers is a strong influence in a child gaining independence from parents - Sex roles are strongly influenced by peer relationships - Differences in play of boys/girls is more pronounced - Group activities- become aware of different viewpoints; formation of rigid rules - Social norms and pressures begin- conformity - Bullying; sibling rivalry - Signs of bullying - Develop heroes and idols Sleep problems, irritability, poor concentration, problems with schoolwork, missing belongings or money, psychosomatic complaints, running away, suicide **Play ** - "Team Play" - Involves physical skill, intellectual ability, and fantasy - Form groups, cliques, clubs, secret societies - Rules and rituals - See the need for rules in games they play - Generally, like competition - Team play- division of labor and group goals - Quiet games and activities- cards, computers, reading **Relationships** - Parents are the primary influence in shaping a child's personality, behavior, and value system - Increasing independence from parents is the primary goal of middle childhood; spend more time with peers - Children are not ready to abandon parental control **Sexuality ** - Sex play as part of normal curiosity during preadolescence - Develop modesty - May ask many questions - Freud: Latency period (relatively dormant) - Middle childhood is the ideal time for formal sex education - Information on sexual maturity and the process of reproduction from a growth & development basis - Requires effective communication with parents - Anatomy, pregnancy, STI's, contraceptives- precise and concrete terms **Dental Health ** - Stage begins with the shedding of the first deciduous teeth, starting with 6 yr molars - Eruption of permanent teeth approx. age 6 - Good dental hygiene- with supervision - Prevention of dental caries - Malocclusion-effects chewing; cosmetic - orthodontics - Dental injury **Promoting Health ** - Up till puberty, there isn't much difference in size & strength of boys and girls - Sleep & Rest need about 10 hours/night - May resist going to bed at age 8 to 11 years - Decrease in nightmares - Nutrition- food habits are well established - Develop a wider variety of likes - Quality of the diet related to the family's pattern of eating - Establishing food habits- impact of social media, advertising - "Fast food" concerns & influence of ads: obesity - Food insecurity is a social determinant of health - Lipid screening - Desire for privacy emerges - Often have to be reminded to perform personal hygiene - Screen time/internet & computer safety - keep in open areas - Avoid chat groups - Do not give out personal information - predators - Screening for depression and anxiety\* Signs? - Depression is not common in this age - AAP recommended screening at 12 - School violence- what do we look for? - Difficulty getting along with peers, outbursts of temper, violence towards animals, sleep/eat problems, social isolation, preoccupation with violent movies/games, decreased productivity at school -- school violence **Injury Prevention ** - Most common cause of severe injury and death in school-age children is motor vehicle crashes, pedestrian and passenger - Helmets - Car restraint systems and appropriate seating in the car - Backseat till age 13 - Most injuries occur near home or school - Appropriate safety equipment for all sports- mouth guards - Fractures, sprains-concern for growth plate injuries - Trampoline injuries, water safety **Adolescence** **Major Changes ** **Growth ** **Sex and drugs ** **Erikson ** **Piaget ** **Egocentrism ** **Kohlberg ** **Screenings **