Peds Exam 1 Study Guide PDF

General principles of Growth and development o Pattern of growth and development is consistent o Rate of growth and development varies as a result of genetics and environment Developmental theories – Erikson/Piaget o Erikson: § Infant: Trust vs Mistrust (Birth to 1 year) Baby lea...

General principles of Growth and development o Pattern of growth and development is consistent o Rate of growth and development varies as a result of genetics and environment Developmental theories – Erikson/Piaget o Erikson: § Infant: Trust vs Mistrust (Birth to 1 year) Baby learns to trust caretakers o Provision of food, clothing, touch, comfort If basic needs aren’t met, infant learns to mistrust others § Toddlers: Autonomy vs Shame and doubt (1 to 3 years) Learn independence (no!), control bladder and bowels, direct motor activity and play Toddlers who are constantly criticized will develop a sense of shame about themselves and will doubt their abilities § Preschooler: Initiative vs. Guilt (3 to 6 years) Initiates activities and play Considers new ideas Involved and busy exploring the world Constant criticism may lead to feelings of guilt and a lack of purpose § School age: Industry vs. Inferiority (6 to 12 years) Takes pride in new accomplishments If the school age child cannot accomplish what is expected, the result will be a sense of inferiority § Adolescent: Identity vs. Role confusion (12-18 years) Involves the definition of who you are, what you value, and the directions you choose to pursue in life If unable to establish a meaningful definition of self will experience confusion in one or more roles of life o Piaget: § Sensorimotor stage (0-2 years) Development through the 5 senses Development through motor response and reflexes Object permanence is developed § Preoperational stage (2-7 years) Symbolic thinking Imagination Abstract thinking is still difficult Asks a lot of questions (intuition) Egocentric (can only see the world from one’s own point of view) § Concrete Operational Stage (7-11 years) Develops concrete cognitive operations  Sorting blocks in a certain order Conservation is developed Conductive reasoning § Formal Operational Stage (>11 years) More rational, logical, organized, moral, and consistent thinking Hypothetical thinking: can think outside the present Abstract concepts o Love, hate, failures, successes Deductive reasoning Influences on development: o Genetics: § Genes determine physical characteristics, intellectual potential, personality type o Mother: § Prenatal illness, nutrition, smoking, drugs, chemical exposure, general state of health o Family structure: § Parenting skills, parents work, siblings, stepparents, homosexual parents o Culture: § Social interaction, touching, language, media, community, school, stress, socioeconomic influences Temperament theory: o Identified characteristics of personality- how children respond to daily events o Personality characteristics in infancy are consistent with those later in life o Describes how a child interacts with the environment o The child’s temperament has a corresponding influence on those around the child (positive or negative) Play/toys: o Play contributes to cognitive growth, physical development (gross and fine motor skills), social interaction, and moral development o Infants- Solitary play § The child is playing all by them self with a toy o Toddlers- Parallel play § The children will play next to each other, but not with each other (not interacting with each other) o Preschoolers- Associative § Children are playing the same game or building the same thing, but not working together or connecting with each other o School-age- Cooperative play § Children are playing the same or building the same thing and are working together Reactions to hospitalization: o Anxiety  o Fear o Separation Anxiety o Loss of control Stressors of the hospitalized child/minimizing stressors: o Therapeutic hugging o Distraction methods such as playing music, talking to them, and watching a movie o Use positions that are comfortable to the child o Engage the child in identifying what would make him or her comfortable Variations in Medication Administration to Children: o Oral Administration: § Children younger than 5 to 6 are at risk for aspiration because they have difficulty swallowing tablets or capsules § Therefore, if tablets are the only oral form available it needs to be crushed or opened and mixed in applesauce or something else o Rectal Administration: § Not preferred because the drug’s absorption may be erratic and unpredictable and it’s invasive § Can be very upsetting to toddlers and preschoolers and embarrassing to school-age children or adolescents § May be used when the child is vomiting or is NPO o Ophthalmic Administration: § Many children are scared to have anything placed in their eyes § Provide an age-appropriate explanation to gain their cooperation § Have the child keep his or her eyes closed until you are ready to administer the medication o Otic Administration: § This can be upsetting to the child because he or she cannot see what is happening § Explain the procedure to the younger child in terms that he or she can understand to help alleviate their fear § Gain the older child’s cooperation by explaining the purpose of the medication and the procedure for administration o Nasal Administration: § Administering nose drops to infants and young children may be difficult, and additional help may be needed to help maintain the child’s position. § For nose drops, position the child supine with the head hyperextended to ensure that the drops will flow back into the nares. A pillow or folded towel can be used to facilitate this hyperextension. § For a child younger than 3 years of age, the nurse pulls the pinna of the ear down and back § For a child older than age 3 years, the nurse pulls the pinna of the affected ear up and back  o Intramuscular Administration: § This method is used infrequently because it is painful and children often lack adequate muscle mass for medication absorption. However, it’s used to administer certain medications, such as many immunizations § Needle size (gauge and length) is determined by the size of the muscle and the viscosity of the medication § The preferred injection site for infants is the vastus lateralis muscle § The dorsogluteal site is not recommended in children younger than 5 years of age o Subcutaneous & Intradermal administration: § Subq administration distributes medication into the fatty layers of the body § SQ is primarily used insulin administration, heparin, and certain immunizations, such as the MMR § The preferred sites for SQ administration include the anterior thigh, lateral upper arms, and abdomen § Site and needle size depends on the adequacy and condition of the subcutaneous tissue and the frequency and duration of the therapy. Assisting Children through procedures: o Use a firm, positive, confident approach that provides the child with a sense of security o Encourage cooperation by involving the child in decision making and allowing the child to select from a list or group of appropriate choices o Allow the child to express feelings of anger, anxiety, fear, frustration, or any other emotions o Remind the child that it is okay to scream or cry, but that it is very important to hold still Therapeutic Play: o Provides emotional outlet or coping devices Approaches to physical assessment: o Approach the child developmentally: § Infants and toddlers-may examine on caretaker’s lap § Preschool may want to inspect the stethoscope (show them the stethoscope and let them touch it) § Involve school age- need sense of control § Teens prefer privacy (do you need your parents to step out?) o Conversing during the exam: § Engage infant, young child as needed for distraction § Talk to/with caregiver for young child § Converse directly with older child or teen o Order of physical examination: § Inspection § Auscultate § Palpation § Percussion Pain assessment: o QUESTT  o Question the child o Use a reliable and valid pain scale o Evaluate the child’s behavior and physiologic changes to establish a baseline and determine the effectiveness of the intervention o Secure the parent’s involvement o Take the cause of pain into account when intervening o Take action Pain assessment tools: o Wong-Baker FACES pain rating scale o Visual Analog Scale o Oucher pain rating scale o Poker chip tool o Adolescent pediatric pain tool Nonpharmacologic therapies: o Relaxation o Distraction o Guided imagery o Massage Pediatric Respiratory and Eustachian tube differences: o They have a short and narrow airway compared to the adult airway o They have fewer alveoli at birth o Intercostal muscles are the primary muscles used to breathe o Flexible-retractions are seen o Short eustachian tube Immunizations: o Hep A&B o Pneumococcal 1-4 o Rotavirus o DTaP 1-5 o Hib 1-4 o Varicella o IPV o MMR 1 & 2 o Meningococcal 1 & 2 o HPV Otitis media: o Clinical manifestations: § Ear pain § Pulling at ear § Fussiness § Fever  § Malaise § Poor feeding § Waking up at night o Management: § Analgesics such as acetaminophen and ibuprofen for mild to moderate pain § Narcotic analgesics for severe pain (maybe) § Application of heat or a cool compress § Numbing ear drops such as benzocaine § Emphasize the importance of follow up § Educate about OME and its potential impact on hearing and speech § If antibiotics are prescribed, emphasize the importance of completing the entire course of antibiotics § Explain the rationale of observation or watchful waiting, if that’s the selected treatment § Encourage parents to stop smoking § Instruct families to avoid excess exposure to individuals with upper respiratory infections § Encourage mothers to stop breastfeed for at least 6 to 12 months § Encourage the parents to have the child get the Prevnar immunization and flu vaccine o Discharge planning: § Contact doctor if there’s new discharge or if discharge is worse § Contact doctor if child has a new or higher fever § Contact doctor if child’s ear pain is getting worse § Contact doctor if child has other new symptoms, such as hearing problems Tonsillitis/tonsillectomy: o Clinical manifestations: § Frequent throat infections § Redness § Breathing and swallowing difficulties § Redness, may have exudate on tonsils § Enlargement of the cervical lymph nodes § Dry mucous membranes- from mouth breathing o Pre-op: § Assess throat and observe tonsils-large, inflamed, red § Assess for pain or difficulty swallowing o Post-op: § Place child in side-lying or prone position § Discourage coughing § Encourage fluids; avoid citrus, brown, or red fluids § Ice collar and analgesics with or without narcotics § Frequent swallowing may indicate bleeding o Complications: § Excessive bleeding  Croup syndromes – LTB, Epiglottis, Bronchiolitis LTB ( Laryngotracheobronchitis): o Pathology: § Inflammation of the larynx, trachea & bronchi occur as a result of a viral infection o Clinical manifestations: § Tachypnea § Inspiratory stridor § Barking or seal-like cough o Diagnosis: § Pulse oximetry § AP and lateral x-ray of upper airway o Treatment: § Racemic epinephrine § Albuterol § Corticosteroids Epiglottitis: o Pathology: § Inflammation of the epiglottis leading to an upper airway obstruction § Most common cause: Haemphilus influenzae type b (Hib) bacteria o Clinical manifestations: § Acute onset of fever § Throat pain § Drooling § Dysphonia (hoarse) § Difficulty swallowing (dysphagia) § “Tripod” positions o Nursing management: § Emergency situation § No visual inspection of mouth and throat § Keep child calm § Airway management § Oxygen, only as tolerated § Prepare for intubation § Drug therapy – antibiotics, antipyretics § IV hydration § Emotional and psychosocial support § DON’T LEAVE CHILD UNATTENDED § NO SUPINE POSITION Bronchiolitis: o Pathology: § Inflammation of the small airways in the lungs § Viral illness usually caused by respiratory syncytial virus (RSV) § Very contagious  o Clinical manifestations: § Nasal congestion § Runny nose § Cough § Sneezing § Fever § Tachypnea o Treatment: § Hydration § Fever management § Humidifier § Nebulizers/steroids § Cool humidified air & oxygen Cystic fibrosis: o Etiology/pathophysiology: § A gene mutation (CFTR) which prevents exocrine glands from properly functioning. This causes a multi-system disorder where this is an increased production of thick mucus o Clinical manifestations: § Salty taste to the skin noticed first by parents § Thick, sticky mucus § Frothy, foul, fatty stools that float § Chronic moist, productive cough § Poor weight gain, voracious appetite § Short stature, delayed onset of puberty § Clubbing of fingers and toes o Diagnosis: § Sweat chloride test – concentration >60 o Management: § Well-balanced diet § High-calorie § High-protein diet § ADEK vitamin supplementation § Pancreatic enzyme supplementation § Inhaled antibiotics for exacerbation § Inhaled dornase Alfa § Chest physiotherapy (multiple times daily) Asthma: o Etiology/pathophysiology: § Chronic inflammatory airway disorder § Airway hyperresponsiveness § Airway edema § Mucus production  § Results in airway obstruction that might be partially or completely reversed o Clinical manifestations: § Tachypnea § Increased work of breathing § Cough § Wheeze o Medications: § Albuterol § Long-acting bronchodilators § Inhaled corticosteroids § Leukotriene modifiers o Nursing management: § Teach the child and their family how to care for the disease § Provide the family with an action plan (should be kept on file at the child’s school) § Emphasize that relief medication should be available to the child at all times § Educate the child and their family on the appropriate use of nebulizers, metered-dose inhalers, spacers, dry-powder inhalers, as well as the purposes, functions, and side effects of the medications § Educate patient and family on the appropriate use of a peak-flow meter § Educate patient and family to avoid allergens and triggers § Promote the child’s self esteem § Promote Family coping GI pediatric differences o Mouth: Highly vascular, entry point for infectious invaders o Esophagus: Lower esophageal sphincter not fully developed o Intestines: Small intestine not fully mature at birth o Biliary system: Liver large at birth, can be palpated, Pancreatic enzymes continue to develop. o Fluid balance & losses: Greater amount of body water, water loss occurs rapidly & in large amounts o Any alteration in GI system decreases body’s ability to obtain nutrients, thus impairing growth o GI system immature at birth, process of absorption and excretion begins after birth o Sucking is a primitive reflex until 6 weeks of age o Small stomach capacity plus increased peristalsis--small frequent feeds o Relaxed cardiac or lower esophageal sphincter – regurgitation (wet burps) o Enzymes not present to aid digestion until 4-6 months--abdominal distension from gas is common o Immature liver function for 1 year  Cleft lip & Cleft palate o Causes: § Facial malformations that occur during 6th week of embryonic development § Occur singly or in combination § Maxillary processes fail to fuse § Environment—Poor prenatal care, maternal smoking § Genetics § Folate—Added to breads and cereals in 1996—decreased incidence of clefts o Pre-op care: § Collaboration of specialists: plastic surgery, hearing, speech therapist, and dentist § Medical management – closure of cleft(s), prevention of complications, facilitation of normal growth and development of the child o Post op care: o CL: § Protect suture line from tension/trauma § Restrain arms at elbow to prevent injury to suture line § Clear liquids first with a dropper or syringe § Feed in upright position § Minimize crying § Clean site/apply antibiotic cream o CP: § Protection of tooth buds and allow for development of normal speech pattern § Fluids best taken from a cup § Do not give pacifier § Blenderized diet given post-op § No hard items – toast, hard cookies, potato chips o Nursing management: § Cheiloplastyis the repair of CL, repaired by 2-3 months of age § Palatoplasty is the repair of cleft palate, repaired at about 12 months of age § Emotional Support § CL is a disfiguring visible defect. It may generate negative responses in both nurses and parent. § Point out a positive aspect of infant’s physical appearance for parents § Acknowledge parents’ concerns § Be positive regarding surgical correction § Before and after photographs of possible cosmetic improvements § Handling of infant – ‘a precious human being’ § Encourage mother to express breast milk and bottle feed  § Hold head in upright position (Prevent aspiration) TEF (Tracheoesophageal Fistula): o Abnormal communication of trachea & esophagus o Fistula typically in distal esophageal segment o Occurs in 4th-5th weeks of gestation o Cause is unknown o Trachea & esophagus connects – air in stomach (air trapping) o Sign and symptoms: § Rattling respirations, drooling or excessive salivation, abdominal distention § Three Cs when feeding: coughing, choking, cyanosis o Nursing management: o Pre-op: § Close observation (risk of aspiration) § Maintain patent airway--suction and remove secretions from airway § Position – HOB slightly elevated—minimize aspiration into trachea § Continuous or low intermittent suction for blind pouch § NPO § IVF § Constant monitoring of vital signs and condition o Post-op: § Maintain gastrostomy drainage § Administer IVF § Administer antibiotics § TPN until G-tube feeds or oral feeding tolerated § Parental support—encourage holding infant, express emotions § Care of G-tube teaching to parents § Desired outcomes of nursing care: adequate nutrition, no respiratory distress, healing without infection, parent-infant bonding Esophageal Atresia: o Esophagus ends don’t communicate o Upper ends in blind pouch & lower variable distance above diaphragm o A pouch holds food until it comes back out GER o Return of gastric contents into the esophagus – usually associated with feedings o Common in premature infants o Often resolves spontaneously by 12 -18 months o Clinical manifestations: § Spit up any time, even between feedings § Cry during feeds and after feeds § Eat often but still lose weight § Color changes during feeding  § Frequent respiratory infections § May aspirate-- pneumonia, apnea § Severe GERD can result in generalized irritability, poor weight gain, weight loss or delayed growth o Diagnosis: § Feeding history: Vomiting episodes, pain with feeding § Upper GI (UGI) series § Check for anatomic abnormalities § pH probe monitoring: 18–24-hour study § Valid and reliable measure of reflux § Determines number of reflux episodes § Gastric emptying study § Endoscopy § Assess for severity of esophagitis, Crohn’s disease § Milk protein allergy test o Medications: § Medications added if conservative measures fail o Management: § Modification of feeding habits—” happy spitter” § Small frequent feeds § Frequent burping § Thicken formula with rice cereal-1 tspn rice cereal per 1 oz formula § Position – Hold child upright after feeds for 20-30 min. § Surgical: Nissen Fundoplication Intussusception: o Etiology/pathophysiology: § Occurs when one portion of the intestine invaginates or telescopes into another (Telescoping of intestine) § Most common site is the ileocecal valve § Telescoping of the intestines obstructs the passage of stools § The walls of the intestines rub together causing inflammation, edema and decreased blood flow § Leads to necrosis, perforation, hemorrhage, peritonitis § One of the most frequent causes of intestinal obstruction in children § Cause – unknown, viral infections, intestinal polyps, medications o Clinical manifestations: § Sudden onset of intermittent abdominal cramps § Vomiting (sometimes bile stained) and/or diarrhea § Lethargy § Tender distended abdomen § Palpable sausage-shaped mass in upper right quadrant § Passage of currant-jelly stools  o Diagnosis: § Palpate for “sausage-shaped” mass (RLQ) § Diagnosed with air or barium enema (IR) § Abdominal X-ray or ultrasound o Management: § Explain basic defect to parent § Prepare child for procedure § Preoperative – Maintain IVF, fluid and electrolyte balance, NG decompression, antibiotic therapy § Postoperative – Monitor for infection, pain management, NG tube patency, assess VS, check for abdominal distension, bowel sounds Hirschsprung’s Disease: o Etiology/pathophysiology: § Congenital anomaly in which inadequate motility causes mechanical obstruction of the intestines § Absence of autonomic parasympathetic ganglion cells in one segment of the colon causes lack of innervation in that segment § More common in males than females (4:1) § Familial tendency § Can occur with Down Syndrome, congenital heart defects, other syndromes § Usually rectosigmoid colon § Prevents peristalsis § Leads to blockage, and stool builds up behind blockage § Results in constipation, abdominal distension, poor weight gain, poor growth o Clinical manifestations: § NEWBORNS – Failure to pass meconium, refusal to suck, abdominal distension, bile-stained emesis § OLDER CHILDREN – Progressive constipation, failure to gain weight, delayed growth, history of abdominal distension, constipation alternating with diarrhea, vomiting, normal or ribbon-like stool o Diagnosis: § History Lack of meconium stool in NB period Older child—Chronic constipation, poor weight gain, abdominal distension § Barium enema § Abdominal X-ray---Dilated bowel § Rectal examination—Rectum small, no stool § Anal manometry § Rectal biopsy-Absence of ganglionic cells  o Management: o Post-op: § Maintain hydration and pain management § Monitor for infection--enterocolitis § Measure abdominal girth § Provide family support § Provide instructions on ostomy care § Provide appropriate referrals and support groups Pyloric Stenosis o Etiology/pathophysiology: A hypertrophic obstruction of the circular muscle of the pyloric canal § Exact cause unknown § Presents at 3-6 weeks of life § The pylorus narrows because of progressive hypertrophy of the circular pylorus muscle § This results in stenosis of the passage between the stomach and the duodenum o Clinical manifestations: § Hard moveable “olive” in RUQ § Non-bilious projectile vomiting (obstruction)-May be blood tinged § Infant hungry, fails to gain weight § Progressive dehydration, metabolic alkalosis and ↑bilirubin o Diagnosis: § Physical examination- visible peristaltic wave across the abdomen moving from left to right § Olive-size mass in mid to right upper quadrant § Pyloric ultrasound § Upper GI series § Blood tests to determine dehydration o Management: § Surgical correction o Pre-op: § Assess skin turgor, fontanels, urinary output, mucous membrane § Measure vomitus/describe vomiting episode § Measure urine specific gravity § Monitor VS § Position- head slightly elevated § Ensure patent NG tube § Promote rest and comfort § Encourage parent to hold and cuddle infant o Post-op: § PO fluids in several hours § Begin with clear fluid, small frequent feeds  § Monitor I/O § Avoid pressure on incision – diapering § Provide comfort, pain relief § Prevent infection § Encourage parents to partake in infant’s care § Usually discharged 24 hours after surgery Diarrhea o Causes: § Viral, bacterial or parasitic § Viral is most likely § May lead to dehydration o Symptoms: § MILD DIARRHEA- Few loose stools each day without fever or vomiting § MODERATE DIARRHEA – Several loose watery stools daily, normal/elevated temperature, vomiting, irritability § SEVERE DIARRHEA – Numerous to continuous stools, signs of dehydration, extremely irritable, ↓ or no voiding o Management: § Depends on severity of diarrhea and fluid/electrolyte imbalance § Goal: Correct fluid and electrolyte imbalances § Oral rehydration is first intervention § Small frequent sips pedialyte, infalyte, Gatorade § IV fluids (isotonic; normal saline, lactated ringers) § Skin care § Strick I/O with daily weight § Clear liquids Dehydration: o Higher body surface area, lose water through skin o Treatment goal restoring fluid volume o Categories: Extracellular fluid volume deficit (dehydration) o Dehydration occurs whenever the total output of fluids exceeds the total intake o Severity of clinical dehydrations: § Mild and moderate dehydration: Oral rehydration is first intervention § Small frequent sips pedialyte, infalyte, Gatorade Parent instructed to give extra fluid for every stool Small amounts of normal diet as tolerated Continue breastfeeding o Clinical findings: § Mild, moderate & severe diarrhea o Complications: § Diarrhea § Vomiting § Decreased oral intake § Sustained high fever § Diabetic ketoacidosis § Extensive burns