ATIPEDS (1) (1).pdf

Care of the Child ATI Chapter 1 Parenting styles: § Dictatorial or authoritarian o Super strict parents, it’s their way or the highway o Parents try to control their child’s behaviors through unquestioned rules or expectations...

Care of the Child ATI Chapter 1 Parenting styles: § Dictatorial or authoritarian o Super strict parents, it’s their way or the highway o Parents try to control their child’s behaviors through unquestioned rules or expectations o Ex. the child is never allowed to watch tv on a school night § Permissive o Very laid back, allow children to set their rules o Parents exert very little control over their child’s behaviors; consult the child when making decisions o Ex. the child assists in deciding whether or not they can watch tv on a school night § Democratic or authoritative o Right in the middle, not too strict but also not too permissive o Parents direct the child’s behaviors by setting rules and explain the reason behind them o Parents negatively reinforce deviations from the rules and may do so by taking privileges away o Ex. the child can watch tv for 1 hour on school nights as long as their homework is done § Passive parents o Do not care what is going on, don’t even consult with the children. Uninvolved, indifferent or emotionally removed Chapter 2 Physical Assessment Findings § Pediatric vital signs differ from an adult’s, except for blood pressure. § Temperature of a one year old is 99.9 degrees § Not until 5 years old when they begin to have a normal temperature of 98.6 § Pulse rate for an infant is 80-180 with respirations of 30-35 § Infant bp systolic is between 65-80 and their diastolic is between 40 & 50 § The fontanels* o Should be flat and soft o Posterior: closes between 6 & 8 weeks o Anterior closes between 12 & 18 months § Infant can have 6-8 teeth by one year of age § There will be 20 deciduous teeth and 32 permeant teeth  § Reflexes* o Moro reflex: present from birth to four months. Allowing the head and trunk of the infant to fall backwards. The arms and legs symmetrically extend and abduct, and fingers form a C shape. o Rooting: stroking the infant’s cheek or edge of mouth causes the infant to turn their head to that side and suck. Birth to 4 months. o Palmar grasp: placing an object in the infant’s palm and the infant grasps the object. Birth to 3 months. o Plantar: by touching the sole of the infant’s foot the toes curl downward. Birth to 8 months. o Startle: by making a loud noise the infant abducts arms and hands remained clenched. Birth to 4 months. o Tonic neck: by turning the infants head to one side the infant will extend the arm and leg on that side and flex the opposite side. Birth to 3-4 months. o Babinski: by stroking the outer edge of the sole up toward the toes the infant will fan its toes upward and out. Birth to 1 year. o Stepping: by holding the infant upright with its feet touching the surface the infant will make stepping movements. Birth to 4 weeks. § Cranial nerves o 1 is olfactory o 2 is optic o 3 oculomotor o 4 trochlear: ability of eye to look down and in o 5 trigeminal: have child close eye and they will detect you touching their face o 6 abducens: the ability to look laterally with the eyes o 7 facial: symmetry facial movements o 8 vestibulocochlear/acoustic: checking hearing o 9 glossopharyngeal: checking for intact gag reflex o 10 vagus: checking for swallowing o 11 spinal accessory: can move shoulders symmetrically o 12 hypoglossal: tongue is midline and can move in all directions Ooh ooh ooh to touch and feel very good velvet such heaven Some say marry money but my brother says big brains matter most Chapter 3 Physical Development: § Doubles by 6 months; triples by 1 year*  § 2.5 cm (1 in) per month for the first 6 months § Length increases by 50% by 12 months of age § First teeth erupt between 6-10 months Age Gross motor Fine motor 1 month Demonstrates head lag Strong grasp 2 months Lifts head up when prone Holds hands in an open position, grasp reflex fading 3 months Raises head and shoulders No longer has a grasp when prone, slight head lag reflex, keeps hands open loosely. 4 months Rolls from back to side Grasps with both hands 5 months Rolls from front to back Uses palmar grasp 6 months Rolls from back to front Holds bottle 7 months Bears full weight on feet. Moves objects from hand Sits leaning forward on to hand both hands 8 months Sits unsupported Begins using pincer grip 9 months Pulls to standing position. Has crude pincer grip. Creeps on hands and knees Dominant hand preference evident 10 months Changes from prone to Grasps rattle by its hand sitting position 11 months Cruises or walks while Places objects into a holding on to something. container. Neat pincer Walks with one hand held. grasp. 12 months Sits down from a standing Tries to build a two-block position without assistance tower w/o success. Can turn pages in a book. Cognitive Development: Piaget § From birth to 24 months they are in the sensorimotor stage § Object permanence occurs around 9 months of age. Language Development: § Should be able to say 3-5 words by age 1 and they know the concept of no. Erickson: § From birth to 1 year is trust vs. mistrust. § Is the caretaker meeting the needs of the infant? § Separations anxiety occurs around 4-8 months of age § Stranger fear occurs around 6-8 months of age Toys: © Rattles, blocks, brightly colored toys, playing patty cake, reading books, mirrors, and playing with balls. Immunizations: © Birth: hep B © 2 months: 2nd hep B, IPV (inactivated polio), RV (rotavirus), PCV (pneumococcal), DTaP, Hib (haemophilus influenza type B) © 4 months: all of the above minus the hep B © 6 months: all including hep B © Should also get flu between 6 months and 1 year Nutrition: § Breastmilk for the first 6 months § No solids until 4 to 6 months, iron fortified rice cereal § Do not need juice or water during first year of life** § Introduce new foods one at a time over a 4 to 7 day period to observe for allergies © Never leave unattended in bathtub © Stay in rear facing cars seat until two years of age © Crib slats should be no more than 6 cm apart, keep pillows out of crib © On back to sleep* Chapter 4: © Quadruple weight by 30 months of age © Grow 3 inches per year © Head and chest circumference should be equal around 2 years of age Age Gross Motor Fine Motor 15 months Walks without help. Creeps Uses a cup. Builds a tower up stairs of 2 blocks 18 months Runs clumsily, falls often, Manages a spoon. Turns throws ball overhead, pages in a book two or jumps in place with both three at a time, build a feet. Pushes and pulls toys tower of 3-4 blocks  2 years Walks up and down stairs Builds tower of 6-7 blocks by placing both feet on and turns pages of books each step one at a time. 2.5 years Jumps across flow and off a Draws circles. Has good chair using both feet. hand-finger coordination Stands on one foot for a moment. Takes a few steps on tip toe © At one year, they are using one-word sentences or hollow phrases. At two years they use multi word sentences, 2-3 words. Erickson: § Autonomy vs. shame § Independence, trying to do stuff for themselves; Expressed by saying “no” a lot. § Thrive on ritualism Toys: © Playing with blocks, push pull toys, large piece puzzles and thick crayons. Finger paints and looking at books. Toilet training: © Depends on age and when the child can recognize the sensation to go. Immunizations: © 12-15 months: IPV and PCV, MMR and varicella, Hib © 12-23 months: hep A (at least 6 months apart) © 15-18 months: DTaP © Annual flu Nutrition: © Breast milk or formula through 1 year © 1-2 years they receive full fat milk © At 2 can transition to low fat milk © Juice consumption should be limited to 4-6 oz per day © Nuts, grapes, hot dogs, peanut butter, raw carrots, tough meats, and popcorn should all be avoided. Injury prevention: © Prevent burns, drowning, and aspiration Chapter 5: © They should gain about 4.5 to 6 pounds per year. © Should grow about 2.5-3.5 inches per year. 3 years old 4 years old 5 years old Rides tricycle Skips and hops on one foot. Jumps rope Jumps off bottom step Throws ball overhead Walks backwards with heel Stands on one foot for a few Catches ball reliably to toe seconds Throws and catches ball Piaget: § Phase of intuitive thought around age 4 § Have magical thinking § Animism is also present Erickson: § Initiative vs. guilt § May regress if a new child is brought home, this is normal for any stress or insecurity Toys: © Playing ball, puzzles, tricycles, dress up and role playing. Immunizations: © 4-6 years: DTaP, MMR and IPV © 3-6 years: seasonal flu Sleep: © Need about 12 hours of sleep © Consistent bedtime routine and avoid letting them sleep with you Dental: © Eruption of primary teeth is finalized by the beginning of the preschool years. © Wear protective gear such as helmets and pads Chapter 6: School-Age Children © Will gain about 4.5-6.6 pounds a year © They will grow about 2 inches per year © Permanent teeth begin to come in Piaget: § Concrete operations § See perspective of others instead of having an egocentric type of view Erickson: § Industry vs. inferiority § Child is trying to make meaningful contributions to society § Cooperate and compete with others Socialization: § Peer groups are very important § Competitive and cooperative play occurs Activities: § Board games, hopscotch, jump rope, bicycles and organized sports. Immunizations § 11-12 years: DTaP and HPV Sleep § At least 9 hours Chapter 7: Adolescents © Girls will stop growing about 2 to 2.5 years after they stop their period. © Boys stop growing around 18 to 20 years of age. Girls © Breast development © Pubic hair growth © Axillae hair growth © Menstruation Boys © Testicular enlargement © Pubic hair growth © Penile enlargement © Axillae hair growth © Facial hair growth © Vocal changes Piaget: § formal operations Erickson: § identity vs. role confusion § figuring out who they want to be Activities: § video games, music, sports, pets, reading and social events. Immunizations: § 16-18: meningitis Safety § Protective gear § Wearing seat belts, no drinking and driving, discourage cell phone use while driving. § Talk about substance abuse Chapter 8: § Oral route is always preferred if possible § Use the smallest measuring device possible § Do not mix into formula because they may not finish the whole bottle § Insert medication into side of mouth; hold cheeks together then stroke chin to get them to swallow more effectively Ear drops: - If the child is less than 3 years old, pull the pinna down and straight back - Child over 3 years old - pull pinna upward and back Injections: § Vastus lateralis is preferred site for IM injections § Ventral gluteal or deltoid would be the second recommended site § 22-25 gauge with a 0.5-1-inch needle § Subcutaneous injections: 26-30-gauge needle When inserting an IV, take the child away from their bed and into a procedure room. You don’t want to mix up their associations between their safe places and unsafe places. Use emla cream to numb the area. Avoid terminology such as a bee sting or a stick. Keep equipment out of sight until you are ready to perform the procedure. Offer nonnutritive sucking to infants before, during, and after procedure. Chapter 9: Pain management - Self-report is only appropriate if the child is 4 years or older. FLACC § From 2 months to 7 years FACES § 3 years old and above OUCHER § 3 to 13 years old Numeric scale § 5 years old and older Nursing interventions: § Use play therapy to explain procedures § Given medications on schedule instead of when needed § Combine opioid and non-opioid for greater effect § EMLA o Apply 60 min prior to puncture o 2.5 hours prior to a deep puncture o Place occlusive dressing over that, and then clean the skin Chapter 10: Infant § Does not know what is going on; unable to describe their illness or how they are feeling § May have stranger anxiety § May express physical behaviors due to the inability to express themselves verbally Toddler § Limited ability to describe illness or follow directions § Behavior may regress during hospitalization § Separation anxiety § Intense reactions to any kind of procedures Preschooler § Magical thinking § Still experience separation anxiety School-age child § Able to describe pain and can understand cause and effect Adolescent § Body image is a key concern § May feel isolated from peers** Interventions: § Preschoolers - explain the procedure in very simple clear language, give a choice if they can (do you want to take your medicine in a cup or a spoon) § School age - give factual information, tell the truth, encourage contact with peer group and to express their feelings § Adolescents - give factual information, encourage contact with peers Play: § Parallel play: one child playing next to another (not with); toddler § Associative play: o Preschoolers o Play together without much organization § Cooperative play: o School age o Play in groups and is more organized Chapter 11: Death and dying Anticipatory grief: when death is expected; outcomes identified Complicated grief: lasts longer than a year Infants & Toddlers § No concept of death § Mirror parents’ emotions § Regress in behavior Preschooler § Magical thinking § Feel guilt or shame because they think they did something that caused death to occur § See dying as temporary School age § Adult concept of death § Express fear through uncooperative behavior Adolescents § Adult concept of death § Rely on peers than family § Stressed out by changes in physical appearance Physical manifestations § Sensation of heat when the body feels cool, decreased sensation, loss of senses, decreased LOC, swallowing difficulties, bradycardia, hypotension, Cheyenne stokes respirations. After death § Allow family to stay with body as long as they like § Assist in preparation of body § Let them be involved Chapter 12: Neurological Disorders Meningitis  § Viral or bacterial o Viral resolves with supportive care for recovery o Bacterial is more dangerous & is contagious (two vaccines - PCV and HIB) § Symptoms o Photophobia, n/v, irritability, headache, o In newborn: poor muscle tone, weak cry, poor suck, refusal to eat, v/d, bulging fontanels is a late sign o For 3 months to 2 years: seizures, high pitch cry, fever, irritability, nuchal rigidity, poor feeding and vomiting. o 2 years to adolescents: seizures, nuchal rigidity, positive Brudzinski sign & Kernig, fever, chills, vomiting, irritability headache and petechiae. § Those signs not reliable in diagnosis for those 3 months to 2 years § Labs o Analysis of cerebral spinal fluid through lumbar puncture o If it is bacterial the CSF will be cloudy, elevated WBC count, elevated protein count, and decreased glucose content. Positive gram stain. o If it viral it will be clear instead of cloudy. A slightly elevated WBC count, a normal or slightly elevated protein, normal glucose content, and a negative gram stain. § Lumbar puncture o Have child empty their bladder before the procedure o Use emla cream on the area to be punctured o Side lying position o After they need to remain in bed for 4 to 8 hours in a flat position § If this disease is suspected, they need to be on droplet precautions**** § If they have a decreased LOC related to the disease, they need to be NPO § Provide a quiet, dimmed environment § PT needs to be on seizure precautions § If it is bacterial, they are going to need an IV antibiotic § Monitor for increased cranial pressure o Infants: bulging fontanels, increased head circumference, high pitched cry, irritability, bradycardia and respiratory changes. o Children: irritability, headache, n/v, seizures, bradycardia, and respiratory changes. Reye’s Syndrome: § Can cause liver dysfunction and cerebral edema § Associated with giving aspirin to children with a fever  § Follows a viral illness like the flu, gastroenteritis, or varicella. § Labs o Liver enzymes will be elevated o Ammonia will be elevated § Do a liver biopsy and CSF analysis to diagnose § Symptoms o Lethargy, irritability, confusion, delirium, vomiting and loss of consciousness Chapter 13: Seizures § Can have an unknown etiology § Risk factors o Cerebral edema, fever, trauma or hemorrhaging, brain tumor, toxins in the body, lead poisoning, hypoglycemia, electrolyte imbalance and infection. § Types o Tonic clonic § Tonic: arms and legs flex up; head and neck extend. Loss of consciousness § Clonic: jerking of muscles in your body. § Postictal phase: awake confused, slow to arouse, and have no recollection of the seizure. o Absence § With school age children, 4-12 yrs § Loss of consciousness for 5-10 sec, looks as if the child is daydreaming. § Lip-smacking or twitching of the eyelids or face o Myoclonic § Brief contraction of a muscle or muscle group but there is no postictal phase o Atonic § Lose tone and fall § Diagnosis o EEG § No caffeine and wash hair prior to § Seizure precautions o Pad the side rails of the bed, suction and oxygen readily available o Gently place on side, make sure airway is patent, loosen any restrictive clothes, move any furniture or obstacles out of the way.  o Post seizure: keep in side lying position, take vital signs, neuro check, no food or liquid until gag reflex is back. § Meds o Antiepileptic meds § Carbamazepine, valproic acid § Phenytoin & diazepam § Surgical o Focal resection of certain areas of the brain o Vagal nerve stimulator § Complication o Status epilepticus: lasting more than 30 minutes, medical emergency § IV access Chapter 14: Head injury Minor § Confusion, vomiting, pallor, irritability, drowsiness, Major § ICP first sign is irritability o Infant: Bulging fontanels, high pitched cry, poor feeding o Chile: Nausea, headache, vomiting, blurred vision, and seizures o Late signs: delayed or impaired pupillary responses, posturing (decorticate = toward the cord) § Decorticate means that there is a problem with the cerebral cortex. § Decerebrate means an issue with the brain stem § Nursing care o Stabilize spin until it is checked, VS, Glasgow coma scale § Ways to decrease ICP o Keep HOB at 30 degrees, maintain head in midline or neutral position, minimize oral or endotracheal suctioning, avoid coughing or blowing nose, insert foley catheter, and give stool softeners to avoid straining. o Implement seizure precautions o Meds § Corticosteroids Dexamethasone Mannitol § Antiepileptics  o Surgery § Craniotomy Relieve pressure § Complications o Epidural hemorrhage, subdural hemorrhage o Brain herniation § Loss of blinking, loss of gag reflex, nonreactive pupils, and coma Chapter 15: Cognitive and Sensory Impairments § When using the Snellen chart, have the child 10 feet away § Visual impairments o Myopia: nearsightedness o Hyperopia: farsightedness o Strabismus: inward or outward deviation of eyes. § Treated by placing a patch on the stronger eye forcing the weaker eye to become stronger. § Hearing (also chapter 37) o Acute Otis media § Middle ear infection § Common in children under the age of 7 § Short and horizontal Eustachian tubes § Antibiotics, analgesics § Surgery: place tubes in middle ear, myringotomy by placing tympanoplasty tube. Tubes fall out on their own after 6 to 12 months, notify doctor when they fall out. Do not get ears wet. Chapter 16: Oxygen therapy Meter dose inhalers  § Shake inhaler 5 to 6 times, the use of a spacer makes it more effective, take deep breath than exhale, while pressing the inhaler take a slow deep breath for about 3 to 5 seconds, and hold breath for 10 seconds. Dry powder inhaler § Do not shake the device Chest physiotherapy § Includes percussion, vibration, and postural drainage. § Schedule one hour before or two hours after a meal § Administer bronchodilator or nebulizer treatment prior to therapy Hypoxemia § Signs o Tachypnea, tachycardia, restlessness, use of accessory muscles, nasal flaring Oxygen toxicity § Will result in hypoventilation and may cause child to become unconscious Oxygen therapy § Oxygen hood o 4-5 L/min o Ensure chin, neck, and shoulders do not rub against hood § Nasal cannula o Provide humidification for greater than L/min § Face mask o Short term therapy o 5-10 L/min Suctioning § Nasal o Use a mushroom tipped catheter Chapter 17: Acute and infectious respiratory illness Tonsillitis  § Signs o Sore throat, difficulty swallowing, fever, bad breath, and redness and swelling of the tonsils. § Meds for the fever and antibiotics § May need a tonsillectomy if recurrent o Keep in side lying position after surgery o Assess for bleeding. Look for frequent swallowing and clearing of the throat. o Clear fluids and liquids, avoid red colored liquids, no citrus juices, no milk products, and no rough or sharp foods. o Discourage any coughing, throat clearing or nose blowing o There may be blood clots in emesis or mucous o Limit strenuous activity, full recovery in two weeks Bacterial epiglottitis § Signs o Drooling, hoarseness difficulty speaking, difficulty swallowing, and high fever. § Do not put anything in their throat, no culture, no tongue blade § Antibiotic therapy, starting with IV antibiotics § Have intubation supplies close by Influenza § Signs o Fever, body aches, nasal congestion, dry cough, photophobia § Antiviral meds can only be given within the first 48 hours Complications § Pneumothorax and pleural effusion § Place a chest tube § Signs o Chest pain, difficulty breathing, tachycardia, decreased oxygen saturation How to prevent the spread of these § Hand hygiene Chapter 18: Asthma § Can be triggered by allergens, cold weather, exercise, smoking  § Symptoms o Difficulty breathing, wheezing, anxiety, use of accessory muscles § Treatment o Bronchodilators: albuterol, comes with tachycardia and tremors. o Anticholinergic: ipratropium o Anti-inflammatory: corticosteroid such as prednisone. Rinse mouth after steroid inhaler. o Peak flow meter: child stands up, ensure the machine is zeroed out, place lips around device and blow as hard and as fast as they can. They do these three times, taking the highest reading. § Complications o Status asthmaticus: airway obstruction that is not relieved by medications that are given. Prepare for intubation and mechanical ventilation. Chapter 19: Cystic fibrosis § Caused by a genetic mutation where both parents have to carry recessive traits for the disease** § Disease causes an increase in the quantity of thick, tenacious mucous. If affects the pancreas, the lungs, the liver, the reproductive system, and the small intestine. § Symptoms o Wheezing, nonproductive cough, dyspnea, mucus plus, cyanosis, barrel shaped chest and clubbing of fingers. o GI: large, loose, fatty, sticky, and foul-smelling stools o Failure to thrive, delayed growth patterns, and deficiency of fat-soluble vitamins. Sweat and tears are extremely salty. § Diagnosing o Sweat chloride test o DNA testing: to check for mutation o Pulmonary function tests § Chest physiotherapy is very important for these patients § GI management o Eat a diet that is high in calories and protein. Take pancreatic enzymes with meals to help with digestion. Also need a vitamin supplement. § Meds o Albuterol o Anticholinergics: ipratropium Chapter 20: Cardiovascular Congenital Heart Defects: § Result in two things: hypoxemia and heart failure § Symptoms o Tachypnea, dyspnea, tachycardia, peripheral edema, cyanosis, intolerance to exercise, and polycythemia. § Increase pulmonary blood flow o Ventricular septal defect (VSD) § Creates a loud, harsh murmur heard at the left sternal border. o Atrial septal defect (ASD) § Loud, harsh murmur with a fixed split-second sound. o Patent ductus arteriosus (PDA) § Bounding pulses and a machine hum murmur § Decreased pulmonary blood flow o Tricuspid atresia § Complete closure of the tricuspid valve § Will also have an ASD o Tetralogy of the fallot § Pulmonary stenosis § Right ventricular hypertrophy § Overriding aorta § Ventricular septal defect § Obstruct blood flow o Pulmonary stenosis § Narrowing of the pulmonary valve § Creates a systolic ejection murmur o Aortic stenosis § Narrowing of the aortic valve o Coarctation of the aorta § Bounding pulses and high blood pressure on the upper half of body § Lower half of body has low blood pressure, faint pulses, cold feet § Narrowing of the aorta near ductus arteriosus § Mixed blood flow o Transposition of the great arteries § Aorta is connected to the right ventricle instead of the left § Pulmonary artery is connected to the left ventricle instead of the right § Requires surgery within the first two weeks of life. Can cause major cyanosis. o Truncus arteriosus § No septum between right and left ventricles  § Requires surgery soon o Hypoplastic left heart syndrome § Left side of heart is underdeveloped § Cyanosis, lethargy § Diagnosing o EKG o Echocardiogram o Cardiac catheterization can help diagnose and repair some defects § No iodine or shellfish allergies, NPO 4-6 hours before, locate both pulses on feet before, assess insertion site for bleeding § Flat for 4-8 hours after § Care o Allow for frequent rest periods, cluster care, provide small frequent meals, keep crying to a minimum, encourage them to be semi-fowlers or fowlers, hold at 45-degree angle o Feed every three hours, use an enlarged opening nipple, § Meds o Digoxin § Help improve contractility of the heart § Monitor for toxicity: nausea and vomiting, decreased HR and appetite o Ace inhibitor § Captopril § Increase vasodilation o Beta blockers § Metoprolol § Helps to decrease HR and BP, also causes vasodilation o Diuretic § Furosemide § Used with heart failure § Main concern is their K levels, due to hypokalemia. § Severe hypoxemia episode o Place them in a knee to chest position, and attempt to calm them down and prevent further crying § These children are at a higher risk for bacterial endocarditis o This means that they will need an antibiotic before any dental or surgical procedure Rheumatic fever § Inflammation of the heart, blood vessels and joints  § Caused by a strep throat infection, either untreated or partially treated, happens about 2-6 weeks after the infection. § Labs o Throat culture o Serum ASO titer § Diagnosing o EKG o The Jones criteria § Two major; One major and two minor § Major: Carditis (chest pain, muffled heart sounds, pericardial friction rub and tachycardia), SubQ nodules (over bony prominences and non-tender), polyarthritis (joint pain in large joints), rash (pink, non- pruritic, macular on trunk and inner surfaces of the extremities), and chorea (involuntary muscle movements) § Minor: fever and arthralgia (pain in one joint) § Treatment o Antibiotics and monitoring heart Kawasaki § Acute systemic vasculitis, inflammation of the vessels in the body § Acute phase o Onset of high fever, does not respond to antipyretics o Irritability, red eyes, red chapped lips, red strawberry tongue, red mucous membranes, red on palms of hands and feet § Subacute phase o Fever goes down, irritability and peeling of skin § Convalescent phase o Altered lab findings § Treatment o Gamma globulin, IVGG o Aspirin § Avoid live immunizations for 11 months from the onset of this disease Chapter 21: Hematologic disorders Epistaxis  § Bloody nose § Sit upright and lean forward, pinch nose for 10 min, ice on nose, or cotton in the nares § Place petroleum jelly to prevent bleeding § Cool mist humidifier to prevent nares from getting too dry Iron deficiency anemia (Know this one for sure*) § Typically caused by a poor diet, or kids who drink a lot of cow’s milk § Labs o H&H low o Low ferratin level § Need a diet high in iron, protein and vitamin C § Iron supplement o Give 1 hour before or 2 hours after the ingestion of milk or antacids o Give with vitamin C o Take with straw to avoid discoloration of teeth o IM injection needs the z-track method o Stools will turn a tarry green color o Brush teeth afterwards § Food o Infants: iron fortified cereals o Dried beans, lentils, peanut butter, and dark leafy greens § Keep locked away and out of reach Sickle Cell Anemia § Autosomal recessive genetic disorder where the body produces abnormal hemoglobin § Red blood cell takes a sickle shape causing increased blood viscosity, obstruction of blood flow, and hypoxia. § Can be very painful, sickle cell crisis is an exacerbation § African Americans, family history, shortness of breath, pallor and jaundice. § Vaso-occlusive crisis o Painful episode with hypoxia o Ischemia in the tissue § Treatment o Fluids, hydration, pain control, blood products  o CDA and any reaction to blood products Hemophilia § Bleeding time is extended due to a lack of factor § A o Lack of factor 8 § B o Lack of factor 9 § Signs o Excessive bleeding, joint pain and stiffness, easy bruising, activity intolerance § Labs o Prolonged aPTT o Platelets and PT will be within the expected range § Nursing interventions o No rectal temperatures o Avoid skin punctures o Maintain pressure on punctures for 5 minutes o Elevate and apply ice to painful joints § Replace the missing factors § Encourage low contact sports, soft bristle brush, medical identification band, and RICE for bleeding episode § Joint deformity can occur if bleeding is severe and happens a lot Chapter 22 Acute infectious GI disorders Rotavirus § Most common cause of diarrhea in children younger than 5 § Symptoms - watery diarrhea, vomiting, and fever Pinworm § Causes perianal itching § Tape test o Place tape over anus while child is sleeping and take off before they wake up to see if there are worms Diarrhea  § Foods o Oral rehydration therapy o Do not give fruit juices, carbonated soda, or gelatin. No chicken or beef broth. o No BRAT diet. Banana’s, rice, apples, toast § Cleanse toys, avoid undercooked foods, do not share utensils and dishes Dehydration § Mild o Slight thirst and cap refill longer than 2 seconds § Moderate o Cap refill takes between 2 and 4 seconds, thirst, irritability, dry mucous membranes, and tears and skin turgor are decreased. § Severe o Cap refill over 4 seconds, tachycardia, extreme thirst, mucous membranes are very dry, skin is tented, no tearing and sunken eyeballs and fontanels, not peeing. Chapter 23 § Cleft lip o Visible separation from the upper lip towards to nose o Repaired around 2 to 3 months of age o Use a wide based nipple o Apply elbow restraints to prevent them from messing with site § Cleft palate o Visible or palpable opening of the palate connecting the mouth to the nasal cavity. o More severe o Repaired between 6 to 12 months of age o Needs to use a specialized bottle with a one-way valve o Place infant on abdomen to promote drainage § Post-op o Avoid the use of a pacifier or sucking on a nipple § Complications o Ear infections and hearing loss o Speech and language impairments o Dental problems § Teeth may not erupt normally GERD  § Gastric contents come up through the stomach into the esophagus and can really damage the esophagus § Common with infants and self resolves by about 1 year. § Symptoms o Excessive spitting up, arching of the back, irritability, chronic cough, difficulty swallowing, and heartburn. § Nursing Interventions: o Small frequent meals o Thicken formula with rice cereal o Avoid foods that can exacerbate, caffeine, citrus, spicy or fried foods. o Head elevated at least 30 degrees for one hour after eating § Meds o Omeprazole o Surgical intervention is wrapping fundus around the distal esophagus Pyloric stenosis § Thickening of the pyloric sphincter causing an obstruction § Projectile vomiting § May also cause dehydration and constant hunger § Olive shaped mass in right upper quadrant § Pylorotomy is surgical correction Hirschsprung’s disease § A lack of ganglionic cells in segments in the colon which results in decreased motility and a mechanical obstruction § Symptoms o Ribbon like stool, vomiting bile, and abdominal distention § Increased risk occurs if the infant fails to pass meconium within the first 24-48 hours of life. § Nursing Interventions: o Give high calories, high protein low fiber diet o Surgery to remove portion of cells Intussusception § A part of the intestine telescopes into another part of the intestine § Main symptom: red currant jelly like stool. Also, a sausage shaped abdominal mass § Cystic fibrosis kids are at risk for this § Tx o Air enema Appendicitis § Average age is 10 years old § Inflammation of the appendix § Abdominal pain in right lower quadrant, decreased or absent bowel cells, fever, increased WBC § CT diagnosis § Avoid applying heat to abdomen, fluids, antibiotics § If it suddenly feels better, it may mean the appendix has ruptured Chapter 24: Enuresis § Uncontrolled or unintentional urination after the age of 5 § Primary o Never had control of their bladder o Never been potty trained § Secondary o Had control of their bladder o Was potty trained o Regression, look at self-esteem § Restrict fluids in the evening, avoid constipation UTI § Symptoms o Frequent urination, foul smelling urine, fever, pallor, poor appetite, vomiting, increase in thirst, swelling of the face, and seizures. § Urine analysis o Looking for increased nitrates and leukocytes § Education o Ensure females are wiping front to back o Cotton underwear o Avoid bubble baths o Frequent voiding, and empty bladder completely o Avoid constipation Chapter 25: Bladder exstrophy: § Where the bladder, urethra or ureteral orifices comes through the suprapubic area § Medical emergency* § Place sterile gauze over the area Hypospadias and Epispadias: § Where the medial opening of the penis is in the wrong spot § Hypo: underside or ventral surface § Epi: upper surface or dorsal side § Should not have a circumcision because the foreskin is used in surgery to help repair the issue Phimosis: § Difficult or impossible to retract the foreskin of the penis Testicular torsion: § Medical emergency* § Enlargement of affected testicle and severe pain Chapter 26: Renal Disorders Acute glomerulonephritis § Associated with a strep infection § Symptoms o Cloudy, tea colored urine, decreased urine output, periorbital edema, facial edema that worse in the morning but spreads throughout the day, and mild to severe hypertension § Urine analysis o Protein in the urine § Elevated BUN and creatinine § ASO titer checking for strep § NI o Restrict Na and fluid  o Careful with skin, frequent turning § Meds o Diuretics, antihypertensives, antibiotics Nephrotic Syndrome § Alteration in the glomerular membranes that allows proteins (Albumin) to pass through the urine. Resulting in decreased serum osmotic pressure. § Symptoms o Facial and periorbital swelling, decreased urine, frothy urine § Urine analysis o Protein in the urine (+2) § Low levels of albumin § Hyperlipidemia, hemoconcentration, hyponatremia § NI o Daily weights o Monitor edema o Measure ascites (at umbilicus) o Restrict fluids and salt o Skin care § Meds o Steroids (prednisone), diuretics and albumin Chapter 27: Fractures § Open or compound o The bone is sticking out § Closed or simple o The bone did not break the skin § Complicated o Some organ or tissue is damaged § Elevate affected extremity, apply ice, stabilize the area, and do a neurovascular check § Neurovascular check o Sensation: no numbness or tingling o Skin temp: should be warm not cold o Skin color: no pallor, pink or normal for the race o Capillary refill: under 3 seconds o Pulses: palpable pulses in the affected extremity o Movement: move affected extremity in a passive motion  § Casting o Elevate the cast for 24 to 48 hours o Apply ice for the first 24 hours o Turn and position PT every 2 hours for air circulation o Assess for increased warmth or hot spots on cast o Plaster casts: use palm of hands to avoid denting o Do not put anything into cast § Traction o Used to align, mobilize and reduce muscle spasms o Maintain body alignment o Give pain meds and meds to prevent muscle spasms o Neurovascular checks frequently o Asses pin sites for pain, redness, swelling and drainage o Make sure the weights hang freely o Do not lift or remove weights unless prescribed and supervised by provider § Halo o Ensure the wrench is attached to the vest for quick access § Compartment syndrome o Compression of the nerves, blood vessels and muscle within a confined space. If not addressed right away necrosis can occur o Symptoms § Intense pain, numbness, pulselessness, inability to move digits, pallor o Fasciotomy § Osteomyelitis o More likely to happen with fractures where the skin is broken o Infection of the bone o Symptoms § Fever, tachycardia, edema, pain o Bone biopsy o Antibiotic therapy Chapter 28: Musculoskeletal Disorders Clubfoot § Deformity of the foot and ankle § Treatment is serial casting Legg-Calve-Perthes disease  § Necrosis of the femoral head § Symptoms o Intermittent painless limp, hip stiffness, limited range of motion and shortening of the affected leg § Treatment o Bracing, casting, traction and/or replacement of the hip joint Developmental dysplasia of the hip § Abnormal development of the hip and structures § Symptoms o Infants: asymmetry of the gluteal and thigh folds, limited hip abduction, a positive Ortolani (hip is reduced by abduction) test or a positive Barlow (hip is dislocated by adduction) test o Children: one leg is shorter than the other, positive Trendelenburg (wearing bearing shows a tilt in the pelvis) sign, and may walk with a limp § Treatment o Newborn to 6 months § Pavlik harness § In place for about 12 weeks, check straps every one to two weeks for adjustment. Parent should not adjust strap. Undershirt and knee socks under the harness. Gently massage skin under straps. Avoid lotions and powders, and place diaper under. o Over 6 months § Bryant traction § hip Spica cast hips need to be flexed at a 90-degree angle with butt raised off the bed, assess elimination and hydration status § Complications o Issues with bowel and bladder elimination, foul odor from cast or urine (keep dry and intact) Osteogenesis imperfecta § Heterogeneous autosomal dominant disorder of the bones resulting in fractures and deformities § Symptoms o Multiple bone fractures, blue sclera, and early hearing loss § Pamidronate o Can help increase bone density o Can cause hypokalemia, hypomagnesia, hypocalcemia, hypophosphatemia § Do low impact exercise Scoliosis § Lateral curvature of the spine and spinal rotation that causes rib asymmetry § To diagnose, have the child bend over at the waist with their arms hanging down and observe for asymmetry of the ribs § Treatment o Bracing, spinal fusion Chapter 29 Cerebral palsy § Impairment of motor function, visual, speech, and hearing impairments, seizures and cognitive disabilities. § Symptoms o Spastic hypertonicity; jerky movements of the tongue, neck, face, and truck, difficulty with coordination, difficulty with precise movements, and low muscle tone. § Treatments o Baclofen o Diazepam § Complications o Aspiration o Potential for injury Spina Bifida § Failure of the osseous spine to close § Associated with insufficient folic acid, maternal malnutrition and drugs taken during pregnancy § Protruding sac midline of the osseous spine and dimpling in the lumbosacral area § Treatment o Sterile, moist, non-adhering dressing is placed and changed every 2 hours. o Prone position with the hips flexed and legs abducted § Complications o Skin ulcerations, latex allergy, increased ICP, bladder issues, orthopedic issues. Down syndrome § A chromosomal abnormality § Small round head, flattened forehead, small nose with a depressed nasal bridge, small ears with a short pinna, protruding abdomen, short stature, hyperflexibility  § Care o Mange secretions and prevent upper respiratory infections, cardiac defects and strabismus o Rinse mouth with water after feeding o Cool mist humidification Juvenile idiopathic arthritis § Chronic autoimmune inflammatory disease § Joint pain, joint deformities and altered joint function § Symptoms o Joint swelling, stiffness, redness, and warmth that is worse in the morning or after a nap § Apply a splint for nighttime sleep § Use of a firm mattress and discourage use of pillows § Apply heat or warm moist packs to the affected area § Encourage warm baths § Meds o NSAIDs o Methotrexate o Corticosteroids Muscular dystrophy § Group of inherited disorders with progressive degeneration of the skeletal muscle groups § Duchenne is most common o Onset of 3 to 7 years old § Symptoms o Muscle weakness, unsteady gait, lordosis, delayed motor skills, frequent falling, learning disabilities, and progressive muscle atrophy o Respiratory or cardiac difficulty § Meds o Corticosteroids § Complications o Respiratory compromise Chapter 30: Skin infections Impetigo § Seen around the nose, red macular almost vascular lesions. § These lesions can burst leaving a dry crusty secretion § Spreads through direct contact § Treatment o Antibiotic ointment o Compresses of burrow’s solution Cellulitis § Inflammation and infection of the soft tissue § Signs o Firm, swollen area of the skin, fever, malaise § Treatment o Antibiotic o Warm, moist compresses Tinea infections § Fungal § Round, red, scaling patches are seen. It is itchy. § Treatment o Head: selenium sulfide shampoo o Topical antifungal § Treat infected pet Lyme disease § Bite from a tick § 3-31 days after being bit § Symptoms o Chills, fever, headache, stiff neck, muscle weakness, itching, and a bullseye rash at the site of the bite § Stage 2 brings more systemic issues o Paralysis, weakness in your face, muscle pain, swelling in the large joints § Stage 3 o Deaf, encephalopathy, arthritis, abnormal muscle movement and weakness, numbness and tingling, and speech issues § Treatment o Antibiotics Scabies § Symptoms o Itchiness, rash, thin pencil mark lines on the skin, pimples on the trunk, blisters on the palms of the hands and soles of the feet § Treatment o 5% permethrin cream over the entire body o Treat entire family*** o Wash clothing, towels, and sleepwear in hot water Lice § Symptoms o Intense itching, nits on the hair shaft § Treatment o Shampoo containing 1% permethrin o Remove nits o Wash clothing, and bedding in hot water o If things cannot be washed seal in a tight bag for 14 days o Boil combs, brushes and hair accessories in lice killing product for one hour o Discourage sharing of personal items Chapter 31: Dermatitis § Diaper o Wash area with warm water and mild soap, expose area to air as much as possible, encourage the use of super absorbable disposable diapers, frequent diaper changes and no bubble baths o Skin barrier with zinc oxide o Cornstarch to reduce the friction between diaper and skin § Poison plan exposure o Treat area with alcohol followed by water and then mild soap and water o Apply a calamine lotion or burrow’s solution o Topical corticosteroid § Seborrheic o Cradle cap o Gently scrub scalp with mild shampoo o Fine tooth comb to remove scales  o Keep nails trimmed short to keep them from damaging the area § Atopic o Eczema causing intense itching, pruritus and associated skin damage o Encourage cotton clothing, avoid excessive heat, avoid irritants o Meds § Antihistamines, topical corticosteroids o Gloves over hands for sleeping Acne § Healthy diet and exercise, mild cleanser, do not pick at § Meds o Tretinoin § Topical, makes them burn easier o Isotretinoin § Can cause birth defects § Elevated cholesterol and triglycerides § Suicidal behaviors Chapter 32: Burns Thermal, chemical, and electrical First degree § Sunburns § Skin is intact, some damage to the epidermis, redness or pain § Heals within 5 to 10 days Second degree § Superficial partial thickness o Damage to the entire epidermis, but dermis below is intact o Pink to red color, blisters, pain, sensitive to temperature changes and light touch § Deep partial thickness o Damage to entire epidermis and part of the dermis o Red to white in color, blisters, pain, and sensitivity to temperature change Third degree  § Full thickness o Damage to entire epidermis and dermis, and some damage to SubQ o Black, brown, red, tan or white. Dry leathery appearance, scarring present, grafting needed. Fourth degree § Deep full thickness o Damage all layers of skin to muscle bone or tendon o Charring, dull and dry, any type of color, no pain present. Grafting is required and amputation may be needed. Rule of nine § Head is 9% for the front and the back. A total of 18%. § The trunk is 18% for the front and back. A total of 36%. § The arms 4.5% on both sides. A total of 9%. § The legs are 6.7% on each side. A total of 13.4%. Nursing interventions § Maintain airway*** § IV access with large bore catheter § Check immunization status o If not had a tetanus vaccine in the last 5 years, they are going to need one § Advise to avoid using greasy lotion on the burn § Fluids is based on the urine output o Kids less than 30 kg, urine output should be 1 to 2 mL per kg per hour o Kids over 30 kg, urine output of 30 mL an hour o Lactated ringers § IV pain management § Antibiotics § Nutrition o Increase caloric intake and protein intake § Maintain active and passive range of motion Meds § Silver sulfadiazine o Causes transient neutropenia § Bacitracin Grafts § Allograft: skin from a human cadaver § Xenograft: skin from animal  § Autograft: the PT uses own skin Chapter 33: Diabetes Type I § Where beta cells in the pancreas are destroyed and the person becomes dependent on insulin Type II § Lifestyle issues Hypoglycemia § BS under 60 § Hunger, shakiness, diaphoresis, irritability, pale cold skin, decrease in LOC, slurred speech, headache and seizures. § 10-15g simple carbohydrate, 4 oz OJ or 8 oz of milk § If unconscious give glucagon IM or subq Hyperglycemia § Polyuria, n/v, dehydration, oliguria, dry mucus membranes, fatigue, weakness. Skin is warm, dry and flushed. Fruity odor on breath. Kussmal respirations. Weak pulse, diminished reflexes. Diagnosing § Fasting BG of 126 or higher § Random BG of 200 or above § Oral glucose tolerance test above 200 § A1C o Determines how well blood sugar is being managed; should be below 7 Monitoring § Take BS before meals and at bedtime Comorbidities § Impacts sight, heat and kidneys. Causes wounds in feet. Foot care § Inspection of feet daily § Dry feet completely § Mild foot powder § Never use commercial remedy for removing calluses or corns § Cut nails straight across § Separate toes with cotton or lamb wool to avoid injury to overlapping toes § Avoid open toe or open heel shoes § Leather shoes are preferred § Slippers with soles § Never go barefoot § Check shoes before putting them on § Clean absorbent socks made of cotton or wool § Never use hot water bottles or heating pads their feet any time § Check water temp with hand Sick Days (for diabetics): § Monitor BG every 3 hours § Continue to take meds § May need more insulin § Sugar free non-caffeinated liquids § Test urine for ketones every 3 hours § Call provider if glucose becomes higher than 240 or a fever of 102 § Any kind of confusion, disorientation or rapid breathing call provider Insulin - Rapid acting: lispro o Onset: 15-30 min o Peak: 0.5 to 2.5 hr o Duration: 3-6 hr - Short acting: regular o Onset: 0.5-1 hr o Peak: 1-5 hr o Duration: 6-10 hr § Give about 30 min before meal - Intermediate acting: NPH o Onset: 1-2 hr o Peak: 6-14 hr o Duration: 16-24 hr - Long acting: glargine  o Onset: 70 min o Duration: 24 hr - Draw short acing insulin first and then NPH. Clear to cloudy. DKA - BG is over 300 - Due to acute illness - Symptoms o Ketones in blood and urine, fruity breath, mental confusion, difficulty breathing, dyspnea, n/a, dehydration, electrolyte imbalances - Metabolic acidosis, and hyperkalemia - Treatment o K levels may drop with the treatment of DKA o Sodium bicarbonate, slow IV infusion Chapter 34: Growth Hormone deficiency - Will cause short stature, delayed epiphyseal closure, and delayed sexual development - Treatment o Somatropin: SubQ injections, given until the epiphyseal has closed. Chapter 35: Immunizations - Common cold or minor illness is not contraindicated - Immunosuppression issues is contraindicated - Influenza hypersensitivity to eggs is contraindicated - Varicella while taking corticosteroids is contraindicated - IPV allergy to neomycin - MMR allergy to gelatin - DTaP: occurrence of encephalopathy or seizures or inconsolable crying that lasted a really long time - Vastus lateralis or deltoid - Date, route, site, type, manufacturer, lot number, expiration - Low grade fever, give Tylenol - With infants, you can give concentrated oral glucose solution on a pacifier two minutes prior to and 3 minutes after the injection to help with the pain Chapter 36: Communicable diseases - Risk factors o No vaccination, poor sanitation, poor nutrition, chronic illness, and crowded living conditions Conjunctivitis - Eye infection, bacterial or viral - It causes red eye, puss, crusting of eyelids. Spread through direct contact Fifths disease - Spread through droplet - Red rash across the cheek, slap cheek Hand foot and mouth - Rashes on the hands and soles of the feet, painful sores in the mouth Mono - Spreads through salvia - Fever, sore throat, swollen lymph glands, splenomegaly - No contact sports Measles - Spread through droplet - Koplik spots: tiny white spots in the mouth Mumps - Droplet - Painful swollen salivary glands - Can be deaf or have swelling of the testicles Pertussis - Violent, rapid coughing - Spread through droplet - Loud, brassy cough Rubella - Spread through droplet - Red rash starting at face then spreading to rest of the body Varicella - Direct contact, droplet - Must be on airborne precautions - Rash starts as macules then turns into papules and then vesicles, high fever, fatigue Nursing care - Use calamine lotion for the rash - Keep fingernails short - Gargle warm water with some salt for sore throat - Antihistamines for itching - Antiviral therapy for varicella or mono - Can cause birth defects to pregnant women Chapter 38: HIV/AIDS - Viral infection that affects the T lymphocytes which suppresses the immune system - Spread through unprotected sex, IV drug use, breast milk, infected blood products - Labs o CD4+T lymphocyte count - Symptoms o Multiple enlarged lymph nodes enlarged spleen and liver, recurrent upper respiratory infections, dermatitis and inflammation of parotid glands. o Kaposi’s sarcoma, pneumocystis carini pneumonia, muscle wasting syndrome. - Nursing care o Standard precautions*** o Diet high in calories and protein o Good oral care o Prevent infections o Antiretroviral Chapter 39 Organ Neoplasms Wilms tumor - A malignancy that occurs in the kidneys or abdomen, unilateral, occurs around age 3 and rarely metastasizes - Symptoms o Firm, nontender abdominal swelling, fatigue, fever - Test o Abdominal ultrasound o Bone marrow aspiration o CT scan - Do not palpate the abdomen - Treatment o Surgical removal, chemo, radiation - Chemo o Antiemetic, observe mouth for ulcerations o Educate on side effects § Mouth sores, loss of appetite, nausea, vomiting, GI issues, hair loss, increased risk of infection, easily bleeds, fatigue o Protect from infection - Radiation o Wear lead apron o Do not wash off marks on skin o Avoid use of soaps, creams, lotions or powders o Keep areas protected from sun Neuroblastoma - A malignancy of adrenal gland, toddler years, half of cases have metastasized by diagnosis - Not really a lot of symptoms o Periorbital bruising - Tests o CT Scan o Bone marrow aspiration Meds - Filgrastim o Helps stimulate WBC production - Epoetin alfa o Stimulate RBC production Nursing Care  - Mouth sores: soft toothbrush, soft nonacidic foods. Avoid viscous lidocaine, hydrogen peroxide and lemon glycerin swabs. Chapter 40: Blood Neoplasms Leukemia - Causes production of immature WBCs, which crowds cells that would normally produce RBCs and platelets. - Most common form of cancer in childhood - Causes anemia, thrombocytopenia, neutropenia, and immature WBCs - Diagnoses o Bone marrow aspiration or biopsy § Give child emla cream o Cerebral spinal analysis Chapter 42 Complications of infants Respiratory - Restlessness, tachypnea, tachycardia, nasal flaring, retractions, grunting, wheezing. - Obstructed airway: use backblows and chest thrusts. In children use abdominal thrusts. - Never perform blind finger sweep Drowning - Lock toilet seats, never leave child unattended in bathtub or swimming pool, pools have a fence around them, life jackets SIDS - Risk factors o Maternal smoking, co-sleeping, prone or side lying sleeping, low birth weight or prematurity - Place child on back to sleep - Avoid smoking, firm mattress in crib, remove all pillows and blankets from crib, breastfeeding Poisoning - Call poison control center - Acetylcysteine - Iron and lead o Chelation therapy - Lock away, and keep out of reach