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Pediatrics ATI CMS Chapter 1: Family Centered Nursing Care Parenting styles - Dictatorial or authoritarian; Parents try to control the child’s behaviors and attitudes through unquestioned rules and expectations - Ex: The child is never allowed to watch television on school nights - Permissive: Parents exert little or no control over the child’s behaviors, and consult the child when making decisions - Ex: The child assists with deciding whether he will watch television - Democratic or authoritative: Parents direct the child’s behavior by setting rules and explaining the reason for each rule setting; Parents negatively reinforce deviations from the rules - Ex: The child can watch television for 1 hr. on school nights after completing all of his homework and chores - Ex: The privilege is taken away but later reinstated based on new guidelines Family Theories - Family Systems: Family viewed as whole system instead of individual family members; change w/ 1 member affects whole family - Family Stress: Stress is inevitable - Developmental: Views families as small groups that interact with larger social system; emphasizes similarities and consistencies in how families change Chapter 2: Physical Assessment Findings Vital signs: Usually all high except for BP Temperature: 3 – 6 months 99.5 1 year 99.9 3 year 99.0 5 years 98.6 7 years 98.2 9– 11 years 98.1 13 years 97.9 Pulse: NEWBORN (birth-2 days) 110 – 160/min INFANT (2 days– 1 yr. ) 90 – 160/min TODDLER (1- 3 years) 80 – 140/min PRESCHOOLER (3 - 5 years) 70 – 120/min SCHOOL AGE (6 - 12 years) 60 – 110/min ADOLECENT (13 - 18 years) 50 – 100/min Respirations: NEWBORN (birth-2 days) 30 – 60/min INFANT (2 days– 1 yr. ) 25 – 30/min TODDLER (1- 3 years) 25 – 30/min PRESCHOOLER (3 - 5 years) 20 – 25/min SCHOOL AGE (6 - 12 years) 20 – 25/min ADOLECENT (13 - 18 years) 16 – 20/min Blood pressure:  in infants but  the older they get -INFANT: 65-78 / 41-52 - 1 year -Female: 83 -114 / 38 - 67 -Male: 80 – 114 / 34 – 66 - 3 years -Female: 86 -117 / 47 - 76 -Male: 86 – 20 / 44 - 75 - 6 years -Female: 91 -122 / 54 - 83 -Male: 91 – 125 / 53 - 84 - 10 years -Female: 98 -129 / 59 - 88 -Male: 97 – 130 / 58 - 90 - 16 years -Female: 108 -138 / 64 - 93 -Male: 111 – 145 / 63 - 94 Head - Erect head posture expected after 4 months - Fontanels should be flat; Post: Closes by 8 weeks; Ant: Closes by 12 - 18 months Teeth -Infants should have 6 - 8 teeth by 1 year old -Children and adolescents should have teeth that are white and smooth, and begin replacing the 20 deciduous teeth with 32 permanent teeth Infant Reflexes Stepping Birth to 4 weeks Palmar Grasp Birth to 3 months Tonic Neck Reflex (Fencer Position) Birth to 3 – 4 months Sucking and Rooting Reflex Birth to 4 months Moro Reflex (Fall backward) Birth to 4 months Startle Reflex (Loud Noise) Birth to 4 months Plantar Reflex Birth to 8 months Babinski Reflex Birth to 1 year Chapter 3: Health Promotion of Infants (2 days to 1 year) Physical Development Weight: gain 1.5 lb./month for 1st 5 months Doubled by 5 months; Tripled by 12 months Height: 2.5 cm (1 in)/ month for the first 6 months Length: Increases by 50% by 12 months Head Circumference: Increases 2 cm/month for 1st 3 months; 1 cm/month from 4-6 months & 0.5 cm/month during 6 months- 1 yr. Dentition: First teeth erupt between 6-10 months; 6-8 teeth should erupt by end of year 1 Immunizations - 12 to 15 months: inactivated poliovirus (third dose between 6 to 18 months); Haemophilus influenzae type B; pneumococcal conjugate vaccine; measles, mumps, and rubella; and varicella - 12 to 23 months: hepatitis A (Hep A), given in two doses at least 6 months apart - 15 to 18 months: diphtheria, tetanus, and acellular pertussis - 12 to 36 months: yearly seasonal trivalent inactivated influenza vaccine; live, attenuated influenza vaccine by nasal spray (must be 2 years or older) Nutrition - Whole milk at 1 year old; 24- 28 oz/day; Can start drinking low-fat milk after 2 years - Juice should be limited to 4-6 oz. per day - Food serving size = 1tbsp per year of age - Foods that are potential choking hazards: Nuts, Grapes, Hot dogs, Peanut butter, Raw carrots, Tough meats, Popcorn Sleep & Rest - Average 11-12 hrs./day including 1 nap; naps often eliminated in older toddlerhood Chapter 5: Health Promotion of Preschoolers (3-6 years) Physical development Weight: Gain 2-3 kg (4.5-6.5 lb.) per year Height: Grow 6.9-9 cm (2.4-3.5 in) per year Fine and gross motor skills - 3 Years; Toe& heel walks; Rids Tricycle; Jumps off bottom step; Stands on one foot for a few seconds - 4 Years ; Hops & skips on one foot; Throws ball overhead; Catches ball reliably - 5 Years; Jumps rope; Walks backward; Throws and catches a ball Cognitive development - Piaget: preoperational stage -Moves from totally egocentric thoughts to social awareness & ability to consider the viewpoint of others - Magical thinking: Thoughts are all-powerful and can cause events to occur -Animism: Ascribing life-like qualities to inanimate objects Psychosocial development - Erikson: Initiative vs. guilt: - Become energetic learners, despite not having all the physical abilities needed to be successful at everything - Guilt can occur when preschoolers believe they have misbehaved or when are unable to accomplish a task Moral Development - Kohlberg; Early preschoolers continue in the good-bad orientation of the toddler years, and actions are taken based on whether or not it will result in a reward or punishment. - Older preschoolers primarily take actions based on satisfying personal needs yet are beginning to understand the concepts of justice and fairness. Age appropriate activities - Transition to associative play - Play is not highly organized, but cooperation does exist between children - Appropriate activities: Playing ball, Putting puzzles together, Riding tricycles, Playing pretend dress up activities, Role-playing Immunizations - 4 TO 6 YEARS: Diphtheria and tetanus toxoids and varicella; and inactivated poliovirus (IPV) - 3 TO 6 YEARS: Yearly seasonal influenza vaccine; trivalent inactivated influenza vaccine; or live, attenuated influenza vaccine by nasal spray Nutrition - Mildly active req 1200-1440 kcal/day; average 1800 kcal/day - Need 13-19g protein/day Sleep and rest - Need about 12 hours of sleep - Keep consistent bedtime routine - Avoid allowing preschoolers to sleep with their parents Chapter 6: Health Promotion of School-Age Children (6-12 years) Physical development Weight: Gain 2-3 kg (4.4-6.6 lb.) per year Height: Grows 5 cm (2 in.) per year Cognitive development - Piaget: Concrete operations - Able to see the perspective of others Psychosocial development - Erikson: Industry vs. Inferiority - A sense of industry is achieved through development of skills &knowledge that allows child to provide meaningful contributions to society - A sense of accomplishment is gained through the ability to cooperate and compete with others - Peer groups play an important part in social development Age appropriate activities; - 6-9; Competitive and cooperative play is predominant; Play simple board and number games; Play hopscotch; Jump rope; Ride bicycles; Join organized sports (for skill building) - 9-12; Make crafts, Build models, Collect things/Engage in hobbies, Solve jigsaw puzzles, Play board & card games, Join organized competitive sports Immunizations - If not given between 4 and 5 years of age, children should receive the following vaccines by 6 years of age: diphtheria and tetanus toxoids and pertussis (DTaP); inactivated poliovirus; measles, mumps, and rubella (MMR); and varicella - Yearly seasonal influenza vaccine: inactivated influenza vaccine or live, attenuated influenza vaccine (LAIV) by nasal spray - 11 to 12 years: tetanus and diphtheria toxoids and pertussis vaccine (Tdap); human papillomavirus vaccine HPV vaccine, and meningococcal vaccine Health Screenings Scoliosis: School-age children should be screened examining for a lateral curvature of the spine before and during growth spurts. Can take place at schools or health care facilities. Sleep and rest: Need 9 hrs. of sleep at age 11 Dental health : First permanent teeth erupt around 6 years of age Chapter 7: Health Promotion of Adolescents (12 to 20 years) Physical development - Final 20-25% of height is achieved during puberty - Girls stop growing at about 2-2.5 years after the onset of menarche; grow 2-8 in & gain 15.5-55 lb. In girls, sexual maturation occurs in the following order: -Breast development -Pubic hair growth -Axillary hair growth -Menstruation - Boys stop growing around 18-20; Grow 4-12 in & gain 15.5-66 lb. In boys, sexual maturation occurs in the following order: -Testicular enlargement -Pubic hair growth -Penile enlargement -Growth of axillary hair -Facial hair growth -Vocal changes Cognitive development - Piaget: Formal operations - Increasingly capable of using formal logic to make decisions Psychosocial development - Erikson: Identity vs. role confusion -Adolescents develop a sense of personal identity and to come to view themselves as unique individuals Age-appropriate activities; Nonviolent videogames, Nonviolent music, Sports, Caring for pet, Reading Immunizations - Yearly seasonal influenza vaccine: Trivalent inactivated influenza vaccine or live, attenuated influenza vaccine by nasal spray. Recommendation can be season-specific. - 16 to 18 years: Meningococcal (MCV4) booster recommended if first dose received between ages 13 and 15 years; booster dose not needed if the first dose is received at age 16 or older. Health Screenings: Scoliosis screenings should continue during adolescent years Chapter 8: Safe Medication Administration Oral - Preferred route of medication administration for children - Avoid mixing medication with formula or putting in bottle of formula because infant may not take the entire feeding, & the medication can alter the taste of the formula - Use the smallest measuring liquid medication for doses of liquid medication - Avoid measuring liquid medication in a tsp. or tbsp. - Administer the medication in the side of the mouth in small amounts - Stroke the infant under the chin to promote swallowing while holding the cheeks together Otic - Children younger than 3 years: Pull the pinna downward and straight back - Children older than 3 years: Pull the pinna upward and back Chapter 12: Acute Neurological Disorders Meningitis Viral (aseptic) Meningitis: supportive care for recovery Bacterial (septic) Meningitis: contagious infection **Hib and PCV vaccines decrease the incidence s/s; Photophobia, vomiting, irritability, headache Newborns: Poor Muscle Tone, Weak Cry, Poor Suck-Refuses Feedings, Vomiting/Diarrhea, Bulging Fontanels (late sign) 3 Months – 2 Years: Seizures with a High-Pitched Cry, Fever & Irritability, Bulging Fontanels, Poor Feedings, Vomiting, Possible nuchal rigidity, Brudzinski’s sign and Kernig’s sign not reliable for diagnosis 2 Years – Adolescence: Seizures (often initial sign), Nuchal rigidity, Fever/chills, Headache/vomiting, Irritability/restlessness that can progress to drowsiness/stupor, Petechiae or purpuric type rash (with meningococcal infection), + Brudzinski Sign: flexion of extremities with deliberate flexion of the neck, + Kernig’s Sign: resistance to extension of the leg from a flexed position Labs; Blood Cultures; CBC; CSF Analysis - Viral CSF; Clear Color, Slightly Elevated WBC & Protein, Normal Glucose, Gram - - Bacterial CSF; Cloudy Color, Elevated WBC, Elevated Protein, Decreased Glucose, Gram + DX: Lumbar Puncture (Definitive Diagnostic Test); Empty Bladder, EMLA Cream 45min – 1-hour prior, Side-lying Position, Head Flexed, Knees Drawn to Chest; Remain in Flat Position to prevent Leakage& Spinal HA NURSING:: Droplet precautions; Maintain NPO status if decreased LOC;  environmental stimuli - Medications: IV antibiotics for bacterial infections Complications: ICP: Newborns and Infants; Bulging or Tense Fontanels, Increased Head Circumference, High- Pitched Cry, Irritability, Distended Scalp Veins, Bradycardia, Respiratory Changes Children; Headache, N/V, Diplopia, Seizures, Bradycardia Respiratory Changes Reye Syndrome: Primarily affects the liver (liver dysfunction) and brain (cerebral edema) - Follows viral illness (Influenza, Gastroenteritis, Varicella), Giving Aspirin for fevers s/s; lethargy, irritability, combativeness, confusion, delirium, profuse vomiting, seizures, LOC Labs:  ALT and AST,  serum ammonia Diagnostic procedures: Liver biopsy/CSF analysis NURSING: Maintain hydration while preventing cerebral edema, Position client (avoid extreme flexion, extension, or rotation), Monitor coagulation & prevent hemorrhage, Implement seizure precautions Medications: Osmotic diuretic (Mannitol) Complications: Neurologic sequalae, Death Chapter 13: Seizures Risk factors; Febrile Episode, Cerebral Edema, Intracranial Infection / Hemorrhage, Brain Tumors / Cyst, Toxins or Drugs, Lead Poisoning, Hypoglycemia, Electrolyte imbalances Generalized seizures Tonic-clonic seizures: AKA Grand mal - Tonic Phase (10-30 seconds); Loss of Consciousness, Loss of Swallowing Reflex, Apnea leading to Cyanosis; Tonic Contraction of entire body: arms and legs flexed, head and neck extended - Clonic Phase (30-50 seconds); Violent jerking movements of the body - Postictal State (30 minutes); Remains semiconscious but arouses w/ difficulty &confused, No recollection of the seizure Absence seizure; AKA petit mal or lapses; Onset between 4– 12 years and ceases by teenage yrs. - Loss of Consciousness lasting 5 – 10 seconds, Minimal or no change in behavior, Resembles daydreaming or Inattentiveness, Can drop items being held, but the child seldom falls - Automatisms; Lip Smacking, Twitching of Eyelids or Face, Slight Hand Movements Myoclonic seizure: Brief contraction of muscle or groups of muscle; No postictal state ; can involve only face & trunk or one or more extremities; might not lose consciousness Atonic or akinetic seizure AKA “drop attacks”; Onset 2-5; Muscle tone is lost for a few seconds often causes fall; period of confusion follows DX: -EEG Abstain from caffeine for several hours prior to the procedure; Wash hair (no oils or sprays) before and after the procedure to remove electrode gel NURSING: Initiate Seizure Precautions: - Pad side rails of Bed | Crib | Wheelchair - Keep bed free of objects that could cause Injury - Have Suction and Oxygen Equipment available – - During a Seizure: - Protect from Injury (move furniture away, hold head in lap) - Maintain a position to provide a patent airway - Suction Oral Secretions - Side-lying Position (decreases risk of aspiration) - Loosen restrictive clothing - Do NOT restrain the child - Do NOT put anything in the child’s mouth - Do NOT open the jaw or insert an airway during seizure, can damage teeth, lips, or tongue - Remain with the child - Note onset, time, and characteristics of seizure - Allow seizure to end spontaneously - Post-Seizure: - Side-lying position to prevent aspiration and facilitate drainage of secretions - Check for breathing, V/S and position of head - NPO until swallowing reflex has returned Medications - Antiepileptic Drugs (AEDs): -Diazepam (Valium) | Phenytoin | Carbamazepine | Valproic Acid | TX: - Focal Resection: of an area of the brain to remove epileptogenic zone - Corpus Callosotomy: separation of two hemispheres in the brain - Vagal Nerve Stimulator Complications - Status Epilepticus: Prolonged Seizure Activity that Lasts >30 minutes or Continuous seizure activity in which the client does not enter a Postictal Phase NURSING: Maintain Airway, Administer oxygen, IV access Chapter 14: Head Injury Concussion; traumatic injury to brain that alters way brain functions Contusion; bruising of cerebral tissue Laceration; tearing of cerebral tissue Skull fractures; caused by direct trauma to skull; can be - Linear; most common; involve single factor beginning from point of impact; DO NOT cross suture line - Depressed; broken bone fragments pushed inward - Comminuted; made up of more than 1 linear fracture; occur following intense impact or repeated trauma to head (abuse) - Basilar; involve those at anterior and posterior base of skull - Open; break in scalp or mucosa of respiratory tract and can lead to osteomyelitis - Growing; fracture worsens due to pressure from brain herniation, dilated ventricles, or cyst s/s: Minor injury: Possible loss of consciousness, Temporary period of confusion, Vomiting, Pallor, Irritability, Lethargy/drowsiness Injury Progression; Marked changes in vital ins, Altered mental status, Focal neurologic deficits,  agitation Severe injury: Increased ICP **Measurement of ICP** Expected range 1- 10 mm Hg; > 15 requires further assessment - Infants: Bulging fontanel, Irritability (usually 1st sign), High-pitched cry, Poor feeding - Children: Nausea/headache, Forceful vomiting, Blurred vision, Seizures - Late signs: Alterations in pupillary response, Posturing (flexion and extension),  motor response,  response to painful stimuli, Cheyne-stokes respirations, Seizures, Flexion: severe dysfunction of the cerebral cortex, Extension: Severe dysfunction at the level of the midbrain NURSING; Ensure spine is stabilized until a spinal cord injury is ruled out; Implement actions to decrease ICP: Keep the head midline with the bed elevated 30 degrees, which will also promote venous draining, Avoid extreme flexion, extension, or rotation of the head and maintain in midline neutral position, Keep the client’s body in alignment, avoiding hip flexion/extension, Minimize oral suctioning, Nasal suctioning is contraindicated, Instruct the client to avoid coughing and blowing the nose; Insert and maintain indwelling catheter; Administer stool softeners to avoid straining Medications - Mannitol: Osmotic diuretic used  intracranial pressure & treat cerebral edema - Antiepileptic: Used to prevent or treat seizures - Antibiotic; in case CSF leakage, lacerations, or penetrating injuries - Analgesics (Acetaminophen); for headache, pain, fever; May give morphine and midazolam TX: Craniotomy: to help relieve pressure; Transfontanel percutaneous aspiration; Subdural drain; Burr holes; For Depressed fracture surgery to elevate depression Complications - Epidural hematoma: Bleeding between the dura and the skull - Subdural hemorrhage: Bleeding between the dura and the arachnoid membrane - Brain herniation: Downward shift of brain tissue Croup syndromes Bacterial Epiglottis (Acute Supraglottic): MEDICAL EMERGENCY s/s: Tripod positioning, Drooling, Dysphonia: thick, muffled voice and froglike croaking sound, Dysphagia, High fever, inspiratory stridor NURSING: Avoid throat culture/putting tongue blade in the mouth, Prepare for intubation, Administer ABX therapy starting with IV, then transition to oral to complete a 10-day course, Droplet isolation precautions for first 24 hr. after IV ABX initiated Acute Laryngotracheobronchitis (LTB); caused by RSV, Influenza A & B, Mycoplasma pneumonia s/s: Low-grade fever, restlessness, hoarseness, barky cough, dyspnea, inspiratory stridor, and retractions; INFANTS AND TODDLERS: nasal flaring, intercostal retractions, tachypnea, and continuous stridor Acute Spasmodic Laryngitis (Midnight Croup) s/s: Croupy barky cough, restlessness, difficulty breathing, hoarseness, and nighttime episodes of laryngeal obstruction NURSING: humidity w/ cool mist, O2 as needed, nebulized racemic epinephrine as prescribed; Administer corticosteroids: oral or IM (dexamethasone), or nebulized (budesonide). Influenza A and B s/s: Sudden onset of chills and fever, Body aches, dry throat & nasal mucosa, dry cough, photophobia, flushed face, myalgia Antivirals must be given within 48 hrs. of onset Amantadine, Zanamivir, Oseltamivir Chapter 18: Asthma Triggers; Allergens, Smoke, Exercise, Cold air or changes in the weather or temperature, colds s/s: Dyspnea, Cough, Audible wheezing, Use of accessory muscles, mucous, restlessness, anxiety, tripod position DX: - Pulmonary function test (PFT); most accurate - Peak Expiratory Flow Rates (PEFR); uses flow meter to measure amount of air that can be forcefully exhaled in 1 second - Bronchoprovocation Testing; exposure to methacholine, cold air or histamine Medications - Bronchodilators; (Sort acting beta 2): albuterol, levalbuterol, terbutaline; (Long acting) Salmeterol; SE: tremors/tachycardia - Anticholinergics: atropine/ipratropium; relief of acute bronchospasms; Dries you up - Anti-inflammatory; (Corticosteroids) prednisone; Rinse mouth afterwards; Leukotriene modifiers; Mast cell stabilizers (cromolyn); Monoclonal antibodies (omalizumab); Theophylline; Magnesium sulfate NURSING: How to use a peak flow meter; Ensure the marker is zeroed, Close lips tightly around the mouthpiece, Blow out as hard and as quickly as possible, Repeat 3 more times, Record highest number Complications - Status asthmaticus: Airway obstruction that is often unresponsive to treatment; Prepare for emergency intubation -Respiratory failure Chapter 19: Cystic Fibrosis Cystic fibrosis; Both biological parents carry the recessive trait for CF - Characterized by mucus glands that secrete an increase in the quantity of thick, tenacious mucus, which leads to mechanical obstruction of organs s/s: EARLY; Wheezing, rhonchi, Dry, nonproductive cough; Increased involvement: Dyspnea, Paroxysmal cough, Obstructive emphysema, and atelectasis on chest x-ray; ADVANCED: Cyanosis, Barrel-shaped chest, Clubbing of fingers and toes GI : Large, frothy, bulky, foul-smelling stools (steatorrhea), Failure to gain weight or weight loss, Delayed growth patterns, Distended abdomen, Thin arms and legs, Deficiency of fat-soluble vitamins (Vitamin A,D,E,K) SKIN; Sweat, tears, and saliva having high content of sodium and chloride DX: Sweat chloride test (most definitive) Chloride > 40for infants < 3 mo & > 60 for all others; Sodium > 90 NURSING ; CPT, High protein/calorie, Give pancreatic enzymes within 30 min of eating a meal or snack, Multivitamin A,D,E,and K Medications - Bronchodilators: albuterol - Anticholinergics: ipratropium bromide - Fluticasone propionate/ salmeterol - Dornase alfa (pulmozyme): decreases viscosity of mucus and improves lung function - ABX; tobramycin, ticaricillin,gnetamicin - Pancreatic enzymes - Vitamins A, E, D, K Chapter 20: Cardiovascular Disorders Defects that INCREASE Pulmonary Blood Flow; (left-to-right shunt) - Ventricular septal defect (VSD): Loud, harsh murmur at the left sternal border - Atrial septal defect (ASD): Loud, harsh murmur with a fixed split second heart sound - Patent ductus arteriosus (PDA): Connection between pulmonary artery and aorta stays open after birth causing mixing of blood; Murmur (machine hum), Bounding pulses Defects that DECREASE Pulmonary Blood Flow - Hypercyanotic (Tet) spell manifest as acute cyanosis and hypernea - Tricuspid atresia: complete closure of the tricuspid valve that results in mixed blood flow; Infants: Cyanosis, dyspnea, tachycardia; Older children: Hypoxemia, clubbing of fingers - Tetralogy of Fallot: Pulmonary stenosis, right ventricular hypertrophy, overriding aorta, & ventricular septal defect (PROV); Cyanosis at birth: progressive cyanosis over the first year of life; Systolic murmur; Episodes of acute cyanosis and hypoxia (blue or “Tet” spells) Obstructive Defects - Pulmonary stenosis: narrowing of the pulmonary valve or pulmonary artery that results in obstruction of blood flow from the ventricles; Systolic ejection murmur - Aortic stenosis: narrowing of the aortic valve; INFANTS: Faint pulses, hypotension, tachycardia, poor feeding tolerance; CHILDREN: Intolerance to exercise, dizziness, chest pain, possible ejection murmur - Coarctation of the aorta: narrowing of the lumen of the aorta; Elevated blood pressure in the arms, Bounding pulses in the upper extremities, Decreased blood pressure in the lower extremities, Cool skin of lower extremities, Weak or absent femoral pulses Mixed defects - Transportation of the great arteries; aorta connected to the right ventricle instead of left & pulmonary artery is connected to the left ventricle instead of right; Severe to less cyanosis depending on the size of the associated defect - Truncus arteriosus: Failure of septum formation, resulting in a single vessel that comes off of the ventricles; Murmur, variable cyanosis, Lethargy, Fatigue, Poor feeding - Hypoplastic left heart syndrome: Left side of the heart is underdeveloped; Lethargy/cyanosis, cold hands & feet Pulmonary Artery HTN (PAH); high BP in arteries of the lungs; progressive & fatal; no cure s/s: Dyspnea w/ exercise; Chest pain; Syncope Infective (Bacterial) Endocarditis; Infection of inner lining of heart & valves, can enter bloodstream; caused by Streptococcus viridians, Candida albicans, Staphylococcus aureus s/s: Fever, malaise, new murmur, myalgia, arthralgias, diaphoresis, weight loss, splinter hemorrhages under fingernails; NEONATES: feeding problems, respiratory distress, tachycardia, septicemia NURSING: Counsel the family of high-risk children about the need for prophylactic antibiotics prior to dental and surgical procedures TX: ABX parenterally for extended period of time (2-8 wks.) Cardiomyopathy; abnormities of myocardium that interfere w/ ability to contract effectively; can lead to HF Classifications - Dilated (DCM); most common; Hypertrophic (HCM); autosomal genetic increase in heart muscle mass lead t abnormal diastolic function; Restrictive; rare, prevents filling of ventricle & causes decrease in diastolic volume s/s: tachycardia, dysrhythmias, dyspnea, hepatosplenomegaly, fatigue & poor growth Shock Cardiogenic shock; results from impaired cardiac function that leads to decrease in CO Anaphylactic Shock s/s: Dyspnea, Breath sounds with crackles, Grunting, Hypotension, Tachycardia, Weak peripheral pulses **MANIFESTATIONS OF HEART FAILURE Impaired myocardial function: Sweating, tachycardia, fatigue, pallor, cool extremities with weak pulses, hypotension, gallop rhythm, cardiomegaly Pulmonary congestion: Tachypnea, dyspnea, retractions, nasal flaring, grunting, wheezing, cyanosis, cough, orthopnea, exercise intolerance Systemic venous congestion: Hepatomegaly, peripheral edema, ascites, neck vein distention, periorbital edema, weight gain DX: Cardiac catherization NURSING: Check for allergies to iodine or shellfish, Provide for NPO status 4-6 hr. prior, Locate, and mark the Dorsalis pedis and posterior tibial pulses on both extremities, Prevent bleeding by maintaining the affected extremity in a straight position for 4-8 hr. ; Limit activity for 24 hrs. Medications - Digoxin: Improves myocardial contractility; - Infant: hold if pulse<90; Children: hold if pulse <70 Types of Dehydration - Isotonic; Water and sodium are lost in nearly equal amounts.; Major loss of fluid from extracellular fluid leads to a reduced volume of circulating fluid; Hypovolemic shock can result; Blood sodium is within normal limits (130 to 150 mEq/L). - Hypotonic; Electrolyte loss is greater than water loss; Water changes from extracellular fluid to intracellular fluid; Physical manifestations more severe with smaller fluid loss; Shock is likely; Blood sodium is less than 130 mEq/L. - Hypertonic; Water loss is greater than electrolyte loss; Fluid shifts from intracellular to extracellular; Shock is less likely; Neurologic changes (change in level of consciousness, irritability, hyperreflexia) can occur; Blood sodium concentration is greater than 150 mEq/L. Levels of Dehydration - Mild; Capillary refill greater than 2 seconds; Possible slight thirst Nursing; 50mL/kg rehydration fluid within 4 hrs. - Moderate: Capillary refill between 2-4 seconds; Possible thirst and irritability Nursing; 100mL/kg rehydration fluid within 4 hrs. - Severe: Capillary refill >4; Tachycardia; Extreme thirst; Very dry mucous membranes and tented skin; No tearing with sunken eyeballs; Sunken anterior fontanel; Oliguria and anuria Nursing; Replacement of diarrhea loses with 10 mL/kg each stool Chapter 23: Gastrointestinal Structural & Inflammatory Disorders Cleft Lip & Cleft Palate Cleft Lip: Results from incomplete fusion of the oral cavity during intrauterine life - Repair usually done withing 2-3 months of age ; POST OP place upright and on back or on side, apply elbow restraints, use water, or dilute hydrogen peroxide to clean site Cleft Palate: Results from the incomplete fusion of the palates during intrauterine life - Repair usually done between 6-12 months of age; POST OP; Place upright; Change position frequently to facilitate breathing and drainage; NPO for 1st 4 hrs., then liquids for 3-4 days For isolated cleft lip: Use a wide-based nipple for bottle-feeding For CP or CL and CP: Use a specialized bottle with a one-way valve and a specially cut nipple; Avoid having the infant suck on a nipple or pacifier Complications: Ear infections and hearing loss, Speech and language impairment, Dental problems GERD; Gastroesophageal reflux (GER) occurs when gastric contents reflux back up into the esophagus, making esophageal mucosa vulnerable to injury from gastric acid; self-limiting and usually resolves by 1 year of age. Gastroesophageal reflux disease (GERD) is tissue damage from GER; GER is s/s: INFANTS; Sitting up or forceful vomiting, Irritability, Arching of back ; CHILDREN; Difficulty swallowing; Chronic cough; Non-cardiac chest pain NURSING: GER; Small, Frequent Meals, Thicken infant’s formula with 1 tsp. to 1 tbsp. rice cereal per 1oz formula, Avoid: Caffeine | Citrus | Peppermint | Spicy or Fried Foods, Assist with weight control, HOB elevated during and after meals (at least 30 degrees); GERD; Initiate interventions for GER, plus administering a proton pump inhibitor (omeprazole, esomeprazole, pantoprazole and rabeprazole), or an H2-receptor antagonist (cimetidine or famotidine). TX: Nissen fundoplication: for severe cases of GERD; Laposcopic procedure wraps the fundus of the stomach around the distal esophagus to decrease reflux Hypertrophic pyloric stenosis; Thickening of the pyloric sphincter, which creates an obstruction – s/s: vomiting after feeding & becomes projectile as obstruction worsen; Constant hunger/dehydration; Olive- shaped mass in the right upper quadrant of the abdomen TX: Pylorotomy Hirschsprung’s disease; Lack of ganglionic cells in segments of the colon resulting in decreased motility and mechanical obstruction s/s: NEWBORN; Failure to pass meconium within 24-48 after birth; Episodes of vomiting bile; Refusal to eat; Abdominal distention; INFANT: failure to thrive, constipation, vomiting; CHILD; undernourished anemic appearance, abdominal distention, visible peristalsis, palpable fecal mass, constipation, Foul-smelling, ribbon- like stool NURSING: High-protein/calorie and low-fiber diet TX: Surgical removal of the aganglionic section of the bowel; may require temporary colostomy Complications; Enterocolitis (inflammation of bowel); Anal stricture & incontinence Intussusception; Proximal segment of the bowel telescopes into a more distal segment; common 3 months- 6 years s/s: sudden episodic abdominal pain, screaming w/ drawing knees to chest during pain, vomiting, fever, tender/distended abdomen, Abdominal mass (sausage-shaped), Stools mixed with blood and mucus that resembles the consistency of red currant jelly TX: Air enema w/ or w/o contrast Appendicitis; Inflammation of the vermiform appendix; Average age is 10 s/s: Abdominal pain in the right lower quadrant, Decrease or absent bowel sounds, rigid abdomen, diarrhea or constipation, lethargy, tachycardia, rapid, shallow breathing, anorexia, Fever Labs: CBC DX: CT scans NURSING: Avoid applying heat to the abdomen, avoid enemas or laxatives; Watch for pain: if patient no longer feels pain, appendix ruptured TX: Removal of nonruptured appendix: - Pre-op: Give IV fluid replacement/IV antibiotic - Post-op: Place NG tube for decompression, assess for bowel sounds Meckel’s Diverticulum; complication from failure of omphalomesenteric duct to fuse during embryonic development s/s: Rectal bleeding (painless); abdominal pain; bloody, mucus stools DX: Meckel’s scan TX: Surgical removal of diverticulum Chapter 24: Enuresis and Urinary Tract Infections Enuresis; uncontrolled or unintentional urination after age bladder control is achieved - Must be at least 5 years of age before there’s consideration about diagnosing enuresis; at least 2x/wk. for at least 3 months Primary enuresis: A child has never been free of bed-wetting for any extended periods of time Secondary enuresis: A child who started bed-wetting after development of urinary control TX: Conditioning therapy ( placing alarm or sensor that rings when child voids to awaken child to use bathroom); Kegel/pelvic exercises; Retention Control Measured Medications; ADH (Desmopressin acetate reduces volume of urine), TCAs (Imipramine hydrochloride inhibits urination), Anticholinergics (Oxybutynin chloride reduces bladder contractions NURSING: Have the child empty bladder before bedtime; Encourage fluids during the day and restrict fluids in the evening; Avoid fruit and fruit drink, caffeinated or carbonated drinks after 1600; Use positive reinforcement; Avoid punishing, scolding, or teaching the child following an incident UTI Bacteriuria: bacteria in the urine; Asymptomatic bacteriuria: bacteriuria with no s/s of UTI; Symptomatic bacteriuria: bacteriuria with manifestations of UTI Recurrent UTI: multiple occurrences of asymptomatic or symptomatic bacteriuria Persistent UTI: bacteriuria that does not resolve with antibiotic therapy Febrile UTI: symptomatic bacteriuria with fever; Urosepsis: febrile UTI with systemic manifestations. Cystitis: inflammation of the bladder Urethritis: inflammation of the urethra Pyelonephritis: inflammation of the upper urinary tract and the kidneys s/s: INFANTS; Poor feeding, vomiting, or failure to gain weight, Increase in thirst, Frequent urination, Foul- smelling urine, Fever, Seizure, Pallor CHILDREN: abdominal or back pain, pain w/ urination, poor appetite, vomit, slow growth, increased thirst, enuresis, dysuria, swelling of face, pallor, fatigue, blood in urine, HTN, tetany Labs: Urinalysis and urine culture and sensitivity (Nitrates & leukocytes will be , acidic pH, + for protein, glucose, ketones, RBC)) Education: Teach females to wipe the perineal area from front to back, Use of cotton underwear, Instruct avoidance of bubble baths, Encourage frequent voiding, Empty complete bladder Chapter 25: Structural Disorders of the Genitourinary Tract and Reproductive System Defects of the genitourinary tract Obstructive Uropathy; structural or functional obstruction of urinary system s/s: hydronephrosis, UTI, oligohydramnios TX: Surgical procedure that divert flow of urine to bypass obstruction (ureteral stent, pyelostomy tube, cutaneous ureterostomy tube Chordee; ventral curvature of penis TX: surgical release of fibrous band Bladder Exstrophy: Eversion of posterior bladder through anterior bladder wall &lower abdominal wall TX: Cover the exposed bladder with sterile, nonadherent dressing; Prepare the child for immediate surgery Hypospadias: Urethral opening located just below the glans penis, behind the glans penis, or on the ventral surface of the penile shaft; Meatus opening below the glans penis; possible chordee present Epispadias: MALE: widened pubic symphysis; Urethra opened on dorsal surface of the penis; possible exstrophy of bladder FEMALE: Wide urethra; Bifid clitoris; possible exstrophy of bladder TX: Surgery 1st year of life TX: Casting-Elevate the cast above the level of the heart during the first 24, Apply ice for the first 24 hours to prevent swelling, Turn and position every 2 hours (cast dries faster | prevents cast from changing shape), Assess for increased warmth or hot spots on the cast surface (infection): Plaster Casts: Use Palms of Hands to avoid Denting, Expose the Cast to Air, Instruct the client not to place any foreign objects inside the cast to avoid trauma Traction care Maintain body alignment, Interventions for Pain and Muscle Spasms, Assess, and monitor neurovascular status, Assess pin sites for pain, redness, swelling, drainage, or odor, Weights should hang freely - Skin traction uses pulling force that is applied by weights. Using tape and straps applied to the skin along with boots and/or cuffs, weights are attached by a rope to the extremity (Buck, Russell, Bryant traction). - Skeletal traction uses a continuous pulling force that is applied directly to the skeletal structure and/or specific bone. It is used when more pulling force is needed than skin traction can withstand. A pin or rod is inserted through or into the bone. Force is applied through the use of weights attached by rope. The weights are never to be removed by the nurse. - Halo traction (cervical traction) uses a halo-type bar that encircles the head. Screws are inserted into the outer skull. The halo is attached to either bed traction or rods that are secured to a vest worn by the client. Complications; Compartment syndrome (compression of nerves, blood vessels, and muscle inside a confined place, resulting in neuromuscular ischemia) Renal Calculi; Embolism (Findings: 5 P’s: 1. Pain: unrelieved with elevation or analgesics, increases with passive movement. 2. Paresthesia: numbness (early finding). 3. Pulselessness: distal to fracture. 4 Paralysis: inability to move digits (nerve damage). 5.Pale: cold skin and cyanosis to nail beds ) Osteomyelitis: infection w/in bone secondary to bacterial infection from an outside source; Endogenous w/ open fractur & Hematogenous from bloodborne bacterial source s/s: fever, irritability, Tachycardia, Edema, Pain is constant but increases with movement NURSING; Administer IV and oral ABX therapy; Monitor hepatic, hematologic, & renal function; Monitor for super infection; Pain meds as prescribed Chapter 28: Musculoskeletal Congenital Disorders Clubfoot; complex deformity of the foot and ankle; can affect 1 or both feet, occur as isolated defect or w/ other disorders - Categorized as positional clubfoot (occurs from intrauterine crowding), syndromic (occurs in association with other syndromes), and congenital (idiopathic) s/s: Talipes varus: inversion (foot bending inward); Talipes valgus: eversion (foot bending outward); Talipes calcaneus: dorsiflexion (toes are higher than the heels); Talipes equinus (“horse foot”): plantar flexion (toes are lower than the heels); Talipes equinovarus: toes are facing inward and lower than the heel TX: Series of castings start shortly after birth & continue until max correction Legg-calve-Perthes disease; Aseptic necrosis of the femoral head can be unilateral or bilateral; Stages- synovitis, necrotic, fragmentation, reconstruction; affects 2-12 yrs. but 4-8 most common s/s: Intermittent painless limp, Hip stiffness, Limited ROM, Shortening of affected leg, Hip/thigh/knee pain TX: Maintain rest and limited weight bearing: Abduction brace, Casts, Physical therapy, Traction Surgical intervention: Osteotomy of the hip or femur Developmental dysplasia of the hip (DDH); variety of disorders resulting in abnormal development of hip structures that can affect infants or children - Acetabular dysplasia: delay in acetabular development (acetabular roof is shallow and oblique - Subluxation: incomplete dislocation of the hp - Dislocation: femoral head does not have contact with the acetabulum s/s: INFANT; Asymmetry & unequal number of skin folds on posterior thigh, Limited hip abduction, Widened perineum, shortening of femur, Positive Ortolani test- Hip is reduced by abduction, Positive Barlow Test- Hip is dislocated by adduction; CHILD: One leg shorter than the other, walk w/ lip, walking on tow on 1 foot TX: Pavlik harness: For newborn to 6 months; Maintain harness placement for up to 12 weeks, Check straps every 1 to 2 weeks for adjustment, Perform neurovascular and skin integrity checks (2-3 times/day), Teach the family not to adjust the straps, Teach the family skin care (Use an undershirt, Wear knee socks, Gently massage skin under straps, Avoid lotions/powders, Place diaper under the straps) When adduction contracture present Bryant traction: skin traction, hips flexed at 90* angle w/ butt raised off bed Hip spica cast (maintains external rotation of hip); needs to be changed to accommodate growth Surgical closed reduction w/ placement of hip spica cast (6 months- 2yrs) Osteogenesis imperfecta “Brittle bone disease”; inherited condition that results in bone fractures and deformity along with restricted growth s/s: Multiple bone fractures, Blue sclera, Early hearing loss, Small, discolored teeth Medications: Pamidronate: Increase bone density; SE: decreases electrolytes NURSING: treatment is supportive; Teach the family and client low-impact exercises; caution w/ live vaccines Scoliosis; Characterized by a lateral curvature of the spine and spinal rotation that causes rib asymmetry Screening; Have the child bend over at the waist with arms hanging down and observe for asymmetry of ribs and flank TX: Bracing: Customized braces slow the progression of the curve. Surgical; Spinal fusion with rod placement-Used for curvatures > 45 degrees Chapter 29: Chronic Neuromusculoskeletal Disorders Cerebral Palsy (CP); non-progressive impairment of motor function, especially that of muscle control, coordination, and posture; can cause abnormal perception and sensation; visual, hearing, and speech impairment; seizures; and cognitive disability Risk factors: Exact cause is unknown; Prenatal, perinatal, and postnatal risk factors s/s: - Spastic CP (pyramidal): Hypertonicity, increased deep tendon reflex; clonus; and poor control of motion, balance and posture; impairment of gross & fine motor skills - Dyskinetic CP (nonspastic, extrapyramidal): Athetoid; Involuntary jerking movements that appear slow, writhing, and wormlike involve extremities, trunk, neck, face, & tongue; Dystonic; slow twisting movements of trunk or extremities w/ abnormal posturing from muscle contractions, drooling & speech impairment - Ataxic CP (nonspastic, extrapyramidal): Poor ability to do repetitive movements, Lack of coordination with purposeful movements (ex: reaching for an object) Medications: Baclofen, Diazepam, Botulinum toxin A, Antiepileptics, Dopaminergic Complications: Aspiration, Injury Spina Bifida; neural tube defect present at birth; failure of the osseous spine to close Spina bifida occulta; not visible externally s/s: dimpling in lumbosacral area, port wine angioma, dark hair tufts, subcutaneous lipoma Spina bifida cystica; visible externally s/s: flaccid muscles, lack of bowel control, rectum prolapse, spinal curvature abnormalities - Meningocele: The sac contains spinal fluid and meninges - Myelomeningocele: *most common; The sac contains spinal fluid, meninges, and nerves Risk factors: Medications/substances taken during pregnancy, Insufficient folic acid intake during pregnancy TX: Closure of myelomeningocele sac as soon as possible to prevent complications of injury and infection; Apply a sterile, moist, nonadherent dressing with 0.9% sodium chloride on sac, changing Q2 hr.; Place in the infant in prone position with hips flexed, legs abducted Complications: Skin ulceration, Latex allergy (Also bananas, avocados, kiwi, chestnuts) - Increased intracranial pressure, Bladder issues, Orthopedic issues Juvenile idiopathic arthritis; Chronic autoimmune inflammatory disease affecting joints and other tissues - s/s: Joint swelling/stiffness/redness/warmth that tends to be worse in the morning or after inactivity, fever, rash, delayed growth, limp in AM NURSING; Apply heat or warm moist packs to affected joints prior to exercise, Encourage warm baths Medications: NSAIDs (Ibuprofen, naproxen, diclofenac, indomethacin, tolmetin): control pain & inflammation Methotrexate; DMARD: slows joint degeneration &progression of RA when NSAIDs don’t work alone Corticosteroid: Prednisone; relief of pain & inflammation reserved for life threatening complication, severe arthritis, pericarditis & uveitis Etanercept; DMARD when methotrexate not effective Muscular Dystrophy (MD); group of inherited disorders with progressive degeneration of symmetric skeletal muscle groups causing progressive muscle weakness and wasting - Duchenne (psuedohypertrophic) muscular dystrophy (DMD): most common form of MD; Onset between 3 and 5 years; lifespan of early adulthood - Facioscapulohumeral muscular dystrophy autosomal dominant inherited; age of onset early adolescence; Progression is slow with normal life span; characterized by facial weakness & inversion of shoulders. - Limb-girdle muscular dystrophy autosomal dominant and recessive, heterogeneous disorder. appears later in childhood with a slow progression. s/s: Muscle weakness beginning in the lower extremities, Unsteady gait, with a waddle, Lordosis, Delayed motor skill development, Frequent falling, Learning difficulties, Progressive muscle atrophy, Respiratory and cardiac difficulties as the disease progresses Medications: Corticosteroids: Prednisone (increases muscle strength) Complications: Respiratory compromise Medications Topical agents: Silver sulfadiazine/ Mafenide acetate; Use with 2nd and 3rd degree burns; Apply to cleansed, debrided area; Wear sterile gloves for applications Bacitracin: Use for prevention of secondary infection 4. Skin coverings Biologic skin coverings: may be used to promote healing of large burns; req repeated surgical application - Allograft (homograft): Skin from human cadavers used for partial and full thickness burn wounds - Xenograft: Obtained from animals: pigs for partial thickness burns - Synthetic skin coverings; used for partial thickness burns - Artificial skin; allows dermis to regenerate, used for partial & full thickness burns (healing is faster) Permanent skin coverings: may be treatment of choice for burns covering large areas - Autografts: Client’s skin - Sheet graft; sheet of skin used to cover wound - Mesh graft; sheet of skin placed in mesher, so skin graft has small slits in it; allows larger areas of burn cover - Cultured epithelium; epithelial cells cultured for use when grafting sites limited Chapter 33: Diabetes Mellitus Risk factors; Genetics; Toxins/viruses: can destroy the beta cells causing type 1; Obesity/physical inactivity/HTN causes type 2 DM s/s: Hypoglycemia: blood glucose <60, Hunger, lightheadedness, and shakiness, Pale, cool skin/diaphoresis, Decreasing LOC, Slurred speech, headache and blurred vision, Seizures leading to coma Hyperglycemia: blood glucose >250, Thirst, Polyuria (early sign)/oliguria (late sign), Nausea, vomiting, and abdominal pain, Skin that is warm, dry, and flushed with poor turgor, Dry mucous membranes, Confusion, Weakness, Lethargy, Weak pulse, Diminished reflexes, Rapid, deep respirations with acetone/fruit odor due to ketones (Kussmaul respirations) DX: 8-hr fasting blood glucose level of 126 or more; Random blood glucose of 200 or more with classic sign of diabetes; An oral glucose tolerance test of 200 or more in the 2 hr sample - Glycosylated hemoglobin (HbA1c):Expected reference range is 4%-5.9%; Acceptable target for children <6 7.5%-8%, 6-12 <8%, 12 + < 7.5%; If >7%: not regulating sugar well NURSING; Trimming toenails straight across with clippers and filing edges with a nail file; Caution against wearing sandals, walking barefoot, or wearing shoes without socks; Dry feet completely; Can use mild foot powder: cornstarch; Never use commercial remedies for removing callus/corn; Sock: cotton or wool; No heating pads for feet Education; Teach the child illness management: Monitor blood glucose and urinary ketone levels every 3 hr , Continue to take insulin or oral Antidiabetic agents, Encourage sugar-free, noncaffeinated liquids to prevent dehydration Call the provider for: Blood glucose >240, Fever 102F, Positive ketones in the urine, Disorientation or confusion occurs, Rapid breathing, vomiting more than once, liquids not tolerated Treat Hypoglycemia with 10-15 g simple carbohydrates (1tbsp sugar) (Ex: 4 OZ orange juice/8OZ milk) - If unconscious or unable to swallow: Administer glucagon SC or IM; Administer simple carbohydrates when tolerated Medications Complications; - DKA: >330 mg/dL, Ketone levels in the blood and urine, Fruity scent to the breath, Mental confusion, Dyspnea, Nausea and vomiting, Electrolyte imbalances: Metabolic acidosis/hyperkalemia NURSING; Monitor serum potassium levels; Administer sodium bicarbonate by slow IV infusion for severe acidosis (pH <7); Have a cardiac monitor Long term complications; Kidney disease, Eye disease, Neurologic complications Chapter 34: Growth Hormone Deficiency - Human growth hormone (GH), somatotropin, is a naturally occurring substance secreted by pituitary gland. GH is important for normal growth, development, and cellular metabolism. A deficiency in GH prevents somatic growth throughout the body. Hypopituitarism is the diminished or deficient secretion of pituitary hormones (primarily GH). Consequences of the condition depend on the degree of the deficiency. s/s: Short stature but proportional height and weight, Delayed epiphyseal closure, Delayed sexual development, Underdeveloped jaw, Delayed dentition,  insulin sensitivity Medications -Somatropin: Given SC until epiphyseal plate closes Chapter 35: Immunizations Contraindications - The common cold and other minor illnesses are not contraindications to immunizations - Severe febrile illness is a contraindication to all immunizations - Do not administer live virus vaccines, such as varicella or MMR, if severely Immunocompromised - DTaP: Occurrence of encephalopathy within 7 days following prior doses of the vaccine - IPV: Anaphylactic reaction to neomycin, streptomycin, polymyxin B -MMR, eggs, gelatin, and neomycin - Influenza vaccine: Hypersensitivity to eggs -Varicella: If taking corticosteroids NURSING; Give IM immunizations in the Vastus lateralis or ventrogluteal muscle in infants and young children; Give IM immunization in the deltoid muscle for older children/adolescents; Give infants a concentrated oral sucrose solution 2 min prior to, during, and 3 min after immunization administration Document date, route, site of immunization, lot number, manufacturer, and exp. Date Chapter 36: Communicable Diseases Conjunctivitis; Spread via direct contact (viral/bacterial) s/s: Pink or red color in the sclera of the eyes, Crusting of the eyelids in the morning Epstein-Barr virus (EBV)/mononucleosis; Spread via saliva s/s: Fever, Swollen lymph glands, Splenomegaly, Hepatic involvement Complications: ruptured spleen (no contact sports) Erythema infectiosum (fifth disease)/parvovirus B19; Spread via droplet/blood s/s: before rash ( fever, runny nose, headache); Rash (7 days to several weeks), Red rash on face (slapped cheek) appears from day 1 to 4 Complications; self-limiting arthritis & arthralgia (more common in women) Mumps/paramyxovirus; Spread via droplet & direct contact s/s: Painful, swollen parotid glands Chemotherapy; Provide antiemetic prior to administration, Observe mouth for mucosal ulcerations Educate about the SE of chemotherapy: Mouth sores, Loss of appetite, Nausea/vomiting, Hair loss, Diarrhea/constipation, Increased risk of infection, Easy bruising or bleeding, Fatigue Radiation: Nurse: wear lead aprons; Instruct the child and family not to wash off marks on the skin that outline the targeted areas; Avoid use of soaps, creams, lotions, and powders unless prescribed; Keep the areas protected from the sun by wearing a hat and long-sleeved shirts NURSING: Encourage the child to avoid crowds while undergoing chemotherapy; Avoid fresh fruits and vegetables; Avoid invasive procedures; Administer SC daily filgrastim (a granulocyte colony-stimulating factor that stimulates WBC production); Administer epoetin alfa give SC 2-3 times per week( Stimulate RBC production); Administer Oprelvekin SC daily (For PLT formation); Encourage the use of soft toothbrush; Mucositis and dry mouth: Lubricate the child’s lips; avoid hydrogen peroxide and lemon glycerin swabs Chapter 40: Blood Neoplasms Leukemia; group of malignancies that affect the bone marrow and lymphatic system; peak onset 2-5 ; causes increase in the production of immature WBCs (leukoblasts) with neoplastic characteristics, which leads to infiltration of organs and tissues s/s: EARLY; Low-grade fever, Pallor, Increased bruising and petechiae, Listlessness, Enlarged liver, lymph nodes, and joints, Abdominal, leg, and joint pain, Constipation, Headache, Vomiting and anorexia, Unsteady gait; LATE; Pain, Hematuria, Ulcerations in the mouth, Enlarged kidneys and testicles, Manifestations of increased intracranial pressure Labs: CBC Anemia (low blood count); Thrombocytopenia (low platelets); Neutropenia (low neutrophils);Leukemic blasts (immature WBCs); Blood smear (immature WBC) DX: Bone marrow aspiration or biopsy analysis: Topical anesthetic such as EMLA cream 45 min-1 hr prior CSF analysis: Have the child empty their bladder, EMLA cream 45 min-1 hr prior, Side-lying position with the head flexed and knees drawn up toward the chest, and assist in maintaining the position (during procedure), Remain in bed 4-8 hr in a flat position to prevent leakage and a resulting spinal headache (after) Medications; Chemo admin at different phases - Induction/remission therapy: To achieve complete remission or < than 5% of leukemic cells in bone marrow - Intensification therapy (consolidation): To destroy any remaining leukemic cells followed by a delayed intensification to prevent any resistant leukemic cells from emerging - Maintenance therapy: To sustain the remission phase. Also requires frequent monitoring of CBC TX: Hematopoietic stem cell transplant (HCST) Allogeneic transplant; blood forming stem cells donated by another person NURSING; administer donor stem cells via IV infusion - Implement protective isolation; Private, positive-pressure room, At least 12 air exchanges/hr, HEPA filtration for incoming air, Respirator mask, gloves, gowns, No dried or fresh flowers, and no potted plants Chapter 42: Bone & Soft Tissue Cancers Bone Tumors; Osteosarcoma usually occurs in metaphysis of long bones, most often in the femur Risk Factors; Osteoscoma peaks at age 15 during growth spurts; more common in boys; Ewing’s sarcoma occurs prior to 30 & more common in Caucasians s/s: Nonspecific bone pain that is often mistaken for an injury or growing pains, Temporary relief of pain when extremity is flexed, Weakness, swelling, decreased movement, or limping ● Palpable lymph nodes near the tumor, Anemia, generalized infection, or unexplained weight loss, Inability to hold a heavy object Medications; Chemo; Osteosarcoma; used in combo or alone before & or after surgery; High-dose methotrexate with citrovorum factor rescue, doxorubicin, cisplatin, ifosfamide, and etoposide; Ewing’s sarcoma; Vincristine, doxorubicin, and cyclophosphamide alternating with ifosfamide and etoposide Amitriptyline TX: Localized radiation therapy, Surgical Biopsy Limb salvage procedure for bone cancers: Includes a course of chemotherapy to shrink the tumor and then total bone and joint replacement after the tumor and affected bone are removed. Limb amputation for bone cancer; The child can receive chemotherapy both preoperatively & postoperatively Complications; Skin desquamation; Myelosuppression Rhabdomyosarcoma; most common soft tissue malignancy in children; most common in child < 5 s/s: Can cause pain in local areas r/t compression by tumor (sore throat can occur with tumor of nasopharynx); Possible absence of pain in some parts of body (in the retroperitoneal area) until tumor begins to obstruct organs BASED ON AFFECTED AREA CNS: headaches, diplopia, vomiting Orbit: unilateral proptosis, ecchymosis of conjunctiva, strabismus Nasopharynx: stuffy nose, pain, nasal obstruction, epistaxis, palpable neck nodes, visible mass (late) Paranasal sinuses: nasal obstruction, pain, discharge, sinusitis, swelling Middle ear: chronic otitis media, pain, sanguine purulent discharge, facial paralysis Retroperitoneal area: usually no findings, abdominal mass, pain, intestinal or genitourinary obstruction Perineum: visible superficial mass, bowel, or bladder obstruction Extremity: pain, palpable fixed mass, lymph node enlargement DX: CT, MRI, Tumor biopsy Medications: Chemo; Vincristine, actinomycin D, cyclophosphamide, ifosfamide, topotecan, irinotecan, and doxorubicin for about 1 yea TX: Localized radiation therapy, Surgical Biopsy Complications; Skin desquamation; Myelosuppression Chapter 42; Complications of Infants PKU; inherited metabolic disorder in which the newborn lacks the enzyme phenylalanine hydroxylase. This enzyme converts phenylalanine, an essential amino acid, into tyrosine. The lack of this enzyme leads to the accumulation of phenylalanine in the newborn’s bloodstream and tissues, which causes cognitive impairment. s/s: Growth failure, Frequent vomiting, Irritability, Musty odor to urine, Microcephaly, Heart defects, Blue eyes, very fair skin, light blonde hair Labs: Newborn metabolic screen ( w/in 2 days of birth); Guthrie test (confirms +blood spot) NURSING: Initiate dietary restrictions as soon as PKU is diagnosed, or within 7 to 10 days of birth. Place newborn on a formula low in phenylalanine ( Intake should be 20 to 30 mg phenylalanine per kilogram of body weight per day, Monitor phenylalanine level, Goal is a phenylalanine level between 2 and 8 mg/dL) Complications; Cognitive impairment (can be severe), Hyperactivity with erratic behavior, Bizarre behavior (fright reactions), Head banging, Arm biting, Disorientation, Spasticity or catatonic-like positions, Seizures Necrotizing Enterocolitis; inflammatory disease of the gastrointestinal mucosa caused by ischemia or hypoxia. s/s: Abdominal distention, Gastric residuals, Bloody stool, Periods of apnea begin or worsen, Hypotension, Lethargy, Poor feeding, Decreased urinary output NUSING: Treatment begins with prevention. Withhold feedings for 24 to 48 hr from newborns who suffered birth asphyxia. Discontinue all feedings at first manifestation of NEC. Administer IV or TPN to rest the GI tract. Insert an NG tube for abdominal decompression. Plagiocephaly; acquired condition that occurs from cranial molding in infancy. The infant’s head becomes asymmetric or oblique in shape due to flattening of the occiput. Plagiocephaly is attributed to the supine sleep position TX: Physical therapy for neck exercises; Proper use of skull-molding helmet Chromosomal Abnormalities Trisomy 21 (Down syndrome; Most frequently occurring chromosomal disorder - Broad, flat nose, Epicanthal fold, Protruding tongue, short neck with extra pad of fat, Hypotonicity, Low set ears, Fifth finger curved inward, Single palmar crease, Mild to moderate cognitive deficits, Cardiac anomalies common, Altered immune system Trisomy 18 (Edwards syndrome); Most die in infancy - Severe cognitive deficits, SGA, Low-set ears, small jaw, Misshapen fingers and toes, Rocker-bottom feet Trisomy 13 (Patau syndrome) - Severe cognitive deficits, Midline body disorders: cleft lip/palate, cardiac defects, abnormal genitalia, Microcephaly, Eyes small or missing Klinefelter syndrome: male who has an extra X chromosome; Characteristics not noticeable until puberty - Testes remain small leading to sterility, Gynecomastia, Elongated lower limbs Turner syndrome: Female who has only one functional X chromosome - Short stature, Small, nonfunctioning ovaries leading to sterility, No secondary sex characteristics develop at puberty except pubic hair , Neck webbed and short, Mild learning disabilities to severe cognitive deficits Chapter 43: Pediatric Emergencies Respiratory Emergencies Respiratory insufficiency: Increased work of breathing with mostly adequate gas exchange or hypoxia w/ acidosis Respiratory failure: Inability to maintain adequate oxygenation of the blood Apnea: Cessation of respirations for more than 20 seconds; Can be associated with hypoxemia or bradycardia: Can be central or obstructive Respiratory arrest: Complete cessation of respirations Airway obstruction: Can be due to aspiration of a foreign body s/s: EARLY Resp Distress; restlessness, tachypnea, tachycardia, diaphoresis, nasal faring, retractions, grunting, wheezing, dyspnea ADVANCED HYPOXIA; bradypnea, bradycardia, peripheral or central cyanosis, stupor, coma CHOKING; universal choking sign (clutch neck w/ hands), unable to speak, weak ineffective cough, high pitched or no sounds, dyspnea, cyanosis NURSING: Obstructed Airway; CHILDREN/ADOLESCENTS: Use abdominal thrusts INFANTS; Combination of back blows and chest thrusts Remove any visual obstruction or large debris from the mouth, but do not perform a blind finger sweep