NCMA-219-Midterms PDF

Property of: Alfie Velasco BSN 2-B-10 NURSING CARE OF HIGH-RISK NEWBORN NEWBORN PRIORITIES 1. Initiation and maintenance of respiration 2. Establishment of extrauterine circulation 3. Control of body temperature 4. Intake of adequate nutrition 5. esta...

Property of: Alfie Velasco BSN 2-B-10 NURSING CARE OF HIGH-RISK NEWBORN NEWBORN PRIORITIES 1. Initiation and maintenance of respiration 2. Establishment of extrauterine circulation 3. Control of body temperature 4. Intake of adequate nutrition 5. establishment of waste elimination 6. Prevention of infection 7. Establishment of an infant-parent relationship 8. Development care of care that balances physiologic needs and stimulation of best development General Points and Nursing Considerations to know: - Initiating and Maintaining Respiration 1. Crying is the first sign of life; it closes the ductus arteriosus 2. Low birth weight, PROM, maternal use of narcotics, meconium staining, congenital anomalies, cord prolapse, prematurity are factors that causes difficulty of respiration among newborn infants 3. Resuscitation, airway patency, lung expansion, drug therapy and proper ventilation maintenance are the common nursing intervention - Establishing Extrauterine Circulation 1. Make sure that there is heartbeat and pulse 2. No audible heartbeat = closed-chest massage 3. 0.1-0.3 mL/kg epinephrine + cardiac compression = cardiac resuscitation - Maintaining Fluid and Electrolyte Balance 1. Hypoglycemia is treated initially with 10% dextrose in water 2. Ringer’s lactate or 5% dextrose in water commonly used to maintain fluid and electrolyte balance 3. Fluid administration should monitor strictly because of patent ductus arteriosus causing heart failure if fluid overload occurs 4. Normal blood glucose is >45mg/dl; 5mg/dl is observable jaundice - Pathologic - First 24 hours of jaundice - Persistent jaundice over 2 weeks in full term formula fed infants Wrist icicle, ride dick bicycle Property of: Alfie Velasco BSN 2-B-10 - Direct bilirubin exceeding 1.5-2mg/dl - Total serum bilirubin over 12.9mg/dl (term infant) or 15md/dl (preterm) the upper limit for breastfed infants is 15mg/dl Therapeutic management: - Exchange transfusion - Light exposure (preferably sunlight) - Phototherapy- light promotes bilirubin by photoisomerization which alters the structure of bilirubin to lumirubin a soluble form Nursing management - Make sure infant who is undergoing phototherapy wears eye protection and genital protection (diapers) - Make sure infant undergoing phototherapy is properly hydrated and monitored - Encourage frequent breastfeeding every 2 hours - Avoid glucose water formula and water supplementation - Monitor for early stooling Wrist icicle, ride dick bicycle Property of: Alfie Velasco BSN 2-B-10 DISEASE OF NEWBORN Necrotizing Enterocolitis- inflammatory bowel disease of premature infants due to ischemia and pneumatosis **Ischemia- poor tissue perfusion **Pneumatosis- gaslight forming bacteria Risk: prematurity, vascular compromise (hypoxic events) Pathophysiology: Prematurity = vascular compromise = bacterial infection → bowel wall is attacked by proteolytic enzymes = necrosis Clinical manifestation: Triad manifestations- Abdominal distention, gastric residua and hematochezia Other manifestations: lethargy, poor-feeding, hypotensions, apnea, vomiting, oliguria, hypothermia **usual onset is 4-10 days after initiation of feeding Diagnostics: Xray (abdominal), MRI, CT-Scan, CBC and culture Lab Findings: Anemia, Leukopenia (Preterms), Leukocytosis (Term), metabolic acidosis, electrolyte imbalance, coagulopathy, sausage-like intestines in radiograph Treatment: PREVENTION - Withheld oral feeding for 24-48 hours - Infant is NPO until resolved - Initiate breastfeeding for passive immunity - Gastric decompression; emptying of gastric acid in the stomach - IV antibiotics, fluids and electrolytes - Radiograph 4-6 hours for monitoring Severe cases: bowel resection and anastomosis Nursing management: - Do not put diapers for observation of hematochezia - Early recognition of signs and symptoms Complications: lifetime use of colostomy bag, peritonitis, fat malabsorption, hard to gain weight Retinopathy of Prematurity- AKA retrolental fibroplasia; A disorder involving immature retinal vasculature Etiology: Hyperoxemia, hypoxia, hypercarbia, hypocarbia, prenatal complications, excessive exposure to light Pathophysiology: Prematurity → severe vascular constriction in retinal vasculature = hypoxia → stimulation of vascular proliferation towards the lens = aqueous and vitreous humor becomes turbid = edema and hemorrhage = retinal detachment → irreversible blindness Therapeutic management: strict oxygen management (91%-94% oxygen saturation), cryotherapy ablation or laser therapy Nursing management: - Decrease constant bright light exposure - Inform parents that the infant’s edematous eyelids are normal and will resolve on its own. Edema may due to laser or cryotherapy or crede’s prophylaxis Hemolytic Disease of Newborn- abnormally rapid rate of RBC destruction Wrist icicle, ride dick bicycle Property of: Alfie Velasco BSN 2-B-10 *normal life span of RBC is 120 Cause: Rh and ABO incompatibility; Rh incompatibility is most common cause Pathophysiology: Rh Incompatibility → Rh+ will enter Rh- maternal circulation = maternal body will recognize Rh+ as foreign invaders → maternal body will develop antibodies to fight of foreign material = antibodies enter fetal circulation → agglutination = hemolysis (erythroblastosis fetalis) + jaundice Diagnostics: Indirect coomb’s test, amniocentesis to determine fetal blood type, ultrasound Therapeutic management: Prevention of Rh Isoimmunization via administration of Rh immunoglobulin (RhIg) - Intrauterine transfusion for fetal anemia - Exchange transfusion Nursing management: - Infant to be put NPO - Assessment of early onset of neonatal jaundice - Phototherapy - Peripheral transfusion of dextrose and electrolytes Transient Tachypnea of the Newborn- transient respiratory distress cause by delayed resorption of fetal lung Cause: Aspiration of meconium or amniotic fluid Clinical manifestations: Tachypnea, intercostal and subcostal retractions, nasal flaring, grunting and cyanosis Diagnostics: CBC, chest xray, blood cultures and sensitivity test Therapeutic management: oxygen therapy, recovery usually occurs 2-3 days Trisomy 21- AKA Down Syndrome; most common aneuploidy of chromosome Etiology: Idiopathic Probable cause: Genetic predisposition, exposure to radiation and mutagens, advanced maternal age Clinical manifestation: slanted eyes, low set of ears, transverse palmar creases, additional fats in neck, flat face, nose and forehead, cognitively impaired Risks: Congenital anomalies, muscle hypertonia, heart and kidney problems, Hirschsprung disease, tracheoesophagial fistula, nystagmus, strabismus, astigmatism, small stature, obesity, delayed sex development Therapeutic management: NO CURE FOR TRISOMY 21, Therapy for patient with Trisomy 21 Nursing management: - Supporting the family upon diagnosis - Assist the family in preventing physical problems - Promote the child developmental progress - Assist in prenatal diagnosis and genetic counseling Wrist icicle, ride dick bicycle Property of: Alfie Velasco BSN 2-B-10 NEWBORN SCREENING - Screening test that determines early detection of infant diseases **Usually done 24-48 hours after birth Tests in NBS - Heel-Prick method- metabolic disorders - Pulse oximetry- heart conditions - Otoacoustic tests- hearing tests Republic Act 9288: Newborn screening Act of 2004 Diseases Detected in Newborn Screening Congenital Hypothyroidism- thyroid gland fails to develop or function properly Clinical manifestations: asymptomatic; 2-3 months untreated → visible deterioration such as cognitive impairment Complications: intellectual and physical impairment Treatment: Levothyroxine, crushed and given once daily mixed in breastmilk Phenylketonuria- autosomal recessive trait caused by an absence of enzyme phenylalanine hydroxylase needed to metabolize the essential amino acids phenylalanine into tyrosine. Tyrosine is a vital component in neurotransmitters. Liver produces the phenylalanine hydroxylase Clinical manifestations: mousy odor urine, >10mg/dl serum phenylalanine Complications: brain injury, cognitive impairment, seizures Therapeutic management: Diet; decrease phenylalanine, increase tyrosine intake, phenylalanine is abundant in meat. Fruits and vegetables, white bread are encouraged Nursing management: - Reinforce restricted diet - Assistance to registered dietitian for proper meal preparation Galactosemia- rare autosomal recessive disorder that lacks 3 enzymes to convert galactose to glucose galactokinase (GALK); galactose-1-phosphate uridyltransferase (GALT); and UDP-galactose 4′-epimerase (GALE) Clinical manifestations: enlarged liver, cataracts, kidney damage, brain injury Therapeutic management: Diet Nursing management: - No breast and formula milk - Advise mother they can give soy milk products (if there is no soy allergy) - Reinforce strict diet - Teach nutritional fact and ingredients - Inform mother to avoid products with lactose, carefully inspect the ingredients. Pharmaceutical products sometimes contain unlabeled lactose, inform the mother to always ask the pharmacist if the medication contains lactose. Complications: fetal death Wrist icicle, ride dick bicycle Property of: Alfie Velasco BSN 2-B-10 Glucose-6-phosphate dehydrogenase deficiency (G6PD)- lack of G6PD that maintains RBC health causing hemolytic anemia. Common among Filipino newborns Clinical manifestation: jaundice, weakness, dark colored urine, heart murmur, enlarged spleen and liver Complications: hemolytic anemia Therapeutic management: blood transfusion, iron supplements Congenital Adrenal Hyperplasia- most fatal; autosomal recessive disorder resulting to improper steroid hormone synthesis Clinical manifestations: ambiguous genitalia in female and precocious genitalia in male, Polyuria Complications: fetal death, infertility Therapeutic management: glucocorticoids to suppress ACTH Nursing management: - Early assessment of genitalia - Explanation of the condition - Give time to parents to grieve for the loss of sense of perfection of their children INFANT AND YOUNG INFANT PROBLEM Failure to Thrive- AKA growth failure. Inability to obtain or use calories required for growth. Common criteria is weight Cause: Inadequate calorie intake, inadequate absorption of nutrients,increased metabolic rate, defective utilization Clinical manifestations: apathy, developmental delays, withdrawn behavior, minimal smiling, lethargic Diagnostics: weight monitoring Therapeutic management: Treat underlying cause, increase caloric intake Colic- Paroxysmal abdominal pain Clinical manifestations: loud crying 3 hours a day occurring more than 3 days per week Etiology: rapid breathing, over feeding, swallowing of excessive air, improper feeding technique Therapeutic management: antispasmodic, antihistamines, anti flatulence, behavioral interventions Nursing management: ASSESS 1. Infant’s diet 2. Diet of breast feeding mother 3. Time of day when crying occurs 4. Relationship of crying for feeding time 5. Presence of family member smoking habits 6. Daily activity of mother 7. Characteristics of cry Wrist icicle, ride dick bicycle Property of: Alfie Velasco BSN 2-B-10 PROBLEMS WITH TODDLERS AND PRESCHOOLERS Lead Poisoning- Ingestion or inhalation of lead Cause: non-intact lead paint, lead contaminated bare soil, lead contaminated food and water Pathophysiology: Hematologic: Lead absorption → interferes with synthesis of heme = accumulation of alternative metabolites + increase erythrocytes-protoporphyrin = anemia Nephrologic: Lead absorption → damage cells of proximal tubules = glycosuria + ketonuria + proteinuria + decrease vitamin D → urinary coproporphyrin and increase alpha-aminolevulinic level + impaired calcium function Neurologic: Lead absorption → increase membrane permeability = increase intracranial pressure → tissue ischemia = atrophy of neurons - Low Dose - distractibility, hyperactivity, impulsivity, hearing deficit, cognitive deficit - High Dose - Lead encephalopathy, paralysis, blindness, convulsions, cognitive impairment, coma and death Diagnostics: blood lead level >10mcg/dl Screening: 1-2 years old; 3-6 years old for those who are not previously screened - Does the house built during 1950? - Does the house built in 1978; is there ongoing renovation within 6 months? - Does the child playmates who has or had lead poisoning? Therapeutic management: degree of management varies as the lead level increases - Education is one of the most important element of the process - Teach parents what lead poisoning is, its adverse effects, possible sources of exposure, how to reduce the exposure, importance of good nutrition - Chelation Therapy- removing lead from the circulating blood, equilibration process between blood, soft tissue and other sites. Several session can be done to avoid rebound. Hydration is important during chelation therapy - Severe lead toxicity (>70mcg/dl) requires immediate inpatient treatment whether symptomatic or not Nursing management: Prevention of initial and further exposure of lead Anticipatory measures: - Ensure that the environmental exposure are reduced before children are exposed to lead - Carefully evaluate toys (manufacturers) or items that the child play - Wearing protective clothing such as wearing shoes when playing in bare soil is encouraged - Identify possible source of lead in the environment During Chelation Therapy: - Nurse should prepare them for injection and makes all efforts to reduce pain - Calcium EDTA is painful; procaine an anesthetic can be administered to reduce pain - Rotation of site is essential to prevent pain and fibrotic tissue formation Wrist icicle, ride dick bicycle Property of: Alfie Velasco BSN 2-B-10 - Treatment is Nephrotoxic; keep record of intake and output and assess urinalysis to monitor renal function Falls- lose someone’s balance; falling from furniture is most common among toddlers. Sustained head injuries and playground injuries are common among preschoolers Cause: toddler’s total neglect and lack of appreciation of danger and immature coordination Nursing management: - Children should learn safety play such as no horse playing on high slides, jungle gyms, and staying away from moving swings - Stairs must have gates on both ends - Children 89cm (35 inches) should sleep in bed rather than crib - Windows left open must be guarded with rails - Parents who opt for bunk beds should be aware of possible dangers such as falls from top bed and ladder, head entrapment etc. Drowning- death occurs mostly in the bathtub and large buckets. Children ages 12-36 months are at the higher risk of drowning Cause: Toddler’s intense drive for exploration combined with unawareness of danger of water makes drowning a viable threat Anticipatory guidelines: close adult supervision when near any deep water source - Touch supervision for small children - Teaching swimming and water safety but cannot regarded as sufficient protection - Pool fencing is critical but it cannot deter fast moving children Aspiration and Suffocation- when objects are placed into the nose or mouth they can be aspirated into the airway causing obstruction Classification: - First degree- allows passageway of air in both direction - Second degree- air able to move past obstruction in one direction only - Complete obstruction- air unable to move in both directions. Foreign body and edematous mucosa obliterate passageway. Fatal **most common among children age 1-3 years old **severity depends on the location, type of objects and extent of obstruction Offending foods (in order): Hotdogs, round candy, peanuts, other types of nuts, grapes, cookies or biscuits, pieces of meat, caramels, carrots, apples, peas, celery, popcorn, fruit and vegetables seeds, cherry pits, gum, and peanut butter **round foods are frequent offenders **fun foods such as hard candies are among the worst offenders **High fat content of potato chips and peanuts add risk for lipoid pneumonia **other items includes plastic or glass beads, button, round battery, pen caps, and coins are frequent offenders **small lithium and cadmium batteries cause esophageal and tracheal corrosion **magnets can trap tissue and mucosa causing necrosis **sharp objects causes irritation and edema Wrist icicle, ride dick bicycle Property of: Alfie Velasco BSN 2-B-10 Cause: children characteristically explore objects with their hands and mouth, thus prone to place foreign body in the airway Clinical manifestations: TRIAD: choking, gagging, coughing, symptoms depend on the site of obstruction. Some may be asymptomatic - Laryngotracheal obstruction: dyspnea, cough, stridor, and hoarseness of voice. Cyanosis may occur when obstruction is worse - Bronchial obstruction: produces cough (paroxysmal), wheezing, asymmetric breath sounds, dyspnea, decreased respiratory rate **If obstruction progresses the child face becomes livid, sometimes it may lead to unconsciousness and death **Respiratory infection located at the distal part of obstruction; recurrent intractable pneumonia is a reason to consider an foreign body in airway Diagnostics: history and physical examination, radioscopy, endoscopy, bronchoscopy (diagnosis and removal) - Fluoroscopy- obstructed lung remains expanded, the diaphragm remains low and fixed **Check valve- heart and mediastinum shifts to unobstructed site **Stop valve- heart and mediastinum drawn to obstructed site, diaphragm in obstructed remains high, unobstructed moves normally Therapeutic management: Emergency abdominal thrust (Heimlich maneuver) for over 1 year old children - Back blows and chest thrusts for children less than 1 year of age - Removal through endoscopy should be done as soon as possible Nursing management: Nurses should learn life saving techniques/maneuvers - Recognize early signs of foreign body obstruction and implement immediate measures to relieve obstruction. Nurses should recognize signs of distress Prevention: - Small children should not be allowed to access small objects - Educate parents about hazards of aspiration in relation to developmental stage - Encourage parents to teach children about safety - Caution parents about behaviors that their children might imitate such as toothpicks in mouth Conjunctivitis- AKA sore eyes; inflammation of conjunctiva - In newborns, conjunctivitis occurs from infection during birth from chlamydia trachomatis or neisseria gonorrhoeae, HSV causes serious ocular damage - Infants with recurrent conjunctivitis may be a sign of nasolacrimal duct obstruction - Chemical conjunctivitis occur within 24 hours of installation of crede’s prophylaxis that causes mild lid edema and sterile non-purulent eye discharge Causes: Allergy, foreign body, viral, bacterial Clinical manifestations - Bacterial- purulent and crusty eyelids upon awakening - Viral- usually occur with respiratory tract infection, watery discharge - Allergy- itchy, watery to thick drainage, stringy discharge - Foreign body- usually affected only one eye, pain, tearing Wrist icicle, ride dick bicycle Property of: Alfie Velasco BSN 2-B-10 Therapeutic management: - Viral- self limiting; removal of infection - Bacterial- traditionally topical antibiotics such as polymyxin and bacitracin (polysporin), sodium sulfacetamide, trimethoprim and polymyxin (Polytrim) Fluoroquinolone is the best ophthalmic antimicrobial according to ophthalmologists, approved for age 1 year or older. Ex: Moxifloxacin, Gatifloxacin, Desifloxacin Corticosteroids are avoided Nursing management: - Keep the eye clean - Remove accumulated secretions from inner canthus downward to outward away from opposite eye - Warm moist compress in clean washcloths wrung out with hot water to remove crusts - Compress are not kept on the eye because occlusive covering promotes bacterial growth - Instill medication immediately after cleaning eyes - Keep child’s washcloths separate from other - Discard tissues used to clean the eyes - Instruct children to refrain from rubbing eyes and teach good hand hygiene Wrist icicle, ride dick bicycle Property of: Alfie Velasco BSN 2-B-10 PROBLEMS OF SCHOOL AGE CHILDREN Enuresis- AKA Bed-wetting; intentional or involuntary passage of urine in children who are beyond the age when voluntary bladder control should normally acquired Classifications: - Primary- children who have never been dry for extended periods - Secondary- onset of wetting after a period of established urinary continence - Monosymptomatic- occurs at night time; dry during day - Polysymptomatic- occasional day time accident in conjunct with other conditions such as UTI **Evaluation recommended when inappropriate voiding occurs at least twice a week for minimum of 3 consecutive month and age of at least 5 years old **more common among boys; bed-wetting ceases between 6-8 years of age Etiology: no clear etiology Probable cause: longer sleep duration in infancy, family history and slower rate of physical development; high incidence among identical twins and even higher incidence among fraternal twins Pathophysiology: Primarily an alteration of neuromuscular bladder functioning due to other factor such as ADHD = passageway of urine - Occasionally, enuresis can be a behavioral manifestation of personality disorder Theories regarding the pathophysiology of Enuresis: - Sleep Theory- stems from parental reports that these children sleep more soundly and are difficult to arouse from sleep - Functional bladder capacity theory- volume of urine voided after maximum delay of micturition - Nocturnal polyuria theory- kidneys of children fail to concentrate urine during sleep because of insufficient secretion of antidiuretic hormone - Dysfunctional detrusor activity theory- suggests that unstable bladder detrusor muscles spontaneously contracts to produce bed-wetting either because of abnormal intervention or unknown Clinical manifestation: immediate urgency, acute discomfort, restlessness and urinary frequency - Nocturnal enuresis- not feeling of urgency, difficulty of awakening to urinate, spontaneous voiding during sleep Diagnostics: Physical and Psychological evaluation - History of bed-wetting behavior, toilet training process - Assess parents/caregivers parental attitudes - Baseline count of enuretic episodes to establish diagnostic capability but also establishing baseline data for reference. Data is gathered for 1-2 weeks by child or family. Usually this is chart or calendar that indicate date and time and volume of urine - Functional bladder capacity- having child to hold off voiding until the strongest urgency is felt at which time child voids into measurement container: **Normal bladder capacity (in ounces) is the child age plus 2, therefore a normal ounce for 6 year old is 8 ounces (237mL) Wrist icicle, ride dick bicycle Property of: Alfie Velasco BSN 2-B-10 **A bladder volume of 10-12 ounces (300-350mL) is sufficient for retention at night Therapeutic management: - Conditioning therapy- the best therapy; includes training a child to awaken to urinate after stimulus is given especially with urine alarm. Urine alarm consists of moisture sensitive urine pad that is placed inside the underpants and attached to a bell or buzzer. This conditions the child to awaken to void in toilet. If relapse occurs, it is addressed by reinstating the alarm during sleep - Retention control- for reduced functional bladder capacity, child drinks fluids while awake and alert, then the child delays urination as long as she/he can so that the bladder is then stretched to accommodate larger volume of urine - Waking-schedule treatment- child is awakened during the night t at intervals to void - Kegel and pelvic exercises during daytime - Drug therapy: Antispasmodics, antidiuretics and tricyclic antidepressants are administered. Imipramine (Tofranil) , a tricyclic antidepressant, is commonly prescribed. **Low doses and individualized treatment last 6-8 weeks followed by gradual withdrawal over 4 weeks to avoid relapse **Oxybutynin is helpful for daytime frequency **Desmopressin acetate nasal spray reduces night time urinary output to a volume less than functional bladder capacity Nursing management: - Support both parents and child. Needs encouragement and patience - Problems are discussed with both parents and child - Parents should be taught to observe side effects of prescribed medication - Deter parents from scolding and shaming their children - Encourage parent to communicate with their child - Assure parents that bed-wetting is not willful misbehavior or emotional disturbance - Reinforce child independency, communicate with children - Nurse should provide consistent support and encouragement to children Encopresis- repeated voluntary or involuntary passage of feces of normal or near normal consistency in places not appropriate for that purpose according to the individual's own sociocultural setting. Event must occur once a month for minimum 3 months and the child must be at least 4 years old Classification: - Primary encopresis- a child never achieved fecal incontinence. Usually results from neglect, lax training, mental subnormality, familial cause - Secondary encopresis- fecal incontinence occuring at a period of where fecal continence is achieved, more common among boys than girls - Psychogenic encopresis- stems out due to stress **must not caused of physiologic effect or general health conditions **fecal consistencies varies- liquid stool is more observable Etiology: Constipation precipitated by environmental change - Abnormalities in digestive tracts Wrist icicle, ride dick bicycle Property of: Alfie Velasco BSN 2-B-10 - Medical conditions such as hypothyroidism, ADHD, IBS, lead intoxication, fecal impaction - Pain-retention-pain cycle - Emotional stressors Clinical manifestation: shameful, withdrawn behavior, putrid odor coming from a child Therapeutic manifestations: aimed toward alleviating the cause of the soiling - Fecal impaction relieved by lubricant such as mineral oil, osmotic laxatives (lactulose) magnesium hydroxide, polyethylene glycol (miralax) - Mineral oil should be avoided to children with dysphagia or vomiting to prevent aspiration - Behavior therapy and psychotherapy intervention - Dietary changes; high-fiber foods, elimination of milk and dairy products, increase fluid intake Nursing management: - Thorough soiling history via direct questioning - Educate regarding physiology of defecation, toilet training as development progresses - Regimen prescribed for stimulating defecation should be explained - Bowel retraining with mineral oil or high fiber diet and regular toilet routine - Placing foot stool below the feet to relax the abdomen - Encourage child to sit in toilet 10-15 minutes after meals for intervals - Enemas may be needed for impacted feces - Positive reinforcement to child for participation in bowel regimen - Family counseling towards reassurance - Behavior modification techniques explained and assisted with plan suited to a situation Attention Deficit Hyperactivity Disorder- developmentally inappropriate degrees of inattention, impulsiveness and hyperactivity. Most common neurobehavioral disorder often persist until adulthood. Most frequent among boys Risk: misconducts, developmental and learning delays, speech and language delays, anxiety and depression, maladaptive behaviors. Their behaviors evoke negative emotions from their peers Etiology: unknown Probable cause: combination of genetic, organic and environmental factors, fragile X and Klinefelter’s syndrome have been implicated ADHD Clinical manifestations: TRIAD: inattention, impulsivity and hyperactivity **degree of severity is highly variable usually in education and family setting - Demonstrate immaturity relative to the age - Inappropriate social skills - Short attention span - Increased incidence of misconduct such as substance abuse - Signs of personality or learning difficulties Diagnostics: Multidisciplinary and thorough assessment - Complete medical and developmental history - Detailed description of child’s behavior in different setting - Psychological testing; projective tests Wrist icicle, ride dick bicycle Property of: Alfie Velasco BSN 2-B-10 - Physical examination, behavioral checklists, and adaptive scales Therapeutic management: - Behavioral therapy and psychotherapy - Pharmacologic: Methylphenidate Hcl (most common), Dextroamphetamines = stimulants - Norepinephrines, adrenergic agonists = non-stimulants drugs Nursing management: - Medication, environmental manipulation: proper room assignment - Psychiatric, psychological and social therapy - Consistency in reinforcing goals - Encourage dependency and taking accountability for one’s actions - Teach parents to create organizational charts for their child - Foster a well structured organization - Frequent breaks is helpful - Verbal instruction should be accompanied by visual presentations - ADHD children need orderly predictable classrooms and environments. Instruction should be clear and coherents Bullying- infliction of repetitive physical, verbal, and emotional abuse by one or more individuals in order to establish power over someone who is perceived as less physically and psychologically dominant that the aggressors. Usually take place where supervisions are minimal but there are enough witness to the attack - Cyberbullying- involves electronic medium to harm or bother another individual **bullies and victims are at risk of long term psychological disturbances and symptoms such as anxiety and depression Nursing management: - Prevented through supportive relationship - Intervention of personnel and involvement of positive peer group Wrist icicle, ride dick bicycle Property of: Alfie Velasco BSN 2-B-10 PROBLEMS IN ADOLESCENTS Amenorrhea- absence of menstrual flow - Absence of both menarche and secondary sex characteristics by age 13 - Primary amenorrhea- absence of menses by age 16.5 years regardless of growth development - Secondary amenorrhea- 6 months or more cessation of menses after a period of menstruation is established **moderately obese women may have early onset of menarche **malnutrition and girls who exercises strenuously before menarche may have delayed onset **amenorrhea is not a disease but it may be a sign of underlying conditions such as anatomic abnormalities, endocrine disorders, chronic disease, physical and emotional distress, drug and substance abuse. Pregnancy is usual cause of secondary amenorrhea Nursing management: - Counseling and education; addressing stressors - Education and discontinuation of medication that affects mens; correct weight loss and routine exercise, addressing underlying conditions - Help identify, cope and eliminate stressors Dysmenorrhea- pain during or shortly before mens. Usually first 3 years after menarche. Usually located suprapubic area, pain is sharp, cramping and gripping - Primary dysmenorrhea- associated with ovulatory cycles, prostaglandins are cause usually 6-12 months after the menarche - Secondary dysmenorrhea- develops later in life typically at age of 25. Mostly pathologic (Adenomyosis, endometriosis, PID, polyps, myoma) Therapeutic management: - Dysmenorrhea is treated toward addressing the underlying cause Nursing management: - Support feeling of positive sexuality and growth - Correct myths and misinformation regarding menstruation - Medications: NSAIDS like hyoscine - Heated pads, heat promotes muscle relaxation - Massaging lower back, effleurage, acupuncture, and yoga - Progressive relaxation, transcutaneous electrical nerve stimulation - Exercise to relieve menstrual discomfort; Pelvic rocking - Diets; decrease salt and sugar intake 7-10 days before mens. Low fat and vegetarian diet minimizes dysmenorrhea - Natural diuretics such as peaches, asparagus, cranberry helps reduce edema Vaginitis- inflammation of vaginal canal Cause: bacterial, viral, candidiasis, allergy, vaginal atrophy Clinical manifestation: pruritic and sore vagina, pain during sex, discharge with light bleeding or spotting, dryness Diagnosis: pap smear, pelvic exam, pH testing Wrist icicle, ride dick bicycle Property of: Alfie Velasco BSN 2-B-10 Therapeutic management: - Bacterial: Flagyl (metronidazole), metronidazole gel, clindamycin (Cleocin), tinidazole (tindamax), secnidazole (solesec) - Yeast: Miconazole (monistat-1), butoconazole (gynazole-1), tioconazole (vagistat), fluconazole (diflucan), Clotrimazole (Lotrimin AF, Mycelox, Triazole-3) - Trichomonas: Flagyl or tindamax - Genitourinary syndrome of menopause (Vaginal atrophy): estrogen in a form of creams, tablets or rings - Non-infectious- pinpoint source of irritation and avoid it. Common causes are, soaps, underwears detergents, tampons, napkins, etc Gynecomastia- enlargement of male breast on onset of puberty - Transient gynecomastia- usually lasts less than a year Therapeutic management: surgery can be done to reduce male breast size Nursing management: - Assure patient that it is benign and temporary - Carefully evaluation should be done to rule out pathologic causes Wrist icicle, ride dick bicycle Property of: Alfie Velasco BSN 2-B-10 HEART DISEASE AND ALTERATION IN OXYGENATION Normal Blood Flow in the Heart Body → Inferior/Superior vena cava → right atrium → tricuspid valve → right ventricle → pulmonary arteries → lungs → pulmonary veins → left atrium → mitral/bicuspid valve → left ventricle → aortic valve → Aorta → body Heart Valves (in order): Tricuspid, Pulmonic, Mitral, Aortic CLASSIFICATION OF HEART DISEASES Wrist icicle, ride dick bicycle Property of: Alfie Velasco BSN 2-B-10 INCREASED PULMONARY BLOOD FLOW Atrial Septal Defect- Patent atrium septa, abnormal opening in atrial septa. Clinical manifestation: asymptomatic but symptoms may arise at 3rd or 4th decade of life: Dyspnea, fatigue, poor growth, soft systolic murmur Pathophysiology: opening of atrial septa = shunting of blood from left to right atrium Diagnostics: Echocardiogram, ECG, auscultation Therapeutic management: Catheterization (Dacron patch), open heart surgery Ventricular Septal Defect- abnormal opening between the right and left ventricles Pathophysiology: opening of ventricular septa → shunting of blood from left ventricle across the pulmonary artery = increased pulmonic blood flow Clinical manifestation: small defects are asymptomatic but VSD exhibits exercise intolerance, poor growth, pulmonary hypertension, increased susceptibility to respiratory infection, systolic murmur Diagnostics: Echocardiogram, ECG, auscultation Therapeutic management: open heart surgery, catheterization, bandaging Patent Ductus Arteriosus- failure of the ductus arteriosus to close within first week of life Pathophysiology: Patent DA → allows blood to flow from higher pressure aorta to the lower pressure pulmonary artery = shunting of blood left to right Clinical manifestation: machinery like murmur, dyspnea, tachypnea, tachycardia, full bounding pulses, hypotension, intercostal retraction, hepatomegaly Diagnostics: ECG, Echocardiogram, auscultation Therapeutic management: Indomethacin a prostaglandin E1 inhibitor, thoracotomy OBSTRUCTED BLOOD FLOW - Blood exiting the heart meets the area of narrowing (stenosis) causing obstruction of the blood flow. Narrowing usually near the valve of the obstructive defect Coarctation of Aorta- localized narrowing near the insertion of the ductus arteriosus which results in increased pressure proximal to the defect Clinical manifestations: lower blood pressure on low extremities, weak femoral pulse, higher blood pressure in upper extremities, neck and head, brachial and radial pulses are bounding, cardiomegaly, cold extremities Diagnostics: MRI (choice for location of coarctation), ECG, Echocardiogram Therapeutic management: surgery (resection, grafting, patch angioplasty, subclavian flap), balloon angioplasty Aortic stenosis- narrowing or stricture of the aortic valve causing resistance to blood flow in the left ventricle, decreased cardiac output, left ventricular hypertrophy and pulmonary vascular congestion Pathophysiology: stricture in the aortic outflow → resistance to ejection of blood from left ventricle = extra workload on the left ventricle = hypertrophy → left ventricular failure develops + Wrist icicle, ride dick bicycle Property of: Alfie Velasco BSN 2-B-10 left atrial pressure increase → increase pressure in pulmonary veins = pulmonary vascular congestion (pulmonary edema) Clinical manifestations: decreased cardiac output with faint pulses, hypotension, tachycardia, poor feeding, exercise intolerance, chest pain, dizziness Therapeutic management: balloon angioplasty, implantable heart devices Pulmonic Valve Stenosis- narrowing entrance to the pulmonary artery. Resistance to blood flow causes right ventricular hypertrophy and decreased pulmonary blood flow. Pulmonary atresia in extreme cases Pathophysiology: Pulmonic stenosis → resistance to blood flow causes right ventricular hypertrophy = right ventricular failure → right atrial pressure increases = reopening of foramen ovale → shunting of oxygenated blood to left atrium = systemic cyanosis Clinical manifestation: Cardiac murmur, mild cyanosis, cardiomegaly Therapeutic management: Balloon angioplasty, surgery (valvotomy, angioplasty) DECREASED PULMONARY BLOOD FLOW - Obstruction of pulmonary blood and an anatomic defect between right and left chambers Tetralogy of Fallot- four defects involved starts with malalignment of VSD 1. Ventricular septal defect 2. Pulmonic stenosis 3. Overriding aorta 4. Right ventricular hypertrophy Pathophysiology: If VSD is large, pressures are equal in right and left side ventricles. Blood is then shunted in the direction of the least resistance (pulmonary or systemic vascular resistance) Clinical manifestations: Blue or Tet spells, cyanosis during feeding and crying Therapeutic management: Palliative care shunt, complete repair, Blalock-Taussig shunt, Gore-Tex graft Tricuspid atresia- Tricuspid valve fails to develop Pathophysiology: with blocked tricuspid valve, blood flows thru an atrial septal defect or a patent foramen ovale to the left side of the heart thru a ventricular septal defect to right ventricle to lungs. Complete mixing of deoxygenated and oxygenated blood in left side of the heart causes systemic desaturation and pulmonary obstruction = decreased pulmonary blood flow Clinical manifestation: Cyanosis; desaturated oxygen saturation, tachycardia, dyspnea, hypoxemia, clubbing of finger nails Therapeutic management: Atrial septostomy - Prostaglandin E1 infusion to keep foramen ovale patent - Palliative shunt (pulmonary-to-systemic and anastomosis) - Modified Fontan procedure - Goal should be achieve 75% oxygen saturation Wrist icicle, ride dick bicycle Property of: Alfie Velasco BSN 2-B-10 MIXED DEFECT - Fully saturated systemic blood flow mixes with the desaturated blood flow causing defective system saturation (oxygen saturation do not exceed 75%) Transposition of Great Vessels- main vein and artery attached to the wrong side of the chambers. Must have patent ductus arteriosus or septal defect ot permit blood flow Clinical manifestation: cyanosis, egg-shaped heart in radiograph, tachypnea, dyspnea Therapeutic management: prostaglandin E1 administration to keep patent ductus arteriosus, balloon atrial septostomy (Rashkind procedure), grafting Hypoplastic Left Heart Syndrome- underdeveloped left side of the heart resulting in hypoplastic left ventricle and aortic atresia Therapeutic management: heart transplant, prostaglandin E1 infusion to keep patent ductus arteriosus. Norwood procedure to create a new aorta using the main pulmonary artery and creation of large atrial septal defect. Modified Fontan procedure, Bidirectional Glenn shunt at 6-9 months to reduce volume load on the right ventricle CONGESTIVE HEART FAILURE - Inability of the heart to pump adequate amount of blood in the system Right Side Heart Failure- right ventricle unable to pump blood to pulmonary artery resulting increased pressure in right atrium and in the systemic venous circulation Clinical manifestations: fatigue, ascites, enlarged spleen and liver, distended jugular vein, weight gain, leg varicosities Left Side Heart Failure- left ventricle unable to pump blood to the systemic circulation resulting to increase left atrium pressure → congestion in lung → increased pulmonary pressure → pulmonary edema = pulmonary edema Clinical manifestations: dyspnea, orthopnea, tachypnea, tachycardia, cyanosis, crackles/rales, wheezes, blood tinged sputum, fatigue Therapeutic management: 1. Improve Cardiac Function - Digoxin (Lanoxin) - treatment of choice: DO NOT GIVE if heart rate is less than 60 or above 120 - Watch out for toxicity (GI disturbance, Dysrhythmia); Antidote = Naloxone 2. Systemic Fluid Overload Correction - Administration of diuretics (Furosemide , Thiazides , Potassium Sparing ) - Do not give if there is a sign of hypokalemia (