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Exam 11, Care of the Pediatric Patient 1

Growth Viewed as quantitative change Increase in number and size of cells Results in increased size and weight
Development Gradual change and expansion as the whole from lower to more complex stages of an individual’s capacities through growth, maturation and learning
Maturation An increase in competence and adaptability Aging Ability to function at higher level
Differentiation Processes by which early cells and structures are systematically modified and altered to achieve specific characteristics
Growth Trends; 3 phases of Directional 1: Head to tail 2:promimodistal 3: Differental
Developmental Pace
Sensitive Periods
Individual Differences
_______ is the most prominent feature of the childhood and adolescence. physical growth
Both_____ and ______ are used indicatorsof development. bone age dentition
when are the two dramatic periods of rapid brain growth? 15-20 weeks 30weeks-1yr
the basal caloric requirment for infants is about ____kcal/kg of body weight. This amount decreases to somewhere between___ and ___ kcal/kg at maturity. 108 40 45
what are the 9 identified charactorists of temperament?
What is the age range that a child can take an oral temp? gretaer then 2 years-5years. when they can hold probe in mouth.
What is reccomended temp route for the age birth- 2years AX or Rectal temp
How long should you count a pulse rate on an infant and young children? 1 full minute
What is the most reliable measurement of pulse taken? apical pulse
While measuring respirations in the infant do you watch the abdomen or the chest? why? abdomen, infants are belly breathers.
BP should be measured annually in children over the age of ? 3 years old
the most important factor in accurately measuring BP is the use of _____ ____ _____. appropriate size cuff.
Freud Define Id, ego, and super ego.
Piaget best known theorist for children Intuitive Concrete operational Formal operations
: How does growth and development impact nursing care of children? : Approach to care, response to illness, application of nursing process, expected development, individual temperament, and intervention to prevent diseases and/or accidents.
What factors influence the formation of a child’s self esteem? Temperament and personality, ability to accomplish age appropriate tasks, significant others, and social roles and expectations.
Self esteeem is at the most risk to which age population? Adolesence
4 factors that influence the formation of a childs self esteem. 1.Temperament and personality 2.Ability to accomplish age appropriate tasks 3.significant others roles and expectations
Name four major stressors of hospitalized children. Separation anxiety Loss of control Bodily injury Pain
Name five nursing considerations for the hospitalized child to help manage stress. Sensitivity/ Parents room-in;/ participate care Staff continuity/ Freedom of movement;/ independence/ Articles from home
Name two pain rating scales for infants and two for children. NIPS-neonatal infant pain scale PRS-pain rating scale FACES pain rating scale-Wong and Baker Numeric Scale (one to 10)
What are some non-pharmacologic pain management techniques? Distraction, relaxation, guided imagery, cutaneous stimulation, thought stopping, positive self-talk
Explain the purpose of dramatic play. Allows child to emotionally release by reenacting frightening or confusing hospital experience; also allows child to learn about new procedures and what to expect prior to experiencing them first-hand
Why is it important for nurses to be culturally competent? It is important for nurses to be culturally competent in order to deal effectively with families in a multicultural community or a community that is different from one’s own.
Respiratory infections account for majority of acute illness, these include: Viruses Bacteria Fungal
Respiratory Sounds Cough Hoarseness Grunting Stridor Wheezing Crackles Absence of breath sounds
Observe Ped For patient for: Evidence of infection Cough Wheeze Cyanosis Chest pain Nasal mucus Halitosis
The lower respiratory tract includes? The lower trachea, main stem bronchi, segmental bronchi, subsegmental bronchioles, terminal bronchioles and the alveoli.
Acute Pharyngitis Inflammation of structures of throat/ 80-90% caused by virus/ Throat culture – GABHS GABHS risks
Therapeutic Management GABHS Penicillin Erythromycin if PCN allergic Antipyretics Push fluids
What is another name for nasopharyngitis? The common cold.
Why aren't antibiotics given for nasopharyngitis? Antibiotics are for bacteria and the common cold is caused by a virus.
Therapeutic Management for STREP Self-limiting and symptomatic—viral Antibiotics for + bacteria (Strep)
why would a PT have an Adenoidectomy Adenoiditis-recurrent Sinusitis-recurrent Otitis media w/ effusion- recurrent Airway obstruction w/ sleep-disordered breathing Rhinorrhea-recurrent
why would a PT have a Tonsillectomy Malignancy Peritonsillar abscess (medical emergency) recurrent Airway obstruction
: What post-operative complication requires immediate medical attention, above all others? Hemorrhage.
Croup Syndromes Generalized term Hoarseness Resonant “barking” or “brassy” cough Varying degrees of respiratory distress originates from Larynx
Acute Epiglottis Serious obstructive inflammatory process 2-8 year olds Requires immediate attention Red Cherry appearance of epiglottis Rapid progression to respiratory distress Appears sicker than clinical findings suggest Drooling
Acute Laryngotracheobronchitis Most common “croup” syndrome Parainfluenza RSV M. pneumoniae Usually preceded by URI
Therapeutic Management for Acute Laryngotracheobronchitis Maintain airway Provide adequate respiratory exchange High humidity Racemic epi steroids
Acute Spasmodic Laryngitis “midnight croup” or “twilight croup” Paroxysmal attacks of laryngeal obstruction Most cases typically ***NO Fever****
Bacterial Tracheitis Features of croup and epiglottitis Serious cause of airway obstruction Many organisms may cause Thick, purulent tracheal secretions—prominent feature
Bacterial Tracheitis, may have the symtoms of LTB(Laryngotracheobronchitis) but is UNRESPONSIVE to treatment. True or False? TRUE
Which form of croup can develop into a respiratory emergency? : Acute croup (laryngotracheobronchitis) ~LTB~
Respiratory Syncytial Virus (RSV) Bronchiolitis is acute viral disease Main cause of hospitalization in <1 year old RSV infection main cause
Transmission of Respiratory Syncytial Virus (RSV) Contact respiratory secretions RSV easily spread Survive for more than 6 hours on counters, tissues soap
Clinical Manifestations Respiratory Syncytial Virus (RSV) URI Runny nose Low grade fever Ear infection / conjunctivitis Cough If disease progresses becomes a lower airway infection
Lower Airway Manifestations Respiratory Syncytial Virus (RSV) Altered air exchange Wheezing Retractions Crackles Dyspnea Diminished breath sounds Apnea—may be the first recognized indicator of RSV in very young infant
Therapeutic Management of Respiratory Syncytial Virus (RSV) Humidifier,hydration,suction,Airway maintenance Ribavirin(Antiviral) Synagis(man-made antibody to respiratory syncytial virus)
Nursing Care for Respiratory Syncytial Virus (RSV) Isolation Limit caregivers Educate on suctioning procedures Monitor oxygenation
How long can RSV (Respiratory Syncytial Virus) survive on countertops, tissues and soap bars? More than 6 HOURS.
Pneumonia types Lobar Bronchopneumonia Interstitial
Etiologic Agents of pneumonia Viral Bacterial Mycoplasmal Aspiration Fungal
How is pneumonia classified? Morphologic, but most useful is based on the etiologic agent.
Etiology of pneumonia Allergy influences Atopy Triggers Viral respiratory infections
_________ is a disorder that causes the airways of the lungs to swell and narrow, leading to wheezing, shortness of breath, chest tightness, and coughing. Asthma
Diagnostic Evaluation for Astma •Recurrent wheezing •Coughing •Trouble breathing •Chest tightness •Symptoms that occur or worsen at night •Symptoms that are triggered by cold air, exercise or exposure to allergens.
Pulmonary chronic airway obstruction due to astma can lead to______. scarring
What are the classic signs of asthma? Dyspnea, wheezing, coughing
What are the goals of asthma therapy? Maintain normal activity, pulmonary function, prevent chronic symptoms, exacerbations, drug therapy, normal and happy child
Cystic Fibrosis causes thick, sticky mucus to build up in the lungs, blocks the ducts of the pancreas affecting the digestive tract, and other areas of the body.Common chronic lung diseases
What are the two main problems related to the GI system as seen in Cystic Fibrosis? : intestinal obstruction and prolapsed rectum
What exercises can the parents be taught to do at home to help move secretions up and out? Postural drainage and chest physical therapy.
Astma Pathology -Inflammation -Bronchial constriction -Decreased airflow -Air trapping -Hypoxemia
Name 4 types of parent teaching for Astma Maintain health/home meds S/S of broncho spasms Avoid allergens promote normal activities
Cerebral Dysfunction Most brain status obtain by indirect measurements/ Newborn health and brain status/ Intellectual disability/ Hypoxic injury/ Developmental milestones/ Level of consciousness (LOC)
Increased Intracranial Pressure (ICP) Any increase in the three components increasing total volume to > 100% 80% brain/ 10% cerebrospinal fluid (CSF)/ 10% blood
Body compensates to keep total volumes equal to 100% by doing what? Reducing blood volume / Decreasing CSF production/ Increasing CSF absorption/ Brain mass shrinkage/ Open fontanels allow skull expansion and widened sutures/ At any age capacity for spatial compensation is limited
S/S of ICP High-pitched cry Headache/ Nausea, vomiting/ Seizures/ Bradycardia/ Decreased motor response to commands, painful stimuli/ coma/ If left untreated, death occurs
Alertness an arousal-waking state, includes ability to respond to stimuli
Cognitive power—the ability to process stimuli and produce verbal and motor responses
power—the ability to process stimuli and produce verbal and motor responses Score 15—unaltered LOC Score =< 8—coma Score 3—deep coma
: What is the Glasgow Coma Scale used for?   It provides an objective measurement of levels of consciousness.
Explain what decerebrate positioning is and what it indicates.   Decerebrate positioning is a sign of dysfunction at the midbrain characterized by rigid extension and pronation of the arms and legs.
What signs of pain would you expect an unconscious child to display? Signs of pain include the following: Changes in behavior (increased irritability and rigidity); Changes in physiologic parameters such as increased heart rate, increased respiratory rate and blood pressure.
Three major causes of Infant and toddler heads injuries. #1 cause—Falls #2 cause—<2 Motor vehicle injuries >2 pedestrian/cyclist injuries #3 cause—bicycle injuries (esp 5-19 years old) Boys > 2x girls due to risk-taking
Types of Head Injury Concussion/Contusions and Lacerations/Fractures (fx)/Edema /Hemorrhage/Diastatic/Open/Basilar/Comminuted/ Depressed/Linear
Name three problems caused by near-drowning. Hypoxia, asphyxiation and hypothermia.
For a child admitted with near- drowning, what is the priority nursing consideration? Respiratory support with attention to vital signs
: What are the most common signs and symptoms of a child with a brain tumor? A child with a brain tumor is 4 hours postop. There is a small amount of clear drainage noted on her dressing. What do you suspect it is and what is the most appropriate thing for you, the LPN to do immediately
: What is the most common way that hydrocephalus is diagnosed in infants? Based on head circumference that crosses one or more gridlines on the growth chart within a period of 2 to 4 weeks.
What are the signs and symptoms of infection in a child that is 24 hours postoperative shunt revision?   The signs and symptoms include: elevated vital signs, poor feeding, vomiting, decreased responsiveness, and seizures.
What defects cause hearing loss? Defect in sound transmission, damage to nerve pathways or a mixture of both.  
What are some methods of communicating with a hearing-impaired child? Visual aids, writing, drawing and sign language.
Three most common bacteria with Otis media Streptococcus pneumonia Haemophilus influenza Moraxella catarrhalis
Acute Otitis Media (AOM) vs Otitis Media with Effusion (OME) TM purulent Bulging, full, opacified, erythematous, nonmobile Immobile TM always indicates at least OME, other symptoms make it AOM
Clinical Symptoms AOM Otalgia acute onset Fever Purulent discharge (otorrhea) Crying, irritability, restlessness, difficulty comforting child Holding, rubbing, pulling on affected ear Loss of appetite Lethargy OM may progress to hearing loss, difficulty communic
Therapeutic Management for AOM Antibiotics: First line - amoxicillin (high dose) Second line Ceftriaxone injectable
What are common signs and symptoms of otitis media? Common s/s include pulling on the affected ear, irritability, fever, loss of appetite and purulent discharge.
To inspect the ear canal in an older child, what is the proper method of pulling the pinna? : Up and back.
What are the most common types of visual disorders in children? : Refractive disorders: Myopia—nearsightedness Hyperopia—farsightedness
Testing Visual Acuity Several tests available assessing vision Ocular Alignment Visual Acuity Peripheral Vision Color Vision
binocularity Object fixation by 3-4 months of age
strabismus Want to detect any nonbinocular vision
amblyopia “Lazy eye” Blindness can occur due to suppression of image from lazy eye
Ocular Alignment Tests/Corneal light test – Hirschberg Test – shine light from about 16 inches away into both eyes and check if light falls symmetrically within each pupil (normal)
Ocular Cover test one eye is covered, look for movement of the uncovered eye while child looks at near or far object (no movement is normal)
Visual Acuity Snellen Eye (Letter) Chart Tumbling E eye chart HOTV eye chart Allen card test
Color Vision/Two types Protanomaly-confusion gray: pink or pale blue: green Deuteranomaly-confusion gray: pale purple or green
When should vision screening first be performed? At the earliest possible age and at regular intervals.
Visual Refractive Errors Myopia Hyperopia Astigmatism
Amblyopia (lazy eye) Reduced visual acuity in one eye Not treated may lead to vision loss in eye
Question: True or False The goal of medical interventions of one with strabismus is to return the eyes to normal functioning and position. Answer: false There is no treatment that will perfectly align the eyes. The goal therefore is to realign them as close to normal as possible.
Question: What nursing responsibility is common to all three of these eye disorders? Answer: Early detection of signs and symptoms and referrals.
Retinoblastoma Most common congenital malignant intraocular tumor or childhood Arises from retina and mutation in gene Can be inherited or sporadic
Leukokoria Leukocoria literally means "white pupil." It occurs when the pupil (the round hole in the colored part of the eye) is white rather than the usual black
Question: What is Retinoblastoma? Answer: The most common congenital malignant intraocular tumor of childhood.
Autism Spectrum Disorders Neurodevelopmental disorders of brain function accompanied by intellectual and social behavioral deficits Autistic disorder Asperger syndrome Pervasive developmental delay Impairment mild to severe
What is Autism? A developmental disorder of brain function.
Dimensions of Care for Intellectually Disabled Cognitive Impairments/Dimension I Intellectual functioning and adaptive skills
Dimensions of Care for Intellectually Disabled Cognitive Impairments/Dimension II Psychological and emotional considerations
Dimensions of Care for Intellectually Disabled Cognitive Impairments/Dimension III Physical, health, and etiology considerations
Dimensions of Care for Intellectually Disabled Cognitive Impairments/Dimension IV Environmental considerations
Cognitive Impairments CI encompasses any type of mental difficulty or deficiency Other terms, used interchangeably-Intellectual Disability; Mental Retardation Definition-consists of three components
Classification of Cognitive Impairments Educable mentally retarded (EMR)— refers to mildly impaired group, usually includes ~ 85% of all people with CI
Classification of Cognitive Impairments Trainable mentally retarded (TMR)— refers to child with moderate levels of cognitive impairment, accounts for ~ 10% of intellectually disabled population
When a child with mental retardation is hospitalized, what can be done to help the child adjust? Allow a parent to stay with the child; allow the child to be as independent as possible; focus on things the child can do.
Fragile X Caused by abnormal gene on the lower end of the long arm of X chromosome Fragile site noted on the DNA and is replicated in affected individuals
What is the most common chromosomal abnormality? Down syndrome.
What role does the nurse play in assisting a child with a cognitive impairment? : The major role is in supporting and educating the family.
Bacterial Meningitis : an inflammation of the meninges, the covering of the brain and spinal cord Incidence: most common for children under 2 months
Most Common Causative Agent for Bacterial Meningitis: Group b streptococcus (GBS) (under 2 months) Streptococcus pneumoniae Neisseria meningitidis
definitive diagnostic for Bacterial Meningitis: Lumbar puncture is the definitive diagnostic test CSF Culture Gram stain Blood cell count Glucose and protein content
Bacterial Meningitis interventions Isolation precautions IV antibiotics Restrict hydration Maintenance of ventilation Reduction of increased ICP Management of shock Control of seizures IV infusion
What is Kernig sign? A sign indicating the presence of meningitis.done by having the person lie flat on the back, flex the thigh so that it is at a right angle to the trunk,extend the leg at the knee joint. The leg cannot be completely extended due to pain.
What does a Brudzinski sign? 1. An indication of meningitis in which passive flexion of the leg on one side causes a similar movement in the opposite leg. 2. Such an indication in which passive flexion of the neck causes flexion of the legs.
What initial medication management plays a role in ICP. Dexamethasone
: What is the most common causative agent of bacterial meningitis in children? Streptococcus pneumoniae and Neisseria meningitidis.
: What is the importance of clustering nursing care? To allow maximum rest and keep stimulation to a minimum.
Encephalitis Pathophysiology Inflammation of the brain parenchyma.
Causative agents include Encephalitis Pathophysiology: Togaviruses and herpes virus type 1 and 2. protozoa Bacteria, spirochetes and fungi.
Encephalitis Manifestations Headache, dizziness, coma. Spasticity Fever Seizures Lethargy Vomiting Stiff neck (nuchal rigidity) Altered Mental Status Tremors Ocular Palsies
Which age group is most at risk for residual damage as a result of encephalitis? Infants.
Reye’s Syndrome an ACUTE NON-INFLAMMATORY encephalopathy and HEPATOpathy, with NO reasonable explanation for the cerebral and hepatic abnormalities.
Reye’s Syndrome Etiology Etiology: actual cause unknown.  Most cases follow a common illness, typically influenza or varicella  Use of ASPIRINE to treat symptoms associated with onset of syndrome.
Reye’s Syndrome DiagnosTic evaluation Lab results: Elevated ammonia levels. Cerebral edema with ICP. Definitive diagnosis: Liver biopsy.
What drug should not be given to a child to treat symptoms associated with chickenpox? Aspirin.
What should be monitored when caring for a child with Reye's syndrome?   Respirations, neuro status, vital signs and I & O.
Sepsis Pathophysiology Sepsis or septicemia, refers to a generalized bacterial infection in the bloodstream that can progress to systemic inflammatory response syndrome (SIRS), shock, multiorgan system failure and death.
Sepsis can occur as a ______ or _____infection (following another infection). primary OR secondary
Sepsis Pathophysiology: Neonates/Children at risk: neutropenic, immunocompromised or in intensive care (due to invasive procedures
Sepsis Manifestations Poor temperature control.  Tachypnea.  Tachycardia.  Hypotension.  Neurological signs such as lethargy.  Jaundice.
SEPsis Diagnostic tests Positive blood culture. Urine culture. Cerebrospinal fluid culture. Anemia. Immature WBCs and neutropenia are ominous signs.
Sepsis Nursing care Monitor neuro status and vital signs. Observe for shock. Administer IV antibiotics as ordered, 7-10 days if positive culture. Verify vaccination against H. influenza type B (Hib) for all children between 2 months and 4 years.
What neonate/children are most at risk for developing sepsis? : Neutropenic, immunocompromised or in intensive care unit.
Seizures* are caused by excessive and disorderly neuronal discharges in the brain.
Seizure Manifestations depend on site of origin and may include: Unconsciousness or altered consciousness. Involuntary movements. Changes in perception, behaviors, sensations and posture.
Epilepsy* Is a condition characterized by two or more unprovoked seizures
Etiology of Epilepsy Classified by type and etiology Some are caused by: Trauma. Hypoxia. Infections. Biochemical events. Fevers greater than 101.8 with rapid elevation.
Partial seizures: 3 types: Simple partial seizures. Complex partial seizures. Simple or complex seizures/ secondarily generalized
Generalized seizures: May occur at any time, includes both Hemi of the brain, they have no memory of the event.
Diagnostic Evaluation/Thorough history and physical. Diet review. Examining the seizure: Onset. Time of day. Any precipitating factors. Duration. Progression. Postictal feelings.
Antiepileptic drugs: Primary therapy is giving appropriate drugs or combination of drugs in the dosage that provides the desired effects without undesirable side effects. Primary drugs for partial seizures and/or tonic clonic seizures: Carbamazepine (Tegretol). Phenytoin (Dilantin).* Valproic Acid (Depakote).
Primary drugs for absence seizures: Ethosuzimide (Zarontin). Valproic Acid (Depakote).*- requires good oral care.
Continuous seizure that lasts more than_____ minutes. 30 min
Status Epilepticus A series of seizures where the child does not regain a premorbid level of consciousness.
What are some possible causes of seizures?   : What should you document if you observe a child having a seizure?
What should you document if you observe a child having a seizure? Activity before seizure, body movements, change in color, respirations, muscle tone, incontinence, body parts involved, duration and appearance, behavior and LOC after the seizure.
Gross motor infant Head control Head lag Rolling over Sitting Locomotion
Infant Fine motor Prehension Palmar grasp Pincer grasp
Toddlers Gross motor Locomotion Walking Running Up and down stairs
Toddlers Fine Motor Fine motor Increasing manual dexterity Pincer grasp to throwing ball Building towers Drawing
Preschoolers gross motor Walking, running, climbing, jumping well Refinement of eye-hand muscle coordination Rides trike, skips, jumps rope Refinement of eye-hand muscle coordination Rides trike, skips, jumps rope
Preschool Fine motor Increasingly skillful manipulation Drawing Dressing self
School-age More graceful Posture improved Double strength Muscles immature “age of loose tooth” “ugly duckling stage”
Adolescents Sexual maturation Final 20-25% of height is achieved Adolescent growth spurt Characteristic sequence for growth Extremities and neck Hip and chest Shoulder width Trunk length Depth of chest
Name one age-specific change for the infant, toddler, preschooler, school-age child, and adolescent. Varies – any of above is correct
Immobilization Congenital defects Degenerative disorders Infections or injuries Musculoskeletal system problems Neurologic system problems Certain therapies
Name four of the most frequent reasons for immobility Congenital defects, degenerative disorders, infections or injuries of skin, musculoskeletal system problems, neurologic system problems, therapies.
Soft tissue injury Muscles Ligaments Tendons Usually results from mishaps during play, common in children
Contusions Bruise Immediate treatment consists of cold application Return to participation Strength Range of motion
Crush injury A crush injury occurs when a body part is subjected to a high degree of force or pressure, usually after being squeezed between two heavy objects.
Crush injury treatment Seek medical treatment Release any subungual hematoma Cold application Treat any lacerations
Dislocations Ligament involvement Pain Inability to move joint Phalanges, elbow
Dislocation treatment Simple dislocations should be reduced as soon as possible Treatment depends on severity of injury Restrict joint, cold application Seek medical attention from ER or provider
Sprains A sprain is an injury to the ligaments around a joint. Ligaments are strong, flexible fibers that hold bones together. When a ligament is stretched too far or tears, the joint will become painful and swell
related to sprain pain S/S Severe Joint laxity Pain “feeling loose” or “snap, pop, tearing” Rapid onset of swelling, immediate disability
Explain the acronym RICE Rest, ice, compression and elevation to reduce edema, bleeding and pain.
The 5 P’s: pain, pallor, pulselessness, paresthesia, paralysis What things need to be included in the assessment of a child with a suspected fracture?
Created by: charlie1010
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