Escolar Documentos
Profissional Documentos
Cultura Documentos
Developmental Theorists
Maslows Hierarchy of Needs (1954)
Principles:
An individuals needs are depicted in ascending levels on the hierarchy Needs at one level must be met before one can focus on a higher level need
Physiologic/Survival Needs Safety and Security Needs Affection or Belonging Needs Self-esteem/Respect Needs Self-actualization Needs
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11 years + :
Formal Operations
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SENSORIMOTOR
Birth - 2 years
Reflexive behavior leads to intentional behavior
Egocentric view of world Cognitive parallels motor development Object Permanence
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PREOPERATIONAL THOUGHT
2 - 7 years
Egocentric thinking Magical thinking Dominated by self-perception Animism No irreversibility Thoughts cause actions
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CONCRETE OPERATIONS
7 - 11 years
Systematic/logical Fact from fantasy Sense of time Problem solve Reversibility Cause & effect Humor
Photo Source: Del Mar Image Library; Used with permission
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FORMAL OPERATIONS
11 years - Adult
Abstract thinking Analyze situations New ideas created Factors altering this: Poor comprehension Lack of education Substance abuse
Photo Source: Del Mar Image Library; Used with permission
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sits with or without support at 6 mo* rolls from abdomen to back Sensory: able to differentiate between light and dark hearing and touch well developed
* triples weight by 12 months Gains 1/2 in (1.25 cm) monthly for next 6 months Teeth begin to come in Motor: Intentional rolling over from back to abdomen* Starts crawling and pulling to a stand* Develops pincer grasp* Sits without support by 9 months* Sensory: Can fixate on and follow objects Localizes sounds
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Distinction in cry at 1 month Coos at 3 months Begins to imitate sound at 6 months babbles Verbalizes all vowels at 9 months Can say 45 words at 12 months
Social smile at 2 months Demands attention & social interaction at 4 months Stranger anxiety & comfort habits begin at 6 months* Separation anxiety develops at 9 months*
Socialization:
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1-4 months
5-6 months
7-9 months
Searches for dropped objects *Object Permanence begins Responds to simple commands Responds to adult anger Recognizes objects by name Looks at and follows pictures in books
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10-12 months
Physical Tasks:
Toddler
Slow growth period Gains 11 lbs (5 kg) Grows 8 inches (20.3 cm) Anterior fontanel closes at 12 - 18 months* Primary dentition (20 teeth) complete by 2 years Develops sphincter control toilet training possible*
Walks alone by 12 - 18 months* Climbs and runs fairly well by 2 years Rides tricycle well by 3 years
Motor Tasks:
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Toilet training
Fears: separation anxiety, loss of control
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Preschooler
Physical Tasks:
Slow growth rate continues Weight increases 4-6 lbs (1.82.7 kg) a year Height increases 2 inches (5-6.25 cm) a year Permanent teeth appear Walks up & down stairs Skips and hops on alternate feet Throws and catches ball, jumps rope Hand dominance appears Ties shoes and handles scissors well Builds tower of blocks
Photo Source: Del Mar Image Library; Used with permission
Motor Tasks:
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Play is work*
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School-age
Physical Tasks:
Slow growth continues Weight doubles over this period Gains 2 inches (5 cm) per year At age 9, both sexes are the same size At age 12, girls are bigger than boys Very limber but susceptible to bone fractures Develops smoothness & speed in fine motor skills Energetic, developing large muscle coordination, stamina & strength Has all permanent teeth by age 12
Photo Source: Del Mar Image Library; Used with permission
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Adolescent
Physical tasks:
Period of rapid growth Puberty starts Girls: height increases 3 inches/year Boys: growth spurt around 13-yrs-old height increases 4 inches/year weight doubles between 12-18 yrs Body shape changes: Girls have fat deposits in thighs, hips & breast, pelvis broadens Boys become leaner with a broader chest
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Adolescent
Sexual Development
Girls
Breasts develop Menses begins First 1 2 years infertile
Boys
Facial Hair growth Voice changes Enlargement of testes at 13 yrs Nocturnal emission during sleep Reaches reproductive maturity with viable sperm at 17 yrs
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Lets Review
A 10 month-old baby was admitted to the pediatric unit. Each time the nurse enters the room the baby begins to cry. The most appropriate action by the nurse would be to:
A. Complete all procedures quickly in order to decrease the amount of time the baby will cry. B. Ask another nurse to assist you with the babys care. C. Distract the baby. D. Encourage the parent to stay by the bedside and assist with the care.
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Lets Review
A 6 month-old is admitted to the pediatric unit for a 3 week course of treatment. The infants parents cannot visit except on weekends. Which action by the nurse indicates an understanding of the emotional needs of an infant?
A. Telling the parents that frequent visits are unnecessary. B. Placing the infant in a room away from other children. C. Assigning the infant to different nurses for varied contacts. D. Assigning the infant to the same nurse as much as possible.
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Lets Review
Which child is most likely to be frightened by hospitalization?
A. 4 month-old admitted with a diagnosis of bronchiolitis. B. 2 year-old admitted with a diagnosis of cystic fibrosis. C. 9 year-old admitted with a diagnosis of abdominal pain. D. 15 year-old admitted with a diagnosis of a fractured femur.
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Infant Nutrition
Birth 6 months:
Breast milk is most complete diet Iron-fortified formulas are acceptable No solid foods before 4 months*
6 - 12 months:
Breast milk or formula continues* Diluted juices can be introduced Introduction of solid foods*(4-6 mo): cereal, vegetables, fruits, meats Finger foods at 9-10 months Chopped table foods at 12 months
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Toddler Nutrition
Able to feed self autonomy & messy! Appetite decreases- physiologic anorexia Negativism may interfere with eating Needs 16 20 oz. milk/day Increased need for calcium, iron, and phosphorus risk for iron deficiency anemia Caloric requirements is 100 calories/kg/day No peanuts under 3 years of age (allergies)* Do not restrict fats less than 2 years of age* Choking is a hazard (no nuts, hot dogs, popcorn, grapes)*
Photo Source: Del Mar Image Library; Used with permission
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Preschooler Nutrition
Caloric requirements is 90 calories/kg/day
May demonstrate strong taste preferences 4 years old picky eaters 5 years old influenced by food habits of others
Able to start social side of eating
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School-Age Nutrition
Caloric needs diminish, only need 85 kcal/kg
Adolescent Nutrition
Nutritional requirements peak during years of maximum growth:
Age 10 12 in girls Age 14 16 in boys Food intake needs to be balanced with energy expenditures
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Adolescent Nutrition
(continued)
Eating and attitudes towards food are primarily family/peer centered
Skipping breakfast, increased junk food, decreased fruits, veggies, milk Boys eat foods high in calories. Girls under-eat or have inadequate nutrient intake.
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Lets Review
The nurse recommends to parents that popcorn and peanuts are not good snacks for toddlers. The nurses rationale for this action is:
A. B. C. D. They are low in nutritive value. They cannot be entirely digested. They can be easily aspirated. They are high in sodium.
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Lets Review
Nutrition is an important aspect of health promotion for the infant. Priority information to give the parents concerning infant nutrition would include (check all that apply):
A. Restrict the fat intake of the infant to help reduce the chances of an obese child. B. Breast or infant formula must be continued for the first year. C. Encourage the use of a pacifier for non-nutritive sucking needs. D. Introduction of solid foods should begin at 4-6 months.
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Lets Review
The nurse is discussing meal planning with the mother of a 2-year-old toddler. Wh2ich of the following statements, if made by the mother, would require a need for further instruction? a. "It is okay to give my child white grape juice for breakfast." b. "My child can have a grilled cheese sandwich for lunch." c. "We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch." d. "For a snack, my child can have ice cream."
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Toddler - Parallel Play, make believe, locomotion (push-pull toys), gross & fine motor, outlet for aggression & autonomy
Preschooler - Associative Play, Imaginary Playmate, dramatic & imitative, gross & fine motor School Age - Cooperative Play, rules dominate play, team games/sports, quiet games/activities, joke books Adolescent - Group activities predominate, activities involving the opposite sex in later years
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Always be honest
Allow choices when possible Allow child to show feelings/talk
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Lets Review
The single most important factor for the nurse to recognize when communicating with a child is:
A. B. C. D. The childs chronological age. Presence or absence of the childs parents. Developmental level of the child. Nonverbal behaviors of the child.
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Health Promotion
Childhood Immunizations Well child check-ups Nutrition Screenings throughout childhood
(APGARS, newborn screenings, lead poisoning, vision/hearing, scoliosis)
Health Teaching
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Immunizations
Primary prevention of many communicable diseases Vaccines safety MMR vaccine and autism (no correlation) Reactions (pre-medicate with Tylenol) Live attenuated vaccines (MMR, Varicella) Weakened form of disease Body produces immune response Contraindicated in immunosupressed individuals Inactivated (killed virus/bacteria or synthetic) 1st dose only primes system- immunity develops after 3rd
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infants and toddlers (falls, burns, poisons) Toddlers and Preschoolers drowning School-age and adolescents motor vehicle accidents and firearms 90% of all accidents are preventable! Safety education is the answer
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Injury Prevention
Methods of Injury Prevention Understanding and Applying Growth and Developmental Principles Anticipatory Guidance Childproofing the environment Educating caregivers and children Legislation Precipitating Factors
Potential Outcomes
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Pediatric Poisonings
Highest incidence occurs in children in 2-year-old age group and under 6 years of age Major contributing factor improper storage, allowing children to play with bottles rattling of pills, drink syrups, toxic portion of plants.
Teach parents about proper storage Knowledge of plants in household, and keep away from infants and children who might chew
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Types of Poisonings
Lead Poisoning
Salicylate Poisoning
Acetaminophen Ingestion
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Major environmental health concern Found in older homes (built before 1978), leadcontaminated soil, water through lead pipes, lead-based paint in ceramics products, Mexican candies made in lead containers Body rapidly absorbs lead specially in periods of rapid growth most harmful to children under 6 years Absorbed in GI tract and accumulates in bones, brain, kidneys Low levels in blood can cause behavioral/learning problems, mid-levels anemia-like symptoms and skeletal growth interference, and high levels can be fatal from CNS edema and encephalopathy Diet high in fat, low in iron & calcium can increase lead absorption Intervention=teaching for prevention. If blood level 45, chelation therapy is needed monitor kidney function during treatment.
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Lead Poisoning
Salicylate Poisoning
Can be acute or chronic ingestion S/S = nausea, disorientation, vomiting, dehydration,
hyperpyrexia, oliguria, coma, bleeding tendencies, tinnitus, seizures Nursing interventions = activated charcoal, sodium bicarbonate for metabolic acidosis, external cooling measures for hyperpyrexia, anticonvulsant and seizure precautions (think patient safety!), vitamin K for bleeding, possible hemo (NOT peritoneal) dialysis
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Acetaminophen Poisoning
Most common drug poisoning in children Acute ingestion S/S start as nausea, vomiting, pallor, sweating
hepatic involvement (jaundice, confusion, coagulation problems, RUQ pain) Treatment is activated charcoal first, then the antidote N-acetylcysteine (Mucomyst) PO every 4 hours for 17 doses after a loading dose given
Lets Review
Which would be the best approach for gastric emptying in a lethargic 18-month-old who ingested antihistamine tablets an hour ago?
A. B. C. D. Diluting toxic substance with water or milk Administering naloxone (Narcan) Gastric lavage Administering ipecac syrup
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Assessment is NOT in the head-to-toe manner When quiet, auscultate heart, lungs, abdomen Assess heart & respiratory rates before temperature Palpate and percuss same areas Perform traumatic procedures last Elicit reflexes as body part examined Elicit Moro reflex last Encourage caretaker to hold infant during exam
Distract with soft voice, offer pacifier, music or toy
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toes Allow toddler to handle equipment during assessment and distract with toys and bubbles Use minimal physical contact initially Perform traumatic procedures last Introduce equipment slowly Auscultate, percuss, palpate when quiet Give choices whenever possible
Photo Source: Del Mar Image Library; Used with permission
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If cooperative, proceed with head-to-toe If uncooperative, proceed as with toddler Request self undressing and allow to wear underpants Allow child to handle equipment used in assessment Dont forget magical thinking Make up story about steps of the procedure Give choices when possible If proceed as game, will gain cooperation
Photo Source: Del Mar Image Library; Used with permission
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present during interview/assessment Provide privacy Head-to-toe assessment appropriate Incorporate questions/assessment related to genitals/sexuality in middle of exam Answer questions in a straightforward, noncondescending manner Include the adolescent in planning their care
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Fever
Causes Often unknown, may be due to dehydration,
most often viral induced Danger in infants is febrile seizures most common between 3 months to five years. The seizure is a result of how quickly the temperature rises. Hydration (20mls/kg is formula for bolus) Antipyretics acetaminophen or ibuprofen Cooling measures avoid shivering
Tepid bath Remove excess clothing and blankets Cooling blankets/mattresses
NO ICE PACKS!
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Pediatric Differences
Fluid & Electrolyte
Percent Body Water compared to Total Body Weight:
Premature infants: 90% water Infants: 75 - 80% water Child: 64% water
Higher percentage of water in extracellular fluid in infants Infants and toddlers more vulnerable to fluid and electrolyte disturbances Concentrating abilities of kidneys not fully mature until 2 years Metabolic rate is 2-3 times higher than an adult Greater body surface area per kg body weight than adults; dehydrates more quickly
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Dehydration
Types:
Isotonic Most common; salt and water lost. Greatest threat Hypovolemic Shock Hypotonic Electrolyte deficit exceeds water deficitphysical signs more severe with smaller fluid losses Hypertonic Water loss higher than electrolyte Vomiting leads to metabolic alkalosis Diarrhea leads to metabolic acidosis
LAB WATCH: monitor sodium, potassium, chloride, carbon dioxide, BUN, and creatinine
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Assessment of Dehydration
Skin gray, cold, mottled, poor to fair, dry or clammy Delayed capillary refill Mucous membranes/lips dry Eyes and fontanels sunken No tears present when crying Pulse and respirations rapid Irritability to lethargy depending on cause and severity, not responsive to parent and/or environment
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Daily weight, I/O Assess hydration status Assess neurological status Monitor labs (electrolytes) Rehydrate with fluids both PO and IV (20 mls/kg of NS) Diet progression: Pedialyte modified Bread-RiceApple Juice-Toast (BRAT) Diet-for-age (DFA) Skin care for diaper rash Stool output (Amount, Color, Consistency, Texture ACCT) HANDWASHING!
Diarrhea
Often specific etiology unknown, but rotavirus is most common cause of gastroenteritis in infants and kids Dont forget contact precautions!! Leading cause of illness in children younger than 5 May result in fatality if not treated properly History very important Treatment aimed at correcting fluid imbalance and treating underlying cause Metabolic acidosis = blood pH < 7.35
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Vomiting
Often result of infections, improper feeding techniques, GI blockage (pyloric stenosis), emotional factors Management directed toward detection, treatment of cause and prevention of complications Metabolic alkalosis = blood pH >7.45
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Lets Review
The most appropriate type of IV fluid to infuse in treatment of extra-cellular dehydration in children is:
A. B. C. D. Isotonic solution. Hypotonic solution. Hypertonic solution. Colloid solution.
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Lets Review
Which laboratory finding would help to identify that a child experiencing metabolic acidosis?
A. B. C. D. Serum potassium of 3.8 Arterial pH of 7.32 Serum carbon dioxide of 24 Serum sodium of 136
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Can use scales like Wongs FACES scale, poker chips, visual analog scales, and numeric rating scales
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Lets Review
The nurse begins a full assessment on a 10 yearold patient. To ensure full cooperation from this patient it is most important for the nurse to:
A. Approach the assessment as a game to play. B. Provide privacy for the patient. C. Encourage the friend visiting to stay at the bedside to observe. D. Instruct the child to assist the nurse in the assessment.
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Lets Review
During a routine health care visit a parent asks the nurse why her 10 month-old infant is not walking as her older child did at the same age. Which response by the nurse best demonstrates an understanding of child development?
A. Babies progress at different rates. Your infants development is within normal limits. B. If she is pulling up, you can help her by holding her hand. C. Shes a little behind in her physical milestones. D. You can strengthen her leg muscles with special exercises to make her stronger.
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Lets Review
When assessing a toddler identify the order in which you would complete the assessment:
1. 2. 3. 4. Ear exam with otoscope Vital signs Lung assessment Abdominal assessment
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Lets Review
When assessing pain in an infant it would be inappropriate to assess for:
A. B. C. D. Facial expressions Localization of pain Crying Extremity movement
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Genetic Disorders
7 Principles of Inheritance g Autosomal Dominant g Autosomal Recessive g Sex-linked (X-linked) Inheritance g Chromosome Alterations 7Downs Syndrome 7Tay-Sachs Disease
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Autosomal Dominant
50% chance offspring will be affected
Normal Parent Affected Parent a a A a
Aa affected
Aa affected
aa normal
aa normal
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Autosomal Recessive
Only child who receives two altered genes Heterozygous Parent Heterozygous Parent develops the disease
A a A a
AA normal
Aa carrier
Aa carrier
aa affected
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X-linked Dominant
When the father is affected, all daughters Normal Mother Affected Father are affected, sons are not
X X XX Affected daughter XY Normal son XX Affected daughter XY Normal son X Y
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X-linked Dominant
When the mother is affected, daughters and sons may be affected
Affected Mother Normal Father X X XX Affected daughter XY Affected son XX Normal daughter XY Normal son X Y
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When the mother is carrier, the daughter will carry the trait, and the son may be affected
Carrier Mother Normal Father X X XX Carrier Daughter XY Affected son XX Normal Daughter Xy Normal son X Y
X-linked Recessive
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Downs Syndrome
Most common cause of cognitive impairment (moderate to severe) 1 in 600 live births Risk factor- pregnancy in women over 35 yrs old Cause - extra chromosome 21 (faulty cell division) Causes change in normal embryogenesis process resulting in:
Cardiac defects, GI conditions, Endocrine disorders, Hematologic abnormalities, Dermatologic changes
Physical features: small head, flat facial profile, broad flat nose,
small mouth, protruding tongue, low set ears, transverse palmar creases, hypotonia
Tay-Sachs Disease
Occurs predominately in children of Eastern European Jewish ancestry Fatal Disease - death usually occurs before age 4 Autosomal recessive inheritance Degenerative brain disease Caused by absence of hexosainidase A from body tissue Symptoms: progressive lethargy in previously healthy 2-6 months old
infants, loss of milestones, visual acuity, seizures, hyper-reflexia, posturing, malnutrition, dysphagia
Diagnosis: Classic cherry red spot on macula, enzyme measurement in
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Lets Review
The infant with Downs Syndrome is closely monitored during the first year of life for which condition?
A. B. C. D. Thyroid complications Orthopedic malformations Cardiac abnormalities Dental malformations
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Pediatric Differences
Neurosensory System
Rapid head growth in early childhood Bones are not fused until 18-24 months
Function:
Autonomic Nervous System is intact - neurons are completely myelinized by 1 year Infants behavior initially reflexive, but are replaced with purposeful movement by 1 year
Pediatric Differences
Neurosensory System
Eye and Vision:
Changes in development of eye and eye muscles *strabismus normal until 6 months
Hydrocephalus
Develops as a result of an imbalance of production and absorption of CSF The increase of CSF causes increased ventricular pressure, leading to dilation of the ventricles, pressing on skull Signs/Symptoms of Increased ICP: Poor feeding and vomiting Bulging fontanel, head enlargement, separation of sutures Lethargy, irritability, restlessness, not responsive to parents CHILD - Headache, vomiting, diplopia, ataxia, papilledema Seizures
A childs head with an open fontanel (under 2 years old) has the ability to expand and better compensate for the increased intracranial pressure.
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Decrease ICP
Determine baseline Assess LOC Assess motosensory Pupil checks Vital signs, Head circ
Seizure precautions Fall precautions Possible restraints Determine LOC ac
Cluster care/ stress Quiet environment HOB 30-45 degrees Appropriate position (head midline, no hip flexion, no prone) Medications(pain meds,corticosteroids, diuretics, stool softeners, antiinfectives, anticonvulsants)
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Psychosocial Support
Child Life consult Teaching
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Spina Bifida:
Occulta and Cystica
(meningocele and myelomeningocele) Etilogy is unknown, but genetic & environmental factors considered. Maternal intake of folic acid Exposure of fetus to teratogenic drugs The severity of clinical manifestations depend on the location of the lesion. T12 - flaccid lower extremities, sensation, lack of bowel control and dribbling urine S 3 and lower - no motor impairment Other complications may occur. Hydrocephalus (80-90%) Orthopedic issues such as scoliosis, kyphosis, club foot Urinary retention Skin breakdown/Trauma
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Spina Bifida
Nursing Interventions
Sterile dressing pre/post-op Monitor VS, S/S infection Use latex free items Avoid stress on sac - prone position only, especially pre-op; no supine until incision healed Monitor for S/S intracranial pressure (ICP) Interventions to ICP Encourage touch & talk Social service consult
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Reyes Syndrome
A true pediatric emergency - cerebral complications may reach an irreversible state. Vomiting & change in LOC to coma Acute encephalopathy with fatty degeneration of the liver causing fluid & electrolyte imbalances, metabolic acidosis, hypoglycemia, dehydration, and coagulopathies.
Most frequently seen in children recovering from a viral illness during which salicylates were given.
Therapeutic management is intensive nursing care and maintaining adequate cerebral perfusion, &ICP. Increased ICP secondary to cerebral edema is major contributing factor to morbidity and mortality.
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Seizures
Febrile seizures are the most common in children, caused by by a RAPID elevation in temperature, usually above 102. Most children do not have a second febrile seizure episode and only about 3% develop epilepsy. Focus of care is on patient safety, cause of fever and education of parents for home care. Remember basic CPR during seizures airway before oxygen Seizure precautions: Suction, oxygen, padded rails
Infants often have subtle seizures with only occular movements or some extremity movements.
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Neuromuscular disorder resulting from damage or altered structure of part of the brain
Caused by a variety of factors: Prenatally - genetic, trauma, anoxia Perinatally - fetal distress, drugs at delivery, precepitate
or breech delivery with delay Postnatally - kernicterus or head trauma
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Cerebral Palsy
(continued)
Spasticity - exaggerated hyperactive reflexes Athetosis - constant involuntary, purposeless, slow writhing motions Ataxia - disturbances in equilibrium Tremor - repetitive rhythmic involuntary contractions of flexor and extensor muscles Rigidity - resistance to flexion and extension
Associated Problems: Mental retardation, hearing loss, speech defect, dental & orthopedic anomalies, GI problems and visual changes
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Special Needs
Nutritional needs include increased calories, assist with feeds, possible GT feeds. Speech, Occupational and Physical therapies
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Bacterial Meningitis
Infectious process of CNS causing inflammation of meninges and spinal cord. ISOLATION IS MANDATORY Signs and symptoms include those of increased ICP plus photophobia, nuchal rigidity, joint pain, malaise, purpura rash, Kernigs and Brudinskis signs Can occur at any age, but often between 1 month-5 years Most common sequele: hearing and/or visual impairments, seizures, cognitive changes Diagnostic confirmation is done by lumbar puncture and CSF is cloudy with increased WBCs, increased protein, and low glucose Nursing Interventions include: appropriate IV antibiotics and meds for increased ICP as well as interventions to decrease ICP
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Causes of Blindness
Genetic Disorders:
Tay-Sachs disease Inborn errors of metabolism
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Causes of Deafness
Conductive:
Interference in transmission from outer ear to middle ear from chronic OM
Sensorineural:
Dysfunction of the inner ear Damage to cranial nerve VIII from rubella, meningitis or drugs
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Lets Review
Which test would confirm a diagnosis of meningitis in children?
A. B. C. D. Complete blood count Bone marrow biopsy Lumbar puncture Computerized Tomography (CT) scan
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Lets Review
In performing a neurological assessment on a patient which data would be most important to obtain?
A. B. C. D. Vital signs. Head circumference. Neurologic soft signs. Level of consciousness (LOC).
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Lets Review
A neonate born with myelomeningocele should be maintained in which position pre-operatively? A. B. C. D. Prone. Supine. Trendelenberg. Semi-Fowler.
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Lets Review
The nurse witnesses a pediatric patient experiencing a seizure. The primary nursing intervention would be:
A. Careful observation and documentation of the seizure activity. B. Maintain patient safety. C. Minimize the patients anxiety. D. Avoid over stimulation and promote rest.
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Lets Review
Which assessment finding in an infant first day post-op placement of a ventriculoperitoneal (VP) shunt is indicative of surgical complications?
A. B. C. D. Hypoactive bowel sounds. Congestion in upper airways. Increasing lethargy. Incisional pain.
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FETAL CIRCULATION
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CLINICAL MANIFESTATIONS-CHF
PULMONARY
Tachypnea Dyspnea Wheezes Crackles Retractions Nasal Flaring Cough
SYSTEMIC
Edema (facial) Sudden weight gain Decreased Urine Output Hepatomegaly Splenomegaly Jugular Vein Distention (JVD, children) Ascites
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Rheumatic Fever
Acquired Heart Disease Inflammatory disorder involving heart, joints, connective tissue, and the CNS Peaks in school-age children Linked to environmental factors and family history
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egg yolks, seafood Calcium inhibits iron, Vitamin C enhances iron absorption
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PATHOLOGY
Normal RBC has a flexible, round shape RBC w/HbS has a normal shape until its O2 delivered to
tissue, then sickle shape occurs Stiff, non-pliable cant flow freely Trapped in small vessels = causes vaso-occlusions, tissue ischemia and infarctions painful episodes, most common area is joints Hemolysis of RBC- lifespan down to 20 days Compensatory mechanism is increased reticulocytes
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HOME MANAGEMENT Pain Control Fluids Teaching Early Identification of infection Immunizations Avoid dehydration
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thrombocytopenia and purpura Cause is unknown, but is to believed to be an auto-immune response to disease-related antigens Usually follows an URI, measles, rubella, mumps, chickenpox Greatest frequency is between 2-8 years of age Platelet count is below 20,000 Therapeutic management is supportive with safety concerns. Activity is usually restricted. Acute presentation therapy can include prednisone, IV immunoglobulin, or Anti-D antibody (causes a hemolytic anemia to rid the body of the antibody-coated RBCs) Chronic ITP will involve a splenectomy.
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Hemophilia
Group of genetic bleeding disorders of which there is a deficiency of a clotting factor Most common are Factor VIII (A) & Factor IX (B) Bleed LONGER not faster Clinical manifestations: prolonged bleeding, bruising, spontaneous hematuria Management: replacement of missing clotting factor (recombinant factor VIII concentrate), cryoprecipitate, DDAVP NSAIDS (aspirin, Indocin) are contraindicated, they inhibit platelet function Regular non-contact exercise/physical therapy is encouraged
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Hemophilia
COMPLICATIONS Bleeding into muscle tissue Hemarthrosis can cause joint pain & destruction
Acute Treatment is rest, ice,
elevation, ROM
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Lets Review
When assessing a child for any possible cardiac anomalies, the nurse takes the right arm blood pressure (BP) and the BP in one of the legs. She finds that the right arm BP is much greater than that found in the childs leg. The nurse reacts to these findings in which way?
A. B. C. D. Charts the findings and realizes they are normal. Suspects the child may have coarctation of the aorta. Suspects the child may have Tetralogy of Fallot. Notifies the physician and alerts the surgery team.
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Lets Review
A 1-month-old infant is being admitted for complications related to a diagnosed ventricular septal defect (VSD). Which physicians order should be questioned by the nurse?
A. Blood pressure every 4 hours. B. Serum digoxin level. C. Diet: Enfamil 20, nipple 6 oz q2H. D. Supplemental oxygen via nasal cannula prn maintain SaO2 >92%.
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Lets Review
A nursing intervention most pertinent for the child with hemophilia is:
A. Sedentary activities to prevent bleeding episodes. B. Meticulous oral care with dental floss to prevent infection. C. Warm compresses to bleeding areas to increase absorption. D. Active range of motion exercises for joint mobility.
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Lets Review
Which is the most appropriate information to teach a parent of a 14 month-old child with iron deficiency anemia?
A. Increase the childs daily milk intake to a minimum of 24 ounces. B. Administer oral iron supplement for the child to drink in a small cup. C. Increase the amount of dark green, leafy vegetables and eggs in the childs diet. D. Encourage the parents to let the child choose foods he prefers.
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Lets Review
Which strategy is appropriate when feeding the infant in congestive heart failure?
A. Continue the feeding until a sufficient amount of formula is taken B. Bottle feed no longer than 30 minutes C. Feed the infant every 2 hours D. Rock and comfort the infant during feedings
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cartilage. The tongue is large. Infants < 6 months old are obligate nose breathers. Chest muscles are not well developed The diaphragm is the neonates major respiratory muscle. Irregular breathing pattern and brief periods of apnea (10 15 secs) are common Abdominal muscles are used for inhalation until age 5-6 yrs. Respiratory rate is higher Increased BMR raises oxygen needs
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Tonsillitis
CLINICAL MANIFESTATIONS
IMPLEMENTATIONS
Ease Respiratory Efforts Provide Comfort
Sore throat Mouth breathing Sleep Apnea Difficulty swallowing Fever Throat C&S/Rapid Strep
necessary
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Tonsillectomy
Pre-operative Nursing Care
Monitor Labs (CBC, PT, PTT) Age-appropriate Preparation/Teaching Surgical Consent
Croup/Epiglottitis
Infection and swelling of larynx, trachea, epiglottis, bronchi Often preceded by URI traveling downward Causative agent: Viral Characterized by hoarseness, barky cough, inspiratory stridor, and respiratory distress Most common ages 6 mo-3 yrs LTB form most common
Photo Source: Del Mar Image Library; Used with permission
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Acute Epiglottitis
Bacterial form of croup affecting epiglottis LIFE-THREATENING EMERGENCY Wellness to complete obstruction in 2-6 hours Most common in ages 2-5 years Do not examine throat! Have functional emergency equipment at bedside - Priority! Often the child is intubated 4 Ds - Drooling, Dysphagia, Dysphonia, Distressed Inspiratory Effort Lateral Neck X-ray shows thumb sign HIB vaccine has reduced the cases dramatically
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Croup/Epiglottitis
Nursing Interventions
Maintain Patent Airway Assess and Monitor Ease Respiratory Efforts
Nursing Interventions
Administer Meds Corticosteroids (HHN) Nebulizer treatment of Racemic Epinephrine PRN stridor Antibiotic for epiglottitis
Promote Hydration
Reduce Fever Calm Environment
Promote Rest
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Bronchiolitis/RSV
Acute viral infection of the bronchioles causing an inflammatory/obstructive process to occur Increased amount of mucus and exudates preventing expiration of air and overinflation of lungs Causative agent in 85% of cases is Respiratory Syncytial Virus (RSV). It is highly contagious - contact isolation must be enforced. Nasal swab or nasal washing obtained for viral panel, including RSV CXR shows hyperinflation and consolidation if atelectasis present Primarily seen in children under 2 years of age Most common in winter and early spring Palivizumab (Synagis)
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Bronchiolitis/RSV
CLINICAL MANIFESTATIONS Nasal Congestion Cough Rhonchi, Crackles, Wheezes Increased RR & SOB Respiratory Distress Fever Poor Feeding IMPLEMENTATIONS Suction priority Bronchodilator via HHN CPT Promote fluids Monitor VS , SaO2, lung sounds & respiratory effort Supplemental oxygen Reduce fever Promote rest HANDWASHING!
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Asthma
CLINICAL MANIFESTATIONS Tachypnea SaO2 below 95% on RA Wheezes, crackles Retractions, nasal flaring Non-productive cough Silent chest Restlessness, fatigue Orthopnea Abdominal pain CXR = hyperinflation INTERVENTIONS Monitor VS (HR, RR) Monitor SaO2 Auscultate lung sounds Monitor respiratory effort Humified oxygen Calm environment Ease respiratory efforts Promote hydration Promote rest Monitor labs/x-rays Patient teaching
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Asthma
Administer Medications
Bronchodilator via HHN or MDI with spacer (Albuterol) Peak flows should always be done before and after Tx Mast cell inhibitor via HHN or MDI (Cromolyn Sodium Intal) Corticosteroid IV or PO (Solu-medrol or Decadron) Antibiotic if precipitated from a respiratory infection
CYSTIC FIBROSIS
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Cystic Fibrosis
1 in 1,500-2,000 live births Dysfunction of the exocrine gland (mucus producing) Multi-system disorder Secretions are thick and cause obstruction and fibrosis of tissue. The clinical manifestations are the result of the obstructive process. Sweat has a characteristic high sodium- Sweat Chloride Test Pancreatic involvement in 85% of CF patients Disease is ultimately fatal. Average age at death: 32 years
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Cystic Fibrosis
PULMONARY MANIFESTATIONS GI MANIFESTATIONS
Initial
Wheezing Dry, non-productive cough
Large, loose, frothy and foul-smelling stools Increased appetite (early) Loss of appetite (later) Weight loss FTT Distended abdomen Thin extremities Deficiency of A,D, E, K Anemia
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Cystic Fibrosis
MANAGEMENT/INTERVENTIONS Airway Clearance - Chest physiotherapy (CPT) Priority Drug Therapy
Bronchodilators - via HHN Mucolytic Agent (Dnase-Pulmozyme) - via HHN Antibiotics - via HHN, IV, or PO Digestive enzymes
Nutrition - needs are at 150% Increased calories and protein - TPN or GT feedings at night Additional fat soluble vitamins Additional salt with vigorous exercise and hot weather Exercise Patient Teaching
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Otitis Media
Acute otitis media (AOM) Infectious process by pathogen Infection can spread leading to meningitis S/S: pain, pulling on ears, fever, irritability, vomiting, diarrhea, ear drainage, full/bulging tympanic membrane Otitis media with effusion (OME)
Inflammation of middle ear with fluid behind tympanic membrane-no infection Peaks spring and fall (allergies)
Most common childhood illness Inflammation of middle ear Impaired eustachian tube causes decreased ventilation and drainage
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Otitis Media
RISK FACTORS Secondary smoke Formula feeding (positioning) Day care Pacifier > 6 mo old TREATMENT Antibiotics (for AOM) Myringotomy with Pressure Equalizing (PE) tubes INTERVENTIONS Teaching No bottle propping Feeding techniques Medication regimen PAIN MANAGEMENT Fever management Surgery prep if needed
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Lets Review
The nurses first action in responding to a child with tachypnea, grunting, and retractions is to:
A. Place the child in an upright, semi-fowlers position. B. Apply a pulse oximeter to determine oxygen saturation. C. Assess for further symptoms. D. Call for a stat respiratory nebulizer treatment (HHN).
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Lets Review
A 3-year-old child is brought to the emergency room with a sore throat, anxiety, and drooling. The priority nursing action is to:
A. Inspect the childs throat for infection. B. Prepare intubation equipment and call the physician. C. Obtain a throat culture for respiratory syncytial virus (RSV). C. Obtain vital signs and auscultate lung sounds.
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Lets Review
An assessment finding in a child with asthma requiring immediate action by the nurse is:
A. B. C. D. Diminished breath sounds. Wheezing in bronchi. Crackles in lungs. Refusal to take PO fluids.
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Lets Review
Which sign is indicative of air hunger in an infant?
A. Nasal flaring. B. Periods of apnea lasting 15 seconds. C. Irregular respiratory pattern. D. Abdominal breathing.
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Lets Review
The priority nursing intervention in caring for the infant with Respiratory Syncytial Virus (RSV) induced bronchiolitis is:
A. Nasopharyngeal suctioning. B. Coughing and deep breathing exercises. C. Administration of intravenous antibiotic. D. Administration of antipyretics for fever.
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Gastrointestinal System
Many GI issues require surgical intervention Nursing interventions will often include general pre and post-op care Bilious vomiting is a sign of GI obstruction and requires immediate intervention Assess stools! Assess hydration status
Photo Source: Del Mar Image Library; Used with permission
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8 Gastrointestinal Disorders
3 3 3
Congenital defects of esophagus EA is an incomplete formation of esophagus TEF is a fistula between the trachea and esophagus Classic 3 Cs - coughing,choking,cyanosis
Photo Source: Del Mar Image Library; Used with permission
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TREATMENT
Surgery: either a one- or two-stage repair Pre-op care focuses on preventing aspiration and hydration Post-op care focus is a patent airway, prevent incisional trauma
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Cleft Lip/Palate
May present as single defect or combined Non-union of tissue and bone of upper lip and
hard/soft palate during fetal development CL-failure of nasal & maxillary processes to fuse at 5-8 weeks gestation CP-failure of palatine planes to fuse 7-12 weeks gestation Cleft interferes with normal anatomic structure of lips, nose, palate, muscles depending on severity and placement Open communication between mouth and nose with cleft palate
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Cleft Lip/Palate
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done by 1 year so speech will not be affected Protect suture lines- priority Monitor for infection
Clean Cleft Lip incision
Pain Management Cleft Palate starts feedings 48-hour post-op: Clear and advance to soft diet No straws, pacifiers, spouted cups Rinse mouth after feeding
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into esophagus - 50% healthy term babies affected Related to inappropriate relaxation of Lower Esophageal Sphincter (LES) making the LES pressure less than the intra abdominal pressure GER may predispose patient to aspiration and pneumonia Apnea has been associated with GER chance of GER after 12-18 mo old related to growth due to elongation of esophagus and the LES drops below the diaphragm
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GASTROESOPHAGEAL REFLUX
SIGNS/SYMPTOMS
Vomiting/spitting up Gagging during feedings Irritability Arching/posturing Frequent URIs/OM Anemia Bloody stools
DIAGNOSTIC EVAL
History of feedings/PE Upper GI/Barium swallow to eliminate anatomical problems Upper GI endoscopy to visualize esophageal mucosa pH probe study
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Medications
Prokinetic agents: LES pressure & gastric motility Histamine H-2 antagonists are added if esophagitis : acid Proton Pump Inhibitors if H-2 ineffective:acid Mucosal Protectants
Dietary modifications
Small, frequent feedings, burp often Possibly thicken formula Avoid fatty, spicy foods caffeine, & citrus Surgery: fundoplication Teach
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HIRSHSPRUNGS
Aganglionic megacolon
No ganglion cells at affected area usually at rectum/proximal portion of lower intestine Absence of peristalsis leads to intestinal distension, ischemia & maybe enterocolitis
Treatment
Mild-mod: stool softeners & rectal irrigations Mod-severe: single or 2-step surgery Colostomy with later pull-through
Photo Source: Del Mar Image Library; Used with permission
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HIRSHSPRUNGS
SIGNS/SYMPTOMS Infants Unable to pass meconium stool within 24 hours of life Abdominal distention Bilious vomiting Refusal to feed Failure to thrive Children
Chronic constipation Pellet or ribbon-like stools (foul-
smelling) Vomiting/FTT
NURSING INTERVENTIONS Surgery prep: bowel cleansing, antibiotics, NPO, IVFs, therapeutic play for surgery preparation Infection & Skin Integrity: monitor ostomy/anus Nutrition & Hydration: NGT, NPO then advance to Diet as tolerated, assess bowel function and abdominal status
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INTUSSUSCEPTION
Prolapse or telescoping of one portion of the intestine into another Abrupt onset Usually occurs in 3-24 months of age Sudden abdominal pain Vomiting Red, current jelly stool Abd distention/tender Lethargy Can lead to septic shock
Photo Source: Del Mar Image Library; Used with permission
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INTUSSUSCEPTION
DIAGNOSTIC STUDY Barium or air enema Abdominal ultrasound
TREATMENT Hydrostatic reduction: force exerted using water-soluble contrast and air to push the affected intestine apart Surgical reduction if hydrostatic reduction is unsuccessful
NURSING INTERVENTIONS Monitor for infection, shock, pain Maintain hydration - assess status! Prepare child/parent for hydrostatic reduction teach, consent, NPO, NGT Monitor stools pre & post procedure If surgery: general pre & post-op care
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PYLORIC STENOSIS
narrowing/ obstruction (bands pylorus) Usually occurs between 2-8 weeks of age Infant presents with non-bilious projectile vomiting, and is always hungry Can lead to dehydration and hypochloremic metabolic alkalosis Weight loss
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PYLORIC STENOSIS
DIAGNOSTIC EVAL
History/PE: olive palpated in epigastrum Upper GI (string sign) Abdominal Ultrasound
INTERVENTIONS
Pre-op: NPO, NGT to LIS, hydration, I/O, monitor electrolytes Post-op: Start feedings in 4-6 hrs. Progressive feeding schedule begin w/5cc GW half strength formula Full strength formula
TREATMENT
Surgical Intervention: Pyloromyotomy
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IMPERFERATE ANUS
Anorectal malformations No obvious anal opening Fistula may be present from distal rectum to perineum or GU system Diagnostic Eval: patency of anus in newborn, passage of meconium; ultrasound is suspected Therapeutic Management: manual dilatation for anal stenosis, surgical treatment for malformations Nursing Implementations: pre and post-op care IV fluids, consent, assessing surgical site for infection and monitoring for complications, possible NGT, diet progression, possible colostomy and teaching; preferred post-op condition is sidelying.
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Celiac Disease
Malabsorption syndrome characterized by intolerance of gluten (rye, oats, wheat and barley)
Reduced absorptive surfaces in small intestine which causes marked malabsorption of fats (frothy, foul-smelling stools)
Child has diarrhea, abdominal distention, failure to thrive Treatment is lifelong low-gluten diet; corn and rice are substituted grain foods
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APPENDICITIS
Inflammation and infection of vermiform appendix, usually related to an obstruction Cause may be bacteria, virus, trauma Ischemia can result from the obstruction, leading to necrosis causing perforation S/S: periumbilical painRLQ pain (McBurneys point), fever, vomiting, diarrhea, lethargy, irritability, WBCs Surgery is necessary If ruptured, often child will receive IV antibiotics for 24 hrs prior to OR Pre-op Care: NPO, pain management, hydration, prep & teaching, consent Post-op Care: routine post-op care, IVF/antibiotics, NPODAT, ambulation, positioning, pain management, wound care, possible drains.
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PINWORM (enterobiasis)
Transmission: oral-fecal Persist in indoors for up to 3 weeks contaminating anything
they contact (toilets, bed linens) S/S: intense perianal itch, sleeplessness, abd pain, vomiting Scotch tape test collects eggs laid by female outside of anus. Must be obtained in am prior to bath or BM. Treatment: *mebendazole (Vermox) for over 2 years of age. Under 2 years of age treatment may be pyrvinium pamoate (Povan) which stains stool and emesis red *All family members must be treated.
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OVERVIEW Description of lesion Preoperative stabilization Preanesthetic evaluation Anesthetic management Postoperative considerations
GUT DEVELOPMENT
Primitive gut - Divided into 3 regions Foregut- Pharynx, esophagus and stomach Midgut- Small and large intestine Hindgut- Colon and rectum
OMPHALOCELE
Greek- omphalos-navel, cele- hernia Absence abdominal wall fascia Herniation abdominal contents Eccentric displacement umbilical cord
OMPHALOCELE
Incidence: 1 in 3 - 5,000 Divided into 2 groups Small hernia umbilical cord (<4 cm) Giant Omphalocele (>4 cm with herniated liver)
Gastrointestinal, Genitourinary, central nervous system, congenital heart defe Cardiac defects- seen in 25% of patients (TEF most common)
ASSOCIATED MALFORMATIONS
UPPER MIDLINE SYNDROME
Pentalogy of Cantrell, Sternal defect, Ectopia cordis, Pericardial
extrophy, Omphalocele
BECKWITH-WIEDEMANN SYNDROME
Macroglossia, Visceromegaly, Omphalocele
OMPHALOCELE
30- 50% develop hypoglycemia May last for first year of life
Associated mortality
Small defect (30%)
GASTROSCHISIS
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GASTROSCHISIS
Greek: Gaster-stomach, schisis- cleft Incidence 1 in 50,000
GASTROSCHISIS
ISOLATED OMPHALOCELE
umbilical ring
DEVELOPMENT SPECULATIVE
after completion of the anterior abdominal wall but, befo completion of the umbilical ring.
GLICK (1984)
GASTROSCHISIS
OBSERVATION
27 - Moderate soft tissue mass adjacent to fetal anterior wall, contained in sac 31 - Mass with loops of bowel identified, contained in sac 35 - Free floating bowel in amniotic fluid
CESAREAN SECTION
4 cm wall defect to the right of the umbilical cord, no sac remnant
visible
PREOPERATIVE STABILIZATION
AIRWAY SUPPORT Often intubated in delivery room GASTRIC DECOMPRESSION
Prevent aspiration
Air progressing past pylorus where irretrievable and cause increased difficulty in repair
TEMPERATURE REGULATION
BOWEL CARE
Bowel covered by moist saline dressing, protect from dehydration
INITIAL RESUSCITATION
Brain & Heart depend on glucose as major energy substrate Limited hepatic glycogen storage < 2.5 kg
PREOPERATIVE EVALUATION
Inspect the protruding viscera, R/O torsion or angulation of Correct dehydration / hypovolemia / hypoglycemia
Temperature stabilization
Evaluation intravascular status
MANAGEMENT
ANESTHETIC MANAGEMENT
Airway Maintenance Monitors
SURGICAL PROCEDURE
SURGICAL PROCEDURE
PRIMARY CLOSURE
Reduced complications
Increased complication
STAGED CLOSURE
POSTOPERATIVE MANAGEMENT
Lets Review
Which intervention would have the highest priority for the nurse assisting in the feeding of a child post cleft palate repair?
A. Permiting the child to choose the liquids desired. B. Providing diversional activities during feeding. C. Applying wrist restraints. D. Cleansing the mouth with water after each feeding.
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Lets Review
Which food choice by a parent of a child with celiac disease indicates a need for further teaching? A. B. C. D. Oatmeal Rice Cornbread Beef
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Lets Review
Which assessment finding would the nurse find in a child with Hirschsprungs Disease?
A. Current jelly stool B. Diarrhea C. Constipation D. Foul-smelling, fatty stool
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Lets Review
Children with gastroenteritis often receive intravenous fluids to correct dehydration. How would you explain the need for IV fluids to a 3 year-old child?
A. The doctor wants you to get more water, and this is the best way to get it. B. Your stomach is sick and wont let you drink anything. The water going through the tube will help you feel better. C. See how much better your roommate is feeling with his IV! You will get better, too. D. The water in the IV goes into your veins and replaces the water you have lost from vomiting and diarrhea.
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Lets Review
The nurse caring for a child with suspected appendicitis would question which physician order?
A. NPO status B. Start IV fluids of D5 NS at 50 mls/hour C. Complete Blood Count (CBC) D. Apply heating pad to abdomen for comfort
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Genitourinary System
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Genitourinary System
Infants & young children excrete urine at a higher rate related to the increased BMR producing more waste Infant kidneys have function if under stress Infant cant concentrate urine well until 3-6 mo In infants, kidney & bladder are abdominal organs Infant kidneys are less protected because of unossified ribs, less fat padding & large size Young children have shorter urethras Nephrons continue to develop after birth
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Pediatric Variances
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Glomerulonephritis
Group of kidney disorders that show main focus of injury is the glomerulus It is characterized by inflammation of the glomerular capillaries Acute disorders occur suddenly and resolve completely Acute poststreptococcal glomerulonephritis (APSGN) is the most common type History, presenting symptoms, and lab results establishes the diagnosis of APSGN
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Glomerulonephritis
PAT H OPHYS I OLOGY
Streptococcal Infecti on
Prod uc ing An tib od ie s Ba ct erial Ant ige ns plus A nt ibod ies f orm I mmun e Com plex es & t ra p in Glome ru lus
Ineffecti ve Fi l trati on
Prot e in s Pa ss Throu gh De crea sed GFR
Ki dn eys E nl arge
wit h so dium, wa te r, was te
EDE MA
Photo Source: Teresa Simbro, RN, Santa Ana College, Used with permission.
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Glomerulonephritis
ASSESSMENT Hematuria Proteinuria Edema: periorbital, ankles Urine Output Hypertension Fatigue Possible fever Abdominal discomfort Labs: +ASO, Bicarb,K BUN, Creat, H & H INTERVENTIONS Monitor Urine (Dipstick) Monitor fluid overload Assess lung sounds/Resp effort Possible fluid & salt restriction Monitor I/O, Daily Weights Monitor VS Antibiotic, diuretic & antihypertensive medications Promote & provide rest Provide comfort measures Monitor labs
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Nephrotic Syndrome
Kidney disorder characterized by proteinuria, hypoalbuminemia, and edema. There is primary (involving kidney only) and secondary (caused by systemic disease or heavy metal poisoning) NS. Primary is the most common (MCNS). Cause not fully understood-may have an immunologic component. Primary age affected is 2-6 years (boys 2:1) There is no occlusion of glomerular vessels. Loss of immunoglobulins also occur (IgG) Hypovolemia and the severe proteinuria put the child in a hypercoagulable state Treatment is prednisone (2mg/kg/day) for about 4-6 weeks. Remission is obtained when the urine protein is 0-tr for 5-7 days Albumin followed by furosemide may be given for the edema
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Nephrotic Syndrome
PATHOPHYSIOLOGY
Alt erat ion in Glomerulus Damage to Basement Membrane of glomerulus (increased permeabilit y )
Fluid Shif t I nt rav ascular t o I nt erst itial HYPOVOLEMI A Dec reas ed Renal Blood Flow Triggers Renin Produc tion Causing Increased Aldost erone Reabs orpt ion of Sodium and Wat er ret ent ion Hy perlipidemia
Photo Source: Teresa Simbro, RN, Santa Ana College, Used with permission.
ED EMA
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Nephrotic Syndrome
ASSESSMENT
Proteinuria (3-4+), frothy urine Edema (pitting):periorbital, genitals, lower extremities, abdominal Urine Output (Hypovolemia) Normotensive or hypotensive Fatigue Recent URI, Pneumonia Abdominal Pain/Anorexia Labs:
Albumin Platelets H & H Cholesterol Triglycerides
INTERVENTIONS
Monitor Urine (Dipstick) Monitor edema/dehydration Assess skin integrity/turn often Possible fluid & salt restriction Monitor I/O, Daily Weights Monitor VS & S/S of infection Administer medications Promote & provide rest Monitor labs HANDWASHING/monitor visitors
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Inflammator y Response
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Enuresis
Involuntary passage of urine in children whose chronological or developmental age is at least 5 years of age Voiding occurs at least twice a week for minimum 3 months More common in boys Alteration in neuromuscular bladder function Often benign and self-limiting Organic factor could be the cause Familial tendency Emotional factor could be considered Therapeutic techniques include: bladder training, night fluid restriction, drugs (imipramine, oxybutynin, DDAVP)
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Lets Review
A clinical finding that warrants further intervention for a child with acute poststreptococcal glomerulonephritis is:
A. B. C. D. Weight loss to 1 pound of pre-illness weight. Urine output of 1 ml/kg per hour. A normal blood pressure. Inspiratory crackles.
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Lets Review
A 3 year-old is scheduled for surgery to remove a Wilms tumor from one kidney. The parents ask the nurse what treatments, if any, will be necessary after recovery from surgery. The nurses explanation is based on knowledge that:
A. B. C. D. No additional treatments are necessary. Chemotherapy may be necessary. Chemotherapy is indicated. Kidney transplant is indicated.
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Lets Review
Fluid balance in the child who has acute glomerulonephritis is best estimated by assessing:
A. B. C. D. Intake and output Abdominal circumference Daily weights Degree of edema
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Lets Review
In evaluating the effectiveness of nursing actions when caring for a child with nephrotic syndrome, the nurse expects to find:
A. B. C. D. A recurrence of pneumonia. Weight gain. Increased edema. Decreased edema.
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Talipes (Clubfoot)
Most common type is when foot is pointed downward and inward Often associated with other disorders May be due to decreased movement in utero Treatment requires surgical intervention Serial casting is begun shortly after birth and usually lasts for 8-12 weeks Priority nursing interventions are skin care and facilitating normal growth and development
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Scoliosis
o Abnormal curvature of the spine (lateral) o Congenital or develops later, most common during the growth spurt of early adolescence (idiopathic) o Diagnosis is made by physical exam and x-rays o Treatment for curvatures < 40 degrees is bracing o Surgical intervention is for severe curvatures internal fixation and instrumentation (Harrington) o Postoperative care includes logrolling, neurologic assessments, pain management, skin care, assessing for paralytic ileus and possible mesenteric artery syndrome o Dont forget the developmental needs of the adolescent
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Muscular Dystrophy
Duchennes Muscular Dystrophy most common Gradual degeneration of muscle fibers S/S begin to show about 3 years of age difficulties in running and climbing stairs Changes to having difficulty moving from a sitting/supine position Profound muscular atrophy continues, wheelchair by 12 yrs Respiratory and cardiac muscles affected and death is usually respiratory or cardiac in nature Diagnosis made with physical exam, muscle biopsy, EMG, serum studies: AST (SGOT), aldolase, creatine phosphokinase high first 2 years of life Nursing care is to maintain optimal level of functioning and to help the child and family cope with the progression and limitations of the disease
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Lets Review
An infant is being treated non-surgically for clubfoot. Which describes a major goal of care for this patient? Prevention of:
A. B. C. D. Skin breakdown Calf atrophy Structural ankle deformities Thigh atrophy
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Lets Review
The nurse is helping parents create a plan of care for their child with osteogenesis imperfecta. A realistic outcome is for this child to:
A. Have a decreased number of fractures B. Demonstrate normal growth patterns C. Participate in contact sports D. Have no fractures after infancy
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Lets Review
During acute, painful episodes of juvenile arthritis, a priority intervention is initiating:
A. A weight-control diet to decrease stress on the joints. B. Proper positioning of the affected joints to prevent musculo-skeletal complications. C. Complete bedrest to decrease stress to the joints. D. High-resistance exercises to maintain muscular tone in the affected joints.
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Adrenocorticotrophic Hormone (ACTH): Activated in adolescent Stimulates adrenals to secrete sex hormones Influences production of gonadotropic hormone
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NUTRITION
Carb counting most childrens calories should not be restricted; meal plan might change as child grows. Some sweets may be incorporated into the diet and may help with compliance. 3meals with 3 snacks per day
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Preschooler
Magical thinking-let them know they did not cause it Use dolls for teaching Urine testing may be done Can choose finger to use for testing
School-age
Very busy with school and activities Likes tasks and explanations Can do self blood testing; injections at age 8-10 years
Adolescents
Peers and body image preoccupation High risk for non-compliance Collaborative health care with parent involvement very important
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Congenital Hypothyroidism
Thyroid is not producing enough thyroid hormone to meet needs of the body (resulting inoxygen consumption, BMR and protein synthesis) Clinical manifestations: cool, mottled skin, bradycardia, large tongue, large fontanel, hypothermic, hypotonia, lethargy, feeding problems - THINK SLOW! Labs: High TSH, low T4 Decreased brain development will result with cognitive impairments Part of newborn screening Therapeutic management is life-long thyroid hormone replacement (levothyroxine)
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Precocious Puberty
Manifestations of sexual development in boys younger than 9 years and girls younger that 8 yrs Causes also an early acceleration of growth with closure of growth plates Therapeutic management is directed toward the specific cause, if known The early secretion of sex hormones will be treated with monthly subcutaneous injections of leuteinizing hormone-releasing hormone (LHRH) Priority interventions are directed at psychological support of child and family encourage play with same age peers
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Lets Review
A child weighing 25 kilograms is being treated with synthetic growth hormone. The recommended dosage range is 0.3 0.7 mg/kg/week. The mother informs the nurse that her child receives 1.25 mg subcutaneously at bedtime 6 times per week. The proper response from the nurse would be:
A. That dose is too high, the doctor needs to be notified. B. You are doing a great job, that is the correct dose for your child. C. The injection should be given intramuscular, not subcutaneous. D. That dose is too low based on your childs new weight.
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Lets Review
The nurse should include which information in teaching the parents of a recently diagnosed toddler with Type 1 diabetes mellitus?
A. Allow the toddler to choose which finger to use for blood glucose monitoring B. Allow the toddler to assist with the daily insulin injections C. Test the toddlers blood glucose every time she goes out to play D. Let the toddler determine meal times
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Lets Review
Which is the most appropriate teaching intervention for a nurse to give parents of a 6year-old with precocious puberty?
A. Advise the parents to consider birth control for their child B. Inform the parents there is no treatment currently available C. Explain the importance for the child to foster relationships with peers D. Assure the parents there is no increased risk for sexual abuse.
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Lets Review
Number in order of priority the following interventions needed while caring for a patient in diabetic ketoacidosis.
_____ Hydration _____ Electrolyte replacement _____ Dietary intake _____ IV Insulin _____ Subcutaneous insulin
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Impetigo
Superficial bacterial skin infection, often secondary from insect bite Highly contagious Late summer outbreak Toddlers & preschoolers Rash is bullous or honeycolored crusted lesions Treatment: topical & systemic antibiotics, comfort measures, teaching, preventing comps
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Roseola
Transmission: contact with secretions (saliva) Virus 6 - 18 months Fever flu symptoms rose-pink macular rash Fades with pressure Treatment is supportive
Photo Source: Del Mar Image Library; Used with permission
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Diaper Rash
Cause could be fungal in nature; assess mucous membranes for thrush Cause could be due to infrequent diaper changes, an allergic reaction to the diaper product or diarrhea Skin care includes appropriate skin barrier cream/ointment, keeping area dry Teach parents appropriate skin care
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Medication Administration
Oral Medication Hold infant with head elevated to prevent aspiration Slowly instill liquid meds by dropper along side of the tongue Crush pills and mix with sweet-tasting liquid if permitted, but dont add too much liquid! Allow choices for the child such as which med to take first Flush following gastrostomy or NG tube
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IM and SQ Meds
Select needle length according to muscle size for IM Infant - should use 1 inch needle Preemies can use 5/8 inch needle Use Z-track for iron and tissue-toxic meds Apply EMLA or other topical anesthetic 45-60 minutes prior to injection May mix medication with lidocaine Some medications may be need to be separated into 2 injections depending on amount
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IV Meds
Site may be peripheral or central Administer IV fluids cautiously Always use infusion pumps with infants and small
children Inspect sites frequently (q 1-2 hours) for signs of infiltration Cool blanched skin, puffiness( infiltration) Warm and reddened skin (inflammation)
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Nose Drops
Instill in one nare at a time in infants because they are
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Ear Meds
Pull the ear down and back to instill eardrops in infants/toddler (3 years pull )
Pull the ear up and out to instill in older children ( 3 years pull ) Have medication at room temperature
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Rectal Medication
Insert the suppository past the anal sphincter Hold buttocks together for a few seconds after
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mouth both with a good seal. Have child inhale slowly after canister is pressed down . Have child take a few breaths with a spacer and without a spacer have them hold breath for few seconds after medication released. Inhalers without spacers arent placed in the mouth because spacers require a seal around mouthpiece; masks with spacers can be used for infants.
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Lets Review
The nurse would prepare which site for an intramuscular injection to a 11 month-old?
A. B. C. D. Dorsogluteal Deltoid Vastus lateralis Ventrogluteal
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Pediatric Oncology
Cancer is the leading cause of death from disease in children from 1 - 14 years. Incidence: 6,000 children develop cancer per year 2,500 children die from cancer annually Boys are affected more frequently
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3. Remission
4. Recurrence
5. Death
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Oncology Interventions
8 Surgery 8 Radiation Therapy 8 Chemotherapy 8 Bone Marrow Transplant
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4. Observation
Pediatric Oncology
Types of Childhood Cancers
D D D D D D Leukemia Brain Tumors Wilms Tumor Neuroblastoma Osteogenic Sarcoma Ewings Sarcoma
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Leukemias
Most common form of childhood cancer Peak incidence is 3 to 5 years of age
Proliferation of immature WBCs (blasts) May spread to other sites (CNS, testes) Types of Leukemia:
Acute lymphocytic leukemia (ALL) 80-85% of childhood leukemia 95% chance of remission
Acute nonlymphocytic Leukemia (ANLL) 60-80 % chance of remission
Leukemias
CLINICAL MANIFESTATIONS
Purpura, Bruising Pallor Fever Unknown Origin Fatigue, Malaise Weight loss Bone pain Hepatosplenomegaly Lymphadenopathy
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Brain Tumors
Second most prevalent type of cancer in children Males affected more often
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Wilms Tumor
Also known as Nephroblastoma
radiation
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Neuroblastoma
Highly malignant tumor extracranial
Often develop in adrenal gland, also found in head, neck, chest, pelvis
Incidence: One in 10,000
Bone Tumors
Osteogenic Sarcoma: Occurs most often in boys between 10-20 yrs
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Psychosocial care for patient and family utilize Child Life and Social Services
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Pediatric Oncology
Teach, teach, teach! Support the child and family Provide resources Be honest Include the child in the care planning
Photo Source: Del Mar Image Library; Used with permission
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Lets Review
In caring for the child with osteosarcoma, it is important for the nurse to inform the child and family of the treatment plan. Which would be appropriate?
A. B. C. D. The affected extremity will have to be amputated. The child will only need chemotherapy. Both surgery and chemotherapy are indicated. Only palliative measures are taken.
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Lets Review
The nurse assessing a child who is undergoing chemotherapy finds the child to be suffering from mucositis. Which intervention would be the highest priority?
A. Meticulous oral care. B. Obtain dietician consult. C. Place the child on a full liquid diet only. D. Medicate for pain around the clock.
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Lets Review
The priority nursing intervention in caring for a child with acute lymphocytic leukemia (ALL) during the childs nadir period is:
A. B. C. D. Handwashing. Monitoring lab results. Administering antiemetics. Monitoring visitors.
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Let parents participate in care as much as they are emotionally capable of doing
Continue to read favorite stories or play the childs favorite music Be aware of the needs of the siblings
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Lets Review
Which intervention would be most helpful in supporting a dying childs family as they cope with the various decision-making periods of a lengthy terminal illness?
A. Encouraging the parents to take their child home to die. B. Encouraging the parents to go through all of the KublerRoss stages of dying as quickly as possible. C. Referring the childs family to the hospital clergy service as soon as possible. D. Using active listening to identify specific fears and concerns of the childs family members.
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Withholding of affection, use of cruel and degrading language towards a child by an adult
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Child Abuse
M Reports of M Many of
violence against children has almost tripled since 1976. the abused children are infants.
Red Flags
Fractures in infants Spiral fractures Injuries do not match story told
Child Abuse
Neglect
Physical or emotional maltreatment Failure to thrive Contributing factors may be ignorance or lack of resources Minor or major physical injury (bruising, burns, fractures) May cause death Munchausen by Proxy (MSP) Shaken baby syndrome (SBS) Incest, molestation, child porn, child prostitution May be suspected, but difficult to substantiate Impairs childs self-esteem and competence
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Physical Abuse
Sexual
Emotional
Child Abuse
Warning Signs
Incompatibility between history of event and injuries Conflicting stories from various people involved History inconsistent with developmental level of child Repeated visits to emergency rooms Inappropriate response from child and/or caregiver Assess: Physical assessment and history of event, observe and listen to caregivers and childs verbal and non-verbal communication Documentation: Complete CAR form and contact Child Protective Services, hospital documentation Support family and child: Social services, resources, teaching
Nursing Interventions
Lets Review
In caring for a 4 year-old with a diagnosis of suspected child abuse, the most appropriate intervention for the nurse is:
A. Avoid touching the child. B. Provide the child with play situations that allow for disclosure of event. C. Discourage the child from speaking about the event. D. Give the child realistic choices to feel in control.
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Lets Review
Which pediatric patient would most necessitate further investigation by the community-based nurse?
A. An adolescent who prefers to spend time with friends rather than family. B. A toddler with dark bruises located on both legs. C. An infant with numerous insect bite marks and diaper rash. D. A preschooler with dirty knees and torn pants.
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