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68c ph2 exam11
pediatrics all in one
| Question | Answer |
|---|---|
| Differentiation | Processes by which early cells and structures are systematically modified and altered to achieve specific characteristics |
| Prenatal (conception to birth): | Rapid growth rate. Total dependency. Most crucial period |
| Infancy (birth to 12 months): | Rapid motor, cognitive and social development. Trust is developed. Foundation for future interpersonal relationships is laid. |
| Early childhood (1 to 6 years): Toddler-1 to 3 years Preschool-3-6 years | Intense activity and discovery. Time of marked physical and personality development. Learn role standards, gain self control and acquire language and wider social relationships |
| Middle childhood (6 to 12 years): | Developing away from the family group and centered on the world of peer relationships. Developing skill competencies and social cooperation and early moral development take on more importance. |
| Later childhood/adolescence (12 to 19 years): Prepubertal from 10-13 years Adolescence from 13 to approximately 18 years | Tumultuous period of rapid maturation and change is known as adolescence. Considered to be a transitional period that begins at the onset of puberty and extends to the point of entry into the adult world. |
| Growth Trends | Directional cephalocaudal proximodistal differentiation Sequential Developmental Pace |
| Temperament Physiologic Changes | The easy child-even tempered, regular and predictable in habits The difficult child-highly active, irritable, and irregular in their habits. The slow-to-warm-up child |
| Psychosexual Development-Freud Centered on self Id Ego Superego | Oral stage- birth to 1 year Anal stage- 1 to 3 year Phallic stage- 3 to 6 year Latency period- 6 to 11 year Genital stage- adolescense and up |
| Psychosocial Development (Erikson) Most widely accepted Key conflicts vs core problems (favorable/ unfavorable) Resolution of stages Predictable stages | Trust vs mistrust- 0-1 years Autonomy vs shame and doubt- 1-3 years Initiative vs guilt- 3-6 years Industry vs inferiority- 6-12 years Identity vs role confusion- 12-19 years |
| Trust vs Mistrust (birth to 1 year): Favorable outcomes: faith and optimism | Establishment of trust dominates the first year of life and describes all the pleasurable experiences in life. Mistrust develops when trust-promoting experiences are lacking or when basic needs are not met. |
| Autonomy vs Shame (1-3 years): Favorable outcomes: self-control and willpower | Autonomy centers on the child’s ability to control their bodies, themselves and their environment. They want to do things for themselves. |
| Initiative vs Guilt (3-6 years): Favorable outcomes: direction and purpose | Children explore the physical world with their senses and powers. They develop a conscience. |
| Industry vs Inferiority (6-12 years): Favorable outcome: ego quality is competence | Children are ready to be workers and producers. They want to engage in tasks and activities they can carry through to completion. Children learn to compete and cooperate with others and learn the rules and consequences. |
| Identity vs Role Confusion (12-18 years): Favorable outcome: devotion and fidelity | Adolescents become overly preoccupied with the way they appear in the eyes of their peers. They struggle to fit in the roles they have played and those they hope to play with current roles and fashions adopted by their peers. |
| Factors influencing self esteem | Temperament and personality Ability to accomplish age appropriate tasks Significant others Social roles and expectations |
| 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. |
| Major Stressors of Hospitalization | Separation anxiety Loss of control Bodily injury Pain |
| Separation Anxiety Occurs in three phases | Protest Despair Denial or detachment |
| Protest | Child reacts aggressively to separation. Child protests loudly. May repeatedly call out for parent. Protests increase as strangers approach. Child is inconsolable in their grief. |
| Despair | Appears after protest stops. Child may appear sad, depressed and withdrawn and does not play actively. Child is uninterested in food and may refuse to drink. |
| Denial or Detachment | Superficially appears to have adjusted. Disinterested when parents visit. Behavior is a result of resignation and not contentment. Can alter bonding if stage is prolonged. |
| Loss of Control Infants and Toddlers: | Trust is being developed. Control environment through emotional expressions. Toddlers seek autonomy. React with aggression to loss of control. |
| Loss of Control Preschoolers: | Egocentric, magical thinking. Fantasize reasons for hospitalization/illness. Uses transductive reasoning and deduct from particular to particular, rather than from the specific to the general. |
| Loss of Control School Age Children: | Particularly vulnerable to loss of control. Respond well as long as they have a measure of control. Problems will arise from boredom and activity limitations. They respond with depression, hostility or frustration. |
| Loss of Control Adolescents: | Struggles are for independence, self-assertion and liberation. Threats to identity results in loss of control. React with rejection, uncooperativeness or withdrawal, anger or frustration. |
| Nursing Care | Be sensitive Allow parents to “room-in” and participate in care Maintain daily routine Continuity of staff Allow familiar items from home Promote freedom and independence |
| Nursing Care cont. | Allow child to care for self as much as possible Promote understanding by informing child of what to expect and what is expected of them |
| 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 |
| Stress Parents | Overall sense of helplessness Questioning the skills of staff Accepting the reality of hospitalization Needing info explained in simple language Dealing with fear Coping with uncertainty Seeking reassurance from caregivers |
| Interventions to Lessen Siblings Stress | They experience feelings of loneliness, fear, anger, worry, resentment jealousy and guilt. Encourage them to visit. Encourage the parents to spend time with them. |
| What are the three phases of separation anxiety? | Protest, despair, denial or detachment. |
| Children are undertreated for pain Reasons include: | The nurses’ misconceptions about pain. The complexities of pain assessment. Lack of information regarding available pain reduction techniques. |
| Pain Rating Scales | Faces Numeric Poker Chip Tool |
| Look for changes in behavior Challenging assessments | ** Crying** most common reported pain behavior in cognitively delayed children Significant neurologic impairment Mental retardation Metabolic disorders Autism Severe brain injury Communication barriers |
| Non-pharmacologic - Decreases fear, anxiety and stress. Nursing Interventions | Distraction Relaxation Guided imagery Positive self-talk Thought stopping Cutaneous stimulation Virtual reality Containment |
| Pharmacologic Nursing Interventions | Nonopioids Opioids – Morphine gold standard for severe pain Combination |
| 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 |
| Pediatric Admission | Introduce the primary nurse. Ask the child what name they prefer to be called. Orient the child and family to the unit. Introduce the child to their roommate. Explain hospital rules and schedules. Conduct a thorough nursing admission history |
| Pediatric Admission cont. | Ask open-ended questions. Spend time with the child during initial procedures. Communicate the assessment |
| Role of Play in the Hospitalized Child | Play is the child’s work One of the most important aspects of life Effective tool for managing stress Essential for child’s mental, emotional, social well-being |
| Functions of Play in the Hospital | Helps child feel more secure in environment Lessens stress of separation/ homesickness Provides for release of tension/ expression of feelings Places child in active role Provides opportunity to make choices and be in control |
| Types of Play | Onlooker Solitary Parallel Associative Cooperative |
| Types of Activities | Diversional activities Expressive activities Creative expression Dramatic play |
| 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 |
| Increased Intracranial Pressure (ICP) | any increase in the three components located in the cranium that increases the total volume to greater than 100%. |
| Body compensates to keep total volumes equal to 100% | 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 |
| Causes of increased ICP | Tumors Other space-occupying lesions Accumulation of fluid in ventricular system Bleeding Edema of cerebral tissues |
| Signs and Symptoms of IICP | High-pitched cry Headache Nausea, vomiting Seizures Bradycardia Decreased motor response to commands, painful stimuli coma If left untreated, death occurs |
| Components of consciousness | Alertness—an arousal-waking state, includes ability to respond to stimuli Cognitive power—the ability to process stimuli and produce verbal and motor responses |
| Glasgow Coma Scale (GCS) | Numeric values from one to five assigned each category Sum of values objective measurement of levels of consciousness Score 15—unaltered LOC Score =< 8—coma Score 3—deep coma |
| Neurologic specific exam | Vital signs: Body temperature Pulse Blood pressure Respirations Breathing patterns Skin: Eyes: Pupil size and reactivity Eye movements |
| Flexion posturing signifies severe dysfunction of the cerebral cortex | known as decorticate posturing |
| Extension posturing is a sign of dysfunction at the level of the midbrain or lesions to the brainstem. | known as decerebrate posturing |
| 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 |
| The unconscious child | Emergency measures of the unconscious child are aimed toward ensuring a patent airway, treatment of shock, and decreasing ICP (if present). |
| Regular assessment of neurologic signs is a vital part of nursing comatose children. Significant alterations/changes must be reported immediately. | Temperature is taken very 2-4 hours, tepid sponge baths or hypothermia blanket are needed if temp exceeds 40 degrees C, rectally, to prevent brain damage Vital signs, LOC, pupillary reaction measured/recorded regularly, may be ordered every 15 minutes |
| Cerebral hypoxia lasting > 4 mins nearly always causes IRREVERSIBLE brain damage Establishment of a patent airway is ALWAYS the first priority. | Oral airway Nasotracheal airway Orotracheal airway Tracheostomy If respiratory center is involved, mechanical ventilation is usually indicated |
| There are four types of ICP monitors | Intraventricular catheter with fibroscopic sensors Subarachnoid bolt (Richmond screw) Epidural sensor Anterior fontanel pressure monitor |
| Indications for inserting an ICP monitor are | GCS evaluation of 8 GCS evaluation of less than 8 with respiratory assistance Deterioration of condition Subjective judgment regarding clinical appearance and response |
| Nursing care includes: ICP | Particular attention to positioning child to avoid neck vein compression; prop child to one side or other Use alternating-pressure mattresses |
| Nursing care includes: cont. ICP | Clinical assessment performed frequently, but at least every two hours; using an ICP monitor does not negate the need for clinical observation and assessment Avoid activities that increase or may increase ICP |
| Nursing care includes: cont.2 ICP | Suctioning and percussion are poorly tolerated and are contraindicated unless concurrent respiratory problems exist If you must suction, hyperventilate with 100% oxygen first, be brief |
| Nursing care includes: cont.3 ICP | Use of vibration does not cause increased ICP and is a good substitute choice for percussion |
| ICP interventions | Over-hydration must be avoided Steroids for inflammatory conditions/ edema Osmotic diuretics indicated with cerebral edema. Sedatives/anti-seizure drugs prescribed for seizure activity. Mouth care at least twice daily Brushteeth Coat lips w ointment |
| ICP interventions cont. | Elevate head of bed Hearing the last sense to go and first to come back—speak to the unconscious child |
| What signs of pain would you expect an unconscious child to display? | Changes in behavior (increased irritability and rigidity); Changes in physiologic parameters such as increased heart rate, increased respiratory rate and blood pressure. |
| Head Injury | #1 health risk for children Leading cause of death in children > 1 year of age |
| Etiology Head Injury | #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 |
| Acceleration-deceleration injuries | Coup-contrecoup Sheering stresses |
| There is a lower incidence of contusions in infants and very small children because of the pliability of their skull and softer consistency of brain tissue. | neurologic impairment, seizures, retinal hemorrhages, and intracranial subarachnoid or subdural hemorrhages. (shaken baby syndrome) |
| Comminuted fractures-- | consists of multiple linear fractures which result from intense impact, may be from repeated blows against an object and may suggest child abuse. |
| Types of Fractures | Linear Depressed Comminuted Basilar Open Diastatic |
| Therapeutic Management Concussions (mild, at home care, no LOC) | Check child every 2 hours Determine if changes to responsiveness Wake the sleeping child to see if rouses normally Follow-up with healthcare provider 1-2 days |
| Therapeutic Management Concussions (severe injuries, LOC) | Loss of consciousness, seizures, focal or diffuse neurological signs must be hospitalized NPO, clear liquids IV fluids Strict I&O |
| Therapeutic Management Concussions (severe injuries, LOC) cont. | Pain and restlessness management Antiepileptics Antibiotics Tetanus toxoid Suturing, surgical reduction, removal of bone fragments |
| What are the potential complications of head injuries? | Hemorrhage, infection, cerebral edema and brain herniation. |
| What nursing intervention is most appropriate for a child with a head injury who is very restless and irritable? | Provide analgesic as ordered. |
| Drowning | Children who can swim but overestimate endurance Boys five times more often than girls 40% < age 5 90% in private swimming pools |
| Near-drowning Near-drowning—survival 24 or more hrs after submersion in fluid medium | Ranks 2nd as cause accidental death children Occurs 5x more in boys than girls 40% are < 5 years old |
| Problems related to near-drown | Hypoxia Acute ventilator insufficiency Asphyxiation of fluid Hypothermia |
| Management near-drown | Resuscitation—begin at scene Maximum ventilatory and circulatory support Restore oxygen delivery to cells Intubation/ mechanical ventilation Manage according to degree of cerebral insult |
| Name three problems caused by near-drowning. | Hypoxia, asphyxiation and hypothermia. |
| Brain tumors | Central nervous system (CNS) tumors account for 20% of all childhood cancers 3.3/ 100,00 cases occur children <15 years old |
| Diagnostic Tests Brain tumors | MRI—determines location/ extent of tumor CT scan Angiography Electroencephalogram (EEG) Lumbar puncture Brain tissue specimen definitive diagnosis |
| Therapeutic management Brain tumors | Treatment of choice—remove entire tumor without residual, but best can hope for is 99%--never take brain tissue margins |
| What are the most common signs and symptoms of a child with a brain tumor? | The most common symptoms are: headache, especially on awakening and vomiting that is not related to feeding. |
| 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. |
| Bacterial Meningitis | Definition: an inflammation of the meninges, the covering of the brain and spinal cord Incidence: most common for children under 2 months |
| Bacterial Meningitis s/s | Common Symptoms: Fever Chills Headache Vomiting Alterations in sensorium Lumbar puncture is the definitive diagnostic test |
| Bacterial Meningitis nursing interventions | Isolation precautions IV antibiotics Restrict hydration Maintenance of ventilation Reduction of increased ICP Management of shock Control of seizures IV infusion |
| Bacterial Meningitis nursing interventions cont. | Keep room quiet Evaluate child for pain Observe vital signs Administer antibiotics Respiratory isolation for 24 hour Monitor I&Os Observe for signs of increased ICP, shock or respiratory distress. Maintain IV infusion |
| 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: 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 |
| Nursing Care Encephalitis | Sedatives & antipyretics. Nutrition & hydration. Seizure precautions. Quiet environment, good oral hygiene, skin care, position changes. |
| Nursing Care Encephalitis cont. | Oxygen as ordered. Record I & O. Prevent complications of immobility. Observe for neuro changes. Keep parents informed & involved. |
| Which age group is most at risk for residual damage as a result of encephalitis? | Infants. |
| Reye’s Syndrome | Definition: an acute non-inflammatory encephalopathy and hepatopathy, with no reasonable explanation for the cerebral and hepatic abnormalities. |
| Reye’s Syndrome | Incidence: Primarily affects children. The younger the child the higher the morbidity and mortality rates. Use of aspirin to treat symptoms associated with onset of syndrome. (cause) |
| Reye’s Syndrome DiagnosTic evaluation | Lab results: Elevated ammonia levels. Cerebral edema with ICP. Definitive diagnosis: Liver biopsy. |
| Nursing Care Reye’s Syndrome | Aggressive Supportive Therapy Monitor I & O. Keep parents informed, involved & reassured. Referrals as appropriate. |
| 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 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 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: | Classified by type and etiology Some are caused by: Trauma. Hypoxia. Infections. Biochemical events. Fevers greater than 101.8 with rapid elevation. |
| Epilepsy Seizure Classification Partial seizures: 3 types Generalized seizures: May occur at any time. | Simple partial seizures. Complex partial seizures. Simple or complex seizures secondarily generalized |
| Diagnostic Evaluation Epilepsy | Examining the seizure: Onset. Time of day. Any precipitating factors. Duration. Progression. Postictal feelings. |
| Diagnostic Evaluation Epilepsy cont. | Complete neuro exam. Lab studies: CBC with white cell count. LP. CT scans, MRI and EEG. |
| Antiepileptic drugs | 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). |
| Therapeutic Management con’t Epilepsy | Once the child is free for 2 years with a normal EEG, the therapy and medications are gradually discontinued. When seizures are caused by tumors, hematoma or other lesions, surgery is the treatment of choice. |
| Status Epilepticus | Continuous seizure that lasts more than 30 minutes. A series of seizures where the child does not regain a premorbid level of consciousness. A MEDICAL EMERGENCY. |
| Status Epilepticus Con’t | Treatment is directed at: Support and maintenance of vital functions. Adequate airway. Obtaining and IV. Place on monitor. |
| Nursing Care during Seizures Observe seizure. Take a good history. | During the seizure: Protect the child from injury. Remain calm and stay with the child. Protect the child’s privacy. Do not move or restraint child. Do not place any objects in the child’s mouth. Place the child in recovery position afterwards. |
| Seizure Precautions | According to hospital and unit policies. Keep side rails elevated and padded. Waterproof mattress on bed if available. Wear medical alert bracelet. |
| What are some possible causes of seizures? | Birth injury, Epilepsy, infection, fever, dehydration, hypoglycemia, anesthetics, drugs and poisons. |
| 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 |
| Hearing Impairment | Pre- or postnatal conditions Family history Anatomic malformations head and neck Severe perinatal asphyxia Low birth weight Perinatal infections Chronic ear infections Cerebral palsy |
| Hearing Impairment cont. | Down syndrome Administration of ototoxic drugs High-risk neonates Environmental noise |
| Nursing Considerations Hearing Impairment | Early detection and treatment is key to preventing complications from hearing loss Universal newborn hearing screening |
| 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. |
| Otitis Media cause | Three most common bacteria Streptococcus pneumonia Haemophilus influenza Moraxella catarrhalis Non-infectious OM is unknown Blocked eustachian tubes Edema of URIs Allergic rhinitis Hypertrophic adenoids |
| 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 |
| Therapeutic Management AOM | Antibiotics: First line - amoxicillin (high dose) Second line Ceftriaxone injectable Spontaneous resolution (wait 72 hrs if over 6 months age) Supportive care Surgery Myringotomy Tympanostomy |
| 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 |
| 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) |
| 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) |
| When should vision screening first be performed? | At the earliest possible age and at regular intervals. |
| Nursing Consideration lazy eye infancy | Infancy Observe response to visual stimuli Parents concerns serious Test for strabismus Ensure treatment of binocularity after 4 mos old Promote parent-child attachment |
| Nursing Consideration lazy eye child | Childhood Test for visual acuity Follow-up if referral made Promote optimal development |
| True or False The goal of medical interventions of one with strabismus is to return the eyes to normal functioning and position. | false There is no treatment that will perfectly align the eyes. The goal therefore is to realign them as close to normal as possible. |
| What nursing responsibility is common to all three of these eye disorders? | Early detection of signs and symptoms and referrals. |
| Retinoblastoma s/s | Strabismus (second most common sign) Red, painful eye, often with glaucoma Blindness (late sign) |
| Diagnosis Retinoblastoma | Positive eye abnormalities White reflex (leukokoria) Strabismus Decreased vision Persistent painfully erythematous eye Ophthalmoscopic exam under anesthesia Imaging studies (ultrasonography, CT) to determine extent of disease |
| Nursing Care Retinoblastoma | High index of suspicion for this rare tumor Parent/patient education post diagnostic symptoms (such as photophobia) Parent teaching on socket/wound care, prosthetic are |
| What is Retinoblastoma? | 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 |
| Clinical manifestations Autism | Hallmark-inability to maintain eye contact Red flag-sudden deterioration in extant expressive speech Bizarre characteristics-social interactions Limited functional play |
| Clinical manifestations autism cont. | Significant GI symptoms—megacolon Self-abuse is common 50-70% some degree cognitive impairment Savants |
| What is Autism? | A developmental disorder of brain function. |
| Classification System cognitive impairment | Dimension I—Intellectual functioning and adaptive skills Dimension II—Psychological and emotional considerations Dimension III—Physical, health, and etiology considerations Dimension IV—Environmental considerations |
| Classification—clinical application cognitive impairment | Mild—IQ 50-55 to 70-75 often not noticed by casual observer Moderate—IQ 35-45 to 50-55 noticeable delays in motor, esp. speech Severe—IQ 20-25 to 35-40 little to no communication Profound—IQ below 20-25 minimal capacity for functioning |
| Classification cont. cognitive impairment | Educable mentally retarded (EMR)—refers to mildly impaired group, usually includes ~ 85% of all people with CI |
| Classification cont. cognitive impairment | Trainable mentally retarded (TMR)—refers to child with moderate levels of cognitive impairment, accounts for ~ 10% of intellectually disabled population |
| Classification cont. cognitive impairment | Use child’s ability to classify severity, don’t focus on IQ numbers |
| 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. |
| Etiology Fragile X | Caused by abnormal gene on lower end of long armX chromosome Fragile site noted,DNA is replicated in affected individuals Inheritance pattern termed X-linked dominant w/ reduced penetrance Both affected sexes fertile/ capable of transmitting disorder |
| Classic physical findings in adult men Fragile X | Long faces with prognathism Large, protruding ears Macroorchidism |
| In children features are less obvious, behavioral manifestations may suggest diag. Fragile X | Mild to severe CI; intolerance to change routine Speech delay Short attention span Hypersensitivity—taste, sounds, touch Autistic-like behaviors |
| 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. |
| Age Specific Changes Infants | Gross motor Head control Head lag Rolling over Sitting Locomotion Fine motor Prehension Palmar grasp Pincer grasp |
| Age Specific Changes Toddlers | Gross motor Locomotion Walking Running Up and down stairs Fine motor Increasing manual dexterity Pincer grasp to throwing ball Building towers Drawing |
| Preschoolers | Gross motor well established Refinement of eye-hand muscle coordination Rides trike, skips, jumps rope 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 |
| most frequent reasons for immobility. | Congenital defects, degenerative disorders, infections or injuries of skin, musculoskeletal system problems, neurologic system problems, therapies |
| Fractures | Common injury in children In children, fractures heal much faster than adults Most often result of trauma incident |
| Plastic deformation | Bone bent Not broken Will not completely straighten on own |
| Buckle or torus | Produced by compression of the porous bone Appears as raised or bulging projection at site |
| Greenstick | Bone is angulated beyond limits of bending Tension side fails Incomplete fracture |
| Complete | Divides bone fragments Often remain attached by periosteal hinge |
| Incomplete | Fracture not completely through bone and fragments remain attached Proximal fragment—closer to midline Distal fragment—farther from midlin |
| Transverse | Crosswise at right angle to long axis of bone |
| Oblique | Slanting but straight Between a horizontal and perpendicular direction |
| Spiral | Slanting or circular Twisting around the bone shaft |
| Simple/Closed | Does not break through skin |
| Compound/Open | Bone protrudes through skin |
| Diagnostic evaluation Fractures | Often stable Child may be able to use Radiographic examination is the most useful diagnostic tool for assessing skeletal trauma |
| Therapeutic management goals Fractures | Reduction Immobilization Restore function Prevent further injury |
| Therapeutic management fractures cont. | Neurovascular status (5 P’s) Pain and point of tenderness Pulse – distal to the fracture sight Pallor Paresthesia Paralysis Apply traction/ tourniquet Elevate injured limb/ apply cold Call emergency medical services |
| Nursing management | Above emergency management Assess for LOC, hemorrhage (treat as necessary) Calm and reassure child/ parent Explain what will happen Provide pain control |
| Explain the acronym RICE. | Rest, ice, compression and elevation to reduce edema, bleeding and pain. |
| What things need to be included in the assessment of a child with a suspected fracture? | The 5 P’s: pain, pallor, pulselessness, paresthesia, paralysis |
| What are three things that can be done to prevent skin breakdown in a child in traction | Provide alternating pressure mattress under the hips and back, Inspect pressure points daily or more often if breakdown is observed, Change position at least every 2 hours to relieve pressure |
| Three degrees of DDH | Acetabular dysplasia (preluxation) Subluxation dislocation |
| Therapeutic management DDH | Newborn to 6 months Pavlik harness Hip spica cast 6-24 months Gradual reduction by traction Attempted closed reduction, open reduction Older child Surgical |
| Nursing care DDH | Assess hips for any deviations Teach parents to apply reduction devices Involve children in developmentally appropriate activities Skin care Hold infants, continue nurturing activities and care |
| Classification clubfoot | Positional clubfoot Syndromic or teratologic clubfoot Congenital clubfoot |
| Therapeutic management clubfoot | Goal to achieve painless, plantigrade and stable foot Three stage process Correction of deformity Maintenance of correction Follow-up observation Serial casting X-rays/ ultrasound |
| Osteogenesis imperfecta (OI) | Most common osteoporosis syndrome in children Pathophysiology Heterogeneous, autosomal dominant disorder Characterized by fractures and bone deformity 7 types |
| Clinical features Osteogenesis imperfecta (OI) | Varying degrees of bone fragility, deformity, fractures Blue sclera Hearing loss Dentinogenesis imperfecta (discolored teeth) |
| Therapeutic Management Osteogenesis imperfecta (OI) | Mostly supportive New research advances Goals of rehabilitative approach Postural contractures and deformities Muscle weakness and osteoporosis Malalignment of lower extremity joints |
| Why would a Pavlik harness be used on a newborn? | To help splint their hips in a safe position with the femur centered in the acetabulum, worn continuously. |
| What things should a nurse do to help prevent fractures while caring for a child with Osteogenesis Imperfecta? | These children require careful handling to prevent fractures, they must be supported when they are being turned, positioned, moved and held |
| Legg-Calve-Perthes disease | Self-limiting disease in which there is aseptic necrosis of the femoral head Pathophysiology Cause and incidence unknown Disturbance of circulation Usually insidious onset Diagnosis established by x-ray, exam with MRI |
| Legg-Calve-Perthes disease Stages | Stage I—initial, avascular stage Stage II—fragmentation or revascularization stage Stage III—reossification or reparative stage Stage IV—residual or regenerative stage |
| Therapeutic management Legg-Calve-Perthes disease goals | Goals Eliminate hip irritability Restore and maintain hip range of motion Prevent capital femoral epiphyseal collapse Ensure well-rounded femoral head at time of healing |
| Therapeutic management Legg-Calve-Perthes disease cont. | Treatment varies Non-surgical Surgical Conservative Self-limiting |
| What two major factors are considered when planning nursing care? | The age of child and the type of treatment. |
| Scoliosis | Pathophysiology Most common spinal deformity Classified according to age of onset Can be associated with other conditions May be genetic component Curves of less than 10 degrees Curves of less than 20 degrees |
| How is scoliosis classified and what is the most common? | Classified by age, and adolescent is the most common. |
| Clinical manifestations Osteomyelitis | General History of trauma Child appears ill Irritability Restlessness Fever Rapid pulse dehydration |
| Therapeutic management Osteomyelitis | Empiric therapy with IV antibiotics after culture obtained Cover with most likely infecting organisms until ID’d At least 4 weeks of appropriate antibiotic—may be IV and oral, starts IV Surgical intervention long |
| Nursing care Osteomyelitis | Position for comfort Pain management Antibiotic therapy Standard precautions, unless otherwise indicated Cast care if indicated |
| Nursing care Osteomyelitis cont. | Adequate nutrition Anti-nausea meds if indicated Play therapy, physical therapy Education for parents on disease |
| How long is the course of antibiotics for osteomyelitis? | 4 weeks IV, may be 6 weeks to 4 months |
| Osteosarcoma Clinical manifestations | Pain, localized to affected site Limping Curtailing own physical activity Unable to hold heavy objects |
| Therapeutic management Osteosarcoma | Surgery Surgical biopsy—diagnostic purposes Limb salvage—en bloc resection Amputation Chemotherapy Vital role Antineoplastic drugs Employed before or after surgery or both Pulmonary metastasis |
| What is the best approach to treating osteosarcoma? | Surgery and chemotherapy. |
| Ewing sarcoma | Pathophysiology Primitive neuroectodermal tumor (PNET) Arises in the marrow spaces of the bone Tumor originates in shaft of long bones and trunk Occurs almost exclusively in individuals under 30 |
| Therapeutic management Ewing sarcoma | Surgical amputation not routinely recommended Treatment of choice Intensive radiotherapy Combined with chemotherapy Chemotherapy varies widely |
| Nursing care Ewing sarcoma | Psychologic adjustment not as traumatic typically as osteosarcoma Prepare child and family for various diagnostic tests, irradiation Prepare for adjusting to chemotherapy side effects |
| Juvenile idiopathic arthritis | Chronic autoimmune inflammatory disease causing inflammation of joints Pathophysiology Starts before 16 years of age Chronic inflammation of the synovium with joint effusion, erosion, destruction, and fibrosis Adhesions between joint surfaces |
| Clinical manifestations Juvenile idiopathic arthritis | Outcome variable and unpredictable Rarely life-threatening Arthritis wax and wane progressive arthritis into adulthood Significant joint deformity Significant functional disability Chronic and acute uveitis can cause permanent vision loss |
| Types of JIA | Systemic arthritis Oligoarthritis Polyarthritis Psoriatic arthritis Enthesitis-related arthritis |
| Therapeutic management JIA | Diagnosis of exclusion No cure Medications Physical and occupational therapy Pain control Preserve joint range of motion Preserve joint function Minimize effects of inflammation |
| Nursing care JIA | Support patient, parents, family Self-care School participation Medications, physical therapy Prevent isolation Relieve pain Promote general health Facilitate compliance |
| Arthritis can cause significant joint deformity and functional disability perhaps requiring what three items? | Medication, physical therapy, future joint replacements |
| Who is responsible for determining the type and amount of activity the child should perform | The physical therapist |
| Respiratory infections account for majority of acute illness | Viruses Bacteria Fungal |
| Anatomic Differences | The distance between structures within the respiratory tract is shorter in young children and organisms may move more rapidly down the respiratory tract |
| respiratory weakness and the seasons | The most common respiratory pathogens appear in epidemics during the winter and spring months. Mycoplasamal infections occur more often in the autumn and early winter. Infection-related asthma occur more often during cold weather and early spring. |
| Clinical Manifestations respiratory infections | Fever Poor feeding Anorexia Diarrhea Abdominal pain Nasal blockage Nasal discharge Cough Sore throat Respiratory sounds |
| Observe For these in the case of respiratory infection | 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. |
| Nasopharyngitis: the common cold. It is the most common infection of the respiratory tract. nasopharyngitis | Rhinovirus RSV Adenovirus Influenza virus Parainfluenza virus. |
| Therapeutic Management nasopharyngitis | Antipyretics are prescribed for fever and discomfort Provision of humidified environment and increasing oral fluids may help some children Decongestants for children over 6 months of age may help shrink swollen nasal passages |
| Educate family members on respiratory complications that should be reported to health professional | earache Breathing faster than 50-60 breaths/min Fever Listlessness Confusion Restlessness / poor sleep irritability Cough for 2 or > days Wheezing Crying Refusal to take oral fluid / low urination |
| Acute Pharyngitis | Inflammation of structures of throat 80-90% caused by virus Throat culture – GABHS GABHS risks Children experiencing GABHS infection of the upper airway are at risk for rheumatic fever (RH) |
| GABHS infection (strep throat) | Subclinical Abrupt onset Pharyngitis Headache High fever Abdominal pain Strawberry tongue Sandpaper rash Palatal petechiae Enlarged cervical nodes Malaise |
| Non-GABHS infection | Gradual onset Pharyngitis Fever Headache Malaise |
| Therapeutic Management GABHS | Penicillin Erythromycin if PCN allergic Antipyretics Push fluids |
| Non-GABHS | No specific treatment Antipyretics Treat symptoms Push fluids |
| Nursing Care | Cold or warm compresses to neck may help pain Warm saline gargles may help throat pain Maintain adequate fluid intake Educate the parents that the child can return to school or day care 24 hours after antibiotics are started. |
| 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. |
| Tonsillitis / Adenoiditis | Tonsillitis often accompanies pharyngitis Causative agent may be viral or bacterial Due to the abundant lymphoid tissue and the frequency of URIs tonsillitis is a common cause of illness in young children |
| Clinical Manifestations Tonsillitis / Adenoiditis | Inflamed tonsils “Kissing tonsils” Difficulty swallowing Difficulty breathing Mouth breathing |
| Therapeutic Management Tonsillitis / Adenoiditis | Self-limiting and symptomatic—viral Antibiotics for + bacteria (Strep) Tonsillectomy Adenoidectomy |
| Nursing Care—Post-operative | Provide comfort Minimize activity precipitate bleeding Liquid to soft diet Cool-mist humidifier Facilitate oral secretion drainage Post-op ice collar Observe for post-op hemorrhage |
| What post-operative complication requires immediate medical attention, above all others? | Hemorrhage. |
| Acute Epiglottis | Serious obstructive inflammatory process 2-8 year olds Requires immediate attention |
| Clinical Manifestations Acute Epiglottis | Abrupt onset Rapid progression to respiratory distress Appears sicker than clinical findings suggest Drooling Irritable, extremely restless, anxious Retractions may be evident, but not struggling to breath |
| Clinical Manifestations Acute Epiglottis cont. | Child usually goes to bed asymptomatic Awakens later complaining of sore throat and pain on swallowing, fever Distinctive large, cherry red, edematous epiglottis visible May progress rapidly to death |
| Therapeutic Management Acute Epiglottis | Keep child quiet Emergency equipment available at all times Invasive procedures wait until child intubated or someone avail to intubate Humidified oxygen as needed IV antibiotics if bacterial |
| Nursing Care Acute Epiglottis | Act quickly but calmly Allow child to remain in position of comfort Continuous respiratory monitoring |
| Acute Laryngitis | Acute Laryngitis—acute infectious laryngitis is common illness in older children and adolescents Viruses are the usual causative agents |
| Clinical Manifestations Acute Laryngitis | Hoarseness—principal complaint Rhinitis Sore throat Nasal congestion Fever Headache Malaise |
| Therapeutic Management Acute Laryngitis | Usually self-limiting Symptomatic treatment with fluids, humidified air, antipyretics, analgesics, decongestants |
| Acute Laryngotracheobronchitis | Most common “croup” syndrome Parainfluenza RSV M. pneumoniae Usually preceded by URI |
| Clinical Manifestations Acute Laryngotracheobronchitis | Suprasternal retractions Cough, hoarseness Respiratory distress, nasal flaring, intercostals retractions, tachypnea, continuous stridor in infants Typical child with LTB has barking or “seal-like” cough/acute stridor after several days of rhinitis |
| Therapeutic Management Acute Laryngotracheobronchitis | Maintain airway Provide adequate respiratory exchange High humidity Racemic epi Steroids |
| Nursing Care Acute Laryngotracheobronchitis | Most important is respiratory monitoring Pulse oximetry Keep child quiet and comfortable |
| Acute Spasmodic Laryngitis Clinical Manifestations | Noisy respirations Restlessness Anxious and frightened Attack subsides in few hours |
| Therapeutic Management Acute Spasmodic Laryngitis | Spasmodic cough usually self-limiting Most managed at home Cool mist humidifier or bathroom with hot shower running Parent takes out into cool night air for trip to ER and coughing subsides by time get to ER |
| Bacterial Tracheitis | Features of croup and epiglottitis Serious cause of airway obstruction Many organisms may cause |
| Clinical Manifestations Bacterial Tracheitis | Similar to LTB but unresponsive to therapy History URI Toxic appearing Stridor affected by positioning High fever Absence of drooling Thick, purulent tracheal secretions—prominent feature |
| Clinical Manifestations Bacterial Tracheitis cont. | May develop rapidly into Life-threatening upper airway obstruction Respiratory failure Acute respiratory distress syndrome (ARDS) Multiple organ dysfunction |
| Therapeutic Management Bacterial Tracheitis | Vigorous management with antipyretics and antibiotics Endotracheal intubation, mechanical ventilation may be necessary Close respiratory monitoring Early recognition Vigorous suctioning if intubated |
| Which form of croup can develop into a respiratory emergency? | Acute croup (laryngotracheobronchitis) and Bacterial Tracheitis |
| RSV and Bronchiolitis | Bronchiolitis is acute viral disease Main cause of hospitalization in <1 year old RSV infection main cause Infection occurs primarily in winter and early spring |
| RSV and Bronchiolitis Clinical Manifestations | URI Runny nose Low grade fever Ear infection / conjunctivitis Cough If disease progresses becomes a lower airway infection |
| Lower Airway Manifestations | Altered air exchange Wheezing Retractions Crackles Dyspnea Diminished breath sounds Apnea—may be the first recognized indicator of RSV in very young infant |
| How long can RSV survive on countertops, tissues and soap bars? | More than 6 hours. |
| Etiologic Agents Pneumonia | Viral Bacterial Mycoplasmal Aspiration Fungal |
| Types Pneumonia | Bronchopneumonia Lobar Interstitial |
| Clinical Manifestations Pneumonia | Fever—usually high Cough Symptoms of respiratory distress Breath sounds Percussion Chest pain Behavior Gastrointestinal |
| Therapeutic Management Pneumonia Viral | Promote oxygenation Cool mist Chest physiotherapy Postural drainage Antipyretics Push fluid intake Family support |
| Therapeutic Management Pneumonia Bacterial | Antibiotic therapy Bedrest Push fluid intake Antipyretics Oxygenation Hospitalization Pleural effusion Empyema Therapy compliance Less than 1 month old Comorbidities |
| How is pneumonia classified? | Morphologic, but most useful is based on the etiologic agent. |
| 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 |
| Drug therapy asthma Long-term control medications Inhaled corticosteroids Cromolyn sodium, nedocromil Long-acting beta-2 agonists Methylxanthines Leukotriene modifiers | Drug therapy asthma Quick-relief medications Short-acting beta-2 agonists Anticholinergics Systemic corticosteroids |
| Nursing Care cystic fibrosis | Assess pulmonary and GI systems Assess newborns for feeding / stooling Careful explanations regarding illness Hospitalized care Home care |
| 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. |
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grayman94
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