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UTA NURS 4431 Exam 1

UTA NURS 4431 Children & Adolescents Exam 1

QuestionAnswer
Diagnosis-related groups (DRGs) a method of classifying related medical diagnoses based on the amount of resources that are generally required by the client
Top 10 DRG’s in North Texas Psychosis, HF, Acute MI, DKA, Shock, Post op pain, CVA, Pneumonia, Change in LOC (Asthma for Peds)
Beneficence One is required to do or promote good for others.
Nonmaleficence One must avoid risking or causing harm to others.
Autonomy People have the right to self-determination. This includes the right to respect, privacy, and the information necessary to make decisions.
Justice All people should be treated equally and fairly regardless of disease or social or economic status.
Morbidity Ratio of sick to well persons in a defined population.
Infant mortality rate Number of deaths per 1000 live births that occur within the first 12 months of life.
family-centered philosophy families are given choices, provide input, and are given information that is understandable by them. The family is respected, and its strengths are recognized.
Fever (hyperpyrexia) an elevation in set point such that body temperature is regulated at a higher level; may be arbitrarily defined as temperature above 38 C (100.4 F).
Hyperthermia Body temperature exceeding the set point, which usually results from the body or external conditions creating more heat than the body can eliminate, such as in heat stroke, aspirin toxicity, seizures, or hyperthyroidism
Hypothermia may result from sepsis, exposure, metabolic disorders; below 36.0 C need to be investigated/retaken
Acute pain usually has a sudden onset, is from an identifiable trauma, and continues for a limited time. Resolution generally occurs with healing of the trauma.
Chronic pain continues for an unpredictable period beyond the expected recovery period, is unlikely to resolve quickly, and may adversely affect the child's daily activities of living.
Most common behavioral pain assessment tool FLACC Scale
FLACC pain assessment tool Used in infants and preverbal or nonverbal children; five behavioral categories: Face, Legs, Activity, Cry, Consolability. Each scored from 0-2, resulting in a total score from 0-10. A higher score indicates higher pain or distress.
FACES Pain Rating Scale pain assessment tool Used in children 3 yr and older. Six cartoon faces with neutral to gradually increasing painful expressions, corresponding to an analog scale with words ranging from a happy face (0; No Hurt) to a crying face (5 or 10; Hurts Worst).
Numeric Rating Scale (NRS) pain assessment tool Used in children 9 yr and older. Patient is asked to give a number that reflects the pain level: 0
Acetaminophen (Tylenol) dosage 10-15 mg/kg/dose every 4-6 hrs. Do not exceed 4 doses in 24 hrs. Given PO, PR, GB (no IV).
Ibuprofen (Motrin, Advil) dosage 10 mg/kg/does every 6 hrs. Given PO or GB.
Timing for pain re-evaluation q 15-30 min after intervention.
Epidural assessment monitor respiratory status, skin care around insertion site, assessment of pain
Opiod reversal agent Narcan
Benzodiazepine reversal agent Romazicon
Brief History (4 critical questions) Why did you seek medical care for your child?; Does the child have any chronic medical conditions?; Is the child currently taking any medications?; Does the child have any allergies?
Observational assessment appearance, respiratory effort, color
ABCDEF Assessment Airway, Breathing, Circulation, Disability (neuro), Exposure, Family
Airway questions Is the airway patent? Can it be maintained? Is intubation needed?
Breathing assessment presence or absence of breathing, RR, HR, presence or absence of retractions, presence or absence of nasal flaring, breath sounds, position assumed, pulse ox
Circulation assessment HR, cap refill, color, skin temp, skin turgor, moisture in mouth, BP, LOC, I&O
Normal urine output in children 1-2 mL/kg/hr
Disability assessment LOC, response to people and environment, reaction to assessments and interventions, behavior, pupil size and reactivity, pain
Disability Assessment Tools AVPU, Pain (Numeric, Wong-Baker Faces, FLACC)
AVPU Awake and Alert, Responds to Verbal stimuli, Responds to Painful stimuli, Unresponsive to stimuli
Exposure Assessment Temperature, Bruises or scars, Rashes
Family Assessment be aware of signs of distress and anxiety in family members
Height/Length measurements Recumbent length for up to 36 months, then standing height after 37 months
Growth measurements taken up to age 2 yrs head circ, weight, & length/height
Growth measurements taken after 2 yrs height, weight, & BMI
Vital Sign order for children 1) RR, 2) apical heart rate, 3) BP, and 4) temp
Lymph nodes that indicated infection enlarged, warm, firm, and fluctuant
Lymph nodes often palpable in healthy infants and children small, firm, and shotty (freely palpable and very small) in the cervical, axillary, and inguinal areas
Moro reflex Hold infant in a supine position then displace the body downward a few centimeters. Response: extends, then abducts the extremities, with fingers spread in a symmetrical fashion; may also elicit a cry. Disappears at 4-5 mos.
Tonic neck (fencing) reflex When placed supine with head turned to one side, opposite arm and leg extend and arm and leg on the same side are flex. If the head is turned to the other direction, reverses. May or may not be present at birth. Disappears at 4-5 mos.
Palmar (grasp) reflex If a finger is placed in the palm, the infant should respond by grasping the examiner's finger. The grasp should be symmetrical. If pressure is put on the balls of the feet, the infant should grasp with the toes. Disappears by 3 mos.
Rooting reflex Stroke or touch the infant's cheek or mouth; the infant should respond by searching for and attempting to suck the examiner's finger. Disappears at 4-5 mos.
Babinski reflex lateral aspect of sole of foot stroked from heel to ball curving medially across the ball. Response: dorsiflexion, fanning of the toes, and hyperextension of the great toe (infant) OR plantar flexion of the toes (walking). Disappears at 10-12 mos.
CN I (olfactory nerve) assessment The child is asked to identify familiar odors with the eyes closed. Each side of the nose is tested separately.
CN II (optic nerve) assessment Visual acuity tested using Snellen, HOTV (young children) or tumbling E (very young children) chart. Each eye is tested separately and then both eyes together. If corrective lenses are worn, the eyes are tested both with and without correction.
CN III, IV, VI (oculomotor, trochlear, abducent nerve) assessment The child is asked to follow a toy or the examiner's finger as the object moves in all directions of gaze (six cardinal fields of gaze).
CN V (trigeminal nerve) assessment Child asked to identify a wisp of cotton on face. Corneal reflex tested by observing for blinking when the approaching face closely. Masseter & temporal muscles’ strength evaluated by biting down on a tongue blade as the examiner tries to remove it.
CN VII (facial nerve) assessment Ask to imitate frown, wrinkled forehead, smile, & raised eyebrow & to keep eyes closed while examiner attempts to open. Sensory portion of facial nerve evaluated by child identifying taste of sugar & salt placed on anterior of tongue.
CN VIII (acoustic nerve) assessment Cochlear nerve tests assess hearing. Audiometric testing is a quantitative evaluation of hearing. The Weber (lateralization) and Rinne (air and bone conduction) tests are qualitative evaluations of hearing.
CN IX, X (glossopharyngeal nerve, vagus nerve) assessment Gag reflex tested by touching the posterior pharyngeal wall. Palatal reflex tested by stroking each side of the uvula. The side touched should rise. Normal function of the vagus nerve is revealed by the child's ability to swallow and to speak clearly.
CN XI (accessory nerve) assessment The examiner palpates and notes the strength of the trapezius and sternocleidomastoid muscles against resistance, or the child shrugs the shoulders against resistance.
CN XII (hypoglossal nerve) assessment The child is asked to stick out the tongue, and the examiner notes any lateral deviation when it is protruded. The strength of the tongue is assessed by having the child push the tongue against the examiner's finger pressed against the cheek.
Infant Ages < 1 year-old
Erikson’s Stage for Infants Trust vs. Mistrust: Development of a sense that the self is good and the world is good when consistent, predictable, reliable care is received; characterized by hope.
Piaget’s Period for Infants Sensorimotor Period: Reflexive behavior is used to adapt to the environment; egocentric view of the world; development of object permanence.
Toddler Ages 1-3 years-old
Erikson’s Stage for Toddlers Autonomy vs. Shame and Doubt: Development of sense of control over the self and body functions; exerts self; characterized by will.
Piaget’s Period for Toddlers Sensorimotor (1-2 yrs) and Preconceptual phase of Preoperational Thought (2-3 yrs): Beginning to use symbolic thought and symbolic play and becomes aware of causal relationships.
Egocentrism Seen in toddlers in the preconceptual phase of Piaget’s preoperational stage; Complete absorption with self; an inability to understand that others have a different point of view.
Animism Seen in toddlers in the preconceptual phase of Piaget’s preoperational stage; Believes that inert objects are alive and have wills of their own.
Magical thought Seen in toddlers in the preconceptual phase of Piaget’s preoperational stage; Believes that magical thought is the cause of events and that wishing something will make it so.
Symbolic thought Seen in toddlers in the preconceptual phase of Piaget’s preoperational stage; The ability to allow a mental image (word or object) to represent something that is not present.
Symbolic play Seen in toddlers in the preconceptual phase of Piaget’s preoperational stage; The use of games and interactions that represent an issue or concern to be addressed.
Preschooler Age 3-5 years-old
Erikson’s Stage for Preschoolers Initiative vs. Guilt: Development of a can-do attitude about the self; behavior becomes goal-directed, competitive, and imaginative; initiation into gender role; characterized by purpose.
Piaget’s Period for Preschoolers Preoperational Stage: Preconceptual (3-4 yrs) and Intuitive thought (4-5 yrs): Thinking remains egocentric, becomes magical, and is dominated by perception. Transductive reasoning; field dependency thinking; centration; irreversibility in thought.
Transductive reasoning Seen in preschoolers in the preconceptual phase of Piaget’s preoperational stage; Reasoning from the particular to the particular rather than from the general to the particular.
Field dependency thinking Seen in preschoolers in the preconceptual phase of Piaget’s preoperational stage; difficulty focusing on the important aspects of a situation (everything is important and interdependent).
Centration Seen in preschoolers in the intuitive phase of Piaget’s preoperational stage; the tendency to center or focus on one part of a situation and ignore the other parts.
Irreversibility Seen in preschoolers in the intuitive phase of Piaget’s preoperational stage; the inability to understand a process in reverse or mentally undo an action that has been performed.
School Aged ages 6-12 years-old
Erikson’s Stage for School Aged Industry vs. Inferiority: Mastering of useful skills and tools of the culture; learning how to play and work with peers; characterized by competence.
Piaget’s Period for School Aged Concrete Operations: Thinking becomes more systematic and logical, but concrete objects and activities are needed. Characterized by reversibility, conservation, classification, logic, humor
Reversibility Seen in school aged in Piaget’s concrete operations stage; can understand a process in reverse or mentally undo an action that has been performed.
Conservation Seen in school aged in Piaget’s concrete operations stage; Ability to understand that certain properties of objects do not change simply because their order, form, or appearance has changed.
Adolescence ages 13-18 year-olds
Erikson’s Stage for Adolescence Identity vs. Role Confusion: Begins to develop a sense of “I”; this process is lifelong; peers become of paramount importance; child gains independence from parents; characterized by faith in self.
Piaget’s Stage for Adolescence Formal operations: New ideas can be created; situations can be analyzed; use of abstract and futuristic thinking; understands logical consequences of behavior.
2 month milestones Smiles spontaneously; looks at faces; vocalizes; lifts head
4 month milestones Smiles responsively; stares at hand; grasps; follows past midline; laughs; lifts head when prone and holds steady when sitting
6 month milestones Reaches for toy; focus on small objects, turn to sound; roll overin both direction
9 month milestone pick up objects; start crawling; imitate sounds; sit-up; cruise
12 month milestones feed self; pincer grasp; bang blocks together; jabber; birth weight tripled
15-18 month milestones imitates; holds cup; builds tower; scribbles; 3-10 single words; points to body parts; walks well; stoops & recovers
2 year milestones removes clothes; feeds doll; uses fork/spoon; hold pencil; builds two-block tower; points to pictures; uses two-word sentences; runs; walks up steps; kicks a ball
3 year milestones brush teeth; put on clothes; build tower of 4-6 cubes; names familiar pictures; throws a ball overhand; jumps; kicks a ball forward
5 year milestones puts t-shirt on; washes hands; stand on one foot; jump rope; adjectives (tired, hot)
6-8 year milestones self-esteem, tie shoes, expansive vocabulary, love sports and games
9-11 year milestones peer opinions more important than parents, clubs, hero worship, boy crazy, away from home experiences, full developed hand-eye coordination and fine motor control, read a lot
11-20 year milestones emotional & social turmoil, opposite-sex relationships, adult fine motor control, future oriented, coordinated muscle control
Suggested communication approach for Infants Calm, soft, soothing voice. Responsive to cries. Turn-taking vocalizations. Talk & read regularly. Prepare infant as you are about to perform care; talk to infant about what you are about to do. Slow approach and allow child time to get to know you.
Suggested communication approach for Toddlers Learn toddler's words, and use them. Describe activities and procedures as they are about to be done. Picture books. Use play for demonstrations. Be responsive to child's receptivity & approach cautiously. Preparation immediately before.
Suggested communication approach for Preschool Children Offer choices. Use play to explain procedures and activities. Speak in simple sentences, and explore relative concepts. Picture and story books, puppets. Limit length of explanations. Engage in preparatory activities 1-3 hr before the event.
Suggested communication approach for School-Age Children Photos, books, diagrams, charts, videos. Make explanations sequential. Engage in conversations that encourage critical thinking. Establish limits and set consequences. Medical play techniques. Introduce preparatory materials 1-5 days in advance.
Suggested communication approach for Adolescents Engage in conversations about adolescent's interests. Photos, books, diagrams, charts, & videos. Use collaborative approach, and foster and support independence. Introduce preparatory materials up to 1 wk in advance of the event. Respect privacy needs.
Common Injuries for Infants Aspiration of foreign objects, asphyxiation, MVA, falls, poisoning, burns, drowning
Criteria for forward facing car seat 2 yrs AND 20 lbs
Common Injuries for Toddlers MVA, drowning, burns, poisoning, falls, aspiration, bodily harm
Number one cause of death in children 1-12 motor vehicle crashes
Common Injuries for Pre-schoolers poisoning, MVA (pedestrian), bicycle injuries
Common Injuries for School aged children MVA (pedestrian or passenger), bicycle injuries, sports injuries
Common Injuries for Adolescents alcohol/drugs, driving, suicide, violence, burns, bullying, self-mutilation
Solitary play begins in infancy and is common in toddlers; child plays alone with toys that are very different from those chosen by other children in the area.
Parallel play usually associated with toddlers; Children play side by side with similar toys, but there is a lack of interactive activity.
Associative play begins in toddlerhood and continues into preschool age; group play without group goals.
Cooperative play begins in the late preschool years; group play that is organized and has group goals.
Onlooker play usually during the toddler years but can be observed at any age; child observes others playing; may ask questions of the players, but does not attempt to join the play
Dramatic play Play in which children act out roles and experiences that may have happened to them, that they fear will happen to them, or that they have observed happening to someone else.
Familiarization play Use of materials that are commonly associated with health care situations in creative and playful activities.
Immunization cautions for children with immunodeficiency can’t have any live vaccines (chickenpox [varicella], MMR [measles-mumps-rubella])
Varicella-zoster virus infections primary infection causes chickenpox; reactivation of latent infection causes Zoster (shingles).
Varicella-zoster virus incubation period 10-21 days.
Varicella-zoster virus infectious period 1-2days before onset of rash until all lesions are dried.
Varicella-zoster virus Transmission Direct contact, droplet, airborne particles
Varicella-zoster virus treatment VariZIG for children at risk; symptomatic and supportive for healthy child
Varicella-zoster virus primary complication secondary bacterial infection of the skin lesions
Bordetella pertussis infection whooping cough
Bordetella pertussis incubation period 6-20 days
Bordetella pertussis infectious period Catarrhal stage (1 to 2 weeks) until the fourth week
Bordetella pertussis transmission Direct contact or respiratory droplets from coughing
Bordetella pertussis primary complication pneumonia
Hepatitis B vaccine minimum age, maximum age, and minimum dose intervals Min: Birth (in hospital); Max: none; Dose intervals: 4 wks, 8 wks (and 16 wks from fist dose with minimum age for final dose 24 wks)
Rotavirus vaccine minimum age, maximum age, and minimum dose intervals Min: 6 wks; Max: <15 wks; Dose interval: 4 wks, 4 wks (with max age 8 mos)
DTaP (diphtheria, tetanus, pertussis) vaccine minimum age, maximum age, and minimum dose intervals Min: 6 wks; Max: none; Dose intervals: 4 wks, 4 wks, 6 mos, 6 mos
Hoemophilus influenza type b (Hib) vaccine minimum age, maximum age, and minimum dose intervals Min: 6 wks; Max: none; Dose Intervals: 4wks (if < 12 mos), 8 wks (final dose if 12-14 mos), no further doses needed (>14 mos)
Pneumococcal (PCV) vaccine minimum age, maximum age, and minimum dose intervals Min: 6 wks; Max: 24 mos; Dose Intervals: 4 wks (if < 12 mos), 8 wks (final dose if 12-24 mos)
Inactivated poliovirus (IPV) vaccine minimum age, maximum age, and minimum dose intervals Min: 6 wks; Max: 18 years; Dose Intervals: 4 wks, 4 wks, 6 mos (min age 4 yrs for final dose)
Varicella vaccine minimum age, maximum age, and minimum dose intervals Min: 12 mos; Max: 18 years; Dose Intervals: 3 mos
Measles, Mumps, and Rubella (MMR) vaccine minimum age, maximum age, and minimum dose intervals Min: 12 mos; Max: none ; Dose Intervals: 3 mos
Hepatitis A vaccine minimum age, maximum age, and minimum dose intervals Min: 12 mos; Max: none; Dose Intervals: 6 mos
Vaccines not given to older children with no immunizations Rotavirus (not given after 14 wks) and Pneumococcal (not given after 24 mos).
Vaccines that contain Neomycin Inactivated poliovirus (IPV) and Measles, Mumps, and Rubella (MMR)
Vaccine associated with egg or chicken allergic reactions influenza, MMR
Vaccine that contains baker’s yeast HPV4
Vaccines given SQ Varicella, MMR, IPV
Vaccines given IM DTaP, Hib, Hep A, Hep B, Influenza (also nasal mist), Pertussis, PCV
Vaccines given PO Rotavirus
Vaccine given to newborn before discharge Hep B
Vaccine documentation parental consent, date/time of admin, manufacturer, lot number, expiration date, administration site, signature and title of person administering
DTaP adverse reactions fever (temperature at or above 40.5° C [105° F]) or collapse or shocklike state within 48 hrs; seizures within 3 days; Guillain-Barré syndrome within 6 weeks; or persistent, inconsolable crying lasting ≥3 hr within 48 hrs.
Pediatric differences related to fluid & electrolyte balance larger extracellular fluid volume (neonates & young infants), greater skin surface area (<2yrs), and water lost through lungs (early childhood), immature kidney less able to concentrate urine and regulate electrolytes (<2yrs)
Mild dehydration up to 5% of body weight lost (40-50mL/kg)
Mild dehydration manifestations watery diarrhea, decreased urine output, increased thirst, slightly dry mucous membranes
Moderate dehydration 6-10% of body weight lost (50-90mL/kg)
Moderate dehydration manifestations abnormal skin turgor, sunken eyes, very dry mucous membranes, depressed anterior fontanel
Severe dehydration 10% or more body weight lost (100+mL/kg)
Severe dehydration manifestations same as moderate (abnormal skin turgor, sunken eyes, very dry mucous membranes, depressed anterior fontanel) plus rapid weak pulse/hypotension, cold extremities, oligoanuria, coma
VS changes with dehydration HR goes up to compensate for less volume, BP decreases
Dehydration management IV fluids (severe), Oral hydration or SQ Hylenex (mild to moderate)
Hylenex recombinant (hyaluronidase human injection) a tissue modifier indicated as an adjuvant in subcutaneous fluid administration for achieving hydration
Daily fluid requirements for 0-10kg 100mL/kg
Daily fluid requirements for 10-20kg 1000mL + 50mL/kg for each additional kg over 10 kg
Daily fluid requirements for 20+ kg 1500mL + 20mL/kg for each additional kg over 20 kg
Minimum urine output for infants and toddlers 1-3mL/kg/hr
Minimum urine output for preschoolers ad young schoolchildren 1-2mL/kg/hr
Minimum urine output for schoolchildren and adolescents 0.5-1mL/kg/hr
Urine output for child in diapers weight in grams of wet diaper – weight in grams of dry diaper; 1g of weight
Suggested rehydration for children with mild to moderate dehydration 50 to 100 mL/kg (based on the degree of dehydration) of oral rehydration solution (ORS) over 3 to 4 hours (1oz [30mL] every 5-10 min), with evaluation of the child's hydration status at least every 1 to 2 hours
Oral rehydration therapy lower-osmolality fluids (Pedialyte, Gatoraid). Because of their osmotic effect, the high carbohydrate content in fluids such as apple juice or colas may further aggravate diarrhea and cause additional fluid loss.
lb to oz conversion 1 lb/16 oz
kg to lb conversion 1 kg/2.2 lbs
inches to cm conversion 1 in/2.54 cm
oz to mL conversion 1 oz/30mL
tsp to mL conversion 1 tsp/5 mL
cup to mL conversion 1 cup/240 mL
liter to mL conversion 1 L/1000 mL
gram to mL conversion (diaper weights) 1 g/1 mL
kg to gram conversion 1 kg/1000 g
gram to mg conversion 1 g/1000 mg
mg to mcg conversion 1 mg/1000 mcg
Pharmacokinetics The time and movement relationships of medications (what body does to a drug).
Pharmacodynamics Behavior of medications at the cellular level (what drug does to the body).
Gastric acidity affect on absorption in infants and children infants less acidic than older children and adults; decreased absorption of meds which require acidic environment and increased absorption of meds that require alkaline environment
Gastric emptying affect on absorption in infants and children intermittent, unpredictable, and usually slower in infants and children. Prolongs the time it takes a medication to reach the intestinal absorption site.
Gastrointestinal motility affect on absorption in infants and children faster or slower depending on when last ate, usually prolonged, but can be increased with adverse conditions (diarrhea). Longer the transit time in the intestine, the more medication that is absorbed and vica versa.
Pancreatic enzyme function affect on absorption in infants and children activity is variable; Medications that require specific enzymes for dissolution and absorption might not be converted to a suitable form for intestinal action.
Differences in body fluids affect on distribution of medication in infants and children greater fluid volume per weight; need higher dose per kg of water-soluble medication.
Differences in fat percentages affect on distribution of medication in infants and children changes as a child grows (increased in a 1-year-old as compared to an infant, but then decreases in a preschool child); dosages of fat-soluble medication must be varied to achieve desired effects.
Differences in proteins affect on distribution of medication in infants and children preterm and newborn infants have lower levels of plasma proteins than do older children. Alters amount of medication needed to maintain a therapeutic drug level and may increase the infant's vulnerability to adverse drug effects.
Blood-Brain Barrier affect on distribution of medication in infants and children immature until about 2 years old. Less selective barrier allows the distribution of medications into the CNS, resulting in possible occurrence of encephalopathy with some medications.
Maturity of liver affect on metabolism of medications in infants and children mmature in newborn and premature infants (may not properly metabolize all the medication). Older infants, toddlers, and preschoolers metabolize certain drugs (e.g., pain medications) more rapidly (larger dosages or more frequent admin might be needed).
Maturity of renal system affect on excretion of medications in infants and children Immature in infants and toddlers; medication can circulate longer and reach toxic levels in the blood.
Administration of SQ injections in infants and children Gauge: 25-27; Size: 3/8” to 5/8”; Volume: 0.5 mL (max 1 mL); preferred sites: outer posterior aspects of the upper arms (dorsum), anterior aspects of the thighs, and abdomen.
Administration of IM injections in infants and children Gauge: 22-25; Size: 1/2 - 1 1/2”; Volume: 0.5-3mL (infants <1mL, toddler/shoolaged <2mL, adolescents 2-3mL); preferred sites: anterior lateral thigh (vastus lateralis) for <3 yrs, Ventrogluteal for 18-36 mos and walking, Deltoid for >3 yr
Differences in GI tract involuntary swallowing (until 6 wks), minimal saliva, stomach is horizontal and has less capacity, less acidic secretions, cardiac sphincter relaxed (causes reflux), peristaltic waves may reverse and can be increased, deficiency in enzymes, liver immature
Celiac Disease results from the inability to digest gluten
Celiac Disease diet eliminate all wheat, rye, barley, oats, and hydrolyzed vegetable protein (includes most pasta, baked products, and many breakfast cereals). Substitute corn, rice, or millet as grains. Take vitamin supplements, especially folate and fat-soluble vitamins.
Short Bowel Syndrome (short gut) decreased ability to digest and absorb a regular diet because of a shortened intestine
Gastroesophageal Reflux return of gastric contents into the esophagus from a relaxation of the lower esophageal sphincter
Gastroesophageal Reflux management diet, positioning, medications, surgery (fundoplication)
Fundoplication A 270- to 360-degree wrap of the stomach fundus around the distal esophagus to tighten the lower esophageal sphincter and prevent gastric reflux.
Gastroesophageal Reflux diet CRAM diet (complex carbohydrates, rice and milk)
Gongenital Aganglionic Megacolon (Hirschsprung Disease) result of an absence of ganglion cells in the rectum and, to varying degrees, upward in the colon. Major cause of lower bowel obstruction in newborns.
Hirschsprung Disease manifestations Delayed passage or absence of meconium stool, chronic constipation, bowel obstruction, abdominal pain and distention, vomiting, and failure to thrive.
Hirschsprung Disease management surgery to remove the aganglionic portion of the intestine
Pyloric Stenosis circular area of muscle surrounding the pylorus hypertrophies and obstructs gastric emptying
Pyloric Stenosis manifestations occurs 2-4 weeks after birth; projectile vomiting (vomiting that is projected with force, perhaps 2 to 4 feet away from the mouth)
Pyloric Stenosis management pyloromyotomy, an incision of the pyloric muscle to release the obstruction
Intussusception an invagination of a section of the intestine into the distal bowel that causes bowel obstruction.
Intussusception manifestations Paroxysms of pain occur, subside, and recur during the first several hours and then progress to a more constant severe pain. Passage of bloody mucus (“currant jelly”) stool and diarrhea. A sausage-shaped abdominal mass.
Intussusception management hydrostatic reduction is performed with a barium, isotonic saline, or air enema under fluoroscopic or ultrasonic guidance. If reduction fails or findings indicate damage to the bowel, immediate surgery is performed.
Volvulus condition caused by a malrotation or twisting of the bowel that results in a bowel obstruction.
Volvulus manifestations pain, bilious vomiting, and other signs of bowel obstruction.
Volvulus management Surgery
Necrotizing Enterocolitis inflammatory disease of the intestinal tract that primarily occurs in premature infants
Esophageal Atresia with Tracheoesophageal Fistula congenital malformations in which the esophagus terminates before it reaches the stomach and/or a fistula is present that forms an unnatural connection between the esophagus and the trachea.
Esophageal Atresia with Tracheoesophageal Fistula manifestations Three Cs: coughing, choking, cyanosis; feeding causes regurgication and coughing, constant flow of saliva, gastric distention
Esophageal Atresia with Tracheoesophageal Fistula management surgical repair to ligate fistula and anastomose esophagus
Imperforate Anus Incomplete development or absence of the anus in its normal position in the perineum.
Imperforate Anus manifestations failure to pass meconium stool, absence of anorectal canal, presence of an anal membrane, external fistula to the perineum.
Imperforate Anus management Anal stenosis is treated with repeated dilations. All other defects require surgical intervention. High defects may require a colostomy and bowel pull-through procedure.
Cleft Lip and Palate abnormal openings in the lip or palate. The defects may occur unilaterally (on either side) or bilaterally and are the most common congenital craniofacial deformity.
Cleft Lip and Palate management A number of professionals are involved in this process, including surgeons; nurses; geneticists; psychologists or psychiatrists; ear, nose, and throat specialists; audiologists; and occupational and speech therapists.
Biliary Atresia the obstruction or absence of the extrahepatic bile ducts. Most common pediatric liver disease necessitating transplantation.
Biliary Atresia manifestations Appears healthy at birth. Manifestations that develop shortly afterward include acholic stools (light in color because of the absence of bile pigment), bile-stained urine, and hepatomegaly.
Biliary Atresia management During and after exploratory laparotomy, the size of the lesion can be identified and drainage can be attempted. If no correctable lesion is found, a hepatic portoenterostomy (Kasai procedure) will be performed to allow bile to drain from the liver.
Umbilical Hernia Imperfect closure of umbilical ring allows intestines to push outward at umbilicus during straining and crying.
Inguinal Hernia protrusion of the bowel into the groin
Hernia management surgical intervention o avoid incarceration
Encopresis inappropriate passage of feces, often with soiling
Acute Appendicitis manifestation RLQ pain, guarding, walk hunched over, hurts to jump up and down, fever, vomiting, diarrhea, elevated WBC
Acute Appendicitis management laparoscopic appendectomy; if ruptured, antibiotics, then surgery
Pinworm manifestations Ingestion or inhalation of eggs, transfer from hands to mouth
Pinworm manifestations Nocturnal anal itching, sleeplessness
Pinworm diagnosis Cellophane tape test and microscopic examination
Pediatric differences in the CNS immature blood-brain barrier, fontanels not closed, papilledema rare (d/t fontanels being open), reappearance of primitive reflexes after 5 months associated with neurological disorder
Papilledema Edema of the optic disk.
Glasgow Coma Scale for Children never 0 (min: 3), anything below 8 may require intubation
Full LOC awake, alert, oriented, interacts with environment
Confused LOC lacks ability to think clearly and rapidly
Disoriented LOC lacks ability to recognize place or person
Lethargic LOC awakens easily but exhibits limited responsiveness
Obtuned LOC sleeps unless aroused; once aroused, has limited interaction with the environment
Stupor LOC requires considerable stimulation to rouse
Coma LOC vigorous stimulation produces no motor or verbal response
Intracranial Pressure pressure within the cranium or skull that surrounds the brain. Caused by the volume of brain mass, CSF, and blood.
Intracranial Pressure manifestations in an infant Poor feeding/vomiting, Irritability/restlessness, Lethargy, Bulging fontanel, High-pitched cry, Increased head circ, Separation of cranial sutures, Distended scalp veins, Eyes deviated downward (“setting-sun” sign), Increased or decreased response to pain
Intracranial Pressure manifestations in a child Headache, Diplopia, Mood swings, Slurred speech, Papilledema (after 48 hr), Altered level of consciousness, Nausea and vomiting, especially in the morning
Late sign of ICP Bulging fontanels
ICP management treat underlying cause, reduce volume of CSF, avoid situations that increase ICP (crying, vomiting).
Anencephaly a congenital neural tube defect in which both cerebral hemispheres are absent
Spina Bifida a congenital neural tube defect characterized by incomplete closure of the vertebrae and neural tube during fetal development.
Spina Bifida occulta distinguishing manifestations no herniation of spinal cord or meninges; vertebral arch with hair tuft
Spina Bifida cystic distinguishing manifestations saclike protrusion containing meninges and CSF (meningocele) or containing CSF, meniges, nerve roots, and spinal cord (myelomeningocele)
Spina Bifida manifestations determined by the level of lesion: T12 Flaccid lower extremities, decreased sensation, incontinence; L1-L3 Hip flexion, flail feet; L2-L4 Hip adduction; L3-S2 Hip adduction & extension, knee flexion; S3 & below No impairment; Sacral roots Plantar flexion
Alpha-fetoprotein test blood test at 16-18 weeks of gestation; if elevated, amniocentesis and fetal ultrasound are performed to test for Spina Bifida, brain tumor, or malignant liver; if low, additional testing for Down syndrome may be indicated.
Spina Bifida management Prenatal microsurgical closure or immediate surgical closure following birth; lifelong management of neurologic, orthopedic, and urinary problems
Neurogenic bladder/bowel unable to control bladder/bowel
Latex allergy risks children with spina bifida and children with abnormalities of the urinary tract (d/t multiple urinary catheterizations); tropical foods (bananas, papayas, mangos)
Hydrocephalus result of an imbalance between the production and absorption of CSF, resulting in enlarged ventricles and an increase in ICP
Hydrocephalus EARLY manifestations in infants Rapid head growth, bulging anterior fontanel, Irritability, Poor feeding, Distended scalp veins, Widely separated cranial sutures;
Hydrocephalus LATE manifestations in infants Setting-sun sign, Frontal bone enlargement or bossing, Vomiting, difficulty feeding and swallowing, Increased BP, decreased HR, Altered respiratory pattern, Shrill (high-pitched cry), Sluggish or unequal pupillary response
Hydrocephalus EARLY manifestations in children Strabismus, Frontal headache in morning & relieved by emesis/sitting upright, n/v, Diplopia, Restlessness, Changes in schoolwork, Behavior/personality changes, Ataxia, Papilledema, Irritability, Sluggish & unequal pupillary response, Confusion, Lethargy
Hydrocephalus LATE manifestations in children Seizures, Increased BP, Decreased HR, Alteration in respiratory pattern, Blindness from herniation of the optic disc, Decerebrate rigidity
Decorticate posturing Abnormal flexion of the upper extremities and extension of the lower extremities.
Decerebrate posturing Abnormal extension of the upper extremities with internal rotation of the upper arms and wrists; lower extremities will extend with some internal rotation.
Hydrocephalus management bypass the blockage and drain the fluid from the ventricles to an area where it may be reabsorbed into the circulation, accomplished by a ventriculoperitoneal shunt, ventriculoatrial shunt (used in older children), or endoscopic third ventriculostomy.
Ventriculoperitoneal shunt used to treat hydrocephalus; a tube leading from the ventricles out of the skull and passing under the skin to the peritoneal cavity, bypassing the blockage and draining the fluid to area where can be reabsorbed.
Cerebral Palsy chronic, nonprogressive disorder of CNS resulting in alterations of posture and movement
Cerebral Palsy manifestations poor head control after 3 mos, stiff/rigid arms/legs, pushing away/arching back, floppy/limp body posture, unable to sit without support by 8 mos, uses only one side of body or only arms, clenched fists aft 3 mos.
Cerebral Palsy management early recognition and intervention to maximize the child's abilities; interdisciplinary team approach to meet many needs of child
Cerebral Palsy nursing considerations may need increased calorie intake, seizure precautions, save environment, communication assistance (board, computer-assisted)
Meningitis most common infectious process affecting the CNS; inflammation of the meninges caused by viral, bacterial, or fungal infection.
Meningitis manifestations in neonate poor feeding; poor sucking; vomiting; diarrhea; poor muscle tone; weak cry; hypothermia or hyperthermia; apnea; seizures; sepsis; disseminated intravascular coagulation (DIC); a full, tense, and bulging fontanel; and lethargy.
Meningitis manifestations in the infant and preschool-age child fever, poor feeding, vomiting, irritability, seizures, a high-pitched cry, a bulging anterior fontanel, and lethargy.
Meningitis manifestations in children and adolescents severe headache, photophobia, nuchal rigidity, fever, altered LOC (lethargy, irritability), decreased appetite, vomiting, diarrhea, agitation, drowsiness, muscle or joint pain, purpura (meningococcal), Kernig’s sign, Brudzinski’s sign.
Meningococcal meningitis distinguishing manifestations petechial or purpuric rash (doesn’t blanch)
Kernig sign meningitis manifestation; pain with extension of leg and knee
Brudzinski sign meningitis manifestation; flexion of head causing flexion of hips and knees
Meningitis management isolation and IV antibiotics (bacterial) or symptomatic and supportive (viral)
Reye Syndrome drug concern may be related to administration of aspirin (including over-the-counter medications containing salicylates [e.g., Excedrin, Pepto Bismal]) to children with a viral disease. Not given to infants or children.
Encephalitis Inflammation caused by infection or toxin, resulting in cerebral edema and neurologic dysfunction.
Encephalitis manifestations Headache, irritability, lethargy, altered level of consciousness, nuchal rigidity, seizures, fever, malaise, dizziness, nausea and vomiting, ataxia, sensory disturbances.
Encephalitis management hospitalization and monitoring for increased ICP; cephalosporin or acyclovir (depending on causative agent), antiepileptics, and antipyretics.
West Nile Virus transmitted by mosquitoes and ticks; can cause encephalitis
Closed head injury Nonpenetrating injury to the head in which no break occurs in the integrity of the barrier between the outside environment and the intracranial cavity
Open head injury Penetrating injury to the head in which there is a break in the integrity of the barrier (skull, meninges) between the outside environment and the intracranial cavity; infection is a major concern
Coup head injury Cerebral injury sustained directly below the site of impact
Contrecoup head injury Cerebral injury sustained in the region or pole opposite the site of impact; caused by the rapid movements of the semisolid brain within the cranial vault
Linear skull fracture Straight-line fracture; dura not involved
Depressed skull fracture Bone pressing downward, indented
Basilar skull fracture Fracture of the base of the skull; symptoms are Battle sign, raccoon eyes, rhinorrhea, otorrhea, and hemotympanum (blood behind the eardrum)
Battle sign bruising behind ears; sign of basilar skull fracture that is seen several days after injury
Comminuted skull fracture Fragmentation of the bone into many pieces or a multiple fracture line
Contusions petechial hemorrhages along the superficial aspects of the brain.
Concussion transient and reversible neuronal dysfunction, with instantaneous loss of awareness and responsiveness.
Epidural intracranial hemorrhage Blood accumulates between the dura and the skull. Arterial damage is the usual type of injury, and the hemorrhage therefore develops rapidly.
Subdural intracranial hemorrhage Blood accumulates between the dura and the cerebrum. A subdural hemorrhage is usually caused by an injury to a vein and can be acute or chronic.
Head injury management assessment of airway, ventilatory function, neurologic status, and any other injuries present.
Subarachnoid bolt instrument for monitoring increased ICP; the end of a bolt is placed in the subarachnoid space and the top of the bolt is attached to a transducer to conduct a waveform to the monitor.
Shaken baby syndrome manifestations No external signs, but should be considered in any infant with signs of increased intracranial pressure, with retinal hemorrhage, seizures, subtle hydrocephalus, and papilledema.
Second most common cause of accidental death in children Drowning
Seizures brief paroxysmal behavior caused by excessive abnormal discharge of neurons.
Generalized Seizures Onset starts at any age. Clinical features indicate involvement of both cerebral hemispheres. Consciousness is impaired.
Tonic-clonic seizures abrupt arrest of activity and impairment of consciousness. Tonic phase: sustained, generalized stiffening of muscles lasting a few seconds. Clonic phase: symmetrical & rhythmic (alternating contraction and relaxation) which ends spontaneously in <5 min.
Atonic seizures an abrupt loss of postural tone, impairment of consciousness, confusion, lethargy, and sleep.
Myoclonic seizures brief, random contractions of a muscle group, followed by loss of muscle tone and forward falling.
Absence seizures very brief episodes of altered consciousness.
Focal Seizures Onset starts at any age. The clinical features suggest that only a limited functional area in one hemisphere of the brain is involved, and therefore symptoms are seen on only one side of the body.
Febrile Seizures Generally seen in young children (<5 yrs). Directly related to how fast temperature go up or down (not how high fever gets).
Epilepsy chronic disorder characterized by recurrent seizures
Seizure management Assess behavior before, during, and after and note the duration, starting body part, progression, how it ends, and any preceding or accompanying manifestations; protect from injury.
Ketogenic Diet Adjuct to anticonvulsant medications in controlling seizures; high-fat and severely restricted carbohydrates
Signs of Readiness for Toilet Training can remove own clothing, willing to let go of toy when asked, able to sit/squat/ walk well, walking for 1 year, notices if diaper is wet, indicates diaper needs to be changed, communicates need to go to bathroom, wants to please parent by staying dry.
Kidney hormonal functions production of rennin (regulates BP), erythropoietin (stimulates RBC production), and metabolizes vitamin D (important for calcium metabolism).
UTI manifestations n/v, anorexia, chills, nocturia, urinary frequency (>q2h), urgency (accidents at school), suprapubic/lower back pain (more serious), bladder spasms, dysuria, burning on urination, fever, hematuria, foul-smelling urine, tender/enlarged kidney, abnormal UA.
Normal Urinalysis (UA) pH 5-9, specific gravity 1.001-1.035, protein <20 mg/dl, urobilinogen up to 1 mg/dl, and no glucose, ketones, Hgb, WBCs, RBCs, Casts, or Nitrites.
Upper UTI distinguishing manifestations typically causes fever, chills, and flank pain
Lower UTI distinguishing manifestations usually no systemic manifestations (no fever, chills, or flank pain)
Vesicoureteral Reflux (VUR) primary contributing factor to upper UTI; retrograde flow of bladder urine into the ureters.
Pyelonephritis inflammation caused by bacteria, fungi, protozoa, or viruses infecting kidneys; can lead to urosepsis and septic shock and death in 15% of cases
Hypospadias a congenital anomaly in which the actual opening of the urethral meatus is below the normal placement on the glans of the penis
glomerulonephritis a group of kidney disorders characterized by inflammatory injury in the glomerulus.
Acute postreptococcal glomerulonephritis (APSG) most common type of glomerulonephritis; noninfections renal disease with onset 5-12 days after infection, characterized by HTN and sudden onset of hematuria, proteinuria, hypertension, edema, and renal insufficiency
An antistreptolysin (ASO) titer indicates the presence of antibodies to streptococcal bacteria; important in diagnosing APSG
APSG management manage edema (daily weights, I&Os, daily abdominal girth), nutrition (low sodium, low to moderate protein)
Nephrotic syndrome a kidney disorder characterized by proteinuria, hypoalbuminemia, hyperlipidemmia, edema and massive urinary protein loss.
Neprhotic syndrome manifestations edema, anorexia, fatigue, abdominal pain, respiratory infection, and increased weight (no HTN as with APSG)
Primary nephrotic syndrome, or minimal change nephrotic syndrome (MCNS) results from a disorder within the glomerulus of the kidney and is the most common type seen in children.
Secondary nephrotic syndrome acquired as the result of a systemic disease, such as hepatitis, systemic lupus erythematosus, heavy metal poisoning, or cancer.
Effect of decreased levels of albumin reduce the plasma oncotic pressure so that the intravascular fluid moves into the interstitial spaces, causing hypovolemia and edema.
Nephrotic Syndrome management supportive care and close monitoring, diet (low sodium and protein), steroids, diuretics, immunosuppressant therapy
Acute renal failure (ARF) the sudden, severe loss of kidney function; the kidneys can no longer filter waste products, regulate fluid volume, or maintain chemical balance.
Most common cause of acute renal failure dehydration
Complications of ARF hyperkalemia, HTN, anemia, seizures, hypervolemia, cardiac failure with pulmonary edema
Chronic renal failure (CRF) an irreversible loss of kidney function that usually occurs over months to years.
Cases of chronic renal failure congenital malformations, VUR with recurrent UTIs, chronic pyelonephritis, chronic glomerulonephritis
Chronic renal failure management manage diet, HTN, recurrent infections, seizures; dialysis (hemodialysis, peritoneal dialysis, hemofiltation); transplantation
Hemodialysis occurs through vascular access (CL, arteriovenous fistula or shunt); 3/week for 3-4 hours each time; achieve rapid correction of fluid and electrolyte abnormalities
Peritoneal dialysis occurs through catheter placed in abdomen; at home every night
Wilms Tumor (nephroblastoma) most common renal tumor in children; usually presents at 3-5 years; more frequent in African-Americans and males
Wilms Tumor manifestations asymptomatic, mobile, abdominal mass; microscopic or gross hematuria, hypertension, abdominal pain, fatigue, anemia, and fever.
Wilms Tumor Nursing consideration Palpation or any pressure on the tumor before surgery must be avoided to prevent possible rupture and spillage of tumor cells into the peritoneum.
Wilms Tumor management surgery and chemotherapy
Intravenous pyelogram (IVP) a radiological procedure used to visualize abnormalities of the urinary system, including the kidneys, ureters, and bladder.
KUB (kidney, ureter, bladder) Radiographs used to diagnose renal stones; done before renal studies
Renal ultrasonography Assesses position, size, and contour of kidneys, ureters, bladder; detects obstruction and stones; localizes for renal biopsy
Cystoscopy Examination of bladder and lower tract; visualization of tumor and stones; removal of small stones; biopsy of bladder or tumors; fulguration of bladder tumors and posterior urethral valves
Renal CT scan Indicated for renal tumors
Voiding cystourethrogram (VCUG) Detects reflux of urine into ureters and its severity; detects bladder emptying problems; detects urethral problem
Serum blood tests for Genitourinary Disorders Hgb/Hct, BUN, Creatinine, serum electrolytes
Created by: camellia