PNC140 PEDIATRICS
PNC140 PEDIATRICS REVIEW SHEET PART 2
ATI Nursing Care of Children Book {" "} :
RESPIRATORY
- {" "} What are the diagnostic tests used to diagnose cystic fibrosis?{" "}
Sweat chloride test, greater than 60 meq is positive; fecal fat test—72 hour stool
- What are the signs and symptoms of cystic fibrosis?
Salty-tasting skin: Elevated NACl in sweat
Profuse sweating when warm
Frequent infections
Dry, non-productive cough
Wheezing, cyanosis, clubbing
Chest has barrel shape
Steatorrhea: Fat in stools with foul order
FTT, thin extremities, distended abdomen, malnourished despite good appetite
Meconium ileus (infants): bowel obstruction from thick meconium
Possible infertility in adulthood from blockage of ducts by mucus
- What is the treatment for cystic fibrosis?
Pulmonary therapy: {" "} CPT & PD (Chest Physiotherapy and Postural Drainage)—vest that shakes secretions loose
Meds : Bronchodilators, mucolytics, antibiotics, Trikakta (elexacaftor/ivacaftor/teacafator)
Pancreatic enzymes : Added to food with each meal to help digest fat; missing trypsin, lipase, and amylase
Diet : Increased calories, increased protein, decreased fat, increased salt (lose much salt in sweat, need to increase when hot); small frequent meals; may need tube feeding
- {" "} What is the most common problem with cleft palate? How do we feed a child with cleft lip/palate?{" "}
Concerns
Feeding : Gagging, choking, poor suck reflex, nasal congestion, Eustachian tube blocked
ESSR : Enlarge nipple, stimulate suck reflex, Swallow, Rest; hold upright
Speech : May be delayed, have nasal or poor articulation; Eustachian tube dysfunction may impair hearing; frequent otitis media which can interfere with hearing/speech; can be corrected with early repair and speech therapy
Psychosocial : Parents may have trouble bonding with child at first; may be helpful for them to see pictures of children with repairs
Feeding
Hold infant in upright position to reduce nasal regurgitation; keep upright after feeding or on right side to promote digestion
Keep chin tucked because neck extension inhibits swallowing
If regurgitation occurs (milk out of nose), stop feeding and allow infant to cough/sneeze to clear airway
Place nipple on top of tongue; may syringe feed to reduce sucking motion after OR
Burp frequently because of increased air ingestion
Limit feeding to 18-30 minute, could be using too much energy, will need more frequent feedings
Follow feeding with sterile water to clean trapped food
- {" "} What are the complications associated with a tonsillectomy?{" "}
Elevate HOB, turn on side
Watch for bleeding: Frequent swallowing, rapid pulse big concern for first 24 hours
Pain meds q4 for first 24-48hrs
Ice collar
Cool fluids: Drink frequently, dry throat hurts more; non-acidic, no red, grape, or chocolate drinks; no milk (can cause mucus)
Soft diet for 3 weeks
Avoid coughing
Avoid straws, sucking may precipitate bleeding
Avoid gargling
- {" "} What are the treatments for croup and what do they do to aid in relieving symptoms?{" "}
Cool mist to decrease edema and reduce spasms:
Steroids possible
Epinephrine by aerosol for short term
Encourage fluids after acute phase
During acute phase IV fluids, NPO
- {" "} Epiglottis…what is it? What are some concerns for the nurse?{" "}
Swelling of tissue above vocal cords (type of croup); rare with HIB vaccine; from infection of H-influenza
Inflamed epiglottis becomes cherry red and edematous; can lead to total airway obstruction
Drooling due to dysphagia
Appear to be in respiratory distress, anxiety, fear
High fever, muffled voice
If suspected, have trach tray at bedside
Never assess with tongue blade: Could cause laryngospasm and respiratory arrest
- {" "} What are the signs and symptoms of RDS? What is the treatment?{" "}
Deficiency of surfactant that occurs mostly in preterm, low-birth weight infants, males and c-sections more at risk
Surfactant decreases the surface tension of fluids in alveoli which keep alveoli inflated and lungs expanded
Without sufficient surfactant, infant can’t keep lungs expanded
Signs and Symptoms
Nasal flaring
Retractions: intercostal, subcostal, substernal, supraclavicular, suprasternal
Expiratory grunting, dusky color
Increased HR, RR
Decreased body temperature
Treatment
Warm, oxygen-rich environment
Nutritional support
Endotracheal administration of artificial surfactant: Q12hrs, up to 4 doses
Steroids to mom 1-2 days before delivery to increase production of surfactant
Monitor response to therapy
Conserve infant’s energy
Position on side with head supported in alignment for open airway
No routine suctioning: Increases risk for bronchospasm and airway damage
- What is the treatment for RSV?
IV fluids, oxygen tent, high humidity, bronchodilators, respiratory isolation
Ribavirin : Antiviral given by inhalation; can affect eyes and reproduction of healthcare worker
- What is SIDS and who is most at risk?
Sudden unexpected death of a healthy child under 1 year old
Death occurs during sleep with no outcry or distress
½ during day, ½ during night
Greatest Risk
Low birth weight infants
Babies born to mothers under age 20
Infants not first born
Infants whose mothers smoked
Occurs more often in winter
Children 2-4 months old peak age
Baby sleeping on back has decreased incidence, also no blankets, pillows, pads, ect
GASTROINTESTINAL
- {" "} What is the treatment for Hirschsprung’s disease? What do we do to prepare the child for surgery?{" "}
Two-stage Surgery: Temporary colostomy first to relieve obstruction; second stage in 3-6 months—excise affected segment and pull normal bowel down through anus
Complete repair without colostomy in first few weeks of life
May require TPN prior to OR for malnutrition; NPO with NG to suction
Prognosis good: Need to drink more fluids due to loss of large intestine, diaper rash
Gastric pacemaker which causes GI motility
- {" "} What are some signs and symptoms of dehydration? What foods should be given/avoided?{" "}
Dry skin/mucous membranes
Depressed fontanels in infants
Increased temperature and HR and RR
Eyes sunken
BP low
Lethargic
Leads to metabolic acidosis: excess bicarbonate is lost, ketoacids are produced
Treatment
Restore fluid and electrolytes, treat cause
Oral rehydration first: Pedialyte for first 4-6 hrs in small amounts
Clear liquids until diarrhea decreased, then begin formula/breast milk
Modified BRAT diet: Bananas, rice, applesauce, toast, dry cereal, crackers, pretzels, vegetable juices (no milk products at first))
Weight: weigh diapers, I&O
Skin integrity
Teaching good handwashing to prevent infections
- {" "} Compare and contrast the GI disorders like esophageal atresia, pyloric stenosis, intussusceptions, hirschsprungs looking at causes, signs and symptoms and treatments{" "}
Too lazy to list these all out!
- What are the symptoms of Celiac disease?
Diarrhea, weight loss, anemia, loss of bone density (low calcium)
Itchy, blistery rash
Damage to dental enamel
Headaches, fatigue, joint pain, reduced functioning of spleen
Nervous system injury: Numbness/tingling of feet/hands; decreased calcium
Acid reflux/heartburn
Infant S/S {" "} : Chronic diarrhea (stools bulky, greasy, foul odor, appearance of fat); swollen belly, FTT, malnourished, short stature
GU DISORDERS
- {" "} What is a Wilm’s tumor and where is it located? What is the treatment? What should not be done with these infants once a diagnosis is made?{" "}
Most frequent intra-abdominal tumor of childhood
Malignant tumor of kidney, more common in left kidney
Peak age is 3 years old; may be hereditary and associated with other genitourinary anomalies
Signs and Symptoms
Abdominal mass (encapsulated)
Firm, nontender: once noted, abdominal palpation should be avoided so that the cells don’t break loose and spread tumor
Often found during bath
Diagnostic Tests
CT scan
Chest x-ray to determine metastasis (lung most common site)
Treatment
Surgery—nephrectomy to remove kidney
Chemotherapy with or without radiation
Prognosis
Highest survival rate of all childhood cancers
- {" "} What are the signs and symptoms of hypospadius? What is the treatment and nursing considerations post op? What is the difference between hypospadius and epispadius?{" "}
Urethra opening is located below the glans penis or anywhere along the ventral surface (underside) of the penile shaft
Signs and Symptoms
Opening other than tip of penis
Downward curve of penis called chordee: cordlike anomaly that extends the from the scrotum to the penis pulling the penis downward in an arc shape
Hooded appearance of penis because only top half is covered by foreskin
Abnormal spraying during urination
Treatment
Surgery : use foreskin for repair, usually done at 3-18 months
Stent while healing of new meatus occurs; in place for 7-21 days
Tip of stent will be visible
Encourage fluids to maintain patency of stent and hydration levels
Avoid tub baths until stent is removed; if no stent in place, tub baths avoided for 7 days
Apply bacitracin to area being careful not to block stent
Complications
Blood in urine: pink-tinged for few days is normal
Fever 102 or greater
Penis tip blue or grey or bandage seems too tight
Child unable to urinate: may urinate around and through stent
Pain not controlled by medication: may be given Tylenol with codeine which can lead to constipation
Surgery allows child to void standing with straight stream; corrects physical appearance to reduce psychological trauma
- {" "} What age group is most likely to suffer from cryptorchidism? What is the treatment?{" "}
Failure of one or both testes to descend normally through the inguinal canal into the scrotum
Incidence increases with prematurity
Factors
Deficiency of gonadotropic hormone
Mechanical obstruction
Defective testes.
Diagnosis
Physical exam
Cremasteric reflex: {" "} Stimulated by cold/touch/pain/fear, testes retract into inguinal canal; 80% of boys 1-11 the reflex can cause fully descended testes to disappear from scrotal sac; if can be moved back down, no treatment necessary; usually gone by puberty
Treatment
Medical : May observe for 6 months to year; if remain undescended, could affect fertility, tumor development, emotional issues, increased risk for torsion
Administer HCG (Human Chorionic Gonadotropin) to promote normal descent of testes; usually done with older children, less effective
Surgery : Orchiopexy, testes brought down and sutured into place; usually done at 9-15 months old; one incision in groin, one on scrotum; may use button to hold testicle down
Goal is to prevent testicular damage and malignancy
- What is Bladder Exstrophy? How is this treated?
Birth defect in which the bladder is inside out and sticks out of the abdominal wall
Other anomalies: widened pubic bone, abnormally shaped/weakened abdominal muscles, shorter than average urethra
Diagnosis : Fetal ultrasound
Treatment : Surgery, usually 24-48hrs after birth
Nursing Care
Protect bladder from infection
Cover with non-adhering plastic wrap, wet and dry dressings could dry out and stick to tissues and cause damage
MUSCULOSKELETAL
- {" "} What are the signs and symptoms of osteogenesis imperfecta?{" "}
Short stature, head normal size so looks big
Laxity in ligaments, hyperextensibility
Structural abnormalities of bone with multiple fractures
Increased bruising due to defective collagen in blood vessels
Whites of eyes may be blue, purple, gray or white
Teeth may be discolored, fragile
Smooth, thin skin
Excess diaphoresis, difficulty tolerating high temps, higher than normal body temp.
Anterior fontanel enlarged with delayed closure: may be open until 3 or 4
Hearing loss due to fracture or deformity of bones in ears
Frequent nose bleeds
May fracture due to sneeze, standing on tip toes, even turning page in a book
Above average intelligence possible
- {" "} What are the signs and symptoms of scoliosis? What is the treatment? What are some of the teaching aspects in care of this patient?{" "}
Signs and Symptoms
Uneven hips, uneven waist
One scapula or breast may appear more prominent
Forward bend, one side more prominent
Shoulder blades uneven
One arm may appear higher
Uneven pants/hemlines
Screenings may be done in schools in 5th and 8 th or 9th grade
Treatment
Exercise : Won’t change the curve, but still good to do
Bracing : Won’t cure, but can slow progression
Milwaukee Brace : neck ring with rests for chin; used for kyphosis
TLSO {" "} (Thoracic Lumbar Sacral Orthosis): more common, fits under arms and around rib cage; customized fit; worn until spine matures. Worn 23 hours/day: allowed to remove to bath; no lotions/powders because they can cause irritation; must wear shirt underneath
Surgery :
Harrington Rod: one rod attached to spine at two points
TSRH: 2 rods attached to spine with hooks
Post Op Care
ICU for 24 hours
Foley for 3 days
IV fluids 3-5 days
PCA for pain control
Hemovac at surgery site
O2 with pulse ox
Log roll every 2 hours
Up to chair day after surgery; early ambulation
Check skin integrity
May be emotional, anxious, often adolescent girl
- {" "} What type of infant is most likely to suffer from congenital hip? What are the signs and symptoms?{" "}
Dislocation of the head of the femur either partially (subluxation) or completely displaced from acetabulum
Risk Factors
More common in girls
First born; possible genetic factor
High levels of estrogen from mother may relax ligaments
Left leg most often affected
Children in colder climates: swaddling can put legs in adducted position
Breech position, large infant, twins
- S/S
Increased gluteal folds on affected side
Decreased abduction on affected side: lay baby on back with hips/knees flexed, press legs back until almost touches exam table (normal); affected side won’t be able to go back as far
Shortening of limb on affected side
Positive Ortolani Click: feel and hear femoral head slip
Barlow’s Maneuver: adduct hip and push thigh backward; if hip dislocates easily = positive sign
When infant prone, one hip is higher
Ultrasound of hip
- {" "} What are the signs and symptoms of Duchene muscular dystrophy? How is this disordered passed?{" "}
Progressive X-linked recessive disorder characterized by gradually progressing skeletal muscle wasting and weakness
Most common form is Duchenne’s MD
Some kinds affect only males
Large calf muscles: eventually muscle replaced by fat/connective tissue; weak, thin thighs
Protruding belly: shoulders and arms held back to maintain balance; waddling gait
Difficulty running, riding bike, climbing stairs
Clumsy, can have frequent falls
Difficulty rising from sitting to standing
Gower’s sign: Stands up with hands pushing on knees
Contractures, joint deformities
NEURO
- {" "} What is hydrocephalus? What are the signs and symptoms?{" "}
Excess of fluid in cranial vault, subarachnoid space, or ventricles
Caused by imbalance between the production and absorption of CSF within the ventricular system
Overproduction of CSF by choroid plexus: Tumors
Obstruction within the ventricular system: Tumors, infections, trauma
Defective reabsorption: Hemorrhage into subarachnoid space that blocks absorption
May develop from infancy to adulthood
If it occurs before fusion of the cranial sutures, the skull becomes markedly enlarged; if suture line close, increase ICP
Signs and Symptoms
Bulging fontanels
Separation of cranial sutures
Dilation of scalp veins
Thin and shiny scalp
Increased head circumference
“Bossing” or prominence of forehead
“Setting sun eyes” or sclera seen above iris
High-pitched cry, irritability, vomiting (signs of increased ICP)
Difficulty sucking and feeding
- {" "} What is a VP shunt? What are the signs and symptoms of shunt malfunctioning?{" "}
VP Shunt {" "} (Ventriculoperitoneal): Most common; catheter placed between lateral ventricles in brain that drains into peritoneum; notify doctor if change in level of consciousness—shunt may not be working
- {" "} What are the signs and symptoms of lead poisoning? Who is most likely to suffer from this?{" "}
Ingesting or inhaling lead-containing substances: paint chips, water from lead pipes, soil or dust contamination, folk remedies, fishing weights
Lead is deposited into soft tissues of body and bone
Attaches itself to RBCs and interferes with production of heme and formation of hemoglobin
Results in anemia; lead is stored in bones
Can alter vascular permeability and lead to increased ICP
Young children at most risk because they do not know what they should and should not put in their mouth/eat
Signs and Symptoms
Hematologic, anemia
Urine/Renal: Positive for glucose, protein, ketones
GI: may have PICA, acute, crampy abdominal pain, vomiting, constipation
Musculoskeletal: Short stature, lead lines in xray
Neurologic: mild—behavioral changes like irritability, hyperactivity, aggressive, learning problems, developmental delays; lethargic/difficult to awaken
Severe, chronic: seizures, mental retardation, increased ICP, paralysis, sensory issues, coma, death
- {" "} What is Reye’s syndrome? What may cause it? What should the nurse monitor for?{" "}
Follows a viral illness (influenza, chicken pox)
5-7 days later starts to continuously vomit, becomes drowsy, irritable, disoriented, hostile
Abnormal accumulation of fat in liver and other organs along with increased pressure in brain
Uncontrolled brain swelling is a real danger, liver damage usually reversible
Disease affects all organs but most dangerous to liver and brain
Risk Factors
Ages 5-15
Most common in January, February, March
Use of aspirin during a viral illness; do not give to children under 19
Not contagious
Mortality rate has declined
Treatment
Accurate I&O: control cerebral edema
Osmotic diuretic to decrease cerebral edema
Monitor BS, low mbs can lead to seizures
Monitor PT: prolonged PT indicative of coagulation problems as a result of liver dysfunction
Watch for signs of increased ICP!!
- {" "} What are the types of spina bifida? How do they differ? What is the treatment?{" "}
Spina Bifida Occulta:
- Most mild form
Usually no signs or symptoms; usually no visible defect
Possible S/S: abnormal tuft of hair, collection of fat, small dimple or birthmark, may only be discovered on x-ray
Meningocele :
Meninges push out through opening in vertebrae; creates cyst-like pouch; no spinal cord involvement; no nerve damage, normal spinal cord; can be transluminated (light shined on area will show up); cyst can be removed with little damage
Myelomeningocele :
Spinal canal remains open along several vertebrae
Both meninges and spinal cord protrude through opening, forming sac on back
Tissues and nerves exposed, prone to infections
Can’t be transluminated (too dense for light to shine through)
Signs and Symptoms
Depends on where opening on spine is
Paralysis is common, spine curvatures, leg, foot, hip deformities
Tethered spinal cord: cord is attached to surrounding tissues and cannot move freely
Bowel and bladder function: inability to voluntarily relax muscles that hold urine and stool; UTIs common
Seizures
Hydrocephalus
Short stature: growth hormone deficiency
Learning disabilities
Latex allergy: exposure to much latex early in life
Treatment
Surgery within first 48 hours of life; or prenatal surgery; can minimize risk of infection and protect spinal cord from trauma; closing opening and covering cord with muscles and skin
Pre-Op Care
#1 priority is to inspect anterior fontanel for bulging which may show increased ICP; would lead to shunting
Prevent infection: monitor VS, give antibiotics
Maintain stable temperature: isolette
Sterile gauze with warm saline to sac to prevent drying: do not allow sac to dry out, handle carefully; change dressing every 2 hours
Frequent checks of sac for abrasions, leaks, irritation, infection
Position on side to decrease tension on sac
Keep prone for feeding:
Diapering avoided:
Bowel sphincter affected: stool may drain continually; keep skin clean, protect sac from urine/feces, place a protective barrier
Watch for skin breakdown
Post-Op Care
Vital signs
I&O
Observe for infection, assess motor and sensory function
Keep prone for 10-14 days until incision healed
- What is cerebral palsy?
Group of disorders that affect ability to move and maintain balance and posture;
Nonprogressive
Damage to part of brain that controls muscle tone
Irreversible
Prenatal Causes : Anything that interferes with oxygen to brain, maternal infection, nutritional deficiencies that affect brain growth, drugs, radiation
Perinatal causes : Anoxia immediately before, during, after birth; maternal analgesia, birth trauma, prematurity
Postnatal Causes : Head trauma, infection, CVA
Classifications
Spastic: {" "} Increased muscle tone, muscles stiff, movements awkward; 70-80% have this
Athetoid or Dyskinetic: {" "} Slow, writhing movements they cannot control, usually hands, arms, feet, legs; may affect face and tongue and cause difficulty talking; 10-20% have this
Ataxic : Problems with balance and depth perception; unsteady when they walk; hard time with quick movements or writing
Mixed : Some have more than one kind; often spasticity and athetoid
SENSES/SKIN
- {" "} What is Otitis Media? Why do small children have more cases than adults?{" "}
Infection in middle ear often following URI
Young children’s Eustachian tube is more horizontal and wider
- {" "} What is a myringotomy? What instructions should be given following a myringotomy?{" "}
Myringotomy : Opening in eardrum to draw out fluid
Myringotomy with Tympanostomy: {" "} Insertion of tubes in eardrum
Small amount of reddish drainage normal for first few days
Report heavier bleeding or bleeding after 3 days post-op
Child should not blow nose for 7-10 days
Report any fever or increase in pain
Earplugs for swimming, baths, showers; no diving
- What is periorbital cellulitis? What is the treatment?
Serious inflammation of eyelid and periorbital area; usually unilateral and has potential to affect the eye and CNS
Causes {" "} : Conjunctivitis, impetigo, insect bites, trauma
Signs and Symptoms
Pain, tenderness
Fever, magenta-colored erythema
Edema of eyelid and periorbital area
Headache, purulent discharge
Treatment {" "} : Admitted to hospital, IV antibiotics, warm compresses, analgesics, antipyretics
- What is done for diaper dermatitis?
Keep diaper area clean and dry
Change diaper frequently
Mild soap and water—use products for sensitive skin
Leave open to air
Do not use commercial baby wipes
Use (plastic) diaper covers only when necessary: hold moisture in
- What does Candidiasis look like? How is this treated?
Thrush” common disorder in infants under 6 months; transmitted by contaminated pacifier, hands; can occur after antibiotic therapy
Caused by candida albicans
Signs and Symptoms
White patches on moist tissues: tongue, mouth, GI tract
Can look like formula that cannot be removed in mouth
On skin: inflamed pustules with whitish yellow or whitish grey patches
Treatment {" "} :
Nystatin after feedings for full 7 days, nystatin cream
Sterilize bottles, pacifiers to prevent re-infection
Risk for dehydration
