Peds Exam 2 PDF

PEDS Exam 2 ​ Cancer in children: may be hard to diagnose (Can’t tell you what's wrong, s/s look like other common things) ​ ​ -Overt signs (see with eye): bruising, bleeding, weight loss, vomiting, skin color changes, moods, headaches, lethargy ​ ​ -Covert signs (ca...

PEDS Exam 2 ​ Cancer in children: may be hard to diagnose (Can’t tell you what's wrong, s/s look like other common things) ​ ​ -Overt signs (see with eye): bruising, bleeding, weight loss, vomiting, skin color changes, moods, headaches, lethargy ​ ​ -Covert signs (can’t see with eye): WBC count, labs, masses not seen ​ Therapies for pediatric cancers: it's okay to encourage a 2nd opinion! ​ -chemotherapy (kills rapidly multiplying cells… skin, GI) ​ -surgery ​ -radiation therapy (kills all nearby cells) ​ ​ ​ Teaching: stay away from the site may peel/discolor, keep covered w/loose clothing, avoid sunlight, separate bathroom, ​ ​ ​ -radiation under 3 can be very harmful ​ -HSCT, stem cell transplant ​ -steroid therapy (suppress immune system) ​ -Biologic agents (new treatments specific to cancer cells) ​ -Complementary + alternative therapies (Not bad! Butttt tell Dr everything you are taking!!) Assessment: emotionally (whole family), coping, comfort, make sure engaged so don’t underdeveloped, VS, head to toe, skin, nutrition Implementation: preparation + education for child/family, pain relief, prevention of complications (hand washing, hemorrhaging- soft toothbrush/clear floors, anemia) Drug toxicity: ​ -n/v (zofran/ondansetron before eating) ​ -anorexia (relaxing feeding pressures, whatever they want to eat whenever ​ -mucosal ulceration (how to clean mouth + prevent infection, look once a day, brush w/ soft brush 2x a day and rinse) ​ -neuropathy (gabapentin may get in GI and extremities) ​ -hemorrhagic cystitis (bladder bleeding; we want SG less than 1.010 before getting chemo) ​ -alopecia (cold caps, have conversations/what they want to do) ​ -mood changes ​ -moon face  ​ Leukemia (Neoplastic Disorder), a blood cancer: most common form of childhood cancer, > 70% survivability, describes broad group of malignant diseases of bone marrow -acute lymphoblastic leukemia (ALL) (better prognosis) -acute myelogenous leukemia (AML) ​ -s/s of bone marrow involvement: petechiae, infection, fatigue ​ -blast cell = immature cell ​ ​ Low Red blood cells s/s: anemia, pallor, fatigue ​ Low platelets: bruising, bleeding ​ Low neutrophil count: infection that won't go away ​ High lymphoblasts (cells won't progress past this): bone pain, fall and trip more ​ -once reach circulation: swollen lymph nodes -leukemia is an unrestricted proliferation of immature WBC’s in the blood forming tissues of the body, compete w/ norm RBC production, can cause low leukocyte count Consequences of leukemia: depressed bone marrow function, anemia from low RBCs, infection, bleeding (not producing enough platelets) ​ -ITP: immune thrombocytic purpura (Spleen attacks platelets) Diagnostic evaluation of leukemia: need a bone marrow aspiration to diagnose, history, physical manifestations ​ Therapeutic management of leukemia: chemo agents, allopurinol (for uric acid build up), cranial irradiation, stem cell transplantation ​ ​ -will test remission after 28 days ​ CNS Tumors: childhood brain tumors derived from neural tissue, most common solid tumor/ 2nd most common type childhood cancer, tumors may be difficult to treat due to location and radiation can be harmful ​ -60% are infratentorial tumors (in cerebellum or brainstem) ​ -40% are supratentorial (mainly in cerebrum) ​ ​ ​ -s/s may occur depending on location and size of tumor and child’s age: vision changes, speech issues, headaches, behavioral changes, seizures ​ -classic sign!: vomiting in morning, b/c when laying flat, putting pressure on imedic center that side of brain, will get up- throw up and feel better ​ Diagnostic evaluation of brain tumor: MRI, CT, EEG, angiography, lumbar puncture, definitive diagnosis based on tissue specimens from surgery ​ Therapeutic management of brain tumors: usually surgery first if safe, prepare families Nursing care management: may have to shave head, prepare child/family for diagnostic and operative procedures, support, establish baseline of data Post op: will go to ICU for at least 24hrs for neuro + I+Os, assess kids before and after! Assessment: VS, neuro, infection, seizures, strict I+Os, CSF (infected would be yellow tinged fluid… call surgeon!!!) ​ Neuroblastoma: most common malignant extracranial solid tumor of childhood ​ The majority of tumors develop in the adrenal gland or retroperitoneal sympathetic chain; other sites are the head, neck, chest, and pelvis ​ “SILENT TUMOR” ​ ​ May have spontaneous regression as embryonic cells mature w/development of an active immune system but will still have to do interventions ​ -do diagnose in utero w/ imaging sometimes Diagnostic evaluation of neuroblastoma: locate primary site, s/s depend on location + stage of disease = radiologic studies + bone marrow evaluation, 24 hr urinecollection​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ -for HVA (homovanillic acid) VMA (vanillylmandelic acid) which are both byproducts of catacholine (the fight or flight hormone), keep on ice Therapeutic management of neuroblastoma: remove then maybe chemo/radiation, the younger the diagnosis the better the prognosis Wilms tumor- Nephroblastoma: 80% diagnoses under the age of 5, peak 2-3 y.o, associated w/ congenital abnormalities (hypospadias), genetic link, wilms tumor is specific to kids Diagnosed: VS, hematuria, stomach pain, pain w/urination, urinary frequency, oliguria, swelling or mass in abdomen, diagnosed usually during bath time and parent feels a lump s/s: firm nontender confined to one side flank, left > right, anemia, hematuria, anorexia, HTN, flushing, headaches, photophobia, bloody noses, irritable Diagnosed: history and physical exam, ultrasound, cat scan, MRI, bone marrow aspiration ​ Therapeutic management: tumor resection/nephrectomy ​ ​ -stages of tumor: 1st (limited to one kidney) ….. 6th (both kidneys) ​ ​ -chemo/radiation ​ ​ Nursing considerations: DO NOT PALPATE- will spread if ruptured, ​ surgery w/ in 48 of diagnosis, ​ support/education, ​ age-appropriate explanations ​ ​ Post op considerations: ​ rapid recovery,  ​ assessment of GI activity, ​ VS (checking for HTN), ​ protective care (physician no contact restrictions, encourage fluids, voiding is important), ​ pain control, family support + education, ​ prep for chemo/radiation ​ Spina Bifida: ​ May cause problems with ambulation ​ neurogenic bladder (won't potty train well) ​ nb assessment checks for tufts of hair, Mongolians spots, dimple and straight spine Meninges: surrounds brain and spinal cord Jerod case study: -0.4 folic acid needed to develop spinal cord (should be started before getting pregnant b/c neuro-tube closes between 3-4 weeks gestation) Screening could: offer inter utero surgery (around 25 weeks gestation), prepare parent, offer therapeutic absorption option, Jerod would be born c-section as well Myelomeningocele- sac on the outside of the spinal cord instead of fluid being inside Hydrocephalus- abnormal buildup of CSF in brain, b/c brain tonsils will settle top of spinal column and will start to obstruct and CSF will not go back down toward spinal column ​ CSF- lubricates, removes waste, protects S/S at birth: ​ high pitched cry- “neuro cry ​ bulging fontanelle ​ head is big in relation to chest circumference ​ Sac on back ​ commonly associated with: ​ Arnold chiari ​ hydrocephalus ​ neurogenic bladder ​ Neurogenic bowel ​ weakness or paralysis in lower extremities  ​ Increased risk of infection - will likely have a shunt in place (to get culture.. Will be on antibiotics) ​ latex allergies - even if not documented will be treated as such avoid BLACK- bananas, licorice, avocado, chestnuts, kiwi (the tree they grow on has a latex component) Pre-op: should be in prone position npo after midnight can breastfeed in prone laying down position VS Q4hrs Straight cath Q4hrs, Notify if no meconium stool by midnight D5.3NS Cefotaxime Head U/S most common shunt - VP- ventricular peritoneal shunt Can draw fluid from, has pressure gage that baby will have to build up before it drains, Post-op: Its a nasty scar, forever do a good assessment on the scar and surrounding tissue Discharge education: infection control shunt malfunctions s/s- ha, neuro cry, icp, fontanelles separate or bulge, head circumference- needs to be measured (remember they can compensate so measure head circumference once a week- can be first indicator) Daily care: ​ Cath ​ measure head circumference ​ skin care ​ ROM exercises ​ s/s of infection (know how to take temperature axillary) ​ follow up care ​ Meds if needed ​ Feeding ​ weights Infant ER visit: assess: ABC- airway breathing and circulation FIRST…. Then neuro PGCS- pediatric Glasgow coma scale 15 is what is desired Teaching about CT scan: look at soft tissue, non invasive, will bundle him so they can't move, will not hurt Skull fracture in infant - abuse Abuse: notify CPS and social worker to file paperwork for abuse any change in the story of the injury indicates abuse is likely or if the story doesn’t match the injury. Epidural hematoma: between the dura and the skull, arterial bleeds much faster, usually seen in older kids and adults. May feel okay and then feel very bad very fast. Signs and symptoms set in really fast post trauma. Usually the one and done impact hit subdural hematoma- shaken baby in the dura, a venous bleed, slower bleed with more space to spread and grow. More common in young kids and the elderly. Signs and symptoms may not present the same day but the following day ​ -ophthalmology consult, to check for retinal hemorrhage ​ -bone scan- for signs of new or old fractures pertaining to hx of abuse Interventions for when GCS decreases and ICP suspected: ​ Administer mannitol (mannitol effective when a decrease in intracranial pressure) ​ Elevate HOB ​ Notify neurosurgery ​ Initiate seizure precautions (ambu bag o2 system ready to go, suction, dim lights, decrease stimuli) Cushing's triad: (an indicator that the ICP is increasing) bradycardia, decrease in RR, widening BP. -unequal pupils: a concern of neurological deterioration Nursing during tonic clonic seizure: ​ record start and end, ​ the movements ​ s/s: baby will look rigid, tight, drooling, ​ do positioning then suctioning ​ use blow by oxygen Lorazepam: PAM ALWAYS COMES TO RESCUE, will stop seizure activity quickly ​ seizure lasts more than 3 minutes nurse will anticipate giving lorazepam first (its a rescue medication) Dilantin; ​ use in-line filter (0.22 micron), ​ infused with 0.9NS, ​ serum levels will be monitored ​ gingival hyperplasia (may go to dentist more often, oral care important) if oral (need to be given without food- noooo milk!!!) ​ small therapeutic window- under amount (seizures will come back), over amount (LOC will decrease) ​ you can't infuse dilantin with D5.9 NS KNOW 5 LOCs: ​ Coma (not arrousbale), ​ obtunded (falling asleep and needs stimulation), ​ stupor (needs full sternal rub), ​ confusion, ​ full consciousness Chapter 50: Special Needs Alterations: genetic happened during birth, after birth lead poisoning Infections Environmental -needs services for communication, social skills etc, never should be put in corner they need to be included! -children are more at risk for injury due to their lack of understanding of consequences should be addressed as early as possible to intervene appropriately, can’t self regulate -the earlier we recognize the deficit the better the outcome Autism- symptoms can be gradual or sudden before the child is 3 years old.  ​ Communication delay or lack, ​ no intonation or fluid cantor ​ does not pick up on social cues ​ slower processing of questions ​ unaware of others, may never learn names of other kids around them ​ can self isolate ​ issues with harmful stims- pinching or pulling or scratching self ​ Repetition is important and do not change their routine! ADD-ADHD: ​ Inappropriate degrees of attention ​ goal is to decrease attention ​ diagnose 6 or more symptoms ​ medication Ultimate goal: decrease impulsivity or lack of focus! To have that child be the most successful in their environment ​ ​ OB TEST 2 Early Perinatal loss is defined by BEFORE 20 weeks of gestation. Types of pregnancy loss ​ Ectopic ​ Spontaneous abortion ​ Therapeutic abortion ​ Molar ​ Stillbirth (post 20 weeks) ​ Neonatal death- live born over 20 weeks, death within first 28 days Causes: ​ Majority are chromosome abnormalities ​ hormone abnormalities ​ maternal diabetes ​ uterine abnormalities ​ incompetent cervix ​ infections ​ smoking  ​ exposure to toxic substance Grief - encourage the family to hold and comfort the baby ​ Mourning ​ anger is common ​ traditions in ceremonies Physical symptoms of grief ​ Exhaustion ​ appetite changes ​ sleeping difficulty ​ restless ​ vision change ​ weight changes ​ Body aches Nursing Support in infant death ​ Encourage family to hold baby ​ express your own sympathy (“im sorry”, your baby looks like you..) ​ it is ok to cry ​ allow the family time to process ​ facilitate mementoes and keepsakes ​ DONT SAY: when was the last time you felt the baby move, you can always have another PPH; Postpartum Hemorrhage ​ Blood loses of >1000cc ○​ Primary- before 24 hours ​ Uterin Atony- boggy needs to contract ​ 80-90% of cases ​ overdistention of uterus ​ grand multip ​ pre-eclampsia ​ prolonged 3rd stage (pushing) of labor ​ Large baby ​ Polyhydramnios ​ Precipitous birth (very fast) ​ Infection ​ Full bladder ​ Low BP, high HR  ​ Treatment ​ fundal massage!!! ​ empty bladder ​ Vitals BP down, pulse up ​ medication- pitocin ​ ligation of uterine artery ​ hysterectomy ​ Lacerations very common with precipitous birth with cervical lacerations ​ firm uterus with steady trickle of blood (first thing to do is call Dr!!) ​ up to 20% of PPH ​ 1st, 2nd, 3rd, and 4th degree ​ Treatment ​ notify provider immediately ​ a repair is needed ​ Retained Placental Fragments (#1 cause of late pph) ​ normal separation should occur 5-30 min post birth ​ persistent bleeding without a laceration ​ Treatment ​ inspect placenta ​ uterine exploration ​ D&C ​ Trauma ​ Hematomas ​ 250-500cc of blood in them ​ sever pain, difficulty voiding, tense tissue ​ Treatment ​ 5cm surgery, antibiotics, I+D ​ antibiotics ​ sitz baths ○​ Delayed PPH -from 24hours to 6 weeks ​ Subinvolution - uterus not going down 1 fingerbreath daily pp. ​ treat; methergine (no hypertensives), antibiotics, D&C ​ Thrombophlebitis ​ Leg- venous stasis. Treat by elevating leg, ted hose in AM, SCD, leg exercises, ambulate (if they can) ​ Pelvis, Treat with anticoagulant and antibiotics ​ Postpartum Infection  ​ perineal wounds ○​ drain, leave open ○​ antibiotics ​ Cesarean ○​ 4-12% ○​ increase with emergency CS ​ Therapy for Infections ​ blood test, UA ​ antibiotics, sitz baths ​ iv fluids ​ Mastitis 3-4 questions ​ breast does not pass milk and becomes infected ​ Increase feedings ​ Increase fluids ​ bed rest if indicated ​ Antibiotics, something if have fever ​ ibuprofen ​ Warm compress ​ Support bra ​ Dont have to avoid breast pump ​ 1 of 3 major causes of death ​ 5-30 minutes to deliver placenta 5 T’s. TONE. TISSUE. TRAUMA. THROMBIN. TRACTION Uternin. Retained Laceration Coag Pulling chord Atony Placenta. Hematoma Distended Clots. Rupture Bladder. Subinvolution Inversion Postpartum Psychiatric disorders ​ BLUES ​ PSYCHOSIS ​ DEPRESSION - lack of concern, wanting to hurt self or baby, lack of appetite or increased, sleep issues, no bonding with baby, uninterested in hygiene. Maternal Factors for High Risk Newborns ​ Diabetes ​ narcotics ​ difficult or prolonged labor  ​ maternal infection SGA- small for gestational age ​ 10th percentile ​ hypothermia- needs extra calories to maintain warmth ​ needs increased calories LGA- large for gestational age ​ 99th percentile ​ Signs of hypoglycemia- heel stick glucose Preterm newborn: before 37 weeks, leading cause is lack of prenatal care s/s: ​ impaired oxygenation (due to lack of surfactant in lungs), ​ translucent thin skin with visible blood vessels ​ Low subq and brown fat- results in low temps ​ diminished bowel sounds, ​ poor suck reflex ​ lanugo in tact on skin (fuzz) ​ underdeveloped genitals ​ resp distress ○​ s/s: retractions, grunting, nasal flaring ​ hypoglycemia: jittery.. If under 45 feed, may not have suck reflex and may have to lavage feed ​ High risk delivery… get equipment and Back up personnel there before delivery ​ watch for volume of urine, weight, ​ baby might like nonnutritive sucking to soothe self (pacifier) (SATA) Advantages of kangaroo care: ​ enhanced bonding, ​ increased breast feeding, ​ maintains temp, ​ decrease length of stay Neonate- respiratory distress: Common causes: ​ RDS (b/c of lack of surfactant- diabetic moms more likely), ​ MAS (meconium in lungs), ​ TTN (transient tachypnea of newborn, ​ DM mothers C-section SGA premature Interventions: ​ hold feeding for rr over 60 (tachy) ​ o2, ​ temp, ​ weight, ​ infections s/s of resp distress: ​ tachypnea, ​ chest retractions, ​ nasal flaring, ​ grunting, ​ seesaw resp movements, ​ cyanosis (late finding) RDS: immaturity + inability to produce surfactant- diabetic mother = less surfactant MAS: mouth and nares suctioned before first breath so dont breath in (mouth then nares), may suction meconium below vocal cords, watch for hypoglycemia Infants of diabetic mothers: hypoglycemia, macrosomic baby, birth injuries Newborns Substance abuse- what do we see ○​ High pitched cry ○​ increase secretions ○​ hyperreflexive ○​ increased temp ○​ diarrhea ○​ sneezing and yawning ○​ persistent fever Alcohol substance abuse in babies: ​ CNS dysfunction, ​ growth retardation, ​ feeding problems (need more time to feed.. Be patient, better if have same consistent nurse, decrease environmental stimuli) Drug substance abuse: ​ jaundice, ​ growth retardation,  ​ behavioral problems ​ Withdraw after 24hrs: Neonatal absence syndrome: -we can test babies first meconium to test what mom was on Hyperbilirubinemia: ​ ​ physiologic : first 24hrs ​ ​ Pathologic: after 24 hrs, ABO incompatibility, RH factor Complications: ​ kernicterus (irreversible brain damage- too much bilirubin) Phototherapy (bililights): ​ turns the fat to water soluble then extretes it, ​ expose as much skin as possible, ​ protect eyes from UV lights, ​ turn frequently, ​ monitor temp, ​ monitor I+Os, ​ monitor for diarrhea. Diabetic moms- ○​ decrease surfactant- do they have any different lung sounds ○​ Large babies over 90th percentile 4000g ○​ hypoglycemia Thermoregulation- ​ low temp= resp depression and hypoglycemia