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PEDs Exam Two
PEDs Exam 2
| Question | Answer |
|---|---|
| Infant Screening | PKU (mandatory in all states) |
| Phenylketonuria (PKU) | Autosomal recessive; deficient phenylalanine hydroxylase (used to convert phyenylalanine to tyrosine); no conversion = toxic -> CNS damage -> retardation |
| PKU - s/s | s/s may not be seen until 3mos; GI probs, V 1st, musty or mousy odor to urine, infantile eczema, hypertonia/hyperactive behavior, hypopigmentation (blond hair, blue eyes) |
| PKU - Dx | screening, before 3rd day of life may give false negative, positive result needs further testing; serum phenylalanine levels >10mg/dL |
| PKU - management | early tx; lifelong dietary restriction; keep serum phenylalanine 2-6mL/dL <12yrs; 2-15mL/dL >13yrs; d/c diet can show dec mental functions; pregnant = strict diet to avoid mental deficiency, microcephaly, retarded growth, seizures, structural defects |
| Congenital hypothyroidism - manifestations NEONATAL | skin mottling; large fontanel; large tongue; hypotonia (tongue protruding); slow reflexes; distended ABD; constipation |
| Congenital hypothyroidism - manifestations EARLY INFANCY | prolonged jaundice; constipation; feeding problems; cool skin; umbilical hernia; hoarse cry; excessive sleeping; large tongue; respiratory problems |
| Congenital hypothyroidism - untreated | s/s usually appear p 6wks; facial features (depressed nasal bridge, short forehead, puffy eyelids, large tongue); coarse, dry, lusterless hair; ABD distention, umbilical hernia; hyporeflexia; delayed neurologic development -> mental retardation |
| Congenital hypothyroidism - tx | lifelong thyroid hormone replacement; synthroid; bone age surveys to monitor optimum growth; normal growth et intelligence if tx begun shortly p birth |
| Growth Hormone deficiency (Part 1) | secreted @ night; assoc c underlying causes such as brain tumors, pituitary gland malformations; may present as hypoglycemia |
| Growth Hormone deficiency (Part 2) | growth normal 1st yr -> slowed curve below 3rd percentile; skeletal proportions normal; appear younger |
| Growth Hormone deficiency - Manifestations | ht <5th percentile; restricted growth rate; ht may be more slowed than wt if nutrition good -> obesity; immature (cherubic) faces; delayed puberty; hypoglycemia; diminished muscle mass; inc fat; micropenis; delay perm teeth; norm intelligence (precocious) |
| Growth Hormone deficiency - Dx | fam hx; child's growth hx, other health hx; physical exam; bone growth studies; endocrine studies |
| Growth Hormone deficiency - Management | synthetic growth hormone subq 6-7x/wk; stopped when growth plates fuse or when acceptable adult ht reached, give @ night; inc growth potential r/t earlier tx; given to children c short stature s GHD no major inc growth |
| Precocious puberty | Early onset of puberty (before 8yrs in girls; before 9yrs in boys); can occur in infancy or early childhood; premature appearance of secondary sex characteristics; accelerated bone growth -> early growth plate fusion -> short stature in adulthood |
| Precocious puberty - manifestations | secondary sex characteristics; acne; growth spurt in females; adult body odor; menses in girls; deepening of voice in boys; moodiness |
| Precocious puberty - management | luteinizing hormone - releasing hormone, IM once q 4wks, d/c @ chronologically appropriate time when puberty desired |
| Precocious puberty - special considerations | treat according to chronological age, not appearance; children often teased; emotional stress; inc risk of child abuse; children are fertile (oral contraceptives will initiate epiphyseal closure) |
| Congenital adrenal hypoplasia (CAH) | group of disorders characterized by deficiency of enzyme needed to make cortisol; inability of adrenal gland to make adequate glucocorticoid -> excess androgen production; autosomal recessive; cortisol needed for maintenance of BS, fluid/lytes, hormones |
| Complete (Salt-Losing) CAH | insufficient amts of aldosterone, cortisol; EMERGENCY (FTT WEAKNESS, V, DEHYDRATION IF NO TX @ BIRTH); aldosterone replacement, supplement dietary salt; frequent labs for lytes, hormone levels |
| CAH - manifestations | ambiguous genitalia of female newborn; post-natal virilization of both genders; salt-wasting crisis (inc K, hypovolemia, hypoTN) |
| Simple Virilizing CAH manifestations | no salt-wasting crisis: muscular body, adv. bone age, premature pubic hair |
| Milder form of CAH manifestations | hirsutism (delayed hair growth), delayed menses, menstrual irregularities |
| CAH - management | surg reconstruction; lifelong glucocorticoid tx; mineralocorticoid replacement for children c salt-wasting CAH florinef; dbl or trpl glucocorticoids when ill, fx, or surgery; bone age studies q yr; monitor BP |
| Type 1 Diabetes | pancreas unable to produce et secrete insulin; genetic predisposition + environmental or viral trigger = autoimmune destructive process; diet (cow's milk) et viruses implicated in triggering autoimmune destructive process; no prevention/cure |
| Type 1 Diabetes - Manifestations | polyuria, polydipsia, polyphagia c wt loss et dehydration, ABD pain et V; routine UA during yearly physical exam (ketones et glucose) |
| Hyperglycemia | onset slow; N/V, confusion, lethargy, polyuria, polydipsia, polyphagia, fatigue, blurred vision, gradual wt loos , HA, hunger, emotional liability; serum glucose >160mg/dL |
| tx for Hyperglycemia | insulin; exercise; inc PO fluids |
| Hypoglycemia | rapid onset; weakness, dizziness, trembling, sweating, tachy, pallor, clammy skin (adrenergic signs); personality chg, irritability, drunken behavior, slurred speech, dec LOC, seizures (nueroglycopenic sign); serum glucose <70mg/dL |
| tx for Hypoglycemia | 15g of carbs (4oz juice); in unconscious or having seizures (glucagon SQ or IM, IV glucose) |
| Ketoacidosis Labs | serum glucose >300mg/dL; serum pH <7.25; positive serum ketones |
| Ketoacidosis | lack of insulin; excessive stress (end of illness) |
| DKA | inc BS; low pH; large urine ketones; inc serum ketones; WBC inc r/t stress; low serum CO2 |
| DKA - s/s | acetone (fruity) breath; ABD et chest pain; deep, rapid resps. (kussmaul); dec LOC; N/V; dehydration |
| Progression of s/s | hyperglycemia (inc glucose, glucosuria) -> ketosis (ketones, glucose in urine; possible dehydration) -> ketoacidosis (dehydration; lyte imbalance; acidosis; kussmaul) |
| Type 2 Diabetes | peak incidence occurs c onset of puberty; females>males; inc esp. among ethnic minorities |
| Type 2 Diabetes - Manifestations | typically overwt; may have all s/s of Type 1; fatigue; frequent infections |
| Goals of Diabetes Management | appropriate growth (ht et wt); age-appropriate lifestyle; near-normal glycosylated Hgb; prevent or min acute complication (hypoglycemia, hyperglycemia) |
| Lispro | onset 15-30min; peak 60-90min; duration 2-3hr |
| Regular Insulin | onset 30min; peak 2-4hr; duration 4-6hr |
| NPH or Lente Mixed Insulin | onset 2-4hr; peak 6-8hr; duration 12-24hr |
| Ultralente Insulin | onset >2hr; peak variable; duration 24-36hr |
| Insulin Administration | need less in honeymoon phase; 2+ injections/day mimics norm insulin secretion; subq; rotate sites to dec adipose hypertrophy; location sites vary in rates of absorption |
| Insulin | store cool dry place; expiration date; draw short before mixing c long; can reuse disposable needles for 1-3days store in fridge; proper disposal of needles; rotate injection sites |
| Long-term complications of diabetes | retinopathy; diabetic nephropathy; foot problems --> good BS control, norm BP, no smoking |
| Developmental issues of Diabetes management | chronic disease; life-time management; child's perception changes over time; parent's goal is to facilitate independence in caring for self; affects entire family |
| Target ages for technical skills | 4-6yrs (urine testing); 4-8yrs (blood testing); 8-10yrs (insulin injections); 10-14yrs (nutrition decision skills); 12-18yrs (management decision skills) |
| Type 1 vs Type 2 Diabetes | 1 (immune disorder; body attacks et destroys insulin producing beta cells in pancreas); 2 (disorder either body does not produce enough insulin or the cells ignore the insulin) |
| Diabetes Dx | Prediabetes (FBS >100; random BS >140); Diabetes (FBS >126; Random BS > 200; A1C >6.5) |
| Meningocele | Saclike cyst of meninges containing CSF; translucent (flashlight able to see through sac); not assoc c neuro deficit; cover c sterile, saline gauze |
| Myelomeningocele | sac contains meninges, CSF, portion of spinal cord or nerve roots; not translucent; first 28 days of pregnancy; any point along spine; usually lumbar or lumbosacral; severity r/t location; 80-85% also hydrocephalus |
| Myelomeningocele - s/s | depends on location |
| Myelomeningocele - tx | initially, prevent infection et surg repair; observe for postop complications of hydrocephalus (head circumference); prepare fam for long-term effects of disability |
| Myelomeningocele - nursing care | assist c dx; place infant prone; moist dressing; goal (prevent infection, preserve or enhance neuro or urologic function); postop assess for infection, hydrocephalus |
| Hydrocephalus | r/t various disease or from injury; communications (impaired absorption of CSF c/in subarachnoid space) OR non-communications (obstruction of CSF flow through ventricular system; arnold-chiari malformation of skull |
| Hydrocephalus - causes | myelomeningocele; intraventricular hemorrhage; tumors; CSF infection; head injury |
| Hydrocephalus - manifestations in infants EARLY | rapid head growth; full anterior fontanel; irritability; poor feeding; distended scalp veins; widely separated cranial sutures |
| Hydrocephalus - manifestations in infants LATE | setting sun sign; frontal bone enlargement (bossing); inc BP; dec HR; altered resp; shrill, high-pitched cry; sluggish or unequal pupil responses to light |
| Hydrocephalus - manifestations in children EARLY | strabismus; frontal HA (worse in AM, relieved by sitting up); forceful V; behavior, school cahnges; ataxia; papilledema; irritability; sluggish or unequal pupil responses; lethargy |
| Hydrocephalus - manifestations in children LATE | seizures; inc BP; dec HR; alteration in resp pattern; herniation of optic disc -> blindness; decerebrate posturing |
| Hydrocephalus - tx | ventriculoperitoneal shunt (drains excess CSF into peritoneal cavity) |
| ventriculoperitoneal shunt - nursing considerations | prevention of infection; assess for shunt malfunction; paralytic ileus or peritonitis; anticipatory guidance; will need revisions as they grow |
| Increased Intracranial Pressure (ICP) - causes | head trauma, infection, hypoxia can cause cerebral edema; overproduction of fluid or "drainage" (spina bifida) problem can affect |
| Inc ICP - s/s | dec LOC (glasgow coma scale); behavior (eventually don't recognize parents, don't respond to pain); pupils sluggish to dilate or become fixed; motor function (dec purposeful movements or posturing); vitals altered |
| Inc ICP - infant s/s | tense, bulging fontanel; separated cranial sutures (esp if approx. before); irritability; high-pitched cry; distended scalp veins; poor feeding; setting sun sign |
| Inc ICP - children s/s | HA, N/projectile V, blurred vision, seizures |
| Inc ICP - behavioral s/s | irritability, restlessness; indifference, drowsiness; inc sleep; inability to follow simple commands; lethargy; drowsiness; diminished school performance, physical activity |
| Inc ICP - late s/s | brady; dec motor response to commands; altered pupil size et reactivity; decerebrate or decorticate posturing; cheynes-stokes resp; papilledema; dec LOC -> coma |
| Levels of consciousness | conscious, confused, disoriented, lethargic, obtunded, stupor, coma |
| Closed head trauma | non-penetrating; no break b/w skull et brain |
| Open head trauma | skull, meninges open; infection a big concern |
| coup | injury directly @ point of impact |
| contrecoup | injury remote from impact; caused by rapid movement of brain away from point of impact |
| skull fx | linear (dura not involved); depressed (bone indented); basilar (base of skull, s/s battle's sign, racoon eyes, rhinorrhea, otorrhea, hemotympanum); comminuted (fragmentation) |
| contusion | bruised area; petechial hemorrhages on superficial aspects of brain |
| primary head injury | occurs at moment of impact |
| secondary head injury | brain tissue destruction secondary to hypoxia, hemorrhage, edema, etc. |
| Intracranial hemorrhage | epidural (b/w dura et skull; arterial damage; develops rapidly); subdural (b/w dura et cerebrum; acute or chronic depending on type of vessels involved) |
| concussion | transient, reversible, neuronal dysfunction; instantaneous loss of awareness et responsiveness; posttraumatic amnesia reflects the extent of injury (retrograde - period of time before injury; anterograde - period of memory loss p injury) |
| Post-concussion syndrome - infants | pallor, sweating, irritability, sleepiness, V |
| post-concussion syndrome - children | behavioral disturbances, sleep disturbances, phobias, emotional lability, irritability, seizures, altered school performance |
| post concussion syndrome | diffues s/s of brain dysfunction (not working); HA; dizziness; impaired conc.; variable duration |
| Meningitis | most common infectious process affecting CNS; usually bacterial; may be primary infection or may occur secondary to trauma, surgery, migration, from other infection sites |
| Meningitis - prevention | HIB vaccine |
| Bacterial meningitis | acute inflammation of meninges et CSF; HIV vaccine; greatest mortality in children birth-4yrs; extension of other illness; nasopharynx common site of entry |
| Bacterial meningitis- manifestations in infants, young children | fever, V, marked irritability, restlessness, seizures, high pitched cry, bulging ant fontanel, nuchal rigidity, Brudzinski (bend neck, knees come up), Kerning signs (s/cannot extend leg at knee when this is flexed) |
| Bacterial meningitis- manifestations in children, adolescents | abrupt onset of fever, chills, HA, V -> alter in sensorium; photophobia, confusion, drowsiness, stupor, coma; nuchal rigidity -> opisthotonos; Brudzinki et Kernig signs; cyanotic, cool skin c poor periph perfusion |
| Bacterial meningitis - complications | sepsis (disseminated intravascular coagulation, shock, bilat adrenal hemorrhage, purpura, mortality rate 90%); inc ICP, hydrocephalus, SIADH, destructive changes in cerebral cortex, cranial nerve damage (hearing, vision losses) |
| Bacterial meningitis - dx | lumbar puncture, full septic workup usually done in any child c signs (urine, blood, CSF cultures, CBC) |
| Bacterial meningitis - tx | antibiotics, steroids, supportive care, hydrations, tx of complication, auditory evals in 6mos, prevention (vaccinations) |
| Seizures | more common 1st 2yrs; prenatal insults/birth injuries most common cause in very young infants; seizure threshold can be altered |
| Seizures - etiology | altered neuronal activity -> seizures; primary (occur in absence of underlying brain structural abnormality; secondary (symptomatic; provoked by temp or perm structural or metabolic abnormality, underlying cause can be found); idiopathic (no known cause) |
| Seizures - causes | cerebral lesions, metabolic disorders, anoxia, trauma, stroke, infections, degenerative disorders, toxic disturbances |
| epileptogenic focus | area of the brain where brief paroxysmal behavior caused excessive abnormal discharge of neurons |
| status epilepticus | prolonged seizure or series of seizures c loss of consciousness at least 30 min |
| epilepsy | recurrent seizure activity not assoc c other illness or procedure like insulin OD |
| refractory seizures | last more than 60min |
| generalized seizures | abnormal excessive impulses THROUGHOUT THE BRAIN; no apparent focal point of onset; altered LOC; can be "convulsive" or not; may begin at a focal point but we don't know where it started |
| partial seizures | begin in ONE PLACE IN BRAIN; may or may not alter LOC, depending on which part of brain is affected |
| generalized tonic-clonic seizures | grand mal (abrupt arrest of activity et LOC); tonic phase (sustained stiffening of muscles); clonic phase (axial symmetric, jerking asymmetric et rhythmic); postictal phase (period of confusion, lethargy, sleep) |
| generalized atonic seizures | abrupt loss of postural tone, confusion, lethargy, sleep |
| generalized myoclonic-infantile spasms | brief, random contractions of a muscle group; occur on both sides of body, singly or in clusters |
| generalized absence seizures | petit mal - very brief alterations in consciousness; may have eyelid twitching, head bobbing; day dreamer, cannot easily bring back |
| partial seizures | abnormal electrical activity in small area of brain; usually temporal, frontal, or parietal lobes; s/s assoc c area of brain affected |
| simple partial seizures | most common syndrome - benign focal epilepsy; varies b/w people; s/s r/t area of brain affected; motor, autonomic or sensory s/s; no change in LOC; odd taste or smell, ABD discomfort, unexplained fear/dread, motor movements may occur |
| complex partial seizures | may begin c/s an aura or c/s simple paritla seizure; impaired consciousness, transient staring, altered mental status, feeling of detachment or unreality; teeth-grinding, lip smacking, followed by variable postictal state |
| febrile seizures | usually young children; 2/3 not have subsequent seizures c 3% develop epilepsy; level et rapidity of temp rise are keys to seizure (usually occurs during rise); simple febrile seizures are familial |
| neonatal seizures | r/t incomplete myelinization; sustained eye opening; horizontal deviation of eyes; sucking, smacking; drooling; tongue thrusting; apnea |
| Seizures - assessment (part 1) | loss of conscious or awareness; color (pale, cyanotic, flushed); unusual movements (tonic-clonic, muscle spasms, head drops); eyes (pupil dilated, rolling upward or deviations to one side); incontinent GI/GU; postictal state; how long return; length |
| Seizures - assessment (part 2) | order of events; duration of seizure activity; significant precipitating events (lights, noise, stress); behaviors; position of eyes, head, body, extremities; color changes; resp changes; incontinence; any postictal state |
| Seizures - ketogenic diet | limit carbs et protein; 4:1 fat:carb |
| Seizures - Medications | block sodium; enhance GABA; inhibit glutamate; type of drug depends on type of seizure |
| Seizures - medications SEs | CNS effects (drowsiness, Keppra - moodiness); GI (N/V, anorexia); skin (Lamictal, Neurontin - rash); blood (anemia, leukopenia, etc.); resp depression; liver damage; hypocalcemia; lymphadenopathy; gingival hyperplasia c dilantin |
| Phenytoin (Dilantin) | prototype; initial drug of choice; CNS et GI SEs; gingival hyperplasia common; oral care |
| Carbamazepine (Tegretol) | r/t tricyclic antidepressants; pharm similar to dilantin |
| ethosuximide (zarontin) | ZZZ for sleep; drug of choice for absence seizures |
| Benzos - Lorazepam (Ativan) | drug of choice for status epilepticus; all have potential for dependence et withdrawal s/s; abrupt withdrawal may precipitate seizure activity (all antiseizure meds) |
| Seizure - management | airway, O2 suction; DO NOT PLACE ANYTHING IN MOUTH; turn on side; seizure meds/ketogenic diet, seizure surgery; prevent injury; referral; teach CPR to parents; side rails up/padded; waterproof mattress; protect during possible hazardous activities; med ID |
| Cerebral palsy | disorders characterized by early onset, impaired movement et posture; NONPROGRESSIVE; may be accompanies by perceptual problems; language deficits; intellectual involvement |
| CP - muscle movements | ataxia; spasm; spasticity; tremors; twitching; dystonia |
| CP - causes PRENATAL | maternal diabetes; Rh or ABO incompatibility; rubella in 1st trimester; intrauterine ischemia; toxoplasmosis; cytomegalovirus; congenital brain abnormality |
| CP - causes L&D | preeclampsia; complication of L&D |
| CP - causes PERINATAL | sepsis/CNS infection; asphyxia; prematurity; low birth wt; prolonged labor/aggressive labor |
| CP - causes CHILDHOOD | meningitis; traumatic brain injury; toxins; et other non-obvious causes |
| CP - manifestations | poor head control p 3mos; stiff or rigid arms/legs; push away/arch back; floppy/limp body posture; can't sit s support p 8mos; uses only 1 side of body/only arms; clenched fists p 3mos |
| CP - behavioral manifestations | extreme irritability or crying; failure to smile by 3mos; feeding difficulties; persistent tongue thrusting p 6mos or persistent gagging or choking |
| CP - clinical manifestations | delayed gross motor; abnormal motor performance - asymmetry or spasticity; alterations in muscle tone (exaggerated arch of back, scissoring of legs); abnormal postures; reflex abnormalities |
| CP - classifications | spastic (most common); athetoid (worm like); ataxic |
| Spastic CP | unilateral/bilateral; hypertonicity c poor control of posture, balance, coordinated motion; impaired fine et gross motor skills |
| Athetoid CP | constant, slow, worm-like writhing movements; extremities, trunk, neck, face, tongue; might have inc caloric needs |
| ataxic CP | wide-based gait; rapid, repetitive movements performed poorly |
| CP - gait abnormalities | ataxia (unable to coordinate movements, staggered, postural imbalance); spastic paraplegic (narrow-based, scissor gait, walk on toes c flexed knees); cerebellar (staggered, unsteady, veers in 1 direction) |
| CP - therapeutic management | PT (ortho devices, adoptive equipment); OT; speech/lang therapy; special ed; surg intervention (contractures, g-tubes); med therapy; case management |
| Adolescence Developmental Question | Look at notes from development based on ATI reading ~week 1 |
| Spina Bifida (Part 1) | congenital neural tube defect - incomplete closure of vertebrae et neural tube during fetal development; may be very mild c no s/s or severe c sensory et motor defects |
| Spina Bifida (Part 2) | maternal folic acid deficiency is linked to disorder; manifestations r/t degree et level deficit; spina bifida occulta/cystica |
| Spina Bifida Occulta | NOT VISIBLE EXTERNALLY; vertebrae do not fuse completely; may have no sensory/motor deficits; usually discovered accidentally c routine xray; tuft of hair or dimple common |
| Spina Bifida Cystica | VISIBLE DEFECT; external saclike protrusion; meningocele (no nerves in sac); myelomeningocele (nerves in sac) |
| Delegation of PEDs pt care with any dx listed here | |
| Down Syndrome | most common genetic cause of mod-severe mental retardation; late maternal age primary factor; cause specific unknown; facial/body features common to all children make IDable; also have common set of potential concomitant conditions |
| Down Syndrome - Characteristics | Intelligence (mild-mod mental retardation); social (2-3yrs delay; sociable c easy temperaments); congenital anomalies (esp. septal defects); sensory (vision, hearing); growth (short stature); sexual development (often delayed) |
| Down Syndrome - common features FACIAL | brachycephaly c flat profile; upward-slanted palpebral fissures; inner epicanthal folds; wide, flat nasal bride; protruding tongue; low-set, small ears; short, broad neck |
| Down Syndrome - common features BODY | short ht; short, broad hands c transverse palmar crease (simian); clinodactyly; broad, stubby feet et wide gap b/w 1st et 2nd toes |
| Down Syndrome - common features CARDIAC | tetralogy of fallot; ASD; VSD; PDA |
| Down Syndrome - common features GI | TE fistula; pyloric stenosis; Hirschprung's disease; imperforate anus; duodenal atresia |
| Down Syndrome - common features MISC. | obesity; alopecia; thyroid dysfunction; male infertility; craniofacial defects, esp. involving jaw, teeth; joint laxity et dislocations |
| Down Syndrome - 3 types | nondisjunction (extra copy 21st chromosome); mosaic (improper division 21st chromosome); translocation (additional 21st chromosome attached to another chromosome; ONLY FORM THAT CAN BE INHERITED) |
| Down Syndrome - Dx | review clinical features for suspected dx; definite diagnosis (prenatal - CVS, amniocentesis; postnatal - blood drawn for chromosomes) |
| What to remember for Down Syndrome | physiologic (heart, pulm HTN, vision, hear, speech, apnea, feeding, small airways); person 1st speech c congrats et positivity info truthful et honest but not overwhelming --> resources |
| Hypoxic-Ischemic Encephalopathy (HIE) | LOOK AT PPT ON MOODLE |
| EXTRA CREDIT!!! | MUSCULAR DYSTROPHY |
| REVIEW ATI!!! | CHAPTERS 12-14, 27-29, 33-34 |
Created by:
kdrummond08
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