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Child Health Nursing (Pediatrics) Notes

by: Kate

Child Health Nursing (Pediatrics) Notes NSG 4403

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These are the notes for each chapter of Wong's Nursing Care of Infants & Children by Hockenberry & Wilson covered for Child Health Nursing (Pediatrics) at Troy University's BSN program.
Child Health Nursing (Pediatrics)
Judy Bazzell
Nursing, pediatric nursing, child health nursing
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Date Created: 05/10/16
Exam 4 Topical Outline Review Pediatrics The following is a list of topics related to exam 4. This list is not inclusive of all topics and is intended to assist with study efforts. Anemia:  Define: A decrease in the number of RBC’s and/or hemoglobin concentration below normal, which leads to decreased oxygen carrying capacity of the blood.  Process: If it develops slowly, the child can adapt. If tissue hypoxia  the kidney releases erythropoietin into the blood stream  the bone marrow is stimulated  produces new RBC’s. o There is a problem in this ^ process with anemia.  Causes: o 1. Inadequate production of RBC’s. o 2. Increased destruction of RBC’s. o 3. Loss of RBC’s through hemorrhage.  Interventions: Transfusion after hemorrhage if needed, nutritional interventions for deficiency anemia’s, IV fluids, Oxygen, bed rest. Conduct labs, main one being CBC.  Treatment: transfusions, and to treat the underlying cause.  **Need for transfusion: hemorrhage?  **Causes for anemia ages 12 and over: I would think inadequate supply of dietary iron or excessive loss of iron? Children should absorb an average of 0.8 mg of iron per day for the first 15 years.  Recommendations (milk; formula): Introduce iron fortified formula, wean off the bottle by 1 year of age, limit cow’s milk to 16-24 oz/day (poor source of iron). o ATI  Provide iron supplements for preterm and LBW infants by 2 months.  Provide iron supplements for exclusively breastfed infants by 4 months.  Recommend iron fortified formula for infants that are not being breastfed.  Limit milk to 32 oz/day. (Bazzell’s says different)  Delay giving milk until after a meal.  Iron supplementation (problems with iron absorption; effects; changes in stool; how to administer): o Give 1 hour before or 2 hours after milk or antacid to prevent decreased absorption. o GI upset (diarrhea, constipation, nausea) is common at the start of therapy, but will decrease over time.  Educate parents to expect tarry green color if the dose is adequate. o Administer iron on an empty stomach. o Give with vitamin C to aid in absorption. o Use straw with liquid supplements to prevent staining of teeth.  Teach to brush teeth after. o Use Z-track method with IM supplements, do not massage after injection. 1 Exam 4 Topical Outline Review Pediatrics Sickle Cell:  Define: SCD is a group of diseases in which abnormal sickle hemoglobin S (HgbS) replaces normal adult hemoglobin (HgbA). o Manifestations and complications of SCA are the result of RBC sickling, which leads to increased blood viscosity, obstruction of blood flow, and tissue hypoxia.  Causes: Inheritance of a gene for a structurally abnormal portion of the hgb chain. o If both parents have the gene = each offspring will have a 25% chance of having. o If only one parent has the trait, the child cannot have the disease, but will have a 50% chance of being a carrier.  Treatment: focus is primarily on prevention (preventing exposure to infection and maintaining normal hydration) and treatment (oxygen, hydration, pain management, and bed rest) of crisis. o Oxygen and blood transfusions #1  Watch for hemosiderosis (increased iron in the tissues), treat with iron chelation (Deferoxamine, deferasirox, deferiprone). o Administer analgesics around the clock for pain. o Apply heat to the area to soothe pain o IV NS for hydration o Elevate HOB no more than 30 degrees o Do not raise knee gatch of bed  Crisis: o Vaso-occlusive: most common, stasis of blood with clumping of the cells in the microcirculation, ischemia, and infarction.  S/S: fever, pain, and tissue engorgement.  Painful episode that lasts 4-6 days.  Large tissue infarctions can occur that lead to organ dysfunction.  Primary care focus is hydration and pain control o Splenic Sequestrian: life threatening caused by pooling of blood in the spleen.  S/S: Profound anemia, hypovolemia, and shock (irritability, tachycardia, pallor, decreased urinary output, hypotension). Splenomegaly and sometimes hepatomegaly.  Treat with splenectomy at early age; results in decreased immunity. o Aplastic: caused by diminished production and increased destruction of RBC’s. Triggered by viral infection or the depletion of folic acid.  S/S: Profound anemia, pallor.  Complications: o CVA report symptoms:  Seizures  Abnormal behavior  Weakness of extremity  Slurred speech  Visual changes  Vomiting  Severe head ache 2 Exam 4 Topical Outline Review Pediatrics  *Blood transfusions are usually preformed every 3 to 4 weeks to prevent a repeat CVA. o Chest Syndrome: see below Chest syndrome  VOC or infection results in sickling in the lungs. (Similar to pneumonia)  S/S: chest pain, fever (101.3 or higher), cough, dyspnea, retractions, tachypnea, wheezing, and hypoxia.  Notify HPC if suspected, it is medical emergency,  Repeated episodes may lead to pulmonary HTN. Transfusion:  Purpose: Increase blood volume and increase oxygen carrying capacity of the blood.  Reactions: o Hemolytic: rare, but severe  S/S: HA, chills, shaking, fever, pain at needle site, N/V, tightness in chest, red or black urine, flank pain, progressive signs of shock. o Febrile: fever, chills o Allergic: urticarial, pruritus, laryngeal edema, flushing. o Circulatory overload: pericardial pain, dyspnea, rales, cyanosis, dry cough, distended neck veins, HTN. o Air emboli: occur when blood is transfused under pressure.  S/S: sudden difficulty breathing, sharp pain in chest, apprehension. o Hypothermia: chills, low temp, irregular heart rate, possible cardiac arrest. o Hyperkalemia from massive transfusions or with renal problems.  S/S: nausea, diarrhea, muscular weakness, flaccid paralysis, Bradycardia, apprehension, cardiac arrest.  Interventions: o Verify recipient and donor blood group o Monitor VS before, for 15 min after, and hourly while infusing o Transfuse first 50ml slowly, for 15-20 minutes. o Use blood within 30 minutes of arrival o Infuse over a maximum of 4 hours o Stop transfusion immediately if reaction occurs. B thalassemia –  Causes: Autosomal recessive disorder resulting in an overproduction of unstable RBC’s.  Clinical manifestations: pallor, fever, poor feeding, enlarged spleen or liver, chronic hypoxia, anorexia, headache, small stature, delayed sexual maturation, bronzed freckled complexion. o Child will often present with severe anemia and FTT.  Goals: o To promote compliance with transfusion and chelation therapy o Assist the child in coping with the anxiety-provoking treatments and the effects of the illness o Foster the child/s and family’s adjustment to a chronic illness o Observe for complications of multiple blood transfusions 3 Exam 4 Topical Outline Review Pediatrics  Problems: o Chronic hypoxia—headache, irritability, precordial and bone pain, decreased exercise tolerance, listlessness, and anorexia o Iron overload (hemosiderosis) is a potential complication of frequent blood transfusions—the body has no effective means of eliminating the excess iron, so the mineral is deposited in body tissues o Hemochromatosis refers to excess iron storage that results in cellular damage o Anemia results form the body’s inability to maintain a level of erythropoiesis commensurate with hemolysis o Aplastic crises after infection o Folic acid deficiencies from the demands of bone marrow hyperplasia o Spleen becomes extremely enlarged (splenomegaly) as a result of extramedullary hematopoiesis o Retarded growth o Delayed sexual maturation—development of secondary sexual characteristics is delayed or absent in many adolescents  Meds: o Treat iron overload with IRON CHELATIN  o Deferoxamine—given with oral supplements of vitamin C  * Given IV or subQ via an infusion pump over a period of 8-10 hours (usually during sleep) for 5-7 days a week  o Deferasirox—treatment of patients 2 years or older  * Daily dose of 20-40 mg/kg is generally well tolerated with mild GI events and rash as common toxicities Aplastic anemia – a deficiency of circulating erythrocytes resulting from the arrested development of all formed elements of the blood with in the bone marrow.  Causes: chronic exposure to myelotoxic agents, viruses, infection, autoimmune disorders, and allergic states.  Treatment: o Blood transfusions: discontinue as soon as bone marrow begins to produce RBC’s. o Corticosteroids and immunosuppressive therapy. o Splenectomy for patients with enlarges spleen that is destroying normal RBC’s and suppressing their development. o Bone marrow transplant = treatment of choice o Administration of antilymphocyte globulin (ALG) or antithymocyte globulin (ATG) to suppress autoimmune response.  Interventions: Advise to wear a medical alert bracelet, monitor for allergic reactions with ALG and ALT, monitor for transfusion reactions. Polycythemia: an abnormally increased concentration of hemoglobin in the blood.  Hematocrit of >55%. Hemophilia-  Define: a group of hereditary bleeding disorders that result from deficiencies of specific clotting factors.  Treatment: replacement of the missing clotting factor by factor VIII concentrate or DDVAP (IV) this is used to cause an increase of factor VIII by 30%. Transfusions after hemorrhage.  Activities: 4 Exam 4 Topical Outline Review Pediatrics o Control bleeding by immobilization, elevation, and the application of ice; apply pressure for 15 minutes for superficial bleeds. o ROM after bleeding stops to prevent contractures, active NOT passive. o NO contact sports, only swimming, golf, walking, jogging, fishing, and bowling.  Labs: o Dx from amniocentesis o Prolonged PTT o Low levels of factor VIII or IX o Normal PT o Normal Platelet count o Normal fibrinogen  Medicines: o DDVAP IV to replace factor VIII (Hemophilia A) o Corticosteroids to treat hematuria, acute episodes of hemarthrosis, and chronic synovitis. o Factor VIII concentrates o Non-steroidal anti-inflammatory agents for chronic synovitis. Platelet destruction – Idiopathic Thrombocytopenic Purpura (ITP)  **Causes:  Clinical manifestations: thrombocytopenia, purpura, normal bone marrow with unusual increase in large immature platelets, platelet count < 20,000.  Treatment: o Prednisone, IVIG, and anti-D antibody o Splenectomy in severe ITP o Avoid NSAIDS or aspirin o No contact sports  Normal platelet count range: 150,000-400,000 Review normal lab values:  RBC: 4.5-5.5  Hgb: 11.5-15.5  Hct: 35-45%  Reticulocyte: .05-1.5%  ANC > 1000/mm3  Platelets: 150,000-40,000 Biopsy: needed to establish the diagnosis of a malignancy Staging:  Stage I: lesions are limited to one lymph node  Stage II: two or more lymph nodes on the same side  Stage III: lymph node regions on both sides of the diaphragm  Stage IV: cancer has metastasized diffusely throughout the body Chemotherapeutic agents: work by interfering with the function or production of the nucleic acids, DNA or RNA.  Vesicants (sclerosing agents): can cause severe cellular damage even if minute amounts infiltrate surrounding tissue  Combining drugs allows for optimum cell cycle destruction  Monitor the patient for 1 hour after infusion for anaphylaxis  Wilm’s Tumor: Dactinomycin (Cosmegen) and Vincristine (Vincasar PFS) 5 Exam 4 Topical Outline Review Pediatrics  Neuroblastoma: o Various agents are used: cyclophosphamide, doxorubicin, cisplatin, etoposide, vincristine, ifosfamide, and carboplatin  Leukemia is treated in three phases: o 1. Induction therapy: 4-6 weeks o 2. Intensification (consolidation) therapy: to eradicate residual leukemic cells and prevent resistant leukemic clones o 3. Maintenance therapy: to preserve remission  Osteosarcoma: high dose methotrexate with citrovorum factor rescue, doxorubicin, cisplatin, ifosfamide, and etoposide  Ewing’s Sacrcoma: vincristine, doxorubicin, and cyclophosphamide alternating with ifosfamide and etoposide  Rhabdomyosarcoma: vincristine, anctinomycin D, cyclophosphamide, ifosfamide, topotecan, and doxorubicin for at least 1 year Intrathecal medication: medication given via injection into the spinal canal, more specifically into the subarachnoid space so that it reaches the CFS. The drug is given this way to avoid the blood-brain barrier.  Chemotherapy agents used are: methotrexate, cytarabine, hydrocortisone and thiotepa. Mucositis: painful inflammation and ulceration of the mucous membranes lining the digestive tract, an adverse effect of chemotherapy.  Frequent oral care  Soft bristled tooth brush  Lubricate lips with lip balm  Soft and bland foods  Assist child to use mouthwashes  Apply local anesthetics (hydrocortisone dental paste (orobase), antiseptic mouth wash (UlcerErase), and aluminum magnesium hydroxide (Maalox)).  Avoid viscous lidocaine, hydrogen peroxide, milk of magnesia, and lemon glycerin swabs. **Corticosteroid use: Bone marrow transplant-  Matching—the importance of HLA (human leukocyte antigen) matching is to prevent serious complications of graft-versus-host disease o Allogenic Bone Marrow Transplant (BMT) involves the matching of hitocompatable donor with the recipient—limited by the presence of suitable marrow donor o Umbilical Cord Blood Stem Cell Transplantation is beneficial because the blood’s relative immunodeficiency at birth, allowing the partially matched unrelated cord blood transplants to be successful—less problematic for transplant match with blood relative o Autologous BMT is where the patient’s OWN marrow that was collected from disease-free tissue, frozen, and sometimes treated to remove malignant cells o Peripheral Stem Cell Transplants (PSCT) is a type of autologous transplant in which stem cells are collected by an “apheresis” machine and stem cells are separated from whole blood—remaining blood and 6 Exam 4 Topical Outline Review Pediatrics plasma are then returned to the patient and stem cells are frozen for later transfusion to the patient  Purpose—to replace bone marrow that is either not working properly or has been destroyed by chemo or radiation  How given—through IV infusion?  When required—if you have certain cancers, such as leukemia, lymphoma, myelodysplasia, and multiple myeloma; a disease that affects the production of bone marrow cells (anemias); or have had chemo that destroyed your bone marrow  Interventions o Coordinate administration of high-dose chemotherapy and possible full-body radiation o Administer donor stem cells via IV infusion o Implement protective isolation  A private, positive pressure room  At least 12 air exchange/hr  HEPA filtration for incoming air  Respirator mask, gloves, and gowns  No dried or fresh flowers, and no potted plants o Educate that the child is at increased risk for infection and bleeding until the transfused stem cells grow Myelosuppressed  Symptoms—infection (reduced leukocytes), hemorrhage (reduced thrombocytes), and anemia (reduced RBCs)  Causes—Elimination of normal blood cells along with cancer cells is a risk with treatment by most chemo agents  Primary interventions o Evaluate lab data and assess for symptoms of complications  Infection—elevated WBC and fever  Hemorrhage—blood in urine or stool, bruising, and petechiae  Anemia—fatigue and decreased hgb/hct o Prevent infection  Private room when hospitalized  Restrict staff/visitors who have infections  Frequent hand hygiene  Avoid live-virus vaccines  Ensure siblings are up-to-date on vaccines  Provide a diet adequate in proteins and calories o Prevent hemorrhage or injury from bleeding  Strict aseptic technique  Gentle technique during mouth care  Clean perineal area carefully to prevent trauma, and avoid obtaining temperatures rectally  Infuse platelets as prescribed o Prevent anemia or injury from anemia  Provide rest periods  Infuse packed RBCs as prescribed 7 Exam 4 Topical Outline Review Pediatrics o Teach family members strategies to recognize complications at home and to prevent damage from infection, hemorrhage, or bleeding Chemotherapy  Types: o Alkylating agents—replace a hydrogen atom of a molecule by an alkyl group (steep dose response curve and can be used in high-dose therapy regimen) o Antimetabolits—resemble essential metabolic elements needed for cell growth but are sufficiently altered in molecular structure to inhibit further synthesis of DNA or RNA (maximum effect occurs in cells that are actively producing DNA) o Plant alkaloids—arrest cells in metaphase by binding to the microtubular cristine and vinblastine o Antitumor abx—natural products that interfere with cell division by reacting with DNA in such a way as to prevent further replication of DNA and transcription of RNA  Side effects—anaphylactic side effects, affects on bone marrow elements, hair, skin, and epithelial cells of the GI tract  Treatment for side effects or prevention o Many chemo drugs are vesicants (sclerosing agents) that can cause severe cellular damage if even minute amounts of the drug infiltrates the surrounding tissue—only nurses experienced with chemo agents should administer vesicants o Anaphylaxis can occur from chemo drugs—if known anaphylactic potential are given, it is standard practice to observe the child for 1 hour after the infusion for rash, urticarial, hypotension, wheezing, nausea, and vomiting—emergency equipment and emergency drugs should be on deck fo sho (BP monitor, bag and valve mask, suction, oxygen, epi, antihistamine, aminophylline, corticosteroids, and vasopressors)  How to administer—Chemotherapeutic drugs must be given through a free- flowing IV line. The infusion is stopped immediately if any sign of infiltration (pain, swelling, stinging, redness) occurs Leukemia  Define—a broad group of malignant diseases of bone marrow and lymphatic system o Leukemia is the unrestricted proliferation of immature WBCs in the blood-forming tissues of the body o Liver and spleen more severely affected organs o Although leukemia is an overproduction of WBCs, often acute form causes low leukocyte count o Peripheral blood smear and bone marrow reveal elevated counts of immature cells or blasts o Cellular destruction takes place by infiltration and subsequent competition for metabolic elements  Treatment (why) o Therapeutic management  IV and intrathecal chemotherapeutic agents  Radiation (in some cases) 8 Exam 4 Topical Outline Review Pediatrics o 3 Phases of Therapy  1) Induction therapy—4-6 weeks  Corticosteroids (prednisone or dexamethasone), vincristine, and L-asparaginase, with or without an anthracycline  2) Intensification (consolication) therapy—to eradicate residual leukemic cells and prevent resistant leukemic clones  L-asparaginase, high-dose methotrexate or intermediate- dose methotrexate with leukovorin rescue, vincristine, doxorubicin, steroids, cytarabine, IM or oral methotrexate, and 6-mercaptopurine  3) Maintenance therapy—to preserve remission and further reduce the number of leukemic cells  Daily dose of oral 6-mercaptopurine, weekly doses of methotrexate, and intermittent pulses of steroids and vincristine  Weekly or monthly CBCs are taken to evaluate the marrow’s response to the drugs  Types o Acute lymphoid leukemia (ALL)  Most common form of childhood cancer  3 or 4 cases per 100,000 Caucasian children younger than 15 years old  More frequent in males older than 1 year  Peak onset between ages 2 and 5 years old  Subvivability  Synonyms—lymphatic, lymphocytic, lymphoblastic, and lymphoblastoid leukemia o Acute myelogenous leukemia (AML)  Synonyms—granulocytic, myelocytic, monocytic, myelogenous, monoblastic, and nonmyeloblastic leukemia  Interventions  Activities Hodgkin (wasn’t sure if she wanted us to know non-Hodgkins too so I added it anyways)  Hodgkin’s disease o More prevalent in 15-19 years old o Neoplastic disease originating in the lymphoid system o Often metastasizes to spleen, liver, bone marrow, lungs, and other tissues o 4 Types: (accurate staging is basis for tx and prognosis)  Lymphocytic predominance  Nodular sclerosis  Mixed cellularity  Lymphocytic depletion o Clinical staging  Stage I=lesions are limited to one lymph node  Stage II=two or more lymph nodes on the same side 9 Exam 4 Topical Outline Review Pediatrics  Stage III=lymph node regions on both sides of the diaphragm  Stage IV=cancer has metastasized diffusely throughout the body  Further divided into…  Stage A—asymptomatic  Stage B—temperature of 38 C, night sweats, weight loss of 10% or more over previous 6 months (poorer prognosis)  Stage E—represents extra lymphatic disease beyond the continuous nodal disease  Stage S—when the disease involves the spleen o Diagnostics  Clinical manifestations: fever, night sweats, weight loss, enlarged lymph nodes  Labs: CBC, uric acid, CRP, alkaline phosphate, UA  CT, X-ray, PET scan  Lymph node biopsy for diagnosis and staging o Therapeutic management  Radiation  Chemotherapy (alone or with radiation)  Prognosis  Nursing considerations—invasive procedure, chemo reaction (N/V, neuropathy, ulcerations), irradiation malaise  Non-Hodgkin’s lymphoma o More prevalent in children younger than 14 years o Approximately 800 new dx of NHL each year in the United States o Clinical appearance  Disease usually diffuse rather than nodular  Cell type undifferentiated poorly differentiated  Dissemination occurs early, often, and rapidly  Mediastinal involvement and invasion of meninges o Diagnostic evaluation  Thorough pathologic staging is unnecessary because most children with NHL have widespread disease at diagnosis  Surgical biopsy for histopathologic confirmation of disease with immunophenotyping and cytogenic evaluation  Bone marrow aspiration  Radiologic studies, especially CT scans of the lungs and gastrointestinal organs  Lumbar puncture o Therapeutic management—aggressive radiation and chemo o Nursing considerations—manage side effects Brain tumor  Symptoms Clinical Manifestations and Assessment of Brain Tumors Headache  Recurrent and progressive  In frontal or occipital areas  Usually dull and throbbing 10 Exam 4 Topical Outline Review Pediatrics  Worsen on arising, less during day  Intensified by lowering head and straining, such as during bowel movement, coughing, sneezing Vomiting  With or without nausea or feeding  Progressively more projectile  More severe in morning upon arising  Relieved by moving about and changing position Neuromuscular  Incoordination or clumsiness Changes  Loss of balance  Poor fine motor control  Weakness  Hyporeflexia or hyperreflexia  Positive Babinski sign  Spasticity  Paralysis Behavioral Changes  Irritability  Decreased appetite  Failure to thrive  Fatigue  Lethargy  Coma  Bizarre behavior Cranial Nerve  Cranial nerve involvement varied according to tumor Neuropathy location  Most common signs: head tilt, visual defects (mystagmus, diplopia, strabismus, episodic “graying out” of vision, visual field defect Vital Sign Disturbances  Decreased pulse and respirations  Increased BP  Decreased pulse pressure  Hypothermia or hyperthermia Other Signs  Seizures  Cranial enlargement  Tense, bulging fontanel at rest  Nuchal riridity  Papilledema (edema of optic nerve) Cerebral: Increased intracranial pressure: Causes: symptoms (various ages)  Increased ICP in children: o Headache o Vomiting (with or without nausea) o Seizures o Diplopia, blurred vision 11 Exam 4 Topical Outline Review Pediatrics  Increased ICP in infants: o Irritability o Poor feedings o High-pitched cry, difficult to soothe o Tense bulging fontanels (feels like a balloon, not normal and soft) o Separated cranial sutures o Distended scalp veins  Behavioral signs of increasing ICP: o Irritability, restlessness o Drowsiness, indifference, decrease in physical activity and motor skills o Compliant of fatigue, somnolence o Inability to follow commands, memory loss o Weight loss  Late signs of increasing ICP: o Decreased LOC o Decreased motor response to command o Decreased sensory response to painful stimuli o Alterations in pupil size and reactivity o Papilledema o Decerebrate or decorticate posturing o Cheyne-stokes respirations Intervention  Patient positioning o Nursing alert: elevate the HOB 15 to 30 degrees, and position the child so that the head is maintained in midline to facilitate venous drainage and avoid jugular compression. Turning side to side is contraindicated due to jugular compression.  Avoid activities that may increase ICP  Eliminate or minimize environmental stimuli (noise)  Cluster nursing activities  Suctioning can cause an increase in ICP o Hyperoxygenate if this has to be done o Vibration (chest physiotherapy) is an excellent substitute  Avoid lumbar puncture Treatment Terms – definitions (coma, etc)—don’t know what all definitions she wants though?  Full consciousness awake and alert, oriented to time, place, and person; behavior appropriate for age.  Confusionimpaired decision making  Disorientation confusion regarding time and place, decreased LOC  Lethargysluggish speech, limited spontaneous movement, drowsiness  Obtundationarouses with stimulation  Stuporresponds only to vigorous and repeated stimulation  Comano motor or verbal response to noxious (painful) stimuli  Persistent vegetative statepermanently lost function of cerebral cortex o Very hard on families, they remain hopeful even though the patient isn’t progressing 12 Exam 4 Topical Outline Review Pediatrics  *Side note: Brain Death = Total cessation of brain stem and cortical brain function that results from any condition that causes irreversible widespread brain injury. To pronounce brain death: o 1. Complete cessation of clinical evidence of brain function o 2. Irreversibly of the condition Injuries- causes, treatment, definitions (concussion, subdural hematoma, epidural hematoma, contusion)  Concussion o Transient and reversible o Results from trauma to the head o Instantaneous loss of awareness and responsiveness lasting for minutes to hours o Generally followed by amnesia and confusion** (hallmarks of concussion) o Usually resolve on their own within 7 to 10 days  Subdural hematoma: usually hemorrhage from two places, 1. Tearing of the veins that bridge the subdural space and 2. Hemorrhage from the cortex of the brain caused by direct brain trauma. o Children with a subdural hematoma and retinal hemorrhages should be evaluated for the possibility of child abuse, especially shaken baby syndrome. o Tends to develop slowly and spreads thinly and widely o Presenting signs of and acute hematoma are: irritability, vomiting, increased head circumference, bulging anterior fontanel, lethargy, coma, or seizures.  Epidural hematoma: hemorrhage into the space between the dura and the skull. Uncommon in children but may occur in low velocity injuries or child abuse. o Can be detected by an initial CT scan  Contusion and Laceration o Terms used to describe actual bruising and tearing of cerebral tissue o Coup—bruising at the point of impact o Contrecoup—bruising at a site far removed from the point of impact Drowning  Drowning is the second leading cause of accidental death in children, usually between 0-4 years of age, TEACH prevention measures  Death occurs from asphyxia while submerged  Can occur with even small quantity of water (even as little as pail water)  Near drowning—survived at least 24 hours after submersion  Always admitted to monitor for complications Pathophysiology of Drowning  Hypoxia  Aspiration  Hypothermia Therapeutic Management  Emergency resuscitative efforts at the scene o Priority is to restore oxygen delivery to the cells and prevent further damage. 13 Exam 4 Topical Outline Review Pediatrics  Management is based on degree of cerebral insult o Warm the hypothermic patient o Monitor for seizures, these lead to increased cerebral oxygen consumption  Aspiration is frequent complication o Aspiration pneumonia can occur 48 to 72 hours after injury  Prognosis o The best predictors of a good outcome are length of submersion less than 5 minutes and the presence of sinus rhythm, reactive pupils, and neurologic responsiveness at the scene. Nursing Considerations  Care depends on condition of the child  Helping parents cope with feelings of guilt  Parental anxiety related to prognosis  PREVENTION OF DROWNING Meningitis- types, symptoms, diagnosis, lab findings, treatment, clinical manifestations Bacterial Meningitis  Acute inflammation of the CNS  Decreased incidence following use of Hib vaccine  Can be caused by various bacterial agents o Strepptococcus pneumoniae o Group B streptococci o Escherichia coli  Treat with 10 day antibiotic therapy, first start with broad spectrum antibiotics, then narrow down to one when the cultures come back  Diagnostics—lumbar puncture is the definitive diagnostic test  Manifestations: o Children: fever, chills, headache, vomiting, nuchal rigidity, Kernig and Brudzinskis sign. Peticheal and purpura rashes occur in 50% of cases and indicate a meningococcal infection. o Infants and young children: fever, or hypothermia, poor feeding, vomiting, marked irritability, restlessness, seizures, bulging or tense fontanel and a high-pitched cry. o Neonates: refuse feedings, have poor sucking, may vomit, or have diarrhea. o Therapeutic Management:  Isolation precautions  Initiation of antimicrobial therapy  Maintenance hydration  Maintenance of ventilation  Reduction of increased ICP  Management of systemic shock  Control of seizures  Control of temperature  Treatment of complications  Dexamethasone may play a role in the initial management of increased ICP and cerebral herniation, but its long-term use is 14 Exam 4 Topical Outline Review Pediatrics controversial. It should not be used with aseptic or nonbacterial meningitis. Bacterial Meningitis (By Age Groups)  Occurs in epidemic form, predominantly in school age children  Less than or equal to one month and <3 months group B streptococci (395) and gram-negative bacilli (32%)  S. pneumoniae >3 months and <10 years  Neisseria meningitis is greater than or equal to 10 years and < 19 years Nonbacterial Meningitis (Aseptic Meningitis)  Causative agents are principally viruses  Frequently associated with other diseases o Measles, mumps, herpes, leukemia  Onset abrupt or gradual  Manifestations—Headache, fever, malaise  Diagnosis and treatment: based on clinical features and CSF findings  Enterovirus = most common cause of aseptic meningitis Tuberculosis (TB) Meningitis  More likely to occur in individuals living in or traveling to developing countries (TB prevalence) in very young, or in immunosuppressed children  Ischemic infarction may occurcan cause paralysis  Fever, altered LOC, seizures  Common complication of this type of meningitishydrocephalus Rabies: Acute infection of CNS. Transmitted by saliva of infected animal, has a long incubation period.  Human rabies is rarely seen. Virus will multiplies in muscles and fat if untreated.  Warn kids of wild animals (raccoons, skunks, foxes, & bats). Unprovoked attack is more likely to indicate a rabid animal.  TX: Inactivated rabies vaccine (HDCV, HRIG-right after exposure). Analgesia with EMLA cream to injection sites. Reye Syndrome (Metabolic Encephalopathy)- causes; meds; symptoms, prognosis, how diagnosed  Causes: Not understood, believed to be mitochondrial insult induced by different viruses, drugs, exogenous toxins, and genetic factors. Most cases follow common viral illnesses that use aspirin.  Salicylates are thought to have effect. (Pepto bismol, aspirin) Warn parents to read label.  Biggest threat: Cerebral edema  Meds:  Symptoms: fatty liver changes, neurologic changes. Intractable vomiting, lethargy, rapidly changing mental status, rising BP, RR, Pulse. Hyperactive reflexes. o Commonly progresses to coma, as coma deepens seizures develop, followed by decreased tendon reflexes, and usually respiratory failure.  Prognosis: Patients will usually improve quickly if caught and treated early.  Dx: Definitive diagnosis by liver biopsy. (Small fat deposits) Seizures- (types); symptoms; treatment 15 Exam 4 Topical Outline Review Pediatrics  Types: o Partial: Simple partial (No change in LOC), complex partial (alteration in consciousness) o Generalized: Absence (loss of responsiveness, maintain posture), Atonic (Drop and fall), Myoclonic (contraction of muscle groups), Tonic- clonic (violent, total body) o Febrile, Status epilepticus  Symptoms: o Review each individually.  Treatment: Anticonvulsants, preferably a single medication. Medications dosages are adjusted as the child grows. Serum drug levels are monitored. Surgery may be necessary to remove a tumor, lesion, or portion of brain identified as causing the seizure.  Meds: Phenobarbital, Phenytoin, fosphenytoin, valporic acid, Diazepam, Ativan, Midazolam Migraine: Autosomal dominant disorder. Cause unknown.  Symptoms: N/V, abdominal pain that is relieved with sleep. Toddlers may have vomiting, pallor, and decreased activity.  Symptomatic pain relief: acetaminophen or ibuprofen. Quiet, dark environment. Osteosarcoma-define, treatment, intervention  Most frequent malignant bone tumor type in children. It presumably arises from bone-forming mesenchyme, which gives rise to malignant osteoid tissue. Primarily effects ages 10-25 years. Primary tumor sites in long bones, especially legs.  Treatment: o Traditional: radical surgical resection or amputation of affected area o Limb salvage procedures: resection of bone with prosthetic replacement of affected area. o Chemotherapy accompanying surgical treatment. o High-dose methotrexate with citovorum factor rescue, doxorubicin, cisplatin, ifosfamide, and etoposide  Intervention: o Preoperative preparation is crucial. Allow child plenty of time to prepare emotionally from the surgery. o Avoid overwhelming child with information. o Support during adjustment to concept of amputation or surgical resection o Body Image concerns o Control SE of medications. o Pain Management: Phantom limb pain. Wilms (Nephroblastoma): define, treatment, intervention  Malignant renal and intrabdominal tumor of childhood  3x more common in AA children.  Peak age of Dx: 2-3 years  More frequent in males  S/S: painless swelling or mass, hematuria, anemia, HTMN, occasional excessive renin 16 Exam 4 Topical Outline Review Pediatrics  TX: Surgical removal (removal of kidney and adjacent adrenal gland), Chemotherapy/radiation  Interventions: o Preoperative: DO NOT PALPATE ABDOMEN. Careful bathing and handling are also important in preventing trauma to the tumor site. o Post-operative: recovery period is usually rapid. Monitor for GI activity: BS, BM, distention, and vomiting. o Family support: post-op is frequently difficult for parents. Support and assess patient’s understanding. Status epilepticus – define, treatment, medications  Seizure lasting more than 30 minutes or series of seizures without regaining premorbid LOC.  Treatment: o Maintain airway o Establish IV access o Medications: Diastat (prefilled rectal syringe), Versed, IV Ativan or valporic acid, IV loading with phenytoin or ongoing management o Emergency management:  High dose sedatives: watch for respiratory impairment  Maintain patent airway  Prepare for respiratory support Hydrocephalus – symptoms, causes, treatment, shunt  Symptoms: cognitive deterioration, gait changes, and incontinence. Focal deficits may also be seen.  Causes: complication of traumatic brain injury, seen when there has been a subarachnoid hemorrhage or infection. Not a single disease entity. Disturbances in the dynamics of cerebral circulation and CSF, which may be caused by various conditions.  Treatment: treatment directed toward relief of ventricular pressure, treatment of the cause of the ventriculomegaly, treatment of associated complications, and management of problems r/t the effect of the disorder on psychomotor development. o Surgery is primary treatment. Most children require the placement of a shunt to provide primary drainage. Typically uses a VP (ventriculoperitoneal) shunt for neonates and young infants. VA (ventriculoatrial) shunt is used for older children. o Watch for shunt dysfunction, which may be indicated by increased ICP. Meds- phenobarbital, phenytoin, lorazepam, valproic acid (side effects, uses, purposes); methotrexate, vincristine, prednisone, L-asparaginase  Phenobarbital o Febrile seizures, neonatal seizures o Also for other seizures—front line IV choice if patient does not respond to diazepam o High dosage may require respiratory support 17 Exam 4 Topical Outline Review Pediatrics o Children taking phenobarbital or phenytoin should receive adequate vitamin D and folic acid, since deficiencies of both have been associated with these drugs.  Phenytoin (Dilantin) o PO or slow IV push (<50mg/min) o Precipitates when mixed with glucose, so use normal saline to flush line o Side effects: Gingival hyperplasia, ataxia, rashes, acne, hirsutism, osteoporosis o Onset 5 to 30 minutes; duration 12 to 24 hours o Do not take with milk  Fosphenytoin o May be given with saline or glucose o Rate up to 150 mg/min o IV or IM  Valproic Acid o Trade names—depakote, depakene o IV or PO o IV for status elipticus o SE—Hepatoxicity*  Diazepam o Trade names—Valium IV, diastat (rectal gel) o Medication of choice for status epilepticus o Rectal gel for home and prehospital management o Onset 3 to 10 minutes; short duration (minutes) o Concurrent loading with phenytoin for sustained control of seizures 18 Exam 4 Topical Outline Review Pediatrics  Ativan o Alternative to diazepam o May be preferable to diazepam o Longer duration of action o Less respiratory distress in children older than 2 years old  Midazolam (Versed) o Intranasal route o For acute epileptic seizures o Onset 3 to 5 minutes; duration  Methotrexate:  Vincristine  Prednisone  L-asparaginase Cushing triad: Indicates Increase ICP  Increase in Systolic BP (Widening Pulse Pressure)  Decreased pulse  Decreased RR **Growth and Development: **Safety: Piaget  Toddler: beginnings of rational judgment, an understanding of casual relationships, and discovery of objects as objects. Preoperational thought is characterized by egocentrism, centration, global organization of thought processes, animisms, and irreversibility.  Piaget does not include a phase that covers ages 3-5 specifically. Its phase covers years 2-7, with two separate groups: preconceptual (2-4) and intuitive (4-7). Main transition is from total egocentrism to social awareness and the ability to consider others viewpoints. Preschoolers also assume everyone thinks as they do so they only offer brief explanations of actions. Play – normal for age group; specific play toys or activities appropriate for age  Toddlers: progresses to parallel play, not playing with children but along side children. Imitation is very prominent. Push-pull toys, stick horses, straddle trucks etc. 19 Exam 4 Topical Outline Review Pediatrics  Preschoolers: associative play, group plays in similar or identical activities but without rigid organization of rules.  Play for physical growth and refinement of motor skills: jumping, running, climbing, swimming, skating, skiing. Language skills – 3 year old and up  Vocabulary increases dramatically from 200 words at 2 to 2100 words at the end of five years. Becomes more complex and sophisticated. Influenced by cognitive ability and environment. Sleep and problems  Toddlers: 11-12 hours of sleep needed, including one nap. Resistance of bedtime and fear prominent. Regular bedtime and routine help with sleep.  Preschoolers: 12 hours of sleep per day, some still require nap. Often have sleep disturbances such as difficulty going to bed and sleep terrors. Use a night-light, consistent bedtime routine, and avoid allowing them to sleep with parents. TX; “slow down routine” **Stress; lying Diet:  Toddlers: enjoy finger foods. Toddlers often experience physiologic anorexia (decreased nutritional need with a decreased appetite. This creates picky, fussy eaters. They also have ritualism, wanting the same cup, plate and etc. Decrease in child’s need for calories.  Preschoolers: Average daily intake of 1800 calories. Importance of healthy diet with variety of foods. Obesity is the major concern, use 5-2-0-1 framework. 5-servings of fruits and vegetables per day, 2 hours of les of screen time, 0 servings of sugar-sweetened beverages, and 1 hour of physical activity per day. Nightmares – sleepwalking – sleep terror  Sleepwalking is very common in preschool age child, and can be related to social rather than developmental factors. Growth patterns:  The average weight of a preschooler is 32 pounds at 3 years, 36.5 pounds at 4 years.  The average toddler weight at 2 years is about 26.5 (12kg) pounds and 34 inches. Average weight gain per year: 4-6 pounds (1.8-2.7kg). Quadruple birth weight by 2 ½ years old. Height increases typically 3 inches (7.5 cm) per year in elongation of the legs **Puberty: (confused since this doesn’t happen until later) **Fine motor abilities: **Electra; Oedipus: o Electra: girl’s sense of competition with her mother for the affections of her father. Experience penis envy. o Oedipus: boy’s sense of competition with father for mother’s attention. Fear castration as punishment. **Peer group: Magical thinking (Preschoolers): Because of egocentrism and transductive reasoning, they believe their thoughts are all powerful. Such as they think about someone dying and they die. This causes vulnerability of guilt and they feel responsible for their bad thoughts that coincide with an actual event. 20 Exam 4 Topical Outline Review Pediatrics Preventive teaching: accidents; injuries  Toddlers are at increased risk for injuries because of an increase in locomotion. Fatal injuries are result of MVAs, drowning, and burn. Injuries inside a car are caused by restraints that have not been used or have been used improperly. Unrestrained children in the front seat are at the highest risk of injury. o If combined weight of child and car seat is more than 65 pounds, parents should use lap belt restraint to restrain child. **Parental involvement and control SIADH-define, symptoms, labs, treatment  Increased secretion or increased production of ADH, which makes the body retain water.  Syndrome of inappropriate antidiuretic hormone (SIADH) may accompany CHS diseases. Can occur in a child with meningitis. o Symptoms:  Decreased UO with hyponatremia & hyposmolality  S/S of over hydration o Labs:  Decreased UO, Increased specific gravity, Decreased sodium, decreased serum osmolality o Treatment: Fluid restriction (500-1000ml/day), observe for electrolyte imbalances (200-300ml of 3%-5% of NaChl for severe hyponatremia), vasopressin administered. Diet: During Chemo, Nutritional Requirements.  Children develop aversions to certain foods if they are eating during chemo-it is best to refrain from offering the child’s favorite foods whole receiving chemo.  Encourage parents to reduce pressure placed on eating. Allow child any food tolerated. Explain expected increase in appetite if child will be taking steroids. Fortify foods with nutritious supplements. Allow child to be involved in food preparation and selection. Make food appealing. Monitor child’s weight.  High Calorie, High protein. 21 Cerebral, Cancer, & Hematology Peds Final Review Cerebral Rabies • An acute infection of the CNS  • Caused by virus transmitted by saliva of infected animal  • Modern prophylaxis almost 100% successful tx immediately after exposure • Virus multiplies in muscles and fatal if untreated  • Infected wild animals are most commonly raccoons, skunks, foxes, and bats o Warn kids of wild animals who appear to be friendly  • Unprovoked attack is more likely to indicate a rabid animal than a provoked attack  Therapeutic Management of Rabies • Inactivated rabies vaccines o HDCV—human diploid cell rabies vaccine • Globulins o HRIG—human rabies immune globulin ASAP after exposure • Guidelines for use from the WHO  Nursing Considerations • Support and reassurance for child and family  • Analgesia with EMLA cream to injection sites Reye Syndrome (RS) • A disorder defined as metabolic encephalopathy associated with other characteristic organ  involvement • Characterized by fever, profoundly impaired consciousness, and disordered hepatic function  • Etiology is not well understood o Believed to be mitochondrial insult induced by different viruses, drugs, exogenous toxins, and genetic factors o Salicylates can be hidden so warn families to check products for this  o Most cases follow a common viral illness (typically influenza or varicella) that use  aspirin therapy  o * Potential association between aspirin therapy for fever and development of RS  • Pathophysiology  o Cerebral edema = biggest threat to life o Fatty liver changesliver usually fully recovers o Neurologic changes • Definitive diagnosis by liver biopsy  • Therapeutic management  • Prognosisusually improves quickly if caught early  • Nursing considerations o Remember that Pepto­Bismol has salicylates in it  Seizures Tiggers: precipitates of a seizure • Most common factors that may trigger seizures in children include: emotional stress, sleep  deprivation, fatigue, fever, physical exercise, sleep, flickering lights, menstrual cycle, alcohol,  heat, hyperventilation, fasting Aura 1 Cerebral, Cancer, & Hematology Peds Final Review • Warning indicator of onset of certain types of seizures Generalized Seizures  • AKA tonic­clonic seizure  • Formally known as grand mal • Usually occurs without warning (no aura)  • Affect both hemispheres of the brain • Consists of two distinct phases o Tonic  Eye rolling and loss consciousness occur at onset of seizure  Tonic muscle contractions o Clonic   Intense jerking movements   Average duration 30­50 seconds  May have incontinence, caution with airway concerns  Hydrocephalus Causes • Disturbance in the dynamics of cerebral circulation and CSF basically either too much CSF, a  block in CSF flow, or a decrease in CSF reduction o Examples: myelomeningocele, intrauterine viral infection (CMV, toxoplasmosis),  aqueduct stenosis, intraventricular hemorrhage, tumor, CSF infection, head injury Symptoms • Infant: o Bulging fontanels (w/ or w/o head enlargement) o Dilated scalp veins o Separated skull sutures (Macewen sign) o Frontal bossing (protrusion) w/ depressed eyes, rotated downward o Setting­sun sign: sclera of eyes may be visible above the iris o Irritable, lethargic, poor feeding • Childhood o Related to IICP or location of focal lesion:  HA on awakening w/ improvement following emesis  Papilledema  Strabismus   Extrapyramidal tract signs, such as ataxia o Irritable, lethargic, apathetic, confused, and often incoherent Treatment: surgical • VP Shunt: shunt that drains fluid from ventricle in brain to peritoneal area o Requires repeated lengthening of tubing from ventricle to peritoneal area to  accommodate for child growth  Timing of revisions varies widely; in most instances, revisions are performed  when physical signs indicate shunt malfunction (s/s elevated ICP, etc.) o Major complications related to infection and malfunction both are considered emergent  and require immediate treatment Meningitis Lab and CSF Findings • Lumbar puncture for definitive diagnosis 2 Cerebral, Cancer, & Hematology Peds Final Review o Bacterial meningitis: increased WBCs and decreased glucose o Viral meningitis: slightly elevated WBC, normal or slightly elevated protein count,  negative gram stain, clear or slightly cloudy in color, normal glucose level ICP Increased Intracranial Pressure  • Early signs and symptoms may be subtle  • As pressure increases, signs and symptoms become more pronounced and LOC deteriorates  • Clinical manifestations of increased ICP in children: o Headache  o Vomiting (with or without nausea) o Seizures o Diplopia, blurred vision  • Cl


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