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Pediatrics 68WM6

Care of the Pediatric Patient and Medications 68WM6

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) 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) 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.
Infants Temp/ Pulse / RR/ BP Normals Temp: from 96.5 to 99.5. Axillary or Tympanic. Pulse: apical pulse average 120 beats/min. Respiratory Rate: average is 30 breaths per minute. Related to activity level.Blood Pressure: average 90/60. Obtain on leg instead of arm.
Toddlers Temp/ Pulse/ RR/ BP Normals Temperature ranges 98 F to 99 F. Taken axillary or tympanic. Pulse ranges from 90 to 120 beats/min. Respirations range from 20 to 30 breaths/min. Blood pressure averages 80 to 100 systolic and 64 diastolic.
School Age Child Temp/ Pulse/ RR/ BP Normals Temperature ranges between 98F and 99F. Can be oral or tympanic. Pulse is between 55 and 90. Can measure by palpating radial artery. Respiratory rate averages 22 to 24 breaths/min. Blood pressure averages 110/65.
Adolescent Temp/ Pulse/ RR/ BP Normals Temperature is the same as the school age. Pulse averages 70 beats/min. Respiratory rate averages 20 breaths/min. Blood pressure averages 120/70.
Trust vs Mistrust (birth to 1 year): 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): 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): Children explore the physical world with their senses and powers. They develop a conscience.
Industry vs Inferiority (6-12 years) 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): 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.
Development of Self Concept How one describes him or herself. One’s self concept may or may not reflect reality. Self concept
Body Image refers to the concepts and attitudes one has towards their body.
Infants Self Concept receive input through self explorations and sensory stimulation from others.
Toddlers Self Concept learn to identify the various parts of their bodies and are able to use symbols to represent objects.
Preschoolers Self Concept become aware of their bodies and discover their genitals.
School Age Self Concept begin to learn internal body structure and function and are aware of differences in size.
Adolescence Self Concept is when kids become most aware of the physical self. They face conflicts over what they see and what they visualize as the ideal body structure.
Self Esteem is the value one places upon themselves and the overall evaluation of oneself.
Factors that influence the formation of a child’s self esteem include: Temperament and personality. Ability to accomplish age appropriate tasks. Significant others. Social roles and expectations
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 &/or accidents
Separation anxiety occurs from middle infancy throughout the rest of their life.
Separation 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.
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
Infants and toddlers greatest stressor is? Separation anxiety
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.
How do Infants and Toddlers react to loss of control? Trust is being developed. Control environment through emotional expressions. Toddlers seek autonomy. React with aggression to loss of control
How do Preschoolers react to loss of control? 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.
How do school age children react to loss of control? 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.
How do adolescents react to loss of control? 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.
What is the nurses role in loss of control? Observe s/s of separation anxiety. Allow parents to room-in Daily routine. Allow the child to have familiar items from home. Promote freedom of movement and independence by giving choices. Informing child of what to expect and what is expected of them
How does the parent respond to loss of control? Disbelief. Anger, guilt or both. Fear and anxiety. Frustration. Depression.
What is the role of the nurse inhelping parents adjust to loss of control? Inform of what to expect and whats expected. Encourage them to be involved. Remain objective and understanding room-in Encourage them to take breaks and rest Establish trust Listen to both verbal and nonverbal messages. Arrange for clergy to visit
What are the three phases of separation anxiety? Protest, despair, denial or detachment.
What is the nurses' role related to separation anxiety? Recognize stages, maintain parent-child relationship, and whenever possible allow the child to make decisions and have choices in their plan of care.
Why are children undertreated for pain? The nurses’ misconceptions about pain. The complexities of pain assessment. Lack of information regarding available pain reduction techniques.
How can the nurse assess a childs pain level? Pain is the “5th vital sign”. QUESTT (Baker & Wong, 1987). Faces Pain Scale. Numeric Scale. Poker Chip.
What does QUESTT stand for? Question the child using appropriate words for pain. Use a pain rating scale. Evaluate behavioral and physiologic changes. Secure parents’ involvement. Take the cause into account. Take action and evaluate results.
Nonpharmacologic Management Decreases fear, anxiety and stress. Must take developmental stage of the child into account as well as level of pain.
What are some nonpharmacologic Management of pain techniques? Distraction. Relaxation. Guided Imagery. Positive self-talk. Thought stopping. Cutaneous stimulation.
Nonopioids Mild to moderate pain. Acetaminophen, NSAIDS.
Combination of opioids and nonopioids Pain on two different levels without side effects. Tylenol with Codeine, Percocet.
Opioids Severe pain. Morphine, Dilaudid, Fentanyl.
What should the nurse keep in mind when it comes to medication dosages in children? The optimal dosage is one that controls pain without causing severe side effects. Children metabolize drugs more rapidly than adults. Dosages are calculated according to weight.
When considering the route what should the nurse keep in mind? The most effective, least traumatic route should be selected.
What can EMLA cream be used for? Local anesthetic applied at least one hour prior to procedures such as IV insertions and blood draws.
What should the nurse know when considering side effects? Respiratory depression is the most serious. Constipation is the most common.
Name some scales used to assess pediatric pain?   Faces, Numeric, and Poker Chip Tools
What are some examples of nonpharmacological pain management? Distraction, relaxation, guided imagery, positive self-talk, thought stopping and Cutaneous stimulation.
What are the elements of a 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
What should the nurse keep in mind when assessing the pediatric during admission? Ask open-ended questions. Spend time with the child during initial procedures. Communicate the assessment.
Why is a nursing admission history conducted? Collect data about the child and family and to assess the child’s usual health habits at home. This will help promote a more normal environment for the child while hospitalized.
When obtaining a nursing admission history, what types of questions are appropriate to ask? Ask open-ended questions so it appears as if you are having a natural conversation which will decrease the overall anxiety of the child.
What are the classifications of play? Social-affective play. Skill play. Unoccupied behavior. Dramatic play. Games.
Social-Affective Play Where infants take in pleasure in relationships with people. Infants learn to provoke emotions and responses with behaviors such as cooing, smiling or crying.  
Skill Play after the infants have developed the ability to grasp and manipulate, they demonstrate their abilities through skill play, repeating the same actions over and over again.
Unoccupied Behavior Where children are not playful but focusing their attention on anything that strikes their interests. Children daydream, fiddle with clothes or other objects, or walk aimlessly.
Dramatic, or Pretend Play Begins in late infancy and is the predominant form of play in the preschool child. By acting out events of daily life, children learn and practice the roles and identities modeled by the members of their family and society.
Games played in all cultures by children both alone and with others. Peek-a-boo.
Explain the purpose of dramatic play? By acting out events of daily life, children learn and practice the roles and identities modeled by the members of their family and society.
Major Stressors of Hospitalization Separation anxiety. Loss of control. Fear of pain.
Children who have prolonged or repeated hospitalizations are not at risk for developmental delays and regression. True or False False they are at risk
How can the nurse provide Opportunities for Play and Expressive Activities in each age group? Small children enjoy small, colorful toys or large playhouses. School-age children enjoy puzzles, Legos and books and games. Adolescents enjoy computers and video games. Most children enjoy painting and drawing. Play must be individualized
Expressive Activities Allow the child freedom to express themselves. NONDIRECTED play. It is not play therapy.
Creative Expression Helps ease the anxieties and fears. Can be used by the nurses as a springboard for future conversations. Music can be used to help the child ambulate and move around the room.
Dramatic Play Reenacting frightening or puzzling hospital experiences. Uses puppets, dolls and other replicas. Can help child learn about procedures and events.
Therapeutic Play Planned activity. Activities include: Letting the child give an injection to a doll or stuffed animal. Can be specific or general.
What is therapeutic play? Therapeutic play is a planned activity where the child is encouraged to express their feelings. It includes activities such as permitting the child to give an injection to a doll or a stuffed toy to reduce the stress of injections.
Why is it 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.
What are cultural considerations important to nursing? Determine the wishes of the family regarding religious rituals. Strive to adapt ethnic practices to the family’s health needs. Do not stereotype
Birth Skeletal system contains more cartilage than ossified bone. Muscular system is almost completely formed. Ballard scoring system is a way to measure neuromuscular maturity at birth.
Newborn Muscle tone increases with maturity, ROM. Legs in flexed position C shaped spine Spinal curve becomes double S shape Toddler’s feet appear flat. A delay in neurological development can cause delay in mastery of motor skills
Musculoskeletal System Assessment Observation. Palpation. ROM. Gait assessment.
Gait Observation 12-13 months Walks along with wide stance for balance. “Toddling” or broad based gait. No arm swing.
Gait Observation 18 months Base narrows. Walk more stable. Attempts to run but falls easily.
Gait Observation 2 to 2.5 years Can walk up and down stairs. Can jump, using both feet. Can stand on one foot for a second or two. Progresses to tiptoe, climbing stairs with alternating footing.
Gait Observation 3 years old Rides a tricycle. Walks on tiptoe. Balances on one foot. Broad jumps.
Gait Observation 4 years old Can hop on one foot. Skips. Catches a ball proficiently. Arms swing with walking.
Gait Observation 5 years old Skips on alternate feet. Jumps rope. Begins to skate and swim. Walk similar to adults.
Gate Observation 6 years old Steadier on their feet. Trunk centered over legs. Movement symmetrical and graceful.
Toe walking after age 3 may indicate a muscle problem.
Nurse's role regarding gait observation? to reassure parents that many minor abnormal-appearing alignments will spontaneously resolve with activity.
Observe Muscle Tone Symmetry. Strength and contour. Neurological examination.
What should be included in your musculoskeletal system assessment of a child? Observation, palpation, ROM and gait assessment.
What are the effects on a young child who is immobilized? Most difficult aspects of illness in children is immobility and it can have a lasting affect on a child. Inactivity leads to decreased functional capabilities and delayed age-appropriate milestones
What kind of feelings can a child develop from immobilization? Can create feelings of helplessness. Even speech and language skills are affected. Monotony can lead to sluggish intellectual and psychomotor responses, decreased communication skills, increased fantasizing and even hallucinations and disorientation
APGAR stands for? Appearance Pulse Grimace Activity Respiration
Nursing considerations for immonbilization? Focus on entire body. Place on special mattress to prevent skin breakdown. Use anti-embolism stockings. Encourage child to stay as active as possible Transport outside room when possible Consult a play therapist or child-life specialist
What type of fractures can disrupt the growth of bones? Epiphyseal plate fractures
Soft tissue injuries usually? Soft tissue injuries usually accompany traumatic fractures related to play or sports activities.
Contusions Tearing of subcutaneous tissue resulting in hemorrhage, edema and pain.
Dislocation Dislocation: The force of stress on a ligament is so great as to displace the normal position of the opposing bone ends. Predominant symptom is pain that increases with movement
Sprain Ligament is partially or completely torn or stretched away from the bone causing damage to blood vessels, muscles and nerves. Rapid onset of swelling, immediately disability and pain are involved.
Strain Microscopic tear to muscle or tendon over time resulting in edema and pain.
RICE stands for? Rest. Ice immediately. Compression (elastic bandage): with ice to reduce edema and bleeding and relieve pain, applied at alternating 30 minute intervals to prevent ischemia. Elevation: several inches above heart to reduce edema.
What is the nurses' role in most diagnostic procedures for musculoskeletal conditions? Preparation of the child/family and escort the child.
Fractures Occurs when the resistance of bone against the stress being exerted yields to the stress force. Fractures in children heal faster. Most are related to traumatic incidents.
Who does fracturesrarely occur in? And what should be done? True injuries that cause fractures rarely occur in infants, therefore if it occurs, it warrants further investigation.
When fracture fragments are separated, the fracture is? When they remain attached they are? complete; the fracture is incomplete.
Transverse fractures are crosswise at right angles to the long bone.
Oblique fractures are slanting but straight, between a horizontal and perpendicular direction.
Spiral fractures are slanting and circular, twisting around the bone shaft. This type of fracture in children may indicate child abuse, and further assessment of the family situation should involve a multidisciplinary team.
If the fracture does not produce a break in the skin, it is a? simple or closed fracture.
Open or compound fractures are those which the bone protrudes.
Diagnostic Evaluation Generalized swelling. Pain or tenderness. Diminished functional use. Bruising. Severe muscular rigidity. Crepitus
What are the goals for therapuetic management for fractures? Regain alignment and length of bony fragments through reduction. Regain alignment and length through immobilization. Restore function to the injured parts. Prevent further injury
How are most fractures treated? Managed by closed reduction and casted for 7 to 10 days.
What fractures are children hospitalized for? Children are hospitalized for fractures of the femur and distal humerus.
What are the 5 Ps? Pain and point of tenderness. Pulse distal to fracture. Pallor. Paresthesia distal to fracture. Paralysis distal to fracture.
What things need to be included in the assessment of a child with a suspected fracture? Pain, pallor, pulselessness, paresthesia, paralysis.
Casts Made of plaster, fiberglass and/or polyurethane resin. All types of casts produce heat after application. Plaster casts take up to 72 hours to completely dry. Synthetic casts dry in about 30 mins.
A nurse has a patient with a cast what are some nursing considerations? Must remain uncovered initially. A child in a body cast must be turned every 2 hours initially. Hot spots should be reported. Elevate the casted extremity and observe for signs of complications and neurovascular compromise
When dealing with patients with casts what should the nurse report immediately to the physician? Unrelieved pain. Swelling with discoloration. Decreased pulses. Inability to move the distal exposed parts.
What can the nurse teach the patient and parents regarding casts? Cast care. Checking for signs that cast is too tight. Maintaining hygiene. If child is in a hip spica cast, teach the parents: Feeding the child with head elevated or prone. Small bedpans or other containers may be necessary for using the bathroom.
How should bleeding be documented? The bleeding should be circled on the cast and dated.
When the cast is removed what should the nurse be aware of? Children may feel vibration. Allow parents to keep cast if desired. Soak the extremity in the bathtub. Do not pull off or forcibly remove caked skin.
What is traction? Most balanced skeletal traction is applied on children after a severe or complex injury to allow physiologic stability, align bone fragments and permit closer evaluation of the injured site.
Why is traction used? Reduce or realign the fracture site. Body weight provides counter-traction. Contact with the bed constitutes frictional force.
What are some nursing interventions for patients with casts? Regular assessments. Ensure traction is maintained as set by the orthopedist. Routine skin observation and pin care are needed. A pressure reduction device on the bed with help reduce skin breakdown. Pain medication. Ensure weights are hanging free
What are the elements of the traction apparatus checklist? Weight’s hanging freely & out of reach. Ropes on pulleys. Knots not resting on pulleys. Linens not on traction ropes. Counter traction in place. Apparatus not touching foot of bed
What are the elements of the patient checklist? Proper alignment. HOB 20 degrees or less. Heels elevated. ROM unaffected parts. Antiembolism stockings.Regular neuro checks. Monitor skin integrity. Pain relief. Prevent constipation. Encourage trapeze
What are you looking for when checking the functionality of the weights on a child in Dunlop’s traction? The weights must be the correct weight, hanging freely and in a safe location.
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.
Certain factors are believed to affect the risk of DDH such as? Gender. Birth order. Family history. Intrauterine position. Delivery type. Joint laxity. Postnatal position.
Acetabular dysphasia there is a delay in the development of the acetabulum.
Subluxation is where there is an incomplete dislocation of the hip.
Dislocation is where the femoral head loses contact with the acetabulum and is displaced posteriorly and superiorly over the rim.
DDH stands for? Developmental Dysplasia of the Hip
What is the mildest form of DDH? Acetabular (Socket) Dysphasia
What is a primary nursing diagnosis for immobilized children? Risk for impaired skin integrity.
When does medical management begin for DDH? As soon as recognized and varies according to age and extent of dysplasia.
What is the goal for treatment of DDH? obtain and maintain a safe position to promote normal hip joint development.
How is DDH diagnosed? Attention to deficits. X-rays after 6 months. Ultrasound.
What is two ways newborns to 6 months with DDH are treated? Pavlik harness. Hip spica.
How are children 6-18 months with DDH treated? Gradual reduction of traction. Open or closed reduction.
How are older children with DDH treated? More difficult. Operative reduction.
What are some nursing considerations for children with DDH? Assess for deviations. Teach parents to apply and maintain reduction devices. Keep child involved in developmentally appropriate activities.
What is congenital clubfoot? Congenital clubfoot is a complex deformity of the ankle and foot where there is an inversion and the foot is pointed downward and inward in varying degrees of severity.
What are the three classifications of clubfoot? Positional. Syndromic or teratologic. Congenital or idiopathic.
Positional clubfoot which is believed to occur from? intrauterine crowding and responds to simple stretching and casting.
Syndromic or teratologic clubfoot which is associated with? congenital anomalies such as myelomeningocele and is a more severe form of clubfoot that is often resistant to treatment
Congenital clubfoot which is often called idiopathic and has a range of rigidity and prognosis.
Which type of clubfoot is typically detected in prenatal ultrasounds? Congenital clubfoot
What are the 3 stages of clubfoot repair? Correction. Maintenance. Follow up observation.
What is the goal of medical management of clubfoot? painless, plantigrade and stable foot
How is clubfoot typically treated? Serial casting. X-rays and ultrasound as needed. Surgery if casting is not effective.
What are some nursing interventions and patient teaching that can be done with clubfoot patients? Care is the same as for any child in a cast. Conscientious observation of skin and circulation is important. Educate parents on overall plan and the importance of complying with plan.
What are some signs osteogenesis imperfecta? Bone fragility, deformity and fractures. Blue sclerae. Hearing loss. Dentinogenesis imperfecta
What is the treatment for osteogenesis imperfecta? Supportive. Prevent contractures and deformities. Prevent muscle weakness and osteoporosis. Prevent Malalignment of lower extremities.
What are some things a nurse should do when treating a patient with osteogenesis imperfecta? Careful handling. Educate regarding the child’s limitations and guidelines when planning activities. Refer to support group.
Why would a Pavlik harness be used on a newborn? The Pavlik harness is used on newborns to help splint their hips in a safe position with the femur centered in the acetabulum. The harness is worn continuously until the hip is proved stable on examination.
What things should a nurse do to help prevent fractures while caring for a child with Osteogenesis Imperfecta? Careful handling to prevent fractures. They must be supported when they are being turned, positioned, moved and held
Legg-Calve-Perthes Disease One of the osteochondroses disorders. A self-limiting juvenile idiopathic vascular necrosis of the femoral head.
Who does Legg-Calve-Perthes Disease most commonly occur in? Caucasian boys 4-8 years old
What are the two most common signs of Legg-Calve-Perthes Disease? Painless limp. Limited movement.
How is Legg-Calve-Perthes Disease diagnosed? Signs and symptoms. Bone imaging and x-ray.
How is LCPD treated? Bed rest & traction. Ambulation-abduction casts or braces. Prognosis is excellent. May require hip replacement as adults.
What are some nursing interventions for LCPD? Support parents & include in planning. Depends on age & prescribed treatment. Holistic teaching of child & family. Pre-op & post-op for surgery. General principles of traction, cast & brace care.
What two major factors are considered when planning nursing care? Age of the child and the type of treatment
Scoliosis a complex spinal deformity in three plans, usually involving lateral curvature, spinal rotation causing rib asymmetry, and thoracic hypokyphosis.
What are the signs and symptoms of scoliosis? S-shaped spine. One shoulder higher than the other. One hip more prominent. Back pain. Clothes do not fit right
What are some nursing interventions for pre/post op scoliosis? Explain brace. Prevent complications of immobility. Exercise, physical therapy and promote developmentally appropriate activities.
What are the 3 types of scoliosis? Functional is caused by poor posture and is easily correctable. Structural is due to changes in the shape of the vertebrae or thorax. Neuromuscular is caused by muscle weakness. Idiopathic.
What are four common ways scoliosis is treated? Boston Brace, spinal fusion, Milwaukee brace, and halo traction. Braces should be worn 23 hours a day.
Which type of scoliosis is easily correctable and why? Functional, because it's just a matter of correcting poor posture.
What is the goal of treatment of scoliosis? Aimed at correcting curvature, and preventing curvature.
Osteomyelitis An infection of the bone.
What bacteria is the most common cause of osteomyelitis? Staphylococcus aureus is causative organism in 74-80%.
What are some signs and symptoms of osteomyelitis? Pain. Decreased movement & limited ROM. Signs of local inflammation. May limp.
How is osteomyelitis diagnosed? Increased WBC & ESR. Bone scan. Detailed history. Blood culture. Urine for bacterial antigens. Tissue biopsy.
How is osteomyelitis treated? IV antibiotics x 4-6 weeks. Bed rest initially. Immobilization. Surgical drainage
What are some nursing interventions for osteomyelitis? Monitor for toxic reaction. Diversional activities, PT & tutoring. Work with home care providers. Routine cast/splint care. Pain management. Position comfortably.
How long is the course of antibiotics for osteomyelitis? 4-6 weeks, IV.
Osteosarcoma primary malignant tumor of the long bones.
Where does osteosarcoma mastasise to? Lungs, brain and other bone tissue also.
What are some signs and symptoms of osteosarcoma? Pain & swelling. Pain may be lessened by flexed position. Pathologic fracture may occur.
How is osteosarcoma diagnosed? CT scan. Bone scan. Bone biopsy. Complete physical
How is osteosarcoma treated? Radical resection or amputation. Internal prostheses. Long term survival with early diagnosis & treatment.
What are some nursing implications for patients with osteosarcoma? Support patient & family. Anticipate grief process, especially with amputation. Post-op care: Vital signs. Stump dressing. Body image change. Positioning. Phantom limb pain (may need to treat). Rehabilitation.
What conditions increase a child's risk for osteosarcoma? Children who had radiation therapy or retinoblastoma.
Ewings Sarcoma malignant growth that occurs from the marrow, usually of long bones but can develop in the skull or flat bones of the trunk.
What are some signs and symptoms of Ewings Sarcoma? Pain. Swelling. Fever.
How is Ewings Sarcoma diagnosed? Skeletal x-ray. Chest x-ray. CT scan of chest. Bone scan. Tumor biopsy.
How is Ewings Sarcoma typically treated? Chemotherapy and radiation therapy. Surgical removal.
What are some nursing interventions for Ewings Sarcoma? Warn against vigorous weight-bearing. Prepare for effects of treatment. Support patient and family.
When is Ewing's sarcoma most likely to occur? During puberty
Juvenile Idiopathic Arthritis an autoimmune inflammatory disease causing inflammation of joints and other tissue
What are the 3 forms of Idiopathic Arthritis? Systemic (10%). Polyarticular (40%). Pauciarticular (50%).
What are the general signs and symptoms of idiopathic arthritis? Swollen, tender and stiff joints. Joints warm to touch.
What is systemic idiopathic arthritis and what age does it typically occur in? High fevers. Transient rash. Elevated sed rate. Enlarged liver and spleen. Ages range from 1-3 years and 8-10 years.
What is polyarticular idiopathic arthritis and what age does it typically occur in? Can involve four or more joints. Often joints of hands and feet. Joints are swollen, warm and tender. Occurs throughout childhood mostly in girls.
What is pauciarticular idiopathic arthritis and what age does it typically occur in? Limited to four or less joints. Usually large joints of hips, knees, ankles and elbows. Occurs in children under 16 years. At risk for iridocyclitis.
Iridocyclitis (inflammation of retina) signs and symptoms? Redness. Pain. Photophobia. Decreased visual acuity. Nonreactive pupils.
How is idiopathic arthritis diagnosed? X-ray studies. Clinical manifestations. Laboratory results. Other disorders ruled out.
What is the goal for treatment of idiopathic arthritis? Reduce pain and swelling. Promote mobility & preserve joint function. Promote growth & development. Promote independent functioning. Help child & family adjust.
How is idiopathic arthritis cured? There is no cure, support is the only treatment
What medical management is used for idiopathic arthritis? NSAIDS. Methotrexate. Immunosuppressant. Gold. Slow-acting anti-rheumatic drugs.
What referrals should be ordered for idiopathic arthritis? OT and PT
What is the nurses role for idiopathic arthritis? Administer meds. Ensure rest. Measures to alleviate boredom. Home care: Use a firm mattress. Age appropriate activities. Modify daily living: Elevate toilet seats. Install handrails. Velcro fasteners. Regular eye exams. Meal planning
What is the PT role for idiopathic arthritis? ROM exercises. Pool exercises. Avoid traumatizing inflamed joints. Warm bath and moist hot packs. Resting splints. Using a very low pillow or no pillow. Maintain proper body alignment.
Which form of JIA involves 4 or less joints? Pauciarticular
Who is responsible for determining the type and amount of activity the child should perform? The physical therapist
Upper respiratory tract Oronasopharynx. Pharynx. Larynx. Upper part of trachea.
Lower respiratory tract Lower trachea. Mainstem bronchi. Segmental bronchi. Subsegmental bronchioles. Terminal bronchioles. Alveoli.
Respiratory Infections Accounts for the majority of childhood illnesses. Influenced by the age of the child, season, living conditions and preexisting medical conditions.
Infants less than ___ months have a lower infection rate. 3 months
What anatomic differences make children predisposed to respiratory illness? Smaller diameter of airways. Distance between structures is shorter. Short open eustachian tubes increase susceptibility
Ability to resist infections depends on? Immune system deficiencies. Malnutrition, anemia or fatigue. Allergies, asthma, cardiac anomalies, cystic fibrosis. Day care attendance.
What are some nursing considerations regarding respiratory illness? Assess respiratory function. Observe for evidence of infection Ease respiratory efforts Promote rest Promote comfort Careful handwashing Decrease fever if necessary Prevent dehydration Nutrition Support and encourage child and family
What are some common nursing diagnosis for respiratory illness? Ineffective breathing pattern. Fear/anxiety. Ineffective airway clearance. Risk for infection. Activity intolerance. Pan. Altered family processes
Nasopharyngitis The most common infection of the respiratory tract Caused by a virus, usually a rhinovirus. Spread by sneezing, coughing direct contact Persistent nasopharyngitis in an older child or adolescent may indicate inhaled cocaine or other drug abuse
What is the key way to prevent spread of infection? Routine hand washing
What are some classic signs of nasopharyngitis? Inflammation and edema of the membranes of the URT Fever up to 104 F not uncommon in children less than 3. Nasal discharge, irritability, sore throat, cough and general discomfort. May develop bronchitis, pneumonitis and ear infections
Nasopharyngitis Treatment No cure. Antibiotics ineffective. Begin early with rest, keep airways clear, maintain adequate fluid intake, Tylenol or Motrin, and moist humidified air.
Nurses role in nasopharyngitis treatment? Provide care in hospital. Teach parents care for at home. Teach children how to clear nose, cover mouth and nose when sneezing, wash hands and discard tissues.
Acute Pharyngitis Inflammation of the structures in the throat. Common in children from 5-15 years old. 80-90% caused by virus, 10% from Group A beta-hemolytic streptococcus (strep throat) Hemophilus influenzae commonly causes condition in children less than 3 years old
What might acute pharyngitis progress to if left untreated? Acute rheumatic fever (ARF), and/or acute glomerulonephritis.
What are some signs and symptoms of acute pharyngitis? Fever, malaise, difficulty swallowing and anorexia. Viral: conjunctivitis, rhinitis, cough and hoarseness. Strep throat in children over 2 years of age: High fever (104 F). Difficulty swallowing. May last longer than a week.
How is acute pharyngitis treated? Antimicrobial therapy orally for 10 days. Critical for nurse to emphasize the need to finish all of the medication. May also recommend salt water gargles if the child is old enough.
What are some possible complications of acute pharyngitis if left untreated? Rheumatic fever. Glomerulonephritis. Peritonsillar abscess. Otitis media. Mastoiditis. Meningitis. Osteomyelitis. Pneumonia.
What are some nursing considerations for pharyngitis? Once antibiotics are started and the fever has decreased the child is no longer contagious. Intramuscular benzathine penicillin G is an appropriate therapy, is not the first choice for children.
A persistent infection may indicate what? The child might be a carrier for group A beta-hemolytic strep, incomplete medications or medication resistant strain has evolved.
What is another name for nasopharyngitis? The common cold
Why aren't antibiotics given for nasopharyngitis? The common cold is typically a virus?
Tonsillitis and/or Adenoiditis inflammation of the tonsils and/or adenoids.
How does tonsillitis manifest? Difficulty swallowing and breathing. Enlarged adenoids. Mouth breathing. Other symptoms similar to those of nasopharyngitis.
What are some nursing considerations for tonsillitis? Cool mist vaporizer. Salt water gargles and throat lozenges. Cool liquid diet. Acetaminophen for comfort.
How is tonsillitis treated? Antibiotics not prescribed unless there's a positive throat culture. Removal of tonsils and adenoids not recommended for children under 3 unless there is persistent airway obstruction or difficulty in breathing. 
What are some post op interventions for tonsillectomy? Positioning Increased pulse and respirations Restlessness Frequent swallowing Vomiting of bright red blood Ice collar. Small amounts clear liquids. Keep child quiet Teach child to avoid coughing
What are some discharge instructions you should teach patient before discharge? Keep the child quiet for a few days and provide nourishing fluids and soft foods. May give acetaminophen for throat discomfort. Protect the child from exposure to infections. Avoid gargling and highly seasoned foods for the first week postoperatively.
What is the most common postoperative complication related to a tonsillectomy/adenoidectomy? Hemorrhage
Croup Various conditions in which the primary symptom is a "barking" (croupy) cough and some degree of inspiratory stridor.
What is the most common type of croup? Acute laryngotracheobronchitis (subglottic croup)
Bacterial Tracheitis (Croup) common signs and symptoms? Children 1 month-6 years. Croupy cough mostly at night. Usually preceded by a URI. May have inspiratory stridor unaffected by position. Fever. Thick, purulent tracheal secretions.
Why should you not give brown or red liquid post surgery? It can be confused with blood
Bacterial Tracheitis Treatment Humidified oxygen. Antipyretics. Antibiotics. May require intubation with frequent suctioning. Early detection is the key. Humidified oxygen. Antipyretics. Antibiotics. May require intubation with frequent suctioning. Early detection is the key.
Acute Spasmodic Laryngitis Children usually between 1 and 3 years old. Cause: Virus, allergy or psychological. Gastroesophageal reflux often the cause. Occurs suddenly, usually at night, last a few hours
Bacterial Tracheitis Children 1 month to 6 years of age. Staphylococcus aureus, group A beta-hemolytic streptococci and H. influenzae.
Acute Spasmodic Laryngitis (Spasmodic Croup) Symptoms? Barking, brassy cough. Respiratory distress. Child is anxious and parents may be frightened. Dyspnea is aggravated by excitement. Child appears well the next day.
Acute Spasmodic Laryngitis (Spasmodic Croup) Treatment Cool mist humidifier. Warm mist from steam. Moderately severe cases: Hospitalized. Cool mist. Racemic epinephrine. Corticosteroids.
What is acute croup cause by? Caused by a virus Para-influenza. RSV. influenza A and B. Mycoplasma pneumoniae.
Acute Croup (Laryngotracheobronchitis)Signs and Symptoms Edema, destruction of respiratory cilia and exudate. Results in respiratory obstruction. Usually preceded by a mild upper respiratory infection. Characteristic barking or brassy cough, stridor and respiratory distress.
Acute Croup (Laryngotracheobronchitis) Treatment Increase humidity Hospitalization required if symptoms of RD continue: Mist tent Blow by Intravenous fluids Organize care to provide long rest periods. Monitor with cardiorespiratory monitor, frequent vital signs and pulse oximeter Oxygen
Acute Croup (Laryngotracheobronchitis) Medications Nebulized epinephrine. Oxygen therapy. Corticosteroids: no history of recent exposure to chickenpox.
Which form of croup can develop into a respiratory emergency? Acute croup (laryngotracheobronchitis).
Acute Croup (Laryngotracheobronchitis) Medications Nebulized epinephrine. Oxygen therapy. Corticosteroids: no history of recent exposure to chickenpox.
How is RSV transmitted? Direct contact with respiratory secretions, usually via contaminated hands RSV can survive 6 hrs or more on surfaces. Cross infection in the hospital is common. RSV immunoglobulin may be given to preterm newborns with bronchopulmonary dysplasi
How is RSV diagnosed? Examination of nasopharyngeal washings for RSV antigen. Admission occurs after the diagnosis is confirmed.
Respiratory Syncytial Virus (RSV) Treatment and Nursing Care Support. Symptomatic care. Priority nursing diagnosis: Ineffective breathing pattern.
What should the nurse report in a patient with RSV? Tachypnea and tachycardia which may indicate hypoxemia. Wheezing, rales or rhonchi, or sudden "quiet chest" which puts child at risk for respiratory arrest. Signs and symptoms of respiratory distress
What should the nurse monitor in patients with RSV? Monitor oxygen saturation levels and adjust oxygen to keep level at 90-95%. Suction to maintain patent airway. Monitor intake and output: Give Pedialyte or Ricelyte as ordered for infants at risk of dehydration. Weigh daily.
Ribavirin (Virazole) Severely ill infants or infants with heart or lung problems. Fine-droplet aerosol mist for 18-24 hours a day for a minimum of 3 days. In infant on ventilator: check tubing which may be warped by medication
Ribavirin Nursing considerations? May cause conjunctivitis if wearing contact lenses around medication. Use caution when opening mist tent and changing linens to avoid releasing droplets of Ribavirin into the air. Complications include reactive airway disease later in life
Who should not be in contact with Ribavirin? Keep all women who are of childbearing age, pregnant or breastfeeding away from medication related to teratogenic effects
How long can the RSV survive on countertops, tissues and soap bars? 6 hours or more
Pnuemonia Inflammation of the lungs in which the alveoli become filled with exudate.
What are the two ways pnuemonia occurs? May occur as either a primary or secondary disease. Primary: pneumonia is the initial disease. Secondary: pneumonia occurs as a complication of another illness.
How is pnuemonia classified? causative organism (i.e. viral or bacterial) or by the part of the respiratory system involved (i.e. lobar or bronchial).
What is the most common viral and bacterial cause of pnuemonia? RSV is the most common cause of viral pneumonia in infants. Streptococcus pneumoniae most common bacterial pathogen for community - acquired pneumonia.
What are three other ways pnuemonia can occur other than bacterial or viral? Aspiration pneumonia due to inhaled substances.   Lipoid pneumonia: an oil substance inhaled into the airways. Hypostatic pneumonia may occur in patients who have poor circulation in the lungs.
What are some common signs and symptoms of pnuemonia? sudden or gradual may be preceded by an URI Cough that is dry at first, then productive and a high fever Shallow Respirations Sternal retractions/nasal flaring   May be listless and have a poor appetite. May have chest pain   An elevated WBC count
Pneumonia Treatment XRAY confirms the diagnosis and is used to determine the exact location and presence of any complications. Antibiotics are ordered if a bacterial infection is suspected.  Antipyretics. Oxygen is indicated for cyanosis and restlessness
What is the nurses role with a patient with pnuemonia? Check vital signs at regular intervals. Cluster care. Encourage fluid intake.
How can the nurse help control fever? Antipyretics as ordered. Cool mist tent. Remove blankets and warm clothing. 
What patient teaching should be done with parents of children with pnuemonia? Emphasize the need to complete all medication as prescribed. Tobacco use should be avoided. Stress the need for Hib immunizations. The use and disposal of tissues, covering the mouth during a cough and modeling proper hand washing techniques.
How is pneumonia classified? Causative organism, part of the respiratory system involved and other classifications (aspiration, lipoid, and hypostatic).
What are the four classifications of pnuemonia? Mild intermittent asthma. Mild persistent asthma. Moderate persistent asthma. Severe persistent asthma.
What is asthma? chronic inflammatory disorder of the airways.
mild intermittent asthma Symptoms occur less than two times a week. Peak expiratory flow (PEF) or forced expiratory volume (FEV) in 1 sec is greater than 80% of predicted value.
mild persistent asthma Symptoms occur greater than once a week, but less than once a day PEF or FEV is less than 60%.
moderate persistent asthma. Symptoms occur daily. PEF or FEV is between 60% and 80%.
severe persistent asthma. Symptoms are continual. PEF or FEV is less than 60%.
Asthma is the most common cause of_________in children. _________ is the strongest predictor. chronic illness atopy (genetic predispostion to response of a specific allergen)
Asthma causes the body to: Inflammation and edema. Accumulation of tenacious secretions. Spasms of smooth muscles and decreased caliber of bronchioles.
What are the clinical manifestations of asthma? Absence of breath sounds with a sudden rise in respiratory rate is a sign of ventilatory failure and imminent asphyxia
What are the goals of asthma treatment in children? Prevent disability. Minimize physical and psychologic morbidity. Assist the child in living a normal life.
What are some examples of asthma triggers? Pet dander, pollen, dust, dust mites, mold, cochroaches, tobacco, wood smoke, odors, perfumes, chemicals, exercise, changes in temperature, coals, medications, emotions, additives, nuts, milk, and dairy.
What patient teaching should be done with children with asthma? Symptoms and management. Allergens. Drug therapy: Long term. Quick-relief.
How is asthma medicaly managed? Medications are given by inhalation with a nebulizer or metered-dose indicator. Always use a spacer. Corticosteroids. Beta-agonists. Chest PT: Helps strengthen respiratory muscles. Do not do when in acute episodes.
Status Asthmaticus what is it and how is it treated? An ongoing attack with no relief MEDICAL EMERGENCY!! Therapy is aimed at: Improving ventilation. Correcting dehydration and acidosis. Treating any infections. Beta2 agonists are used along with corticosteroids and subcutaneous epinephrine if needed.
What are some common nursing diagnosis in patients with asthma? Risk for suffocation. Ineffective airway clearance. Activity intolerance. Interrupted family processes. Risk for fluid volume deficit. Risk for injury.
What are some common signs of an impending asthma attack? Early signs of an impending attack: Rhinorrhea. Cough. Low-grade fever. Irritability. Itching especially in the front of the neck and chest. Apathy. Anxiety. Sleep disturbance. Abdominal discomfort. Loss of appetite.
What should the nurse teach the child regarding asthma? How to use medication devices. Adverse effects. Overuse.
What should the nurse teach the parents about asthma? Use of peak flow meter. Need annual flu vaccination. Breathing exercises. Join self-management asthma programs
How should the nurse care for a acute asthma attack? Monitor child continuously. Check vital signs frequently. All child to sit as comfortable. Do not leave child alone. Support the child and family. All expression of feelings. Educate them. Encourage them.
What are the signs of air hunger? Nostril flaring, cyanosis, use of accessory muscles and orthopnea.
What is a good exercise for children to strength muscles of breathing? Swimming
What is Cystic Fibrosis? inherited as an autosomal recessive trait; the affected child inherits the defective gene from both parents, with an overall incidence of 1:4. The mucousal glands increase the viscosity of the mucousa, and a increase in sweat electrolytes.
What are the characteristics of cystic fibrosis? Increased viscosity of mucous gland secretions. Elevation of electrolytes lost via sweat. Increase in several organic and enzymatic constituents of saliva. Abnormalities in autonomic nervous system function
What are some signs and symptoms of cystic fibrosis? Pancreatic fibrosis. Steatorrhea and azotorrhea. Thick mucous causes atelectasis. Mucous serves as a medium for bacteria. Reduced exchange causes: Variable degrees of hypoxia. Hypercapnia. Acidosis.
What are the goals regarding medical treatment of cystic fibrosis? Prevent or minimize pulmonary complications. Ensure adequate nutrition for growth. Encourage appropriate physical activity. Promote a reasonable quality of life
What is the medical management of cystic fibrosis? Antibiotics. Removing secretions. Perform Chest PT at least twice a day right after bronchodilators are given. Encourage aerobic exercise.
What signs and symptoms should a nurse monitor for which could indicate a pnuemothorax? Tachypnea. Tachycardia. Dyspnea. Pallor. Cyanosis.
In cystic fibrosis how is GI problems treated? Replacing pancreatic enzymes. Need a well-balance, high-protein, high-calorie diet. May need OG feeding if still not getting enough calories.
What are some patient teaching the nurse should do regarding cystic fibrosis? Parents need education about home equipment and know how to use it. Educate parent and child on healthy diet. Teach parents about the preferred diet. Fat, increased protein and carbs. Do not restrict salt especially if warm weather
How can the nurse support the family of a patient with cystic fibrosis? Meet the emotional needs of the child. Help the family seek out respite care. Take part in age appropriate activities. Help prepare family for end-of -life decisions.
What is the normal sweat chloride level? 40 MEQ
How is ICP caused? ICP may be caused by: Tumors or other lesions. Accumulation of fluid. Bleeding. Cerebral edema.
Unconsciousness is depressed cerebral function is? The inability to respond to sensory stimuli. Assessment of consciousness is the earliest indicator of improvement or deterioration in neurologic status.
What is coma? State of consciousness from which the patient cannot be aroused despite painful stimuli.
What is the Glasgow Coma Scale (GCS)? Eye opening. Verbal response. Motor response.
Neurologic Exam includes what? Purpose is to establish a baseline. Simple, objective descriptions. Vital signs: Elevated body temp=intracranial bleeding.
The craniums total volume includes what percentage of what elemenets? 80% brain 10% CSF 10% Blood
During a neurological exam of a patient with cerebral dysfunction what vital signs may be noticed? Variable pulse. Variable BP: Normal. Elevated. Shock levels. Changes in pulse and blood pressure are very late signs and are more important than the direction of the change. Slow, deep and irregular RR.
What should be assessed when the nurse is conducting a skin assessment? Skin must be examined for the presence of injury, needle marks, petechiae bites or ticks.
What should be assessed during a eye exam and what kind of dysfunctions may be noticed? Assess pupil size and reactivity. Doll’s eyes. If pupils remain dialiated for more than 5 minutes this may indicate brain stem damage.
What is Dolls Eyes? Rotate the head quickly for one side to the other. Normal is when the eyes move together in the direction opposite to the head rotation. Absence of this response suggests dysfunction of the brainstem or oculomotor nerve.
What is the oculovestibular response? When ice water is ejected into the ear canal the eyes should turn towards the affected side.
What should the nurse observe for when assessing motor function? Observe spontaneous activity, posture and response to painful stimuli. Tremors, twitching, seizures and spasms are common.
What testing can be done to rule out cerebral dysfunction? Blood glucose, Urea Nitrogen & CBC MRI CT Scan LFT Toxic Studies Electrolyte Panel Lumbar Puncture EEG Spinal Tap Brain Scan
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.
Emergency measures are directed toward what in the unconscious child? ensuring patent airway, treatment of shock, and reduction of ICP (if present).
Flexion Posturing is seen with severe dysfunction of the cerebral cortex typical flexion posturing includes rigid flexion with arms held tightly to the body flexed elbows and wrists and fingers, plantar flexed feet legs and arms internally rotated
Extension Posturing is a sign of dysfunction of the at the level of midbrain or brain stem it is characterized by rigid extension and pronation of the arms legs flexed wrists and fingers, clenched jaw, and extended neck, they also may present with a arched back.
How often should vital signs be assessed in a cerebral dysfunction? Regular assessment of neurologic signs is vital. Every 15 minutes
How should the nurse assess pain? Assess pain documenting behaviors pre and post intervention.
When assessing respiratory status what should the nurse keep in mind? Respiratory management is the primary concern. Respiratory obstructions and subsequent compromise leads to cardiac arrest. Maintain patent airway. Position to prevent aspiration and minimize ICP. Ensure measures to decrease likelihood of vomiting
When monitoring ICP what should the nurse do? Care must be taken when positioning: Prop onto one side. Specialty Bed. Elevate head of bed. Maintain head midline position. Gentle ROM exercises. Schedule non-therapeutic touch and painful procedures Eliminate noise Suction as necessary
What are some nursing considerations for nutrition of the ICP child patient? IV fluids only. Avoid overhydrating. Watch for s/s of dehydration. Provide NG or G-tube feedings as ordered. Avoid overfeeding.
What medications may be ordered for ICP patients? Infections need antibiotics. Corticosteriods for inflammatory conditions.
Why are drug induced comas are controversial? Requires extensive monitoring. Requires cardiovascular and respiratory support. Paralyzing agents may be needed.
Thermoregulation Thermoregulation-hyperthermia usually accompanies cerebral dysfunction; measures to reduce temperature are implemented to prevent brain damage and reduce metabolic demands.
When concerning elimination what should the nurse do with the ICP patient? Retention catheter is placed. Suppositories or enemas may be needed. Record activity daily.
What are some nursing interventions for ICP concerning hygiene? Goal is to prevent skin breakdown. Perform mouth care at least twice daily. Examine eyes and protect them from damage. Save any shaved hair.
When concerning stimulation of the ICP patient what should the nurse consider? Sensory stimulation helps. Tactile stimulation is not appropriate for some. Hearing is the last to go and first to come back.
Regaining consciousness is a gradual process how might the child feel? Initially the child may feel strange. May not display their pre-hospitalization personality.
How might the parents of a child with cerebral dysfunction feel? Parents may experience guilt, fear, hostility & anxiety. Involve the parent in caring for the child. If the child dies, support and guide the parents in coping. Parents search for signs of hope.
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.
What drugs may be used to drug induce coma? morphine, midazolam, pancuronium (pavulon). Midazolam is used frequently because of its half life.
Head Injuries Head injury is a process involving the scalp, skull, meninges, or brain as a result of mechanical force. Injuries are the number one health risk for children and the leading cause of death in children older than 1 year of age
3 major causes of head injury in children? Falls: Infants and toddlers with proportionately larger heads. Motor vehicle injuries: Under 2 years: passengers. Older children: pedestrian or cyclists. Bicycle injuries: Ages 5 to 19 years.
Boys are affected twice______as often as girls. twice
_________ and __________ are used to describe visible bruising and tearing of cerebral tissue. Contusion and laceration
Contusions can be caused by? Petechial hemorrhages. Cause focal disturbances in strength, sensation or visual awareness. Lower incidence with infants and very small children. Shaken baby syndrome.
_____________ are generally associated with penetrating or depressing skull fractures. Cerebral lacerations
What are the 6 types of skull fractures? Linear. Depressed. Comminuted. Basilar. Open. Diastatic.
What are four common complications of head injuries? Hemorrhage. Infection. Cerebral Edema. Brain herniation.
Concussion Confusion and amnesia are hallmarks. Forces stretch, compress and tear nerve fibers.
Most common head injury. Concussion
___________ __________ can sustain a greater degree of deformity. Immature skulls
What is a epidural hemorrhage and what are the hallmark signs? Blood between the dura and skull. Classic picture: Momentary unconsciousness followed by lethargy or coma. Seldom evident in children. Nonspecific complaints such as irritability, headache and vomiting occur
What is a subdural hemorrhage and why is it important to diagnose? Blood between the dura and cerebrum. More frequent in children. Develops slowly and spreads.
Cerebral Edema Caused by direct injury induces vascular stasis, anoxia and further vasodilatation. If it continues to progress, ICP exceeds arterial pressure and the pressure causes herniation of a portion of the brain.
What is the medical management of a mild to moderate concussion? home. Give parents instructions: Check child every 2 hours. Keep follow up appointments.
what is the medical management of Severe concussion? hospital. Keep NPO or on clear liquids. IV fluid balance: Monitor I & O and daily weights. Give medications as ordered.
What are some nursing considerations for children patients with head injuries? Neuro assessment. Vital signs. Bedrest with elevated HOB. Provide sedation and analgesia as ordered. Note abnormal positioning or posturing. Observe for seizure activity. Note any drainage from any orifice. Suctioning from nares is CONTRAINDICATED
Children with retinal hemorrhage should be elvaluated for what? Child abuse
How can drainage be tested to confirm if it is CSF? Dextrostix (positive for glucose) and Halo test
How can the nurse support the family of a child with a head injury? Encourage the family to be involved. Honesty, kindness and competent care. Discharge expectations.
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.
Near Drowning Survival for at least 24 hours after submersion in a fluid medium. Ranks second cause of accidental death in children. Occurs 5 times more in boys than girls. 40% are less than 5 years old.
Accidental drowning occurs _______ times more often in boys than girls under the age of 5. 5
The major changes that occur in drowning are directly related to? The length of time of submersion, the victims response, and the degree of immersion hyppthermia
Hypoxia Results in global cell damage.
Asphyxiation of fluid Results in pulmonary edema, atelectasis, airway spasms and pneumonitis.
Hypothermia Occurs rapidly in infants and children.
How is near drowning patients treated? Begin resuscitation at scene. Transport to hospital. First priority: restore oxygen delivery to cells and prevent further damage. Intubate and ventilate if unconscious.
Neurons sustain irreversible damage after ___ to ___ minutes. 4-6
What are some nursing interventions for near drowning patients? Depends on condition of the child: May need intensive care. Attention to vital signs, ventilation, blood gas, chest therapy, IV infusions. Family support. Be sensitive to the needs of the child and family.
How id brain death established in a child 7 days- 2 months? 2 months- 1 year? Over 1 year? 2 seperate exams and two EEGs seperated by at least 48 hours. 2 seperate exams and 2 EEGs seperated by at least 24 hours. 2 seperate exams seperated by at least 12 hours.
For a child admitted for a near drowning, what is the priority nursing consideration? Respiratory support with attention to vital signs.
Brain Tumor Most common tumors in children. Second most common childhood cancer. Majority occur in the posterior third of the brain. Most often will not see signs and symptoms in infants until their head size dramatically increases.
Brain Tumor Signs and Symptoms Signs and symptoms are related to location, size and age. Common signs are: Headache, especially on awakening. Vomiting not related to feeding
Brain Tumor Diagnostic Testing MRI. CT, angiography, EEG and LP. Definitive diagnosis: brain tissue specimen
Brain Tumor Medical Management Surgery: Remove entire tumor. Radiation: Shrink size of tumor. Chemotherapy: Used to delay radiation if less than 3 years.
The prognosis depends on ____ of tumor, ____, extend of disease and ___ of child. type, size, age
What should the nurse observe for in children with brain tumors? Establish a baseline. Vital signs per protocol: Report sudden variations. Neuro assessment with vitals: Measure head circumference. Observe for headaches: Note location, severity and duration. Observe for clues to discomfort.
How should the nurse prepare the child and parents for procedures and treatments? Explain the procedure. Removing tumor may not remove symptoms. Be honest without providing false hope.
How can the nurse prepare the child for the change of their image before treatment? Shaving: Very sensitive issue. Show child how they look at different stages of the process. Provide privacy and a scarf if desired. Dressing. Visit ICU prior to surgery.
How can the nurse prevent post op complications in children with tumors? Follow strict orders cooling blanket If temp is elevated 1 -2 days postop suspect infection Neuro checks Observe dressing for drainage Restrain if needed get orders on positioning 2 nurses to turn patient Provide relief measures(pain meds)IV Fluids
How can the nurse help support the family after brain surgery? Direct parents thinking towards helping child recover Discuss how to tell the child Promote return to optimal functioning Ultimate goal is cure and max functioning Wear helmet until healed Prepare child for remarks Make outside referrals
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.
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? The presence of colorless drainage is reported immediately because it is most likely CSF from the incision area.
What are some nursing interventions/considerations for a cranial deformity? Observe and identify children. If surgical correction, monitor: Lab values. Signs of hemorrhage. Infection. Pain. Swelling. Teach parents suture care and safety.
What does craniosynostosis mean? A premature closure of the suture line which inhibits growth.
Hydrocephalus Caused by an imbalance in production and absorption of CSF. May be congenital or acquired. It is a symptom of an underlying brain disorder.
How is hyrdrocephalus diagnosed? Head enlargement during infancy is the predominant sign. Diagnosis is made based on head circumference.Primary diagnostic tools are CT and MRI
How is hydrocephalus treated? Directed towards relief, treating complications and managing problems. Surgical: Removing obstruction. Placing a shunt. Complications include: Kinking. Plugging. Separation of shunt.
What are some preoperative nursing considerations for hydrocephaly? Observe for signs of increasing ICP. Measure daily. Palpate fontanels and suture lines. Maintain adequate nutrition. Ensure head is well supported.
What some post op nursing considerations for hydrocephaly? Keep child flat or positioned as ordered. Pain management. Observe for signs of ICP and abdominal distension. Observe for signs of postoperative infection: Elevated vital signs. Poor feeding Vomiting Decreased responsiveness
The posterior fontanel closes at ___ weeks. The anterior fontanel closes at ______ months. And the sutures are unable to be seperated at _____ years. 8 weeks, 18 months, 12 years
60% of child brain tumors occur in the _______. The other 40% typically occur_______. infratentorial supratentorial
What position is typically the post op hyrdrocephaly patient palced in and why? Flat on the unoperated side.
What is the most common way that hydrocephalus is diagnosed in infants? Based on head circumference that crosses on 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 an inflammation of the meninges, the covering of the brain and spinal cord.   Incidence: majority of cases occur in children between 1 month and 5 years.   Most Common Causative Agent: Streptococcus pneumoniae and Neisseria meningitidis
What are the most common ways children contract meningitis? Teeth. Sinuses. Tonsils. Lungs
What are some common signs and symptoms of bacterial meningitis? May be preceded by a URI and several days of GI distress. Severe Headache Delirium Irritability Restlessness High pitch cry in infants Convulsions are common Coma Opisthotonos (involuntary arching of the back Petechiae
How is bacterial meningitis diagnosed? Lumbar puncture "spinal tap“: fluid is clear early in disease process, cloudy as disease progresses. Increased protein. Decreased glucose. High white cell count. Gram stain and culture of CSF. History and physical.
What are the 3 types of meningitis? Bacterial TB and Viral
How is baterial meningits treated? IV fluids. IV antibiotics. Respiratory isolation. Sedative. Anticonvulsant
What are some nursing interventions/considerations for bacterial meningitis? Prepare isolation room. Disposable equipment. Indirect lighting. Caution with side rails. Minimal stimulation. Frequent vital signs, neurological checks & monitor I & O. Control fever. Observe for signs of increased ICP.
Observe for residual effects of bacterial meningitis including? Weakness of limbs. Speech. Mental confusion. Behavior problems. Developmental deficiencies.
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.
What is encephalitis? A inflammation of the brain.
Causative agents of encephalitis are? Togaviruses and herpes virus type 1 and 2. Following URI. Rubella or rubeola. Lead poisoning. Bacteria, spirochetes and fungi.
____________ are at the greatest risk of fatality and residual effects of encephalitis. Infants
What are some common signs and symptoms of encephalitis? Headache, drowsiness, coma. Convulsions. Fever. Cramps. Abdominal pain. Vomiting. Stiff neck (nuchal rigidity). Delirium. Muscle twitching. Abnormal eye movements.
What are some effects of untreated encephalitis? Slowed speech. Slowed mental processing & motor ability. Brain damage. Mental retardation. Seizures.
What are some nursing interventions for encephalitis? Sedatives & antipyretics. Nutrition & hydration. Seizure precautions. Quiet environment, good oral hygiene, skin care, position changes. Oxygen as ordered. Record I & O. Prevent complications of immobility. Observe for neuro changes.
Reyes Syndrome an acute non-inflammatory encephalopathy and hepatopathy, with no reasonable explanation for the cerebral and hepatic abnormalities.
Who is more at risk for Reyes Syndrome? Primarily affects children.  The younger the child the higher the morbidity and mortality rates.
How is Reyes Syndrome diagnosed? Elevated ammonia levels. Cerebral edema with ICP. Definitive diagnosis: Liver biopsy.
What are some Stage 1 signs and symptoms of Reyes Syndrome? Vomiting. Lethargy. Drowsiness. Liver dysfunction. Follows commands. Brisk papillary reaction.
What are some Stage 2 signs and symptoms of Reyes Syndrome? Disorientation. Combative. Delirium. Hyperventilation. Hyperactive reflexes. Appropriate response to pain. Liver dysfunction. Sluggish pupillary response.
What are some stage 3 signs and symptoms of Reyes Syndrome? Obtunded. Coma. Hyperventilation. Decorticate rigidity
What are some Stage 4 signs and symptoms of Reyes Syndrome? Deepening coma. Decerebrate rigidity. Loss of oculo-cephalic reflexes. Large and fixed pupils. Minimal liver dysfunction.
What are some Stage 5 signs and symptoms of Reyes Syndrome? Seizures. Loss of deep tendon reflexes. Respiratory arrest. Flaccidity. No evidence of liver dysfunction.
How is Reyes Syndrome treated? Care same as with a child with altered LOC and increased ICP. Accurate I & O. Vital signs including CVP and CO. Observe for signs of impaired coagulation.
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 or septicemia is defined as? refers to a generalized bacterial infection in the bloodstream that can progress to systemic inflammatory response syndrome (SIRS), shock, multiorgan system failure and death.
Who is most at risk for sepsis and why? Neonates/Children at risk: neutropenic, immunocompromised or in intensive care (invasive prcedures)
What are some common signs and symptoms of sepsis? Poor temperature control.  Tachypnea.  Tachycardia.  Hypotension.  Neurological signs such as lethargy.  Jaundice.
How is sepsis diagnosed? Positive blood culture. Urine culture. Cerebrospinal fluid culture. Anemia. Immature WBCs and neutropenia are ominous signs.
What are some nursing considerations for sepsis? 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.
Seizures Caused by malfunctions of the brain’s electrical system.
What causes seizures? Most are idiopathic. Some are caused by: Trauma. Hypoxia. Infections. Biochemical events. Fevers greater than 101.8 with rapid elevation.
What are the two types of seizure classifications? Partial seizures: 2 types: Simple partial seizures. Complex partial seizures. Generalized seizures: May occur at any time.
How are seizures diagnosed? Thorough history and physical. Diet review. Examining the seizure: Onset. Time of day. Any precipitating factors. Duration. Progression. Postictal feelings.Complete neuro exam. Lab studies: CBC with white cell count CT scans, MRI and EEG
What medications are used to treat seizures? 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).
Once the child is free for ____ years with a normal EEG, the therapy and seizure medications are gradually discontinued. 2
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.
What is the nurses role during the seizure? Observe 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 after
What are 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 can the nurse teach the patient regarding seizures? Explain the drugs. Warn parents about the possible changes in behavior. Encourage normal healthy activities. Notify the school nurse and teacher. Help identify triggering factors and how to avoid them. Refer parents to Epilepsy Foundation of America.
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.
Phenytoin Nursing considerations? Folic Acid Vitamin D, Do NOT take with milk
Hearing loss can affect what developmental processes? Loss of hearing can have an impact on: Speech. Language. Social development. Emotional development. Behavior and academic achievement.
Hearing impairment describes a range of hearing loss.
Deaf is a person whose hearing disability precludes processing verbal information.
Hard of hearing is when the person with use of a hearing aid, has hearing sufficient to process auditory information.
What are the causes of hearing loss? May be prenatal or postnatal. Family history. Anatomic malformations. Severe perinatal asphyxia. Perinatal infections. Chronic ear infections. Cerebral palsy. Down syndrome. Administration of ototoxic drugs.
Conductive or middle-ear hearing loss results from interference of transmission of sound to the middle ear.
Perceptive or Nerve Deafness involves damage to the inner ear structures or the auditory nerve.
Central Auditory Imperception includes all hearing losses that does not demonstrate defects in the conductive or sensorineural structures.
Functional type of hearing loss occur without lesions or another explanation for central hearing loss.
What is the medical management of hearing loss? Treatment depends on cause of hearing loss. Cochlear implants.
What are some nursing considerations when caring for a patient with hearing loss? Early diagnosis and treatment is key to preventing complications from hearing loss. Universal newborn hearing screening. Observe the reflexes.
What are some common nursing diagnosis for hearing loss? Sensory/perceptual alteration r/t hearing impairment Impaired verbal communication r/t inability to hear Altered growth and development r/t impaired communication Risk for injury r/t environmental hazards, infection
How can the nurse promote communication? Lip reading. Cued speech. Sign language. Speech therapy. Additional aids such as teletypewriters. Socialize children. Support child and family.
What are some nursing considerations when caring for a child with hearing loss? Supplement verbal explanations. Allow to draw, write or gesture. Participate in therapeutic play. Participate in prevention measures. Assess for environmental noise pollution.
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.
Autism Autism is a developmental disorder. Occurs in 1 in 500, more common in males. The etiology is unknown, but there has been a reported association between autism and conditions such as fragile X, meningitis and structural brain anomalies.
Ottis Media One of the most prevalent diseases of early childhood. May be caused by RSV and H. influenzae. Common in children ages 0-7, boys Streptococcus pneumoniae, H. Influenzae and Moraxella are most common bacteria.
Passive _________ increases the risk. smoking
How is Ottis Media diagnosed? Primarily result of malfunctioning eustachian tubes. Diagnosed by assessing the tympanic membrane: Will look purulent and appear bulging and red.
What are the signs and symptoms of Ottis Media? Ear pain. Fever. Purulent discharge. Crying. Irritability and restlessness. Holding, rubbing, or pulling on affected ear. If chronic: Hearing loss. Tinnitus. Vertigo.
What is the medical management for Ottis Media? Antibiotics: Amoxicillin. Ceftriaxone. Spontaneous resolution. Surgical treatment: Myringotomy. PE tubes if there are recurrent episodes of long duration.
What are 3 important nursing interventions/ patient teaching for ottis media? Relieving pain: Acetaminophen and Ibuprofen. Narcotics as ordered. Facilitate drainage: Clean external canal with cotton swabs. Prevent complications: With tubes, bathwater and shampoo should be kept out of ears. If tubes fall out, notify provider
What four elements of the nursing role are crucial for patient care? Detection Intervention Education Support (Referral)
To inspect the ear canal in an older child, what is the proper method of pulling the pinna?   Up and back.
A newborn has a visual acuity of around __/__ and may reach __/__to___/__ by 2-3 years of age. 20/400 20/30 to 20/20
What is the Snellen chart, how is it used, and who is it most appropriate for? Most effective for children 6 years or older. Child stands back 10 feet. Cover the left eye and read the appropriate line. Then switch and cover the right eye and read. To pass, the child must correctly identify four of six symbols.
What is the Tumbling E and who is it used on? Useful for children who do not know their alphabet. Point in the direction that the E is facing.
What is HOTV and how is it used? Child is given a board with HOTV; the examiner points to the letter on the wall and the child points to the correct letter on the board.
When using an Allen card what should the nurse remember to do? Make sure to identify the figures prior to testing.
Who are infants vision assessed? In newborns, test by checking light perception. Assesses the ability to illicit a response. In infants, the ability to fix on and follow a target is an indication of vision.
When should vision screening first be performed? At the earliest possible age and at regular intervals.
Refractive Errors Occur when light rays are bent and fall in front of or behind the retina. Myopia. Hyperopia.
How is refractive errors corrected? Glasses
Strabismus Eye muscles do not coordinate. Condition can affect either one or both eyes and results in two images instead of one being received by the brain.
Strabismus common signs and symptoms? Common S & S: Squinting. Closing one eye. Tilting head. Difficulty focusing.
Strabismus treatment? Treatment varies but no treatment will perfectly align the eyes. Goal: realign them as close to normal as possible. May patch stronger eye.
Amblyopia Known as “lazy eye”. Vision is lost in one eye simply because the child favors that eye. Early detection and prompt treatment with patching and/or glasses is essential.
What are some nursing interventions for vision problems? Refractive Errors: Ensure vision screening is done. Strabismus: Explain treatment plan and instruct parents on eye exercises and patches. Be alert to signs and symptoms and provide instruction and support on patch use.
The goal of medical interventions of one with strabismus is to return the eyes to normal functioning and position. True or False False. There is no treatment that will perfectly align the eyes. The goal therefore is to realign them as close to normal as possible.
Visual Impairment Common during childhood. Refers to loss that cannot be corrected. Legal blindness: visual acuity of 20/200 or less and a visual field of 20 degrees or less.
What causes visual impairment? Perinatal infections. Retinopathy of prematurity. Trauma. Postnatal infections. Disorders such as sickle cell, juvenile rheumatoid arthritis, Tay-Sachs disease, albinism and retinoblastoma.
The ____________ are the most common types of visual disorders in children. refractive errors
Nursing diagnosis relating to visual impairment? Altered family processes r/t diagnosis. Altered growth and development r/t surgery/perceptual alterations. Risk for injury r/t environmental hazards, noncompliance with plan.
Retinoblastoma Most common congenital malignant intraocular tumor. Caused by a mutation in the gene. May be inherited or occur sporadically.
Signs and Symptoms of Retinoblastoma? Cat’s eye reflex. Strabismus. Red, painful eye. Blindness is a late sign.
How are some ways retinoblastomais treated? Plaque brachytherapy. Laser photocoagulation. Cryotherapy. Thermotherapy. Chemotherapy. Enucleation.
What are some nursing considerations for retinoblastoma? Have a high index of suspicion. Educate parents on tests and screening. If enucleation is done, educate the parents and show them pictures of another child with an artificial eye.
What are some pre op patient teaching that can be done on a child with retinoblastoma? Prepare the parents for the child’s facial appearance after surgery. Care for the socket as ordered.
_____________ is most common congenital malignant intraocular tumor of childhood. Retinoblastoma
What are the same signs and symptoms of autism? Symptoms: Hallmark: failure to make eye contact. Limited functional play. May have significant GI symptoms such as constipation. Majority has some degree of mental retardation.
What are some nursing interventions for patients with autism? Highly structured and intensive behavior modification and routine. Recognize that not all children with autism are the same and require individual assessment and treatment. Decrease stimulation:
What should the nurse be aware of when caring for a patient with autsim? May willfully starve themselves or gag to prevent eating. Communicate at the child’s developmental level, brief and concrete. Family support Refer to Autism Society of America.
What is Autism? A developmental disorder of brain function.
What is cognitive impairment? Encompasses any type of mental difficulty or deficiency/mental retardation.
3 components of diagnosisng cognitive impairment are? Intellectual functioning with an IQ of 70 or less. Impairment in at least 2 of 10 different skills. Communication.Selfcare Home living Social skills. Leisure Health and safety. Self-direction. Younger than 18 yrs when diagnosed.
What are the two classifications of cognitive impairment? Educable mentally retarded (mild). Trainable mentally retarded (moderate).
What causes cognitive impairment? The causes are primarily genetic, biochemical and infectious or unknown. Events may lead to retardation: Infection and intoxication. Trauma that causes brain injury. Gross postnatal brain disease. Chromosomal abnormalities.
What are some nursing considerations when caring for a child who has cognitive impairment? Major role in identifying children. Take parental concerns seriously. Conduct developmental assessments and note delays. Educate the family and child: Basic skills. Use simple directions. Use positive reinforcement.
What are some nursing interventions for children who are cognitive impaired? Care during hospitalization: Parents should be encouraged to stay. Allow the child to be as independent as possible. Take a detailed history. Focus on the things that the child can do.
Fragile X Syndrome The most common inherited cause of mental retardations. Second most common genetic cause of mental retardation. More common in males. Females are carriers.
What are some signs and symptoms of fragile X? Cognitive impairment. Speech delay. Short attention span. Hypersensitivity to taste, sounds and touch. Autistic-like behaviors. May be aggressive.
How is fragile X treated? There is no cure. Serotonin agents are used to control outbursts. CNS stimulants such as clonidine are used to improve attention span and decrease hyperactivity. Care is the same care that is given to any family with child with mental retardation.
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.
Created by: alexandra.bell