NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain Col, Exams of Nursing

Download NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain Col and more Exams Nursing in PDF only on Docsity! NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide MIDTERM STUDY GUIDE: PART-1 1. CHALAZIONS – Benign, chronic lipogranulomatous inflammation of the eyelid • Causes – blockage of the meibomian cyst • Risk – hordeolum or any condition which may impede flow through the meibomian gland. Also, mite species that reside in lash follicles • Assessment – PAINLESS, NOT INVOLVING LASHES Lid edema, or palpable mass Red or grey mass on the inner aspect of lid margin • Prevention – good eye hygiene • Treatment – warm, moist compresses 3x per day Antibiotics not indicated because chalazion is granulomatous condition, if secondarily infected consider SULFACETAMIDE, ERYTHROMYCIN • Follow up – 2-4 weeks, if still present after 6 weeks follow up with ophthalmologist 2. BLEPHARITIS – Inflamation/infection of the lid margins (chronic problem) • 2 types – seborrheic (non ulcerative) : irritants (smoke, make up, chemicals) o s&s – chronic inflammation of the eyelid, erythema, greasy scaling of anterior eyelid, loss of eyelashes, seborrhea dermatitis of eyebrows and scalp • Ulcerative- infection with staphylococcus or streptococcus o s&s – itching, tearing, recurrent styes, chalazia, photophobia, small ulceration at eyelid margin, broken or absent eyelashes • the most frequent complaint is ongoing eye irritation and conjunctiva redness • Treatment – clean with baby shampoo 2-4 times a day, warm compresses, lid massage (right after warm compress) For infected eyelids – antistaphyloccocal antibiotics BACITRACIN, ERYTHROMYCIN 0.05% for 1 week AND QUIONOLONE OINTMENTS For infection resistant to topical – TETRACYCLINE 250 MG PO X4 DOXYCYCLINE 100 MG PO X2 3. OTITIS MEDIA- AOM is an acute infection of the middle ear The AAP Clinical Practice Guideline requires the presence of the following three components to diagnose AOM • Recent, abrupt onset of signs and symptoms of middle ear inflammation and effusion (ear pain, irritability, otorrhea, and/or fever) • MEE as confirmed by bulging TM, limited or absent mobility by pneumatic otoscopy, air- fluid level behind TM, and/or otorrhea • Signs and symptoms of middle ear inflammation as confirmed by distinct erythema of the TM or onset of ear pain (holding, tugging, rubbing of the ear in a nonverbal manner) TYPE CHARACTERISTICS AOM Suppurative effusion of the middle ear Bullous myringitis AOM which bullae form between inner and middle layers of the TM and bulge outward Persistent AOM AOM that has not resolved when antibiotic therapy has been completed or AOM recurs with days of treatment Recurrent AOM 3 separate bouts of AOM with in 6 mth period or 4 with in a 12-month period; often a positive family history of otitis media and other ENT disease S. pneumoniae, nontypeable Haemophilus influenzae, Moraxella catarrhalis, and S. pyogenes (group A streptococci) are the most common infecting organisms in AOM. S. pneumoniae continues to be the most common bacteria responsible for AOM. The strains of S. pneumoniae in the heptavalent pneumococcal conjugate vaccine NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide (PCV7) have virtually disappeared from the middle ear fluid of children with AOM. With the introduction of the 13-valent S. pneumoniae vaccine, the bacteriology of the middle ear is likely to continue to evolve. Bullous myringitis is almost always caused by S. pneumonia. Nontypeable H. influenza remains a common cause of AOM. It is the most common cause of bilateral otitis media, severe inflammation of the TM, and otitis-conjunctivitis syndrome. M. catarrhalis obtained from the nasopharynx has become increasingly more beta-lactamase positive, but the high rate of clinical resolution in children with AOM NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide • Weight-appropriate doses of ibuprofen or acetaminophen should be encouraged to decrease discomfort and fever. • Topical analgesics, such as benzocaine or antipyrine/benzocaine otic preparations, can be added to systemic pain management if the TM is known to be intact. Topical analgesics should not be used alone. • Distraction, oil application, or external use of heat or cold may be of some use. 2. Antibiotics are also effective. • Amoxicillin remains the first-line antibiotic for AOM if there has not been a previous treated AOM in the previous 30 days, there is no conjunctivitis, and no penicillin allergy Beta-lactam coverage (amoxicillin/clavulanate, third-generation cephalosporin) is recommended when the child has been treated with amoxicillin in the previous 30 days, there is an allergy to penicillin, and the child has concurrent conjunctivitis or has recurrent otitis that has not responded to amoxicillin. If there is a documented hypersensitivity reaction to amoxicillin, the following antibiotics are acceptable, follow the non-type 1 hypersensitivity and type 1 hypersensitivity recommendations in • Ceftriaxone may be effective for the vomiting child, the child unable to tolerate oral medications, or the child who has failed amoxicillin/clavulanate. • Clindamycin may be considered for ceftriaxone failure but should only be used if susceptibilities are known. • Prophylactic antibiotics for chronic or recurrent AOM are not recommended. 3. Observation or “watchful waiting” for 48 to 72 hours allows the patient to improve without antibiotic treatment. Pain relief should be provided, and a means of follow-up must be in place. Options for follow-up include: • Parent-initiated visit or phone call for worsening or no improvement • Scheduled follow-up appointment • Routine follow-up phone call • Given a prescription to be started if the child's symptoms do not improve or if they worsen in 48 to 72 • Communication with the parent, reevaluation, and the ability to obtain medication must be in place. 4. Recommendations for follow-up include: • After 48 to 72 hours if a child has not showed improvement in ear symptomatology, the child should be seen to confirm or exclude the presence of AOM. If the initial management option was an antibacterial agent, the agent should be changed. Diagnosis Treat Any child with moderate/severe bulging TM with otorrhea not associated with AOM Yes Any child with mild bulging of the TM with recent (<48 hours) onset pain (holding, tugging, and so on) or intensely erythematous TM Yes Babies ≥6 months of age with severe signs of AOM (fever >102.2° F [39° C], otalgia for ≥48 hours) Yes Any child 6 to 23 months old with acute bilateral otitis media without severe symptoms, without fever, and sick less than 48 hours Yes Young children with unilateral AOM without severe symptoms and fever <102.2° F [39° C] Provide prescription and/or wait Close follow-up NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide Children ≥24 months old without severe symptoms Provide prescription and/or wait Close follow-up Children not treated and no improvement in 48 to 72 hours See the patient again Clinician discretion whether or not to treat NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide 4. CONJUCTIVITIS – inflammation or irritation of conjunctiva Bacterial (PINK EYE) – in peds bacteria is the most common cause, contact lens, rubbing eyes, trauma, S&S – purulent exudate, initially unilateral, then bilateral Sensation of having foreign body in the eye is common Key findings – redness, yellow green, purulent discharge, crust and matted eyelids in am Self-limiting 5-7 days. Eye drops – polytrim, erythromycin, tobramycin or cipro Improvement 2-4 days Most common organism H. influenza <7 Viral – adenovirus, coxsackie virus, herpes, molluscum • S&S – profuse tearing, mucous discharge, burning, concurrent URI, enlarged or tender preauricular nose • Antihistamines/decongestant • Improvement, self-limiting, 7-14 days Chlamydial – chlamydia trachomatis • S&S – profuse exudate, associated with genitourinary symptoms, 1-2 weeks after birth • Gonococcal – 2-4 days after birth, most concern can cause blidness • PO azithromycin, doxycycline (tetracyclines increase photosensitivity, don’t use in pregnancy) • Improvement 2-3 weeks Allergic – IgE mast cell reaction, environmental, cosmetics • S&S – marked conjuctival edema, severe itching, tearing, sneezing • Topical antihistamine or topical steroids • Improvement 2-3 days Chemical –thimerosal, erythromycin, silver nitrate • S&S conjuctival erythema, 30 minutes afer prophylactic antibiotics drops • Avoid contact • Can consider steroids Conjunctivitis never accompany vision changes Diagnostic studies: swap and scraping must be done, gram and Giemsa staining, ELISA, PCR testing, newborn < 2 weeks needs to be tested for gonorrhea Non –pharm – clean towels, change pillows, warm compress, no contacts, no eye make up – mascara Gonococcal conjunctivitis: newborn – give Ceftriaaxone IM once (don’t give if hyperbilirubinemia, Non-gonococcal – erythromycin 0.5% ointment Consider fluorescein staining if abrasion suspected CDC recommends prophylactic administration of antibiotic eye ointment (ERYTHROMYCIN) 1 hour after delivery Refer to ophthalmologist if herpes, hemorrhagic conjunctivitis or ulcerations present May return to work/school 24 hours after topical 5. OTITIS EXTERNA- Otitis externa (OE), commonly called swimmer's ear, is a diffuse inflammation of the EAC and can involve the pinna or TM. Inflammation is evidenced as (1) simple infection with edema, discharge, and erythema; (2) furuncles or small abscesses that form in hair follicles; or (3) impetigo or infection of the superficial layers of the epidermis. OE can also be classified as mycotic otitis externa, caused by fungus, or as chronic external otitis, a diffuse low-grade infection of the EAC. Severe infection or systemic infection can be seen in children who have diabetes mellitus, are immunocompromised, or have received head and neck irradiation. OE results when the protective barriers in the EAC are damaged by mechanical or chemical mechanisms. OE is most frequently caused by retained moisture in the EAC, which changes the usually acidic environment to a neutral or basic environment, thereby promoting bacterial or fungal growth. Chlorine in swimming pools adds to the 743problem because it kills the normal ear flora, allowing the growth of pathogens. Regular cleaning of the EAC removes cerumen, which is an important barrier to water and infection. Soapy deposits, alkaline drops, debris from skin conditions, local trauma, sweating, allergy, NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide • Systemic antibiotics should not be used unless there is extension of infection beyond the ear or host factors that require more systemic treatment (severe OE, systemic illness, fever, lymphadenitis, or failed topical treatment). • Treatment for OE must include thorough parent education regarding the instillation of otic drops so that they are effective in eradicating infection. The drops should be administered with the child lying down with the affected ear upward. Drops should run into the EAC until it is filled. Move NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide the pinna in a to-and-fro movement or pump the tragus to remove any trapped air and ensure filling . The child should remain lying down for 3 to 5 minutes, leaving the ear open to the air. • If the infection is severe and not improving in the first 5 to 7 days, aural irrigation with water, saline, or hydrogen peroxide may be tried, or refer to the otolaryngologist for débridement and suction. • If significant swelling is present, inserting a wick into the EAC is helpful. A wick made of compressed cellulose, hydrogel polymer (Merocel XL), or gauze (0.25 inch) usually works well. The tip of the wick is lubricated with water or saline just before insertion into the ear. Once in place, the wick should be impregnated with antibiotics for as long as it remains in the auditory canal. (This may require reapplication of drops every 2 to 3 hours.) Wicks are usually removed after several days. The wick will fall out when the swelling has subsided, and treatment with direct application of drops to the ear canal should continue for the entire course. • Avoid cleaning, manipulating, and getting water into the ear. Swimming is prohibited during acute infection. • Administer analgesics for pain. Narcotic analgesics may be necessary for severe pain but are only indicated for short-term use. • Débridement with a cotton-tipped applicator, self-made cotton wick, or calcium alginate swabs is indicated once the inflammatory process has subsided and can enhance the effectiveness of the ototopical antibiotic drops. Lance a furuncle that is superficial and pointed with a 14-gauge needle. If it is deep and diffuse, a heating pad or warm oil-based drops can speed resolution. • If impetigo is present, clear the canal by using water or an antiseptic solution followed by a warm-water rinse. Apply an antibiotic ointment (mupirocin) twice a day for 5 to 7 days. There is increasing resistance to mupirocin, and retapamulin might be necessary in children over 9 months of age (The child should avoid touching the ear. Fingernails should be short, and hands should be cleansed with soap and water. Systemic antibiotics are generally unnecessary. • Fungal OE is uncommon in primary OE. Fungal OE is more likely related to chronic OE or following treatment with topical and/or systemic antibiotics. Aspergillus and Candida species are most commonly seen in mycotic OE Treatment consists of antifungal solutions, such as clotrimazole-miconazole, nystatin, or other antifungal agents, including gentian violet and thimerosal 1 : 1000. • The canal should be cleansed with a 5% boric acid in ethanol solution prior to antifungal solution. If the child is not improved within 72 hours (relief of otalgia, itching, and fullness), recheck to confirm diagnosis. Lack of improvement may be due to obstructed ear canal, foreign body, poor adherence, or contact sensitivity among other things. A follow-up visit may be necessary after 1 to 2 weeks for reevaluation of the OE and removal of debris. If symptoms are worsening or there is no improvement in a week, a referral to an otolaryngologist or dermatologist is indicated. Complications o Infection of surrounding tissues with impetigo, irritated furunculosis, and malignant OE with progression and necrosis caused by Pseudomonas are possible complications. Involvement of the parotid gland, mastoid bone, and infratemporal fossa is rare Prevention The patient should be instructed to do the following: • Avoid water in the ear canals. • Use well-fitting earplugs for swimming especially in “dirty water.” • Use alcohol vinegar otic mix (two parts rubbing alcohol, one part white vinegar, and one part distilled water) 3 to 5 drops daily, especially after swimming or bathing, to prevent the recurrence of OE • Use a blow dryer on warm setting to dry the EAC. • Avoid persistent scratching or cleaning of the external canal. • Avoid prolonged use of ceruminolytic agents. NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide 6. HAND-FOOT-AND-MOUTH DISEASE – HIGHLY CONTAGIOUS, viral illness clinical entity evidenced by fever, vesicular eruptions in the oropharynx that may ulcerate and a maculopapular rash involving hands and feet, the rash evolves to vesicles, especially on the dorsa of the hands and feet. Last 1 to 2 weeks. NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide Toxic shock Rocky mountain spotted fever Steven-johnson syndrome Juvenile RA • Tests: based on S&S and diff CBC, anemia, platelets 50% > 450 000 ESR >100 C-reactive protein EKG – prolonged PR intervals, decrease QRS Chest Xray – dilated heart, pleural effusion Pyuria/mild proteinuria • Pharmacology IVIG single dose of 2g/kg for over 12 hours in the first 10 days Aspirin 80-100 mg/kg/d in 4 doses (Reye’s syndrome) • Complications MI Development and rupture of coronary artery aneurysm may lead to emboli, HF, heart valve problems, dysrhythmias, myocarditis 9. RHEUMATIC FEVER – An inflammatory disease that develops in 1-3% of children who have untreated infection with group A strep (GAS). This can affect the heart, blood vessels, joints , skin, CNS, connective tissues • S&S – hx of pharyngitis 2-4 weeks prior onset of symptoms. o Modified Jones criteria used to diagnose patient: o 2 major, or 1 major and 2 minor criteria must be presented as evidence • Major – carditis: 65% have with murmurs o Polyarthritis:75% o Chorea: 15% o Erythema marginatum (macular rash with erythematous border o Subcutaneous nodules • Minor o Fever 101-104F o Artharlgias o Elevated ESR, C-reactive protein o Prolonged PR intervals on EKG • Tests: throat cultures, negative antigen test o ESR, C-reactive protein NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide o ASO tites o EKG o Chest xray o CBC NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide • Treatment: first line PCN, if allergic Azithromycin Prednisone Aspirin AHA 2010 no longer recommends prophylaxis treatment for endocarditis in those with rheumatic fever 10. RSV BRONCHIOLITIS PEDIATRIC BENIGN SKIN LESIONS MILIA (superficials cysts filled with keratin) – white papules found on the forehead, face, chin, and cheeks of infants, 1-2 mm in size, disappear few weeks after birth, may appear on palate – EPSTEIN’S PEARLS’S PORT-WINE STAIN (Nevus flammeus) – permanent defect that grows with child, if forehead and eyelids are involved, there is potential for multiple symptoms, includidng Sturge-Weber, Klippel-Trenaunay-Weber and Parkes Weber. Flat port wine stain- dark red to deep purple lesions present at birth, frequently found on face, do not fade with time SALMON PATCH – fade with time, usually by 5 or 6 years old, no treatment needed. Salmon patches (called a "stork bite" at the back of the neck or an "angel's kiss" between the eyes) are simple nests of blood vessels (probably caused by maternal hormones) that fade on their own after a few weeks or months. Occasionally stork bites never go away.CAFÉ AU LAIT SPOT – smooth, regular borders, Child > 5, 6 or more , >1.5 cm - possible Von Recklinghausen’s disease (90 -100%) *LEOPARD syndrome (Lentigines, Electrographic abnormalities, Ocular hypertelorism, Pulmonary stenosis, Abnormalities of genitalia, Retardation of growth, Deafness In child <5 years, 5 or more , 0.5 cm suggests neurofibromatosis Smaller 1-4 cm in diameter I axillae ( axillary freckling or Crow’s sign) rare but diagnostic sign of neurofibromatosis HEMANGIOMA – (dilation of capillaries) – raised, cavernous: appear bluish, located deep beneath the skin, NOT present at birth, appear within a few month and then disappear before the end of first decade of life. Capillary- STRAWBERRY hemangiomas : bright red vascular overgrowth, elevated, vary in size Possible steroids IMPETIGO – Superficial infection of the skin which begins as small superficial vesicles which rupture and form honey colored crust 2- 5 years Bullous – is caused by Staphyloccocus aureus or group A strep Non – Bullous – MRSA • 1-2 mm vesicles which rupture and form honey colored crusts, weeping shallow red ulcer • common on mouth, face, nose, or site of insect bites • fluid filled vesicles <0.5 cm appear as red macules and papules or pustules • regional lymphadenopathy Treatment: good hygiene, hand washing • Mupirocin (Bactroban) topical – 3x a day, don’t use <2 month • Retapamulin (Altabax) - >9 months, apply thin film 2 x a day • For large area- first generation cephalosporin, if unable to use PCN, consider macrolide • Resolve within 7-10 days MOLLUSCUM CONTAGIOSUM Molluscum contagiosum is an infection caused by a poxvirus (molluscum contagiosum virus). infection is usually a benign, mild skin disease characterized by lesions (growths) that may appear anywhere on NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide - Diarrhea o Contains 10-90 sodium, 10-80 potassium, and 40 HCO3 o S& S of dehydration:- lack of external jugular venous filling when supine, sunken fontanelle, oliguria, AMS, decreased cap refill. NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide o Total body water makes 50-75% of total body mass o Highest in infants and young children Acute Diarrhea o is a disruption of the normal intestinal net absorptive versus secretory mechanisms of fluids and electrolytes, resulting in excessive loss of fluid into the intestinal lumen. o This can lead to dehydration, electrolyte imbalance, and in severe cases, death o In children younger than 2 years old, this translates to a daily stool volume of more than 10 mL/kg (this definition excludes the normal breastfeeding stooling of five or six stools per day). o In children older than 2 years old, diarrheal stooling is described as occurring four or more times in 24 hours. The duration can last up to 14 days. Epidemiology • Females have higher rates of Campylobacter species infections and hemolytic uremic syndrome; • otherwise the incidence of cases shows no gender preference. Nontyphoidal Salmonella, Shigella, Campylobacter, E. coli organisms (bacteria); rotavirus, norovirus, • In the United States, those most vulnerable include Native Americans and Native Alaskans, • The most common viral pathogens are noroviruses and rotavirus, followed by adenoviruses and astroviruses. • Food-borne bacterial or parasitic diarrheal diseases are most commonly due to Salmonella and Campylobacter species, followed by Shigella, Cryptosporidium, E. coli O157:H7, Yersinia, Listeria, Vibrio (Vibrio cholerae and other species), and Cyclospora species. potentially serious infection in the upper intestine indicators • Food-borne illness suspected • Bloody diarrhea, weight loss, dehydration, severe abdominal pain, and fever • Diarrhea lasting several days with more than three stools per day • Neurologic involvement on physical examination • Diagnostic Studies • Diagnostic studies are ordered if the symptoms of more serious infection are present. • Stool examination & Stool cultures • Electrolytes • CBC Management The foundation of all treatment of acute diarrhea is fourfold: • Restore and maintain hydration and correct/maintain electrolyte and acid-base balance. • Oral rehydration with an oral electrolyte solution should be attempted when dehydration is assessed between 3% and 9%. • Antibiotics are recommended for acute diarrhea caused by G. lamblia, V. cholerae, and Shigella species and can be considered for infections caused by E. coli(if infection prolonged), Yersinia for those with sickle cell disease, and Salmonella in young infants with fever or positive blood culture findings . • Children with HIV at risk for acute diarrhea may benefit from cotrimoxazole and vitamin A • Flagyl (1st line for c-diff) Amoxicillin (salmonella, shigella), azithromycin, vanco & Cipro (ecoli, c-diff), ceftriaxone. • loperamide in children older than 3 years old is safe and decreases the duration and frequency of diarrhea • Children younger than 3 years old and those who are malnourished, those with moderate or severe dehydration, those who are systemically ill, or those who have bloody diarrhea should not be treated with this drug • Some over-the-counter products intended for diarrhea contain salicylates (e.g., Pepto- Bismol), and there is concern for Reye syndrome. Chronic Diarrhea NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide - Chronic diarrhea is defined as loose stools of less than 10 mL/kg/day in infants and less than 200 g/24 hours in older children. continuing diarrheal illness that started as acute diarrhea and is affecting growth. - TABLE 33-13 Common Causes of Chronic Diarrhea Seen in Children NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide Diagnostic Studies • Stool: Culture, O&P (best done on three specimens collected on separate days), pH, reducing substances, occult blood, leukocytes, fat and fecal elastase (to evaluate for pancreatic insufficiency) (Normal stool pH greater than 5.5 indicates negative carbohydrate.) • CBC with differential, electrolytes, and albumin • UA and culture in young children • The following are ordered as indicated by the history, physical examination, and consideration of differential diagnoses: • ESR, CRP • Hormonal studies to assess for secretory tumors (vasoactive intestinal peptide, gastrin, secretin, urine assay for 5-hydroxytryptamine [5-HT]) • Breath hydrogen test for lactose or sucrose intolerance (difficult to assess in infants) • Viral serologies, such as HIV or CMV • Sweat chloride test • Endoscopy, barium studies Management • Treat the underlying cause. • Chronic nonspecific diarrhea (toddler's diarrhea): Normalize the diet; remove offending foods and fluids; eliminate sorbitol and fructose-containing fluids; reduce fluid intake to no greater than 90 mL/kg/24 hours (give half of fluid as milk [whole or 2%]); increase fat to 35% to 40% of the diet; and increase fiber to bulk up stools. • Treat carbohydrate malabsorption by decreasing lactose or sucrose; add lactase or sacrosidase as indicated by particular carbohydrate intolerance. • Post-gastroenteritis malabsorption syndrome (evidenced in infants with weight loss and fat globules in the stool) can be given a predigested formula (e.g., Pregestimil or Alimentum), if tolerated, for 3 to 4 weeks (elemental formula can be used if those are not tolerated). Refer the following patients to a gastroenterologist: Newborns with diarrhea in first hours of life; patients with growth delay or failure or abnormal physical findings (anorexia, abdominal pain, chronic bloating, vomiting, or weakness); or those with severe illness Pyloric stenosis Patho: • Pyloric stenosis is the narrowing of the lower portion of the stomach that leads into the small intestine. • The muscles of the stomach thicken, narrow the pylorus and prevent food from moving from the stomach to the intestine. • The environment and genetics play a role. sign and symptoms : • forceful projectile vomiting, olive shaped abdominal mass, visible peristalsis, weight loss, dehydration, fewer bowl movements, constipation, jaundice and lack of energy. diagnosis • included a firm olive mass in the mid abdomen • Blood tests, barium swallow and abdominal ultrasound Treatment • Pyloric stenosis is treated with IV fluids and then pyloromyotomy is performed. • This surgery uses an open or laparoscopic approach that opens up the tight muscle that caused the narrowing. • The outcome is great, there is only 1% chance for pyloric stenosis to occur Intussusception Pathophysiology • Is a condition where the one section of the intestine folds into the another section of the intestine resulting in obstruction. The proximal bowel is trapped in the distal segment • The trapped bowel can exert pressure on the walls which squeezes the blood vessels and leads NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide to ischemia and infarction Cause: NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide • Most cases are idiopathic, but many cases were associated with hyperplastic lymphoid tissue, suggesting an infectious cause, • Predisposing factors include:- polyps, Meckel diverticulum, constipation, lymphomas, lipomas, parasites, rotavirus, adenovirus, and foreign bodies Risk factors: • Infants between 6 and 12 months • Male gender • History of previous intussusception • History of intestinal malrotation • Family history • Prior viral illness Epidemiology • It is considered to be the most common cause of intestinal obstruction in children older than 3 months up to 6 years. ▪ In the US, intussusception occurs in 18 to 56 per 100,000 infants ▪ It most commonly occurs in infants between 5 and 10 months of age. ▪ 2/3 of the intussusception happens in infants under one year of age, but it even occur in adults Signs and symptoms • Classical triad symptoms include intermittent/ colicky abdominal pain, vomiting, and bloody mucous stools characterized as “currant jelly”) • Emesis is usually nonbilious. • Other symptoms include lethargy, history of URI, fever, sausage like mass in the right upper quadrant or in right lower when abdomen is empty, tender and distended abdomen • Diagnostic Studies • The most accurate diagnostic tool recommended is an abdominal ultrasound. • It shows “bull’s eye” which is telescoped intestine on end. • Other diagnostic tools such as x-ray , CT, and Air contrast enema can also be used Management • Intussuception can develop suddenly putting the infant at a potential risk for developing ischemia and possible infection and even sepsis. Therefore, rapid treatment is necessary. • MEDICAL EMERGENCY • Rehydration and correction of electrolyte imbalance is very important. • After correction of dehydration and electrolyte imbalance, the gold standard is radiologic reduction via air contrast enema under fluoroscopy • The Outcome of air or contrast enema reduction is 100% cure, but 10% recurrence has been identified. • Surgical reduction is also associated with a recurrence rate of 2 to 5%. Celiac disease Risk factors • Malabsorption syndromes can be caused by many different genetic, congenital, and acquired conditions and usually lead to an initial decrease in weight followed by a deceleration in height velocity. • Celiac disease is an immune-mediated systemic disorder triggered by dietary exposure to wheat gluten and related proteins in barley and rye. • It is characterized by the presence of a variable combination of gluten-dependent clinical manifestations, celiac disease–specific antibodies, HLA-DQ2.5 or HLA-DQ8 haplotypes, and enteropathy. • Celiac disease has a worldwide distribution with overall prevalence of 1% • Demographic changes • Increased gluten exposure • infants born by cesarean section; NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide Clostridium difficile Unknow n Variety of symptom s and severity During or after sever al Acquired from the environ ment or Stool culture s; enzym Discontinue current antibiotic (any NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide are seen: mild to explosive diarrhea, bloody stools, abdomin al pain, fever, nausea, vomiting Mild to moderate illness is character ized by watery diarrhea, low- grade fever, and mild abdomin al pain week s of antib iotic use; can occu r with out bein g assoc iated with such treat ment from stool of other colonize d or infected people by the fecal- oral route e immun oassay for toxin A, or A and B; positiv e gross blood, leukoc ytes; CBC: ↑ WBCs; ESR normal antibiotic, but notably ampicillin, clindamycin, second- and third- generation cephalospori ns). Fluids and electrolyte replacement are usually sufficient. If antibiotic is still needed or illness is severe, treat with oral metronidazol e (drug of choice in children) or vancomycin for 7 to 10 days. Supplement with probiotics. Lactobacillus GG, Sacchar omyces boulardii are recommende d (Jones, 2010; Shane, 2010). Complications include pseudomemb ranous colitis, toxic megacolon, colonic perforation, relapse, intractable proctitis, death in debilitated children. NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide Enterohemorrhagi c Escherichia coli(EHEC) 1 to 8 days Severe diarrhea that is 5 to 10 days Undercoo ked beef, Stool culture ; E. Supportive care: Monitor NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide and enteroadheren t E. coli (frequent cause of traveler's diarrhea) abdomin al cramps, some vomiting; often cause of mild traveler's diarrhea contami nated with human feces . ETEC require s special laborat ory techniq ues for identifi cation. If suspect ed, must request specifi c testing. Antibiotics are rarely needed except in severe cases. Recommend ed antibiotics include TMP-SMX and quinolones. See www.cdc .gov/travel. Rotavirus 1 to 3 days; prev alent durin g cool er mont hs in temp erate clim ates Acute-onset fever, vomiting, and watery diarrhea occur 2 to 4 days later in children <5 years old, especiall y those between 3 to 24 months old 3 to 8 days Fecal-oral; viable on inanima te objects; rarely contami nated water or food Enzyme immun oassay and latex aggluti nation assays for group A rotavir us antigen ; virus can be found by electro n micros copy and specifi c nucleic acid amplifi cation method s. Supportive care: May need to correct dehydration and electrolyte imbalances. Oral IG has been used in those immunocom promised. Preventive care: Rotavirus vaccine; hygiene and diapering precautions in day care facilities. NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide Salmonella spp. 1 to 3 days Diarrhea, fever, abdomin al cramps, rebound tendernes s, vomiting. S. typhi and S. paratyphi produce typhoid with insidious onset character ized by fever, headache , constipati on, malaise, chills, and myalgia; diarrhea is uncomm on, and vomiting is not usually severe 4 to 7 days Contamin ated eggs, poultry, unpaste urized milk or juice, cheese, contami nated raw fruits and vegetabl es (alfalfa sprouts, melons) S. typhi ep idemics are often related to fecal contami nation of water supplies or street- vended foods Routine stool culture s; positiv e leukoc ytes and gross blood. CBC: WBC can be slightly ↑ with left shift, ↓, or normal . Supportive care: Only co nsider antibiotics (other than for S. typhi or S. paratyphi) for infants <3 months old, those with chronic GI disease, malignant neoplasm, hemoglobino pathies, HIV, other immunosupp ressive illnesses or therapies. If indicated, consider ampicillin or amoxicillin, azithromycin , or TMP- SMX; if resistance shown to any of those, use IM ceftriaxone, cefotaxime; or azithromycin or quinolones. A vaccine exists for S. typhi in certain cases. NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide Juvenile idiopathic arthritis and osteomyelitis Condition Age pain Historical Findings Clinical Findings Causative Factors Management Juvenile arthritis (JA) Child to 16 yearo f age + Fever, rashes, ↑ WBCs; some iritis; joint stiffness and swelling; S&S >3 months Mono-/polyarticul ar arthropathy; + ANA (25% to 88%); ↑ ESR in moderate/seve re JA Unknown; genetic (HLA) or environment al Treat with NSAIDs initially; may need sulfasalazine, methotrexate ; corticosteroi ds; joint replacements when older Acute Hematogeno us osteomyelitis Toddler, child, adolescen t + Varied: malaise, low-grade to high fever; may have severe constitution al symptoms; toxicity Refusal to walk or move limb; point tenderness; limp; 7 to 10 days to see radiographic bony changes; 25% ↑ WBCs; ↑ CRP S.aureus Organism (Likely) Appropriate antibiotic coverage (generally 7 days, IV; 4 to 6 weeks total or until ESR normal) Juvenile Idiopathic Arthritis • Also as juvenile rheumatoid arthritis (JRA), now encompasses several disorders that have a common feature of arthritis. • The diagnosis of JIA requires a persistent arthritis for more than 6 weeks in a pediatric patient younger than 16 years old. TABLE 25-1 Juvenile Idiopathic Arthritis Subtypes and Clinical Joint Characteristics Juvenile Clinical Joint Characteristics Idiopathic Arthritis Subtype Oligoarticular Four or less joints with persistent disease never having more than four-joint involvement and extended disease progressing to more than four joints within the first 6 months Polyarticular (RF negative) Five or more joints with symmetrical involvement Polyarticular (RF positive) Symmetric involvement of both small and large joints NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide ▪ however, laboratory studies may be normal in these children. • Imaging studies (MRI) can help in managing joint pathologic conditions. o Analysis of synovial fluid is not helpful in the diagnosis of JIA. NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide Management o Ophthalmology referral and evaluation is critical in a child with a positive ANA (Uveitis) o The main treatment goals are to suppress inflammation, preserve and maximize joint function, prevent joint deformities, and prevent blindness. o there is no curative treatment • Aggressive early treatment to induce a remission is a key consideration in JIA management in order to prevent deformity and improve • Aspirin therapy has largely been replaced with the use of nonsteroidal anti-inflammatory drugs (NSAIDs). • NSAIDs: Children with oligoarthritis generally respond well to NSAIDs • Ibuprofen: 30 to 40 mg/kg/day three to four divided doses (maximum single dose is 800 mg; maximum daily dose 2400 mg/day) • Naproxen, Indomethacin, Celecoxib (Older than 2 years old and adolescents) • Oral, parenteral, intraarticular corticosteroids: • Disease-modifying antirheumatic drugs (DMARDs o Nonbiologic DMARD treatment: methotrexate, sulfasalazine, leflunomide (managed by pediatric rheumatologist) o Physical therapy—range of motion muscle-strengthening exercises and heat. Rest and splinting are used if indicated. passive, active, and resistive exercises o Ophthalmologic follow-up every 3 months for 4 years (even if it has resolved) for all ANA- positive JIA children. • The disease process of JIA wanes with age and completely subsides in 85% of children; however, systemic onset, a positive RF, poor response to therapy, and the radiologic evidence of erosion are associated with a poor prognosis. Onset of disease in the teenage years is related to progression to adult rheumatoid disease. Dysplasia of the hip • The femoral head and the acetabulum are in improper alignment and/or grow abnormally. • Includes:- dysplastic, subluxated, dislocatable, and dislocated hips. • Dysplasia is characterized by a shallow more vertical acetabular socket with an immature hip/acetabulum. • Dysplasia may be diagnosed many years after the newborn period. Risk factors o hormonal effect of maternal estrogen and relaxin that are released near delivery and produce a temporary laxity of the hip joint. o Mechanical factors in utero o This is seen with first pregnancy, oligohydramnios, and breech presentation, 4x more in girls, positive family history (genetic risk factors) increases o Increased in cultures swaddle infants in extended position or cradleboard placement o In the newborn, the left hip is most often involved because this hip typically is the one in a forced adduction position against the mother's sacrum. o 60 to 80% of abnormal hips of newborns resolves by 2 to 8 weeks (self-limiting, but close observation) Clinical Findings . In the older infant, 6 to 18 months old: • Limited abduction of the affected hip and shortening of the thigh is a reliable sign o Normal abduction with comfort is 70 to 80 degrees bilaterally. o Limited abduction less than 60 degrees of abduction or unequal abduction o Positive Galeazzi sign o Asymmetry of inguinal or gluteal folds- NOT thigh-fold o unequal leg lengths, shorter on the affected side. In the ambulatory child who was not diagnosed earlier or was not corrected, the following might also be noted: NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide • Short leg with toe walking on the affected side • Positive Trendelenburg sign • Marked lordosis or toe walking • Painless limping or waddling gait with child leaning to the affected side NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide • There are seven classic endocrine glands; the pituitary, thyroid, parathyroid, testes, ovaries, adrenal (cortex and medulla), and endocrine pancreas. • Hormones released from an endocrine gland either work directly on the gland itself, or travel through circulation to target tissue and cells where they exert action on the cell or cell nucleus directly. • The hypothalamus and pituitary gland of the brain are critical to this process because the hypothalamus stimulates the pituitary gland action. Delayed Puberty: Males • No secondary sexual characteristics by 14 years ➢ 5 years since first signs of puberty to Tanner V • Causes: constitutional growth delay, primary or secondary gonadal failure, malnutrition or disordered eating, Klinefelter’s syndrome Delayed Puberty: Females • Evaluated if no pubertal signs by 13, or no menarche by 16 • Failure to complete development Tanner V within 4 years of onset of secondary sex characteristics • Most common cause: constitutional growth delay (delayed skeletal muscle growth) • Other causes: Turner’s Syndrome, extreme athleticism, disordered eating, primary or secondary gonadal failure. Precocious Puberty • Pubertal development prior to normal age of onset • GIRLS: • Before 8 years old in Caucasian, 7 years old African-American and Latino • Pubertal onset advanced in obesity • Central: Breast development, followed by pubic hair growth, menarche • *Note that girls who are obese can have breast bud development without other signs of puberty. • BOYS: • Secondary sexual characteristics prior to age 9 • BOTH • Bone age on X-ray will be older than chronological age. • Treatment in both is medications to stop stimulation of their hypothalamus-pituitary-adrenal axis. Contraceptives Epidemiology • Unintended pregnancy rates are highest among poor and low-income women, women aged 18–24, cohabiting women and minority women • Rates tend to be lowest among higher-income women, white women, college graduates and married women. • highest rate of unintended pregnancy was seen among women 20 to 24 years of age, followed by women 18 to 19 and women 25 to 29 years of age. • IUCs, implants, and sterilization are considered a “top-tier” method because less than 1 pregnancy per 100 women occurs in a year with the use of these methods. • These methods are more effective in preventing pregnancy than the second tier methods, not due to their mechanisms of action, but because they are easier to use properly. Once the top tier methods are initiated, they require little additional action to provide highly effective contraception. Sterilization • Vasectomy is an outpatient surgical procedure for male sterilization. • The failure rate of vasectomy is very low—0.10 % with perfect use and 0.15 % with typical use. • Vasectomy is cheaper, safer, and more effective than female sterilization • Traditional tubal occlusion • A surgical procedure (either by minilaparotomy or laparoscopy). • Requires a small abdominal incision and general or regional anesthesia. NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide • Occlusion techniques include tying (ligating) and blocking with mechanical devices, such as clips or rings and cauterizing. • Typical failure rates are less than 1%. NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide Newer tubal occlusion : transcervical sterilization (nonsurgical methods)Essure: ▪ Employ micro-inserts that expand and occlude the fallopian tubes as tissue grows in and around the insert. ▪ Involve a half-hour procedure, using a hysteroscopic technique. ▪ Procedure is performed in an outpatient setting, under local anesthesia. ▪ Candidates: • Women who want permanent birth control and are willing to use another birth control method for the first 3 months after the procedure, and who have a medical condition that precludes general anesthesia. • For women with medical conditions such as heart disease and obesity, microinsert procedure may be safer, partly because of routine use of local anesthesia. Some of these women are ineligible for conventional tubal sterilization. Intrauterine Contraception • There are two general categories of Intrauterine devices; ▪ one containing no hormone ▪ the other containing a small amount of levonorgestrel • The Cooper T (Paraguard) IUD is a small T-shaped device made of polyethylene. • The device has two flexible arms that fold down for insertion and expand to form a T shape when released inside the uterus. • The vertical stem of the device is wound with fine copper wire, and the two horizontal arms also have a sleeve of cooper. • The Copper-T IUD is approved for 10 years of use; however, efficacy lasts 12 years or more. LNG IUS: • Two products with 52 mg (Mirena by Bayer and Liletta by Activis); Mirena® Approved for up to 5 years of use; data demonstrate 7-year efficacy Liletta™ Approved for 3 years of use Bayer has two newer products: Skyla and Kyleena • Skyla Contains 13.5 mg of LNG, and Kyleena has 17.5 mg LNG ▪ Smaller size and lower dose than Mirena, aimed at greater acceptability among younger, nulliparous women ▪ Nulliparous women may have smaller uterine cavities and tighter cervical os than their parous counterparts. • Horizontal length = 28 mm; vertical length = 30 mm Vs. Mirena which measures 32 mm in both directions ▪ Skyla Approved for up to 3 years of use and Kyleena for 5 years Candidates: • Women who are at low risk for STIs Women who are looking for a convenient method Women who are considering sterilization However, appropriate candidates include all women of reproductive ages who are seeking a long-term, highly effective contraceptive. TYPES OF IUC ▪ The Copper T IUD:- • who don’t want hormonal contraception • women who want regular periods o women seeking a form of emergency contraception. ▪ Can be inserted up to 5 days after unprotected intercourse to prevent pregnancy ▪ More effective than use of emergency contraception pills. Insertion of a copper T IUD can reduce the risk of pregnancy after unprotected intercourse by more than 99%. NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide Mechanism of Action: o •The contraceptive effect of NEXPLANON® is primarily achieved by suppression of ovulation. o In addition to inhibiting ovulation, the implant increases viscosity of the cervical mucus, which helps inhibit sperm migration. NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide o Finally the implant alters in the endometrium by decreasing its thickness. Back up method for 4 days, if insertion is not during the first five days of menses. Inserted at the inner side of the non-dominant arm about 8-10 cm (3-4 inches) above the medial epicondyle. Insertion is subdermal. Advantages: Disadvantages: o Rapid reversibility. After implant is removed, most women (94%) ovulate by 3 months, the majority within 3 weeks. o Can use when lactating as soon as 6 wks postpartum o Noncontraceptive benefits, such as improved dysmenorrhea and possibly acne. o Bleeding irregularities, including infrequent bleeding (33.6%), amenorrhea (22.2%), prolonged bleeding (17.7%), and frequent bleeding (6.7%). o ethinyl estradiol may help control bleeding during the first few months of implant use. potential side effects Most common (≥10%) adverse reactions o change in menstrual bleeding pattern, headache, vaginitis o weight increase, acne, breast pain, abdominal pain, and pharyngitis. o Initial potential side effects include: ▪ Hormone types of side effects, including headache, acne, etc. ▪ Spotting, cramping ▪ Slight bruising, discomfort o Ongoing potential side effects include: ▪ Lighter menses or amenorrhea ▪ Less predictable light, short menses Absolute contraindications: o Current breast cancer is rated Category 4, However, breast cancer in the past; no evidence of disease for 5 years is a Category 3. o regnancy o Unexplained vaginal bleeding o Current breast cancer o Severe cirrhosis o Malignant liver tumor Combined Oral Contraceptives o Combined oral contraceptives (COCs) are a combination of estrogen and progestin. o Most COC formulations now contain between 20 to 35 mcg of ethinyl estradiol plus one of 8 available progestins. o A high number of unintended pregnancies are due to misuse or discontinuation of OCs. o Consider the “quick start” method when initiating oral contraceptives. ▪ If last menstrual period (LMP) was within the last 5 days, the method can be started immediately. ▪ In unprotected sex within last 2 weeks, start the contraceptive method today and advise patient to return to the clinic for a pregnancy test in 3 weeks. ▪ Instruct women who are using the pill, patch, ring, injection, or implant to use backup contraception for the first 7 days. ▪ Research shows that there are no significant differences in the number of bleeding- spotting days or any other bleeding parameter between the immediate and conventional starters. Mechanism of Action: NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide o The progestin in COCS is the main actor in preventing pregnancy. It suppresses the secretion of gonadotropin (mainly luteinizing hormone) by the pituitary gland. The estrogen primarily inhibits follicle-stimulating hormone secretion. o The estrogen also works synergistically with the progestin to affect the uterine lining and cervical mucus production. NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide Reduced libido • Progestins • Most Androgenic: levonorgestrel, norgestre Androgenic: norethindrone, ethynodiol diacetate Least Androgenic: desogestrel, norgestimate Spirinolactone like: drosperinone • Side effects related to Estrogen: • Breast tenderness Nausea Vomiting Headaches Elevated blood pressure (rare) Postpartum and oral contraceptives • postpartum women should not used combined hormonal contraceptives during the first 21 days after delivery because of high risk for (VTE) during this period. During days 21-42 postpartum, women without risk factors for VTE can generally initiate combined hormonal contraceptives. W Women with risk factors for VTE, such as previous VTE or recent cesarean delivery generally should not use these methods. After 42 days postpartum, no restrictions on the use of combined hormonal contraceptives based on postpartum status apply. “Mini-pills,” progestin-only pills o There are currently two formulations--norethindrone (Micronor) and norgestrel (Ovrette). Candidates: Advantages: Contraindication: Disadvantages: Counseling: o Progestin-only pills are useful for women who want immediately reversible hormonal contraception but for whom estrogen is contraindicated because of breastfeeding, cardiovascular disease, and migraine with aura, for example. o Progestin-only pills (COCs also are used) can be used to correct dysfunctional uterine bleeding. o no estrogen-related side effects that COCs have, such as nausea, headache, and bloating, but they do cause irregular vaginal bleeding. o These pills protect against cancer of the uterus and ovaries, benign breast disease, and pelvic inflammatory disease. o The only contraindication to taking progestin-only pills is current breast cancer. o The primary side effect is irregular menstrual bleeding, including spotting or breakthrough bleeding, amenorrhea, or shorted cycles. Irregular bleeding decreases in many users by cycle 12. Less common side effects are headache, breast tenderness, and dizziness. o The pill must be taken at the same time each day. o If a pill is more than 3 hours late, a backup method of contraception should be used for at least the next 48 hours. Inform women about emergency contraception. Transdermal contraceptive patch o is applied once a week to the abdomen, buttock, upper outer arm, or upper torso. ▪ Serum concentrations are maintained for up to 10 days, suggesting that clinical efficacy would be maintained even if a scheduled change is missed for as long as 2 full days. NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide ▪ Three consecutive 7-day patches (21 days) are applied, followed by 1 patch-free week per cycle. ▪ Use of the patch should be initiated during the first 24 hours of menses; no back-up is recommended. ▪ The contraceptive efficacy of the transdermal patch is comparable to that of combination NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide OCs.. Disadvantages: o Increased exposure to estrogen, which may increase the risk of side effects o Application site reactions. Adhesion is not affected by heat, humidity, or exercise. o Breast tenderness (1st few cycles) o Contraceptive failures may be increased among women weighing 90 kg (198 lbs) or more. Vaginal ring: Nuva ring o One ring is inserted into the vagina per cycle and is to remain in place continuously for 3 weeks, followed by a ring-free week. o Women not previously using hormonal contraception should insert the ring on or before day 5 of the cycle, counting the first day of menstruation as day 1. o Back-up contraception is recommended for the first 7 days of ring use. o Women switching from a combination OC may insert the ring any time within 7 days after the last combined estrogen/progestin OC and no later than the day that a new cycle of pills would have been started. No back-up method is needed. o Ring improves vaginal flora, leading to reduced frequency of bacterial vaginosis. o low incidence of gastrointestinal problems, such as nausea and vomiting. Disadvantages: o Possibility of leukorrhea and vaginitis, and 1% possibility of expulsion o Hormone-related side effects o ring is rarely felt during intercourse. **If the ring falls out, it should be rinsed with warm water and reinserted within 3 hours** 3- month injectable (Depo-Provera) : PROGESTIN-ONLY intramuscularly into the deltoid or gluteus maximus muscle every 11–13 weeks. Mechanism of Action: o As with other progestins it not only prevents ovulation; it also reduces ovarian production of estradiol. Candidates: o DMPA can be initiated immediately postpartum because it does not contain estrogen--it does not affect breastfeeding. o May improve conditions such as menorrhagia, dysmenorrhia, and iron deficiency anemia. o At least one-half of users develop amenorrhea within 12 months. o DMPA also can decrease the risk of dysfunctional menstrual bleeding in women who are overweight. o Women who do not wish to conceive immediately after discontinuing it. Advantages: o Reduces the risk of endometrial cancer by up to 80%, with continuing protection after discontinuation. o Reduces risk of PID and uterine leiomyomata o Can decrease the number and severity of crises in patients with sickle cell anemia. Contraindication: Known or suspected malignancy of the breast Disadvantages: o Weight gain o Menstrual irregularities o Long Return to fertility (10 months) o Currently is a “black box” warning that prolonged use (> 4 years) of DMPA causes an increase in fractures or has an effect on postmenopausal bone health. OTHER METHODS Less effective methods include male and female condoms, sponge, spermicides, and the cervical cap, which are likely to prevent pregnancy about 75% of the time with typical use. A new study indicates that the withdrawal method is almost as effective as the male condom at preventing NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide o Certain daily oral contraceptive pills that contain a combination of estrogen and progesterone when prescribed in higher-than-normal doses o Insertion of the copper-T IUD. NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide Testicular torsion - Acute scrotal pain is a medical emergency requiring PROMPT attention to rule out testicular torsion. • the result of twisting of the spermatic cord, which subsequently compromises the blood supply to the testicle. Generally, there is a 6-hour window following a testicular torsion before significant ischemic damage and alteration in spermatic morphology and formation occurs occur after physical exertion, trauma, or on arising. most common in adolescence and is uncommon before 10 years old. left side is twice as likely to be involved because of the longer spermatic cord. Clinical Findings • Sudden onset of unilateral scrotal pain, often associated with nausea and vomiting. The pain is unrelenting. History of bouts of intermittent testicular pain. Prior episodes of transient pain are reported in about half of patients. May be described as abdominal or inguinal pain by the embarrassed child. Fever is minimal or absent. Gradual, progressive swelling of involved scrotum with redness, warmth, and tenderness The ipsilateral scrotum can be edematous, erythematous, and warm Testis swollen larger than opposite side, elevated, lying transversely, exquisitely painful Spermatic cord thickened, twisted, and tender Slight elevation of the testis increases pain (in epididymitis it relieves pain) Transillumination can reveal a solid mass The cremasteric reflex is absent on the side with torsion Neonate—hard, painless, non-transilluminating mass with edema or discolored scrotal skin Diagnostic Studies • UA is usually normal and pyuria and bacteriuria indicate UTI, epididymitis, or orchitis. Doppler ultrasound: Testicular flow scan considered if Doppler ultrasound within normal and time allows. Management • surgical emergency Occasionally manual reduction can be performed, but surgery should follow within 6 to 12 hours to prevent retorsion, preserve fertility, and prevent abscess and atrophy. • Rest and scrotal support do not provide relief Wilms Tumor • Wilms tumor or Nephroblastoma is the most common type of renal cancer in children accounting for 90% of childhood malignancies that arise in the urogenital tract. It is the fifth most common type of pediatric cancers. Wilms tumor is an embryonal renal neoplasm which contains blastemal, stromal or epithelial cell types. Epidemiology • Wilms tumor is seen more in females than males, Whites more than Blacks and rarely in Asians. It makes up 6-7% of all childhood cancers. More than 80% are diagnosed before age 5 years. The median age at diagnosis is 3.5 years. It makes up 95% of all renal cancers seen in children younger than 5 years old. Etiology of Wilms • The majority of cases are of sporadic occurrence. In some children they also have malformation or syndromes including: aniridia( no iris in either eye), hemihypertrophy (where one side of the body is larger than the other, these children have 100 times the risk factor), GU abnormalities (cryptorchidism, hypospadias, gonadal dysgenesis, pseudohermaphroditism, and NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide horseshoe kidney), Beckwith Wiedermann syndrome ( a genetic over growth syndrome), Denys-Drash Syndrome, and WAGR Syndrome( Wilms tumor, aniridia, ambiguous genitalia, mental retardation ). NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide The length and type of chemotherapy given depends on stage and histology results. In Europe chemo therapy is started preop to downgrade tumor staging at surgery. No studies have been done as of yet to show if chemo preop changes patient outcomes or not. The national Wilms Tumor Study Group’s 4th study (NWTS-4) stated survival rates were improved by intensifying treatment initially but shortening the treatments from 60 weeks average to 24 weeks. currently 4-year overall survival rates through NWTS-4 are as follows: stage I FH, 96%; stage II–IV FH, 82%–92%; stage I–III UH (diffuse anaplasia), 56%–70%; stage IV UH, 17%. Follow up management • Pts with Wilms tumor treatment will be followed up every 4 months for first year then every 6 months for year 2 to 3 then yearly. At each follow up appointment they will have CBC and CT scan of chest and abdomen. For patients at risk for Wilms tumor should have renal ultrasound every 3 to 4 months until age 5 years. Questions 1. Sally age 15 months is brought to your office for her 15month well child visit. Her mother and father are both present for the exam. Her mother tells you she has noticed over the past 3 weeks that Sally had to go up a size in clothes because they are too tight on her stomach. On examination of Sally’s abdomen, you feel a smooth firm mass in the right upper quadrant of her abdomen. Bowel sounds are normal and abdomen is soft other than for the mass. What needs to be ordered to evaluate this mass? a) CT Scan chest and abdomen 2. Jane is 3 months old she is the first born of Steve and Mary. Steve works as an autobody repairman and Mary works as a pest exterminator. What does Janes history put her at risk for? a) Wilms Tumor 3. What is the standard for screening high risk children for Wilms Tumor. a) renal ultrasound every 3-4 months until age 5 years Cardiac Symptoms and Diseases in Children Review of Fetal Circulation and Cardiac Cycle Cardiac anomalies affect almost 8 in 1,000 children, with 90% of these patients living well into adulthood - The majority of children are noted to have a murmur at some point in their life noted on routine physical examinations, but less than 1% of all murmurs are caused by a congenital defect - review the differences between fetal and non-fetal circulation and have a working knowledge of the locations and closure times for open fetal circulation routes. - Please note the location of the following fetal shunts. Ductus venosus: Connects the umbilical vein to the inferior vena cava. Ductus arteriosus: Connects the pulmonary artery to the aorta. Foramen Ovale: Opening between the right and left atrium. • A routine and complete cardiac exam for symptomatic patients or for patients undergoing a sports physical should include a thorough familial and past medical history and include the evaluation of syncopal events, past cardiac history, medications, other substances, diet, hydration, and neurological symptoms. The physical exam should include vital signs, general inspection, skin and nail bed color, respiratory rate, and full inspection, auscultation, and palpation of the chest and peripheral pulses. Evaluation of Murmurs Murmurs are the most common finding leading to a cardiology referral in children. New onset, worsening, or murmurs associated with other symptoms should always be evaluated further by a pediatric cardiologist. In documenting murmurs, the following should be noted. • Location • Radiation • Relationship to the cardiac cycle • Intensity (Grade I-VI) • Quality NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide • Positional changes Grading for murmurs is as follows. Grade I—soft Grade II—soft, but easily heard NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide Grade III—loud but without a palpable thrill Grade IV—loud and with a precordial thrill Grade V—loud with a thrill, and audible with only the edge of the stethoscope Grade VI—very loud and audible with the stethoscope off of the chest There are several types of innocent murmurs. Two of the most common are below: Newborn murmurs—This murmur is heard at the left lower sternal boarder and only in the first few days of life, is quiet and does not radiate, and lasts only the first few weeks of life. Still’s murmur—This murmur is the most common innocent murmur in children. It is soft, grade I-III, is more prominent in a supine position, with fever or anemia, and can disappear with inspiration. (Hay et al., 2014) Congenital Cardiac Disease Congenital cardiac anomalies and the structure of the heart should be known by the NP. Many anomalies are noted prior to birth now due to ultrasonography, but many can still go undetected. For example, Coarctation of the aorta can be missed until the child is well into their first year of life or has presenting symptoms. Do not assume that you will not find congenital cardiac defects in children outside of the newborn period and be aware of signs and symptoms of disease. The following are listings of acyanotic and cyanotic heart diseases. Acyanotic Cyanotic Atrial septal defect Tetralogy of Fallot Ventricular septal defect Pulmonary atresia Atrioventricular septal defect Tricuspid atresia Patent ductus arteriosus Hypoplastic left heart Pulmonary valve stenosis Transposition of the great vessels Coarctation of the Aorta Truncus arteriosus Aortic stenosis Prolonged QT Syndrome and Sudden Cardiac Death Sudden cardiac death in youth and athletes can occur for various reasons; prolonged QT syndrome and cardiovascular disease are two of the most common. The survival rate of non-traumatic cardiac arrest is only 7.8%, but bystander witnessed ventricular fibrillation has a 57% survival rate (American Heart Association, 2013). Athletes are at increasing risk due to increasing rates of youth hypertension, high cholesterol, and stimulant use. The majority of sudden deaths in athletes from cardiovascular disease are male (89%), in high school (54%), during exertion (82%), and being of African-American descent (29%) (American Heart Association, 2013). Some of the most important actions to prevent deaths are completion of a good history and sports physical examination, screening of children with a familial history of sudden cardiac death, education of patients, families, and schools about the importance of limiting exertion in heat, adequate hydration, and proper training of coaching staff to deal with and recognize important symptoms and take action in emergent situations. Iron deficiency anemia (Microcytic anemia ) Approximately 3% to 7% of children at age 1 year suffer from iron deficiency 9% of adolescent girls develop iron deficiency and 2% to 3% between the ages of 12 and 19 years old develop anemia primarily due to rapid growth, heavy menses, and nutritionally inadequate Iron deficiency is the most common cause of anemia, even as cases steadily decline when nutritional practices improve. R i s k F a c t o r s f o r I r o n D e f i c i e n c y A n e m i a NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide n Width y Iron deficiency anemia Low or normal Low High (>14%) Low High NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide Classification History Physical Findings Screening Tests Diagnostic Studies Treatment (IDA) Patient and Family Education • increase iron-rich food sources in their child's diet. • Exclusively breastfed term infants should be started on iron supplementation at 4 months old and pureed meats added to the child's diet after 6 months old. • Whole cow's milk should be avoided in infants younger than 12 months old due to its low iron content and possibility of insensible GI blood loss. • After 12 months old, cow's milk ingestion should be limited to 24 ounces per day. • For preterm infants, supplementation with oral iron drops should begin no later than 1 month old. (2 mg/kg/day after 2 weeks of age through 12 months old) • avoid giving iron with meals or milk, that vitamin C juice enhances absorption, and that the child's stools will probably turn black. • Foods containing soy can inhibit the absorption of iron. • Any dental staining associated with taking iron can be removed with dental cleaning. • Commercial cereal (such as, Kix) can be given as a dry food snack Febrile seizures • most common type of seizures in children. brief, generalized, clonic or tonic-clonic in nature, and can be either simple or complex. A concurrent illness is present with rapid fever rise to at least more than 102.2° F (39° C), but the fever is not necessarily that high at the time of the seizure. Minimal postictal confusion is associated with febrile seizures. Simple febrile seizures last less than 15 minutes and may recur during the same febrile illness period. Complex febrile seizures last longer than 15 minutes, can recur on the same day, and can have focal attributes (even during the postictal phase). Febrile SE is uncommon, rarely stops spontaneously, is fairly resistant to medications, and can persist for a long period of time. Most children in febrile SE require one or more medications to end the seizure. A report found that reducing the time from seizure onset to anticonvulsant medication administration was key to reducing the seizure duration during an episode. Risk factors • Family medical history for febrile seizures or in those with predisposing factors (e.g., neonatal intensive care unit [NICU] stay more than 30 days, developmental delay, day care attendance). Age 6 months to 60 months. Male gender lower sodium level. Approximately 2% to 5% of neurologically healthy infants and young children experience at least one simple febrile seizure with about 30% of this group experiencing a second episode Diagnostic Studies. • A lumbar puncture may be done in infants younger than 12 months old and who may also have used an antibiotic prior to seizure onset, and/or in those who have signs of meningeal irritation. Blood glucose in all children. CBC, calcium, electrolytes, and urinalysis are optional but frequently included. EEG if neurologic signs are present or seizure was atypical. MRI for complex febrile seizure features or if any doubt exists about the diagnosis. Management • Protect the airway, breathing, and circulation if the seizure is still occurring. Place the child in a NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide side- lying position to prevent aspiration or airway obstruction. Reduce the fever with acetaminophen or ibuprofen (oral or suppository) after the seizure has stopped, although the use of antipyretics will not necessarily prevent another febrile seizure. NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide Monitor • Growth using spcld growth chart OSA Annual vision/hearing Annual thyroid screen Caution- Increased risk of leukemia, duodenal atresia & cardiac anomalies Developmental Cues: (Burns) pg 1163 • Intellectual disability/ developmental delays Hearing loss Hypotonia as infant Etiology/Incidence 1. Three different genetic alterations a. In 95%, Down syndrome is result of a random nondisjunction (trisomy 21) b. Less commonly, it occurs as mosaicism where some cells are affects and others are normal c. Balanced translocation, often involves chromosome 21 and 14 2. 1 in 800 to 1,000 live births 3. Affects males and females equally. Risk factors include • advanced maternal age, previous child with Down syndrome or another chromosomal abnormality; parental balanced translocation; parents with chromosomal problems Signs and Symptoms • Mental retardation, mild to severe Typical phenotypic signs at birth Head—midface hypoplasia; small brachycephalic head with epicanthal folds, fl at nasal bridge, upward slanting palpebral fissures, Brushfield spots, small mouth Eyes- Myopia b. Ears—small ears c. Neck—excessive skin at the nape of the neck d. Hands and feet—simian crease and short fifth finger with clinodactyly; a wide space, often with a deep fissure between the first and second toes; lymphedema, brachydactyly (shortened digits), e. Neurological—mental impairment is variable,ranging from mild (IQ: 50–70), to moderate (IQ: 35–50), and only occasionally to severe (IQ: 20–35) f. Cardiac—increased risk of congenitalheart defects (50%) g. GI—Hirschsprung’s disease (1%); gastrointestinal atresias (12%) h. Musculoskeletal—hypotonia; acquired hip dislocation (6%) Differential Diagnosis: Other genetic or chromosomal syndromes NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide Physical Findings: • Phenotype as above Hearing loss (75%); otitis media (50%–70%)3. Obstructive sleep apnea (50%– 75%) Signs of congenital heart disease—50%; Endocardial cushion defect most common(45%) with ventricular septal defects (35%) second NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide Signs of hypothyroidism and other endocrine problems—15% Signs of anomaly of GI tract 5%; Celiac disease15% Ligamentous laxity—100% Hematological—leukemia ( 1%)9. Eye—eye disease (60%), including cataracts 15%), and severe refractive errors (50%) Obesity—50% by early childhood Musculoskeletal—ankle pronation and pes planus Premature aging At risk for Alzheimers, Hypothyroidism & Leukemia Diagnostic Tests/Findings Pre or postnatal chromosome analysis reveals 47 XY or XX _ 21 karyotype • CBC with differential to identify those with leukemia; 10 to 15 fold increased risk Symptoms of atlantoaxial instability (neckpain, decreased range of motion of theneck, gait disturbance, bowel or bladder dysfunction, hyperreflexia or paresthesias): radiographic finding of atlantoaxial instability Ophthalmologic evaluations every two years between 3 to 5 years then yearly after this (50% risk of refractive errors between (3 to 5 years) Management/Treatment : Primary prevention via education : ▪ Risk factors: Secondary prevention via prenatal diagnosis Monitor for growth and family support every well visit • CBC at one year, every year starting at age 13 to 21, and if clinically indicated Initial evaluation by cardiology to rule out congenital heart defect even if no murmurs are hear Screen for celiac disease using tissue transglutaminase and IgA starting at age 2 Early intervention by PT, OT, speech therapists; special education; review individualized educational plan Genetic counseling for parents and older siblings Periodic full history and physical with sensory and developmental evaluations Nutritional support Screen for thyroid disease yearly; up to 30% risk Prompt referral for associated conditions Patient advocate and guide family during transition to adult care Referral to appropriate web sites for education and support Precocious puberty - Signs of puberty earlier than expected All endocrine occurs in the pituitary Causes : • Exogenous Adrenal Obesity Signs- no endometrial stripe should be present o Females • Thelarche o Generally considered the onset of puberty o Occurs in most girls at 9.5-10.4 • Menarche o Mean age of onset = 12 yrs • Adrenarche NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide (F2 ALPHA) in the endometrium- causing uterine contractions and vasoconstriction leading to ischemia and pain, elevation or peak of prostaglandins is brought about by falling progesterone levels during luteal phases in ovulatory cycles. NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide Epidemiology: Clinical findings: o Leading cause of absenteeism in schools and work > 10% o Present in 50 % of adolescents ▪ Ask about history (menstrual), attitudes and beliefs ▪ Onset: 6-24 mos after menarche ▪ Location- lower mid-abdominal area radiating to back/thighs ▪ Duration/ timing of pain ▪ Character ▪ Associated sx, n/v, diarrhea, headaches, fatigue, nervousness, dizziness, urinary frequency low back pain ▪ Aggravating factors ▪ Treatment or meds tried including complementary and Alternating medicines, (CAM) ▪ Sexual activity ▪ Absenteeism from school and work ▪ Cigarette smoking ▪ Family hx of dysmenorrhea For secondary dysmenorrhea ask about onset and pelvic pain other menstruation, character of pain, hx of infection dyspareunia, hx of sexual abuse, family hx of endometriosis Physical Examination: ▪ Complete physical exam if secondary dysmenorrhea is suspected, may defer bimanaul or speculum if hymen intact Diagnostic studies if indicated: ▪ NAAT’S or cervical cultures for GC ▪ CBC with sed rate if PID suspected ▪ Pregnancy test ▪ Pelvic ultrasound Management- ▪ Prostaglandin Synthetase inhibitors, administered at onset of menses or if cramping precedes menses at onset of sx. ▪ Tx for duration of pain 1-2 days ▪ Trial period should extend 3 cycles if fails try another alternative prostaglandin inhibitor, eg- PI ARE ▪ Ibuprofen 400-800 mg po tid with food ▪ Naproxen 500 mg at onset f/o by 250 mg-500mg ▪ Naproxen Sodium: 550 mg at onset f/o 275 mg q6-12 hrs, max dose 1375 mg/24 hrs ▪ Mefenamic acid : 500 mg at onset f/o 250mg q6h ▪ Meclofenanate: 100 mg initially 50-100mg q6h ▪ OCP’S used also as suppress ovulation total progesterone-induced prostaglandin production is decreased in the endometrium. Dose recommended is 30-35 mcg estrogen-progestin combimation pill for 3-6mos trial if PI arenot successful. ▪ CAM is beneficial like, application of topical heat, ▪ Thiamine 100 mg/daily ▪ Toki-shakuyaku-san (herbal remedy), 2.5mg 3 times a day ▪ High frequency TENS ▪ Vit E , 500 units/DAY ▪ Magnesium ▪ f/o up by telephone or visit to adjust dose or change as needed. ▪ Stress, reduction exercise, and well-balanced diet wit ample of fiber and water in addition to decreasing caffeine, chocolate, and salt intake maybe helpful. NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide Coarctation of the aorta (Burns, 779) NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing M o s t C o m m o n Ty p e s o f P r i m a r y H e a d a c h e s S e e n i n P r i m a r y C a r e S e t t i n g s Diagnostic Criteria Based on History Pediatric Migraine Headache More than five attacks fulfilling features of B through D Duration: 2 to 72 hours At least two of the following features: 1. Bilateral or unilateral (commonly bilateral in young children; unilateral pain usually emerges in late adolescence or early adult life) NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide Supravalvular Aortic Valve Stenosis: (Burns) pg 777 ▪ Most common form of stenosis ▪ Usu bicuspid rather tricuspid ▪ Stenosis causes increased pressure load on the left ventricle leading to LVH and ventricular failure ▪ The bicuspid valve becomes more stenotic and often regurgitant ▪ More common in females with Turners syndrome ▪ AS occurs in 3%-8% of all CHD with male to female ratio of 4:1 Signs AND Symptoms: ▪ Asymptomatic with a murmur noted on routine P.EXM as progression is experienced ▪ Activity intolerance, chest pain and fatigue or syncope can develop ▪ CHF, low cardiac output and shock may be evident in newborns ▪ Sudden death from arrhythmias can occur from increasing stenosis and exertion ▪ Growth and development is normal Physical Examination ▪ BP may reveal a narrow pulse pressure, apical pulse is pronounced ▪ A grade III TO IV/VI , loud, harsh systolic crescendo-decrescendo ▪ Murmur is best heard at upper right sternal border radiating to neck. LLSB and apex ▪ With a valvular lesion a faint early systolic click at LLSB may be heard Diagnostic Tests ▪ Chest radiographs are usually normal or may show LVH enlarged heart, and or rib notching ▪ Adults develop calcification of aortic valves over time ▪ ECG/EGG can be normal or show LVH and inverted T-Waves ▪ 24 hr holter monitor or 30-day monitor can show ventricular arrhythmia ▪ ECHOCARDIOGRAM is the diagnostic examination of choice. Management ▪ Balloon valvuloplasty of the stenotic valve is the initial palliative tx in the newborn ▪ In older children valve replacement may be necessary ▪ Patients with supravalvular aortic stenosis require resection of the narrowed area wit patch material ▪ For gradient > 35 mmHG surgical resection is required ▪ Children with mild AS, can participate in all sports but should have all annual cardiac examination ▪ Moderate aortic stenosis children should low intensity sports such as ( golf, bowling, table tennis or softball). ▪ Children with severe AS, or moderate AS should avoid competitive sports because of the risk of sudden death from ventricular arrhythmias. ▪ SBE prophylaxis is necessary for 6 mos after surgery ▪ Anticoagulation is necessary with mechanical valve replacement Headaches: Burns, (pg 685) NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide a. Usually frontal/temporal b. Occipital is unusual and should be carefully evaluated (occipital headache in children whether unilateral or bilateral is rare and calls for diagnostic caution; many cases are attributable to structural lesions) 2. Pulsating quality 3. Moderate to severe intensity aggravated by routine physical activity 4. At least one of the following: a. Nausea and/or vomiting b. Photophobia and phonophobia (can infer from behavior) 5. Not attributed to another disorder Infrequent Episodic Tension Type Headache A. At least 10 episodes occurring on <1 day per month on average (<12 days per year) and fulfilling criteria B through D B. Headache lasting from 30 minutes to 7 days C. Headache has at least two of the following characteristics: 1. Bilateral location 2. Pressing/tightening (non-pulsating) quality 3. Mild or moderate intensity 4. Not aggravated by routine physical activity, such as walking or climbing stairs D. Both of the following: 1. No nausea or vomiting (anorexia may occur) 2. No more than one of photophobia or phonophobia E. Not attributed to another ICHD-3 diagnosis Chronic Tension Headache A. Headache occurring on ≥15 days per month on average for >3 months (≥180 days per year) and fulfilling criteria B through D B. Headache lasts hours to days or may be continuous C. Headache has at least two of the following characteristics: 1. Bilateral location 2. Pressing/tightening (non-pulsating) quality 3. Mild or moderate intensity 4. Not aggravated by routine physical activity such as walking or climbing stairs D. Both of the following: 1. No more than one of photophobia, phonophobia, or mild nausea 2. Neither moderate or severe nausea nor vomiting E. Not attributed to another ICHD-3 diagnosis ICH Physical Examination. A complete physical and neurologic examination is in order: • Blood pressure, supine and standing with 2-minute interval between them • Height and weight • Head circumference (all children) • Eyes: Palpate for tenderness; check discs for papilledema, movements • Ears: Patency of canals, normal tympanic membranes • Neck: Palpate muscles; check range of motion for nuchal rigidity • Sinuses (frontal and maxillary) • Teeth (percuss, inspect) • Temporomandibular joints (mouth and jaw): Palpate and check range of motion • Thyroid gland • Bones and muscles of skull: Palpate for tenderness; listen for cranial bruits; check range of motion of cervical spine • Extremities: Tandem gait NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide • Nerves: Palpate supraorbital, trochlear, occipital nerves; assess CN IX to CN XII • Reflexes: Pronator drift test (Romberg) • Vision screen NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide • Fatigue, dizziness, or anxiety • Migraine headaches • Chest discomfort Most people who have mitral valve prolapse (MVP) don't need treatment because they don't have symptoms and complications. If you need treatment for MVP, medicines can help relieve symptoms or prevent complications. Very few people will need surgery to repair or replace the mitral valve. MVP puts you at risk for infective endocarditis, a kind of heart infection. To prevent it, doctors used to prescribe antibiotics before dental work or certain surgeries. Now, only people at high risk of endocarditis need the antibiotics. Overview • NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing NR 602 NRMIDTERM study NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing guide Aortic dissection and aortic aneurysm An aortic dissection is a serious condition in which the inner layer of the aorta, the large blood vessel branching off the heart, tears. Blood surges through the tear, causing the inner and middle layers of the aorta to separate (dissect). If the blood-filled channel ruptures through the outside aortic wall, aortic dissection is often fatal. Aortic dissection is relatively uncommon. The condition most frequently occurs in men in their 60s and 70s. Symptoms of aortic dissection may mimic those of other diseases, often leading to delays in diagnosis. However, when an aortic dissection is detected early and treated promptly, the chance of survival greatly improves. Symptoms Aortic dissection symptoms may be similar to those of other heart problems, such as a heart attack. Typical signs and symptoms include: • Sudden severe chest or upper back pain, often described as a tearing, ripping or shearing sensation, that radiates to the neck or down the back • Sudden severe abdominal pain • Loss of consciousness • Shortness of breath • Sudden difficulty speaking, loss of vision, weakness or paralysis of one side of your body, similar to those of a stroke • Weak pulse in one arm or thigh compared with the other • Leg pain • Difficulty walking • Leg paralysis NR 602 NRMIDTERM study guide latest update RATED A+ Chamberlain College of Nursing