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NCTC Pedi LVN
| Question | Answer |
|---|---|
| Separation anxiety Stages: | Protest Despair Denial |
| Protest | Sense of abandonment is expressed loudly Cry is continuous until they fall asleep |
| Despair | Crying stops but child is sad and depressed Children move about less and withdraw from strangers as they approach Children do not play with toys |
| Denial (AKA detachment) | Children deny their need for the parent Children become detached and disinterested in parents' visits As they become more active with others or toys, it appears they have adjusted but this is a coping mechanism |
| Separation Anxiety Nursing Interventions | Facilitate parent-infant bonding at all times Teach parents not to sneak out while child is distracted Promote leaving with loving hug, wave, and prompt exit Return at the promised time promotes reestablishing trust |
| Regression | loss of achieved function to a past level of behavior that was successful during earlier stages of development |
| Regression Nursing Interventions | Accurately assess child's abilities Plan care to support and maintain growth and development Do not punish regression - ignore it Praise appropriate behavior |
| THE HOSPITALIZED INFANT | Breastfeeding may not be possible May regress if previously used cup at home They miss their continuous affection of the parents Daily schedules are upset |
| Indications for assessing pain in the infant: | Crying becomes more intense Increased body movements Skin changes (pale or flushed, diaphoretic) Facial grimaces VS fluctuations |
| Nursing interventions for the hospitalized infant | Major nursing goal is to facilitate parent-infant bonding Ease tension of parents to ease tension in infant Role model by cuddling, rocking, talking, singing Use liberal visiting hours |
| THE HOSPITALIZED TODDLER | Separation anxiety is most pronounced for the toddler |
| transitional object | favorite blanket or toy to promote security |
| Toddler hospital nursing interventions | Be truthful about painful procedures using age-appropriate explanations immediately Avoid treatments in the playroom Allow child to play with safe equipment used in their care Allow freedom of movement as much as possible |
| THE HOSPITALIZED PRESCHOOL CHILD | Is less threatening to preschooler than the toddler May feel guilty if hospitalization is due to mischief on their part Are afraid of bodily harm worry about physical deformities Will be inventive to get food if NPO |
| THE HOSPITALIZED SCHOOL-AGE CHILD | Able to accept hospitalization more readily Like to talk to adults and desire respect about their opinions Education must continue throughout the hospitalization likes to appear brave |
| THE HOSPITALIZED ADOLESCENT ; Early adolescence (10 - 13) | Hospitalization is mainly a threat to body image Worry about how illness will affect appearance, functioning, and mobility Self-portrait drawings may be effective at this time Still desire relationships with same sex friends |
| Middle adolescence (14 - 16) | Will be anxious about their appeal to the opposite sex Hospitalization can be especially taxing because of loss of control for independence Incorporate choice, privacy, appropriate hair and cosmetic appearance, and opportunity for peer visitation |
| Late adolescence (17 - 21) | Hospitalization may pose threat of postponement of career and future plans Are able to think abstractly and understand implications of their illness Need to participate in care decisions anxiety in proportion to past experience and available strengths |
| Roommate selection - Adolescent | Is extremely important for this age Teens usually do better with one or more roommates than in a single room Ideally will assign roommates of like peers - no dying elderly people!! Recreation area for peer group association and privacy should be provided |
| Patients in pain have: | Higher levels of cortisol Compromised immune systems More infections Delayed wound healing |
| Techniques for relieving pain | Drawing - tells how and where it hurts Distraction - story telling, quiet conversation, puppet play Imagery - describing themselves in a safe place to lessen anxiety Relaxation - breathing techniques Cognitive techniques - "thought stopping" |
| Pain in children | tends to be under treated If you are going to do something painful be honest about it Nurses need to have high level of suspicion of pain Infants cannot show where it hurts Children do not realize they should report pain Pediatric pain scales |
| Fear | Invasive procedures are fear-producing They disrupt the child's trust level They threaten self-esteem and self-control They require restriction of activity Perform the procedure as gently as possible and maintain dignity, modesty, and privacy |
| Fostering intercultural communication | essential for successful outcomes of parent - infant teaching Design teaching strategies to approach the topic from the perspective of the culture |
| Essential safety measures in the hospital setting | Keep crib side rails up Identify child be bracelet, not room number * Inspect toys for sharp edges and removable parts Remain with the small child while taking temperatures |
| Safety Don'ts | Don't prop bottles or force feed small children. remove dressings or bandages unless specifically instructed leave small children or infants unattended, especially in baby swing, feeding table,bathtub, highchair or when out of the crib |
| Tachycardia | early sign of shock - should be considered an emergency |
| Hypotension | late sign of shock - should be considered an emergency |
| Fontanels: | Flat = normal Sunken = dehydration Bulging = increased intracranial pressure |
| Bradycardia | is a medical emergency |
| Pulse and respirations | taken in the same manner as the adult for 1 full minute under 5 years of age get an apical pulse |
| Pulse | Infant 120-160 Toddler 110-130 Preschool 100-120 School-age 90-115 Adolescence 70-110 |
| Respirations | Infant 26-40 Toddler 20-30 Preschool 20-30 School-age 18-24 Adolescence 16-24 |
| Blood pressure | Cuff should cover two-thirds of the upper arm Pressures in the legs are generally higher Determine pulse pressure by subtracting diastolic from systolic Widening pulse pressure may indicate increasing intracranial pressure |
| Temperature route should always be recorded on graphics sheet | Oral temperature (97.6 - 99.3) Rectal temperature (98.6 - 100.0) Axillary temperature (96.6 - 98.0) Tympanic temperature (98.4 - 99.5) |
| Weight | means of determining progress of recovery Infants weighed naked on scale covered with scale paper or diaper and rebalanced |
| Head circumference | is measured on infants and toddlers Tape is placed above eyebrows and ears for measurement |
| Urine specimens | Explain procedure carefully as age-appropriate weigh diapers - 1g =1ml |
| Gastric influences | Absence of hydrochloric acid until age 2 |
| Intestinal influences | Rapid transit through gut if under 5 Pancreatic enzymes are lower if under 1 |
| Topical medications (ointments) | Increased absorptive capability in infants and children May be increased even more when skin is covered with diaper |
| Parenteral medications (IM) | Slowed absorption due to poor peripheral perfusion IM meds in neonates will more readily pass the blood-brain barrier Requires more care with meds that depress the respiratory center |
| Metabolism | Immature liver and enzymes require careful timing to prevent toxic levels |
| Excretion | Immature kidneys prevent proper excretion of some drug |
| NURSING RESPONSIBILITIES IN ADMINISTERING MEDICATIONS TO INFANTS AND CHILDREN | Observe for toxic symptoms Document positive and negative responses Calculate safe dosages before administering any medication Official safe dosages provided by manufacturer and PDR |
| Medication teaching instructions for parents | Importance of administering the medicine Importance of completing the prescribed course Techniques of measuring amount of medication to give in each dose Do not use home teaspoons to measure meds Use calibrated measuring devices from the pharmacy |
| Techniques of administering medications to their infant or child | Use dropper, syringe, or measured cup Do not mix medication with formula, food, or water Shake meds before administering Refrigerate unused portions of medications |
| Techniques of encouraging child compliance | Allow toddler and young child to assist Provide praise for cooperation and perhaps a chart of stars or stickers for compliance Provide good tasting liquid or ice-pop following administration of a medication that has a bad taste |
| Calculating pediatric drug dosages | BSA is most accurate Always double-check calculations with another nurse |
| Nose drops | Restrain child when necessary Extend neck over pillow or place head over side of mattress Instill drops Maintain position for ½ - 1 minute |
| Ear drops | administered at room temperature 3 yrs. and under, pull pinna of ear down and back ;over 3 yrs., pull pinna up and back Massage area in front of ear to facilitate entry of drops Remain on side for 5 - 10 minutes as possible |
| Eye drops/creams | Apply drops into the lower conjunctival sac, never directly onto the eyeball After application, close eye but do not squeeze it (expels some of the med) |
| Rectal medications | Insert suppository about half as far as the forefinger will reach Hold buttocks together until the desire to expel the suppository subsides |
| Absorption occurs by slow diffusion into the capillaries Rotate sites Do not administer irritating meds SQ | |
| IM route | Aspirate syringe to insure med will be instilled into the muscle and not the vein Vein injection can cause a toxic response |
| IM sites | Vastus lateralis muscle is preferred for children 3 and under Ventrogluteal can be used after child has been walking for over 1 year Avoid dorsogluteal in infants Avoid deltoid until after age 6 |
| Reducing the pain of injections | Position the child carefully Can use topical anesthetic EMLA when time of injection can be planned in advance Insert needle rapidly Inject medication slowly Remove needle rapidly Mildly massage site Select proper gauge of needle |
| Intravenous medications | Sites must be assessed q hour for signs of inflammation, infiltration, leakage, fluid overload, or other complications Hourly refill of buretrols and flow rates |
| Otitis externa | Acute infection of the outer ear Often called "swimmer's ear" External ear is red, but tympanic membrane is normal Irrigation and topical antibiotics are treatments of choice |
| Otitis media | Inflammation of the middle ear Connected to throat by eustachian tube and mucous membranes May be secondary to URI or accompany communicable diseases Infants are more prone due to short, wide, straight eustachian tubes |
| Otis Media Manifestations | Ear pain, irritability, hearing loss, fever, headache, vomiting, diarrhea, febrile convulsions Infant may pull at ears Some are asymptomatic Pus drains from ear with perforation of eardrum |
| Treatment and nursing care; Otis Media | Throat culture is taken to identify causative organism Antibiotics are administered empirically for 10 days Analgesics may be administered to relieve pain Myringotomy may be necessary to relieve pressure in the middle ear |
| Hearing impairment | Hearing impaired children are usually seen for conditions unrelated to hearing Congenital deafness results when mom was exposed to viral illness during early prenatal life Acquired deafness results after infectious diseases |
| Complete deafness | may be accompanied by behavior problems, aggression, affected personality development from ridicule, and speech impediments |
| Nurse must be aware of the symptoms of deafness | Persistence of moro reflex beyond 4 months Newborn response to auditory stimuli No verbal attempts by 18 months Indifference to sound Behavior problems |
| During hospitalization | Smile and use communicative body language Face child when speaking and position yourself at eye level Be seen before touching child Speak in short sentences in clear, natural tone Use careful explanation for procedures |
| Barotrauma | Avoid discomfort when flying by feeding or use of pacifier during take-off and landing |
| Newborn can see but sight is not mature | Visual acuity is approx 20 / 400 and rapidly improves to 20 / 30 or 20 / 20 by age 2 - 3 Eyes may appear crossed in the early weeks of life Tears are not present until 1 - 3 months Depth perception does not develop until about 9 months |
| Snellen chart | has E version and picture version for preschoolers and alphabet version for school-age children who can read |
| Amblyopia (lazy eye) | Is reduction or loss of vision in children who favor one eye Prognosis depends on how long the condition has been present before treatment and the age of the child |
| Amblyopia (lazy eye) Treatment and nursing care | Older children may take months or years to correct Daytime patching (occlusion) may be difficult to maintain Children may be ridiculed by other children |
| Reye syndrome | Is nonspecific encephalopathy with fatty degeneration of the viscera Mainly affects the liver and brain Disease is triggered by virus and results in brain swelling |
| Manifestations Reye syndrome | Early, there are symptoms of viral infection from which the child is recovering like flu or chicken pox Clinically the child will have malaise, persistent vomiting, and lethargy Liver enzymes, serum ammonia levels, and prothrombin times will be elevated |
| Prevention of Reye syndrome | education to avoid use of salicylates during viral illness |
| Treatment and nursing care Reye syndrome | Treatment is supportive and intensive care is indicated Fluid management and mannitol prevent IICP EEGs monitor brain stabilization Monitor closely the respiratory status |
| Meningitis | inflammation of the coverings of the brain and spinal cord |
| Factors that increase the risk of meningitis | CNS anomalies, immunity deficiencies, immunosuppressive therapy, sickle cell disease, and congenital or traumatic absence of the spleen |
| Meningitis Manifestations | Severe headache, drowsiness, delirium, irritability, restlessness, fever, vomiting, stiff neck and spine, high-pitched cry in infants, convulsions, coma, opisthotonos (involuntary arching of the back), petechiae |
| Meningitis Treatment | Lumbar puncture reveals presence of pus, increased number of WBCs, increased protein, and decreased glucose Isolation is necessary for 24 hours after antibiotic therapy (10 days) IV therapy Sedatives Anticonvulsants |
| Meningitis Nursing care | Decrease stimuli Plan care to facilitate as much rest as possible Monitor for signs of IICP: Monitor for residual effects from the disease Weakness of the limbs, speech difficulties, mental confusion, behavior problems |
| Febrile seizures | Transient condition of children between ages of 6 months to 5 years Seizure is in response to rapid rise in temperature Rarely evolve into epilepsy |
| Epilepsy | Disease is characterized by recurrent paroxysmal attacks of unconsciousness or impaired consciousness |
| Important nursing observations during any seizure activity | Activity immediately before seizure Body movements Changes in color, respiration, or muscle tone Incontinence Parts of the body involved How long the seizure lasted Appearance, behavior, and level of consciousness after the seizure |
| Tonic-clonic (grand mal) | Most common and dramatic 3 distinct phases Aura Tonic-clonic seizure Postictical lethargy (sleep) |
| Absence (petit mal) | Characterized by transient loss of consciousness - usually less than 30 seconds Following the seizure, the child is alert and appears normal |
| Partial seizures | Consciousness is intact or impaired Often mistaken for alterations in behavior |
| Seizure Diagnosis made by | history, neurologic exam, skull x-ray, CT scan to rule out pathology, MRI, EEG, lumbar puncture if infection is suspected Lab studies include: CBC, serum calcium, BUN, lumbar puncture |
| Status epilepticus | Condition of prolonged seizure activity that does not respond to treatment for 20 minutes or more Frequent cause - sudden stopping of medication or generalized infection |
| Cerebral Palsy | Group of nonprogressive disorders that affect the motor portion of the brain causes- birth injuries, neonatal anoxia, subdural hemorrhage, & infections like encephalitis or meningitis In toddlers - lead poisoning, head injuries, febrile illness |
| Cerebral Palsy - Spasticity - most common | Characterized by tension in certain muscle groups When child tries to move the voluntary muscles, jerky motions result Lower extremities are usually involved - legs cross and toes point inward |
| Athetosis - second most frequent type of Cerebral Palsy | Characterized by involuntary, purposeless movements that interfere with normal motion Speech, sight, and hearing defects may be present Convulsions may be present Emotional problems may complicate the situation |
| Cerebral Palsy - Treatment and nursing care | Objective is promote maximum functioning as possible Encourage participation in community resources Long course of the disability is financially draining Caretakers require respite care encourage active ROM Orthopedic surgery may be indicated |
| Epiphyseal plate | fractures in children can disrupt growth of bone |
| Important developmental milestones to remember | Newborn hip has limited internal ROM Newborn feet normally turn inward (varus) or outward (valgus) Toddler feet appear flat due to the fat pad of the foot |
| Bryant traction | used in children under 2 to suspend both legs vertically Child's weight is the countertraction Pulleys and weights should hang freely Legs are at right angles to the body with buttocks off bed |
| Volkmann's ischemia | caused by arterial occlusion resulting in anoxia of the muscles and reflex vasospasm Can lead to contractures and paralysis if unnoticed and untreated |
| Buck's extension | skin traction that pulls hip and leg into extension Traction pulls from the foot with the body as countertraction |
| Russell traction | uses a sling under the knee to keep the distal thigh above the bed Pulls leg in two directions - from the knee and the foot - with one set of weights |
| Skeletal traction | a pin or wire inserted through the bone is the site for traction weight A boot or sling supports the lower leg |
| Crutchfield or Barton tongs | - used in the skull to provide cervical traction |
| DUCHENNE'S MUSCULAR DYSTROPHY (Pseudohypertrophic) | One of a group of disorders in which there is progressive muscle degeneration Duchenne occurs in childhood and is most common hereditary on the X chromosome and affects boys only Death is usually a result of respiratory infection or cardiac failure |
| Duchenne's MD Primarily affects muscles of the shoulders and pelvis | Onset between 2 and 6 with possible developmental delays evidenced during infancy Waddling gait, enlarged calfs Gower's maneuver when arising from the floor Biopsy shows replacement of muscle with fat and connective tissue EMG and EKG shows abnormalities |
| OSTEOSARCOMA | Primary tumor of the long bone, particularly in adolescent boys High incidence is noted in children who have had radiation for other types of cancers and children with retinoblastoma mets quickly |
| OSTEOSARCOMA Manifestations | Pain and swelling at the site Pain may be lessened when the joint is flexed Pathologic fracture may occur |
| Treatment and nursing care osteosarcoma | Surgery is treatment of choice; may include amputation as a last resort Chemo may be given prior to surgery Long-term survival is possible with early detection and treatment |
| EWING'S SARCOMA | Malignancy of the mid-shaft of the long bones and in the flat bones Occurs mainly in older school-age children and early adolescence If mets is present during diagnosis, prognosis is poor Primary sites for mets is lung and other bones |
| JUVENILE RHEUMATOID ARTHRITIS | Most common arthritic condition of childhood Is systemic inflammatory disease involving the joints, connective tissues, and viscera Etiology is unknown but believed to have infection and autoimmune components |
| Rheumatoid Arthritis - Systemic | Manifested by fever, rash, pleuritis, pericarditis, and enlarged liver and spleen Joint symptoms may not manifest until later |
| Rheumatoid Arthritis -Polyarticular- | many joints at once become swolen Joints become swollen, warm, and tender Occurs primarily in females during childhood and adolescence |
| Rheumatoid Arthritis- Pauciarticular - | Limited to 4 or fewer joints, generally the larger joints Occurs mostly in girls under 3, and boys over 13 Approximately 35% of all JRA patients have this type Are prone to developing iridocyclitis (inflammation of the iris of the eye) |
| Rheumatoid Arthritis -treatment and druig Therapy | Aspirin - monitor for side effects Corticosteroids - monitor for signs of infection that may be masked by steroid therapy NSAIDS Gold compounds - administered IM by may cause severe photophobia Exercise - particularly swimming |
| SCOLIOSIS | S-shaped curvature of the spine Most commonly discovered among adolescent girls Many are not progressive and only require periodic evaluation Untreated scoliosis may lead to back pain, fatigue, disability, and heart and lung |
| Scoliosis treatment | Curves up to 20 degrees no further treatment Curves between 20 and 40 degrees require daily exercise and Milwaukee bracing or Boston bracing urves of more than 40 degrees may require surgical spinal fusion and insertion of rods or wires |
| Scoliosis screening | Screening begins in middle school with physician referrals Involves examining the spine from the back, front, and side while the student stands erect and while leaning forward from the waist |
| Scoliosis Types and causes | Functional Caused by poor posture Curve is flexible and easily corrected Structural Result from changes in the shape of the vertebrae or thorax Usually accompanied by rotation of the spine |
| Battered child syndrome | refers to a clinical condition in young children who have received serious physical abuse from a parent or foster parent |
| s/s Child abuse | Should be suspected when the injuries are not consistent with the history of the injury or the developmental level of the child Contusions in many stages of healing |
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