NUR 320 Exam 3 Study Guide
NUR 320 Exam 3 Study Guide NUR 320
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This 27 page Study Guide was uploaded by Serena Buckley on Friday March 6, 2015. The Study Guide belongs to NUR 320 at University of Miami taught by Deborah Salani in Winter2015. Since its upload, it has received 107 views. For similar materials see Pediatric Health Nursing in Nursing and Health Sciences at University of Miami.
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NUR 320 Study Guide For Exam 3 Spring 2012 Alterations in Eye Ear Nose and Throat Function 1 Clinical Signs of OTITIS MEDIA OM In ammation of the middle ear that may be associated with infection Breastfeeding is protective against OM Pulling at the ear is a classic sign Diarrhea vomiting and fever No visible landmarks upon otoscopic examination Treated with Amoxicillin for 10 days under the age of 6 and 57 days over the age of 6 hrD goom 2 Clinical Manifestation of Mumps a Viral infection of the salivary glands b Face pain fever headache swelling of parotid glands and tempromandibularjoint 3 Pediatric differences in anatomy and physiology of the ear 4 Prophylactic eye treatment a Erythromycin is used to prevent opthalmia neonatorum in newborn babies from mothers ghonorrhea or chlamydia 5 Treatment of eye injuries a Most common in males age 1114 b May need a tetanus booster Neurological Functioning 1 Why are children at risk for HEAD INJURIES a Increased risk for brain and spinal cord injuries because of developing anatomic structures i Top heavy head is large in proportion to the body ii Neck muscles are poorly developed iii Thin cranial bones not well developed iv Unfused sutures expand until age 2 9 prone to brain injury with falls v Excessive spinal mobility vi Immature muscles vii Joint capsule wedgeshaped cartilaginous vertebral bodies viii Incomplete ossi cation of the vertebral bodies ix Greater risk for high cervical spine injury at C1C2 level or vertebral compression fractures with falls 2 Identi cation of and assessment of a child with HYDROCEPHALUS a Hydrocephalus imbalance between production and absorption of CSF i Leads to increased CSF volume in brain ii Commonly associated with myelomeningocele spinal uid lled sac protruding through vertebrae associated with low IQ b Signs and Symptoms i Early signs 1 Rapid increase in head circumference 2 Bulging fontanel 3 Prominent scalp veins taunt skin 4 Head lag difficulty holding head up ii Late signs 1 Sunsetting eyes sclera visible above iris 2 Retinal papilledema 3 Shrill highpitched cry 4 Difficulty swallowing or feeding 5 Apnea spells c Acquired hydrocephalus i Early AM headache accompanied with vomiting has to do with waking up and changing position ii Irritable confusion apathy decreased LOC d Treatment i Diuretics furosemide reduces rate of CSF production ii Ventricular access device to drain uid iii Surgical removal of obstruction iv VP shunt decreases amount of CSF by shunting uid from ventricles into the abdomen 1 Needs to be adjusted as child grows to prevent shunt failure e Nursing Diagnoses Myelodysplasia and Hydrocephalus i Risk for infection related to the presence of shunt ii Risk for caregiver role strain related to care of a child with a chronic condition iii Risk for delayed development related to compression of brain tissue with excess CSF 3 Care of children with CEREBRAL PALSY a Cerebral Palsy group of permanent disorders of movement and posture causes activity limitations i Nonprogressive in nature doesn t worsen or improve ii May have additional sensory cognition communication and behavior problems 1 Still have normal or nearnormal intelligence b Community care i Case manager OTPT services Early intervention Financial needs School assistance and lEP c Clinical Manifestations i Activity limitations sensory movement speech ii Abnormal muscle tone and lack of coordination with spasticity iii Delayed in meeting developmental milestones iv My have normal or near normal intelligence v Additional sensory cognitive communication and behavior problems 9 visual defects hearing loss cognitive delay retardation d Multidiscplinary Care VI Orthopediac surgeon might have skeletal defects need braces or splints seral casting positioning and mobility devices to maintain adequate ROM control of involuntary movements Speech therapy difficulty eating and talking 1 Severity differs per person may be completely aphasic or just slurred speech Regular eye exams typically need glasses Pediatric NP or pediatrician Support groups comfort and education Teach parents Feeding difficulties adapt to child PTOT Get parents to maximize growth and development Probably don t need meds maybe seizure meds control GI side effects 5 Anticipatory care still need normal things like dentist appointments gtUUI 39 e Parent Teaching VI vii viii Adequate nutrition tach how to feed them might take extra effort or may need special nipple Skin integrity use tshirt or pillows under brace properly alignment Promote mobility PT position for exion Promoting GD get parents to maximize it use proper terms depending on level help develop positive self image use assistive technology or sign language Support services OT PT speech therapy Safety safety belts car seats Anticipatory guidance still need regular care Immunizations risk for seizures 4 Care of the child with BACTERIAL MENINGITIS a Meningitis in ammation of the meninges covering the brain and spinal cord Bacterial is more fatal and causes more harm than viral Infants at greatest risk because of weak immune system 1 May occur secondary to other bacterial infection otitis media sinusitis In ammatory response impedes CSF ow increases ICP and hydrocephalus b Assessment Lumbar puncture fetal position to access meninges very sterile procedure 1 Attach manometer to measure pressure if opening pressure is high gt15 then we know something caused the increased ICP 2 CSF should be clean if cloudy or bloody it could be infection or bad technique a Glucose level will be LOW in CSF b 24 hours for preliminary result 36 hours for full result c Signs and Symptoms onset may be sudden or develop over 12 days Nuchal rigidity Fever Hemorrhagic rash petechiae prupura IV Headache most often frontal v Nausea and vomiting vi Photosensitivity vii Muscle orjoint pain viii Altered LOC delirium confusion irritable lethargic ix Kernig s sign raise the child s leg with the knee exed and resistance or pain is a positive test x Brudzinski sign ex the child s head while in a supine position if the action makes the knees or hips ex involuntary it is positive xi lnfant fever change in feeding pattern vomiting diarrhea anterior fontanel may be bulging or at rocking or cuddling may irritate the child d Positioning Opisthotonic position hyperextension of the head and neck to relieve discomfort 1 Completed arched decreases pressure on the meninges e Treatment VI Prophylactic antibiotics until cultures are returned 9 more speci c antibiotics Speci c antibiotics are administered IV for 721 days Corticosteroids dexamethasone may be given monitor for GI bleeds NPO and IV uids may initially be restricted for monitoring of increased ICP and SIADH Isolation and droplet precautions Encourage immunizations HIB pneumococcal meningococcal f Nursing Management ii iii iv v Measure head circumference frequently in infants to monitor for hydrocephalus Monitor the ability to control secretions and drink sufficient uids Assess for any sensory de cits Monitor for SIADH sodium concentration urine speci c gravity Enhance interaction educate visitors to use PPE encourage parents to do daily GD activities g Complications Neurological sequelae most common involve cranial nerves especially 8 resulting in hearing loss Seizures hydrocephalus subdural effusion diabetes lnsipidus SIADH developmental delays 5 SEIZURES vs EPILEPSY a Differences and de nitions Epilepsy a chronic gt6 months disorder of recurrent unprovoked seizures secondary to an underlying brain abnormality 1 Normal intelligence no loss of consciousness no postictal period attacks occur most often upon falling asleep or waking quick involuntary muscle jerks of neck arms ii Seizures periods of abnormal electrical discharges excessive concurrent rings in the brain that cause involuntary movements behavior and sensory alterations b Seizure Types i Partial focal simple seizures caused by an abnormal electrical activity in one hemisphere or a speci c area of the cerebral cortex most often temporal frontal or parietal lobes 1 No LOC lasts less than 30 seconds no postseizure confusion no aura 2 Motor responses may involve one extremity twitching loss of tone tingling numbness automatisms ii Generalized diffuse electrical activity that begins in both hemispheres of the brain simultaneously and spreads throughout the cortex into the brainstem 1 2 anew Movements and spasms are bilateral and symmetric tonic clonic Consciousness is impaired may or may not have an aura postseizure confusion Loss of bowel and bladder function Eyes roll up drooling foaming grunting crying Increased BMR 9 hypoxia hypoglycemia Absence go out of focus and lose attention Pseu o seizure false seizures have to rule out because kids can be convincing Febrile seizure occur at very high temperatures 103 or 104 around 6 months 3 years 1 2 3 During an infection your body will increase in temperature to help kill organisms Some kids are sensitive to high temperatures and could seize at lower temperatures A child who has a febrile seizure one time does not epHepsy Clinical manifestations generalized tonicclonic 5 movements and rolling back of the eyes lasting a few seconds to 12 minutes a Brief postical period and there is no reoccurence in24 hours Use acetaminophen or ibuprofen to lower fever keep the child cool with light clothing v Aura predisposing feeling that indicates a seizure will occur c Nursing Management i Maintain airway 1 2 Don t put anything in mouth to avoid knocking out teeth that could be aspirated Position prone on side so secretions can drain out of the mouth vi 3 Monitor the child to ensure adequate oxygenation color should be pink heart rate normal or slightly elevated and pulse ox gt95 Ensure safety 4 5 1 Protect from selfharm during violent seizures 2 3 Frequent recurrent seizures should wear a helmet to Side rails should be padded to prevent injury protect head during falls Medicalert bracelet Do not leave the child alone in the bathtub a buddy should be present during swims a life vest should be warn while boating avoid areas where fall risks are increased Administer medications 1 2 3 IV benzodiazepines should be given very slowly to minimize the risk of respiratory or circulatory collapse Crush pills and mix them in a spoonful of applesauce or other soft food to make them easier to swallow If child is on ketogenic diet it is important to limit glucose and dextrose from all sources Provide emotional support 1 2 3 Very scary for parents make sure the parents are informed about the cause of seizures When child comes out of seizure they are disoriented don t let them fall wait for a while to let them walk Stress the importance to treat the child as normally as possible Provide education 1 Refer to support groups Ketogenic diet 1 5 6 High intake of fat 90 adequate intake of protein 1 gmkg low intake of carbs uids restricted to 80 of usual Ketosis is believed to produce anticonvulsant effects coordinate care with dietician Diet must be maintained for 23 years and urine ketone values must be frequently monitored Common complications constipation kidney stones a Treat with MTC oil and increasing uids Ensure vitamins and medicines are carb free shouldn t use sunscreen with sorbitol Should be tapered off when discontinued 6 Care of the child with INCREASED INTRACRANIAL PRESSURE ICP a lntracranial pressure force exerted by brain tissue CSF uid and blood within the cranial vault Important indicator of neurological functioning b Normal ICP 015 39 Increased ICP 9 decreased LOC 9 decreased cerebral perfusion 9 potentially death If fontanels have closed the brain has a nite amount of space to expand and grow c Glasgow Coma Scale use to measure responsiveness I ii iii iv The higher the score the better Get a baseline level on admittance Never want to see it decrease we want it to decrease Categories eye opening 4 verbal response 5 motor response 6 d PERRLA equal reactive response to light accommodation lntracranial mass unilateral dilated and reactive pupil Brainstem herniation impending xed and dilated pupil Brainstem herniation from increased ICP bilateral xed and dilated pupils e Infant Responsiveness Assessment Do they respond to parents Are they babbling and cooing BOX 33 1 Assessment of Infant Responsiveness 1When initially checking the responsiveness of infants the acronym AWU provides a method for rapid assessment Alert responsive to parents cuddles coos or babbles smiles Verbal responsive to verbal stimulation lPai39n responsive to painful stimulation only lUnresponsive to painful stimulation Additionally assess the infant for a loud energetic quality to the cry feed ing for a strong suck and suckeswallowi39ng coordination and the presence of appropriate primitive reflexes for age These signs all indicate intact men tal status f Clinical Manifestations of Increased ICP vi vii viii ix X Early signs headache visual disturbances nauseavomiting dizziness vertigo slight change in vital signs pupils not as reactive or equal sunsetting eyes slight change in LOC 1 Additional signs in infants bulging fontanel wide sutures increased head circumference dilated scalp veins irritability highpitched catlike cry Late signs signi cant decrease in level of consciousness seizures xed and dilated pupils papilledema 1 Cushing s triad a Increased systolic BP and widened pulse pressure b Bradycardia c Irregular respirations LOC responsiveness GCS recognition lethargy VS increased BP widened pulse pressure bradycardia irregular resps late signs of inc ICP Fontanelssutures bulging or wide indicate increased ICP early sign Cognitive function verbal skills follow directions developmentally appropriate Pupils PERRLA size should be equal Posture and movement primitive re exes DTRs spontaneous activity tone strength motor skills appropriate to GD Neck stiffness should have full ROM of neck concerned about nuchal rigidity or stiffness Cranial nerves g Treatment i Oxygen assisted ventilation correct electrolyte imbalances antibiotics ii Ventricular catheter to drain CSF and decrease ICP h Nursing Care i Maintain airway patency intubation frequent suctioning oxygen trach tubes pulse ox to ensure gas exchange anticipate seizures so pad side rails ii Routine care eye ointment mouth care adequate nutrition NG tubes iii Prevent complications of immobility proper body alignment with rolls or towels ROM exercises skin integrity change position QZH foam mattress transparent dressings iv Provide sensory stimulation talk play music touch bring objects from home v Emotional support referrals 7 Care of the child in STATUS EPILEPTICUS a An acute seizure that lasts over 30 minutes or a series of seizures where consciousness isn t regained b Electrolytes glucose blood gases temperature and blood pressure need monitoring if a seizure occurs for longer than 10 minutes i While actively seizing that long they use up a lot of glucose and electrolytes ii Child may become pale or cyanotic as a result of hypoxia or hypoglycemia c Nurses need to administer medications i Ativan anticonvulsant is best absorbed rectally can also be given IV ii Don t get Dilantin phenobarbital Topamax tegretol etc because they are all used for prevention and require a therapeutic drug level iii Certain seizure medications cause blood dyscrasias gingival hyperplasia d Management i Maintain airway muscle rigidity may compromise the airway keep suction available 1 Give oxygen by mask prevent hypoxia 2 Monitor VS and circulation with pulse oximetry and cardiorespiratory monitor 3 Perform neurological assessments every 510 minutes ii Ensure safety 1 Insert an NG tube to reduce risk of aspiration due to vomiting 2 Assess blood glucose level if the child is hypoglycemic 3 Manage thermoregulation iii Administer medications 1 IV line to administer uids or medications 2 Administer benzos such as diazepam Ativan lorazepam or midazolam If no response an additional dose may be repeated a Cumulative doses may produce respiratory arrest so prepare to assist with ventilator support and intubation if needed nd out if parents gave anything b Phenytoin or phenobarbital may be necessary if seizure activity continues iv Provide emotional support v Provide education 8 Side effects of SEIZURE MEDICATIONS Valproic acid Dilantin a Benzodiazepines IV diazepam Valium lorazepam Ativan rectal diazepam diastat i Action anticonvulsant agent used for status epilepticus ii Management IV push medication is administered into the IV entry site closest to childs body push VERY SLOWLY 1 Monitor VS for hypotension tachycardia and respiratory depression 2 Rectal preparation is prescribed for home administration to prevent status epilepticus b Phenobarbital PO IV IM i Actions limits spread of seizure activity by increasing threshold for motor cortex stimuli used for generalized and partial seizures and status epilepticus ii Management IV in site closest to child s body administer very slowly 1 Monitor VS frequently when given IV 2 Tablets may be crushed and mixed with food or uid c Phenytoin Dilantin P0 or IV i Action inhibits seizure activity reduce voltage frequency and spread of electrical discharges within motor cortex used for partial and generalized seizures ii Management educate family to ensure adequate intake of VITAMIN D FOLIC ACID CALCIUM 1 Promote frequent dental care for gingival hyperplasia d Carbamazepine Tegretol PO i Action similar to phenytoin used for simple and complex partial seizures ii Management give with food to enhance absorption do not administer suspension simultaneously with another liquid medication to prevent formation of a precipitate 1 Causes photosensitivity reactions e Valproic Acid Depacon Depakote PO i Action anticonvulsant used for partial and generalized seizures ii Management give with food to decrease GI irritation tablets should not be chewed 1 Do not used carbonated beverages to dilute syrup 2 Monitor platelet counts and bleeding times 3 Do not use with aspirin sedatives and allergy medications f Gabapentin Neurontin PO i Action GABA neurotransmitter analog used for partial seizures ii Management vision concentration and coordination may be impaired 1 Do not take within 2 hours of an antacid g Topiramate Topamax PO i Action GABA inhibitor used for partial and generalized seizures ii Management monitor for metabolic acidosis increase uid intake to reduce risk of kidney stone h Adolescent females need to be educated about the potential teratogenicity of antiepileptic medications valproic acid carbamazepine i Some cause oral contraceptive failure i Rapid changes in weight may lead to loss of seizure control if medication dosage is not adjusted well j Regular dental care is important because of gingival hyperplasia 9 Pre and postop care of the child with a VENTRICULOPERITONEAL VP SHUNT a Shunt failure shunt breaks as they grow in length i Shunt has to be replaced periodically ii Indication of a blocked VP shunt signs and symptoms of recurrent hydrocephalus and increasing ICP con rmed by CT scan or MRI b Perioperative IV antibiotics are received to reduce the risk of infection c Post op VS level of responsiveness irritability respiratory status lO pain level measure HC i Surgical site evaluated for signs of drainage and infection redness swelling leakage of CSF nuchal rigidity neck or back pain or photophobia d Most serious complication is shunt infection i Can occur at any time but most often occurs within 6 months after placement ii Signs change in responsiveness irritability after fever is controlled low grade fever malaise headache nausea iii Con rmed by CSF culture abx prescribed shunt removed and external drainage is placed e Nursing Priorities i Infection shunt ii Impaired physical mobility weight of head and decreased muscle mass iii Caregiver role strain iv Developmental delay compression of brain tissue f Planning and implementation i Place in at position to prevent rapid CSF drainage HOB raised gradually position carefully ii Good skin care to prevent breakdown iii Small frequent feedings with frequent burping because child is prone to vomiting iv Provide emotional support to parents v Educate parents on signs and symptoms of infection of VP shunt failure and need to tell HCP vi Teach parents these kids shouldn t be placed in forward facing car safety seats vii May have very low le viii Totally dependent on caregivers child may or may not be able to take care of themselves ix Harder to take care of the older they get weigh more etc 10 Preop and postop care of the child with SPINA BIFIDA a Occulta may not be visible means that it s hidden i Possible gait disturbance may have a funny walk or a limp ii Decreased bowel and bladder function b Cystica saclike protrusion on back i Menigocele sac with meninges and uid 1 Not as severe might have a funny gait or a little urine ddbeng 2 Typically don t have paralysis might just have weakness ii Myelomeningocele spinal cord nerve roots spinal uid and meninges 1 Everything extending out of the sac is nonviable 2 You have to close the sac if it s broken you have an avenue for infection into CSF a When removed you ll have the occulta everything below the lesion is paralyzed no bowel or bladder control 3 Majority of the kids have normal intelligence unless they have hydrocephalus c Signs and Symptoms i Sensory disturbanes and motor impairment ii Joint deformities such as contractures kyphosis scoliosis hip dislocation d Nursing Care i Surgery within 2472 hours to decrease trauma hydrocephalus and infection 1 Don t want to break the sac huge portal for infection into the CSF ii lnfant kept warm and keep pressure off sac prone or side lying position 1 Incubator to stay warm but always keep them off the sac iii Cover sac with STERILE dressing and keep moist normal saline iv Monitor for signs and symptoms of increased ICP monitor for infection v Keep surgical site free of urine and feces frequent cleanings vi Use crede method to empty bladder 1 Teach parents that they will have to catheterize these children at home myelomeningocele 2 Also teach how to digitally impact the kids vii Keep hips abducted teach use of brace 1 The brace helps keep pressure off the surgical site and helps keeps legs from being accid 2 Also will need OTPTneuro consults 11 12 13 14 15 0390 0390 Immunizations to prevent MENINGITIS in children HIB and pneumococcal vaccines have reduced the incidence of bacterial meningitis in the US At risk for meningitis immunosuppressed VP shunt cochlear implant penetrating brain injury Identi cation of a BLOCKED VP SHUNT Signs of recurrent hydrocephalus and increased intracranial pressure Change in responsiveness irritability after fever is controlled low grade fever malaise headache nausea Laboratory CSF values of a patient with meningitis CSF glucose level is LOW Parental guilt and neurological conditions in children Think they caused it May feel guilty about not noticing the onset of an illness or disreguarding earlier symptoms May compensate by not disciplining or restriting the child appropriately stress to treat the child as normally as possible Use of sedatives and narcotics with children who have head injuries a b Not a good idea need to be able to tell if they are having a decline in neuro function and you can t if they are sedated Monitor with 02 sat if we see change it might be correlated with change in neurological system Cardiovascular Functioning 1 Diagnosis of COARCTATION OF THE AORTA a Etiology narrowing in the descending aorta near the ductus arteriosus or left subclavian artery obstructs systemic blood ow b Manifestations symptomatic but constrict progressively develop CHF by 3 months Reduction in blood ow through descending aorta causes lower BP in legs and higher BP in arms and neck 1 If signi cant reduction renal failure and necrotizing entercolitis may develop Brachial and radial pulses are bounding femoral pulses are weak or absent Older kids may complain of pain in legs after exercise 52 loud and single on auscultation systolic ejection murmur thrill palpated Infants moderate constriction may show poor feeding failure to thrive increased respiratory effort and CHF c Diagnosis i Radiograph Cardiomegaly pulmonary venous congestion and indentation of descending aorta ii Rib notching from collateral vessels is rarely seen before 10 years of age iii EKG shows left ventricle hypertrophy and right ventricle hypertrophy severe 1 EKG permits measuring aorta imaging of coarctation and functioning of the aortic valve and left ventricle iv Cardiac cath and MRI show site of coarctation d Treatment i Balloon dilation ii Surgical resection and anastomosis are palliative coarctation may recur 2 Signs and symptoms of CHF in children in all ages with cardiac defects a Increased pulmonary blood ow allow blood ow between right and left heart i Increased pulmonary vascular resistance to try and reduce blood ow 9 pulmonary HTN 9 right ventricular hypertrophy b Manifestations of CHF i Dependent edema dyspnea retractions HTN ii Diagnosed when born not chronic iii JVD happens in babies too but not at same degree too much uid iv If not treated mental status changes c Treatment i Diuretics be concerned about potassium ii When tachypneic or tachycardic harder to eat concerned about breathing takes energy 1 Takes a long time to eat may eat 2 ccs and then fall asleep iii Importance of infant nutrition need brain development 1 Attempt to PO feed so they learn to eat 2 Feed through NG tube feedings 3 Continuous feeding at night rest and digest growth hormones are released 3 Nursing care of the child with CONGESTIVE HEART FAILURE a Cardiac output is inadequate to support body s circulatory and metabolic needs i Tires easily weight loss diaphoresis irritability abdominal distention S3 gallop frequent URI ii Older child exercise intolerance dyspnea abdominal pain or distension peripheral edema b Assessment i Respiratory rate 1 Newborns 3055 2 1 year 2540 3 3 years 2030 4 6 years 1622 5 10 years 1620 6 17 1218 Tachypneic nasal aring grunting retractions cough crackles pulmonary venous congestion Pulse tachycardia to compensate late stages see hypotension Color normal cyanotic gray may be mottled or pallor Edema generalized uid volume overload concerned about skin breakdown 1 Periorbital and facial edema JVD and hepatomegaly are signs of uid volume excess c Diagnosis Primarily on clinical manifestations tachycardia respiratory distress crackles Chest radiograph reveals cardiac enlargement venous congestion signs of pulmonary edema d Management vii viii Goal enable heart to work more efficiently and to remove excess uid 1 Priority manage circulation and breathing know what their normal 02 sat is Fluid balance measure lO weigh diapers weigh at the same time daily 1 g 1 mL urine 1 Check for edema circulation redness breakdown Developmental Denver 2 assessment social interaction Promote oxygenation make sure tubing is patent ow rate correct humidi cation is good 1 Keep calm and quiet Cardiovascular function monitor vital signs Administer medications give digoxin at the same time daily 1 Check for bradycardia potassium level before giving 2 Observe for tachycardia bradycardia NV dizziness headache weakness fatigue arrhythmias for toxicity a First sign in children is cardiac arrhythmias Promote rest cluster care frequent small feedings with burping every half ounce 1 Feedings should last no more than 2030 minutes 2 Older children can be encouraged to engage in quiet activities Foster development use toys to stimulate hand eye coordination and ne motor movements toys appropriate for each age group encourage sitting and walking with adequate rest Adequate nutrition burp frequently to permit rest and prevent vomiting increased calories 1 Teach parents that changes in feeding habits like decreased intake vomiting sleeping through feedings increased perspiration with feedings may indicate deteriorating cardiac status Special feeding techniques NG tube Breast feeding is ok but the sucking may cause increased dyspnea and slower feeding JUN x Teaching make sure parents understand how to administer medication and signs of worsening conditions xi Medications 1 Digoxin improves hearts ability to contract and increase output and lessens workload a Action increases contractility improving systemic circulation b Check electrolyte levels especially potassium c Chick apical pulse if lt100 hold it have the dose veri ed by a second nurse d Toxicity nausea and vomiting is rst sign e Bradycardia is a side effect 2 Lasix Thiazidies Spiraldactone a Diuretics to promote uid excretion b Monitor K may need supplements c Teach parents signs of dehydration d Monitor vital signs intake and output and electrolyte imbalances e Assess for digitoxicity 3 Ace Inhibitors a Lessen workload and help heart work more effectively b Common side effects cough hyperkalemia worsening renal function 4 Beta blockers a Propanolol and carvedilol b Increase contractility c Monitor vital signs and peripheral perfusion monitor IO and daily weights 4 What structural defects are involved in TETRALOGY OF FALLOT a Four structural defects i Pulmonary stenosis ii Right ventricular hypertrophy iii Overriding aorta iv Ventricular septal defect b Clinical manifestations hypoxic episodes cyanotic systolic murmur in pulmonary area polycythemia metabolic acidosis poor growth exercise intolerance kneechest positioning 5 Nursing care of a child during a HYPERCYANOTIC spell quotTetquot spell a When there is a severe obstruction to pulmonary blood ow the child will stop what they re doing and squat to relieve dyspnea b Knee chest position reduced Co by decreasing venous return from the lower extremities and by increasing the systemic vascular resistance Occurs between 2 months 2 years old Signs i Increase rate and depth of respirations cyanosis pallor ii Poor tissue perfusion increased heart rate diaphoresis iii Irritability crying seizures 0 e Care put in knee chest positive give oxygen morphine propranolol lV i Monitor for metabolic acidosis or prolonged unconsciousness f Educann i Tell parents to know normal 02 saturation and watch for decreases that may indicate worsening hypoxia Observe for signs of worsening cyanosis especially in the morning which could signal the beginning of a hypercyanotic episode ii Parents should call 911 and try to keep the child calm and reassure the infant iii Place them in a kneechest position with knee bents and legs folded upward towards chest iv Provide oxygen in a manner that does not upset the infant 6 DIGOXIN TOXICITY Therapeutic serum levels 082 ngmL levels over 2 are toxic Nausea and vomiting Bradycardia Anorexia dizziness headache weakness fatigue arrhythmias Family Education about Digoxin i Take the pulse before giving digoxin report if below phisician s guidelines ii Administer at the same time consistently each day with or without food Consistent is important iii Do not repeat the dose if the child vomits unless told by HCP iv Do not give OTC medications for colds cough allergies GI upset or obesity with HCP approval v Do not give herbal medications such as ginseng mahuang or ephedra can cause toxicity vi Keep medication locked and out of reach of children Accidental ingestion is an emergency vii Potential interaction between dig and certain antibiotics tetra mycin betalactams DP00quot 7 What are the causes of CYANSOSIS in children with CONGENITAL HEART DEFECTS a In defects causing decreased pulmonary blood ow cyanosis occurs when the ductus arteriosus closes causing hypoxemia b Cyanosis occurs when the amount of reduced hemoglobin in the veins reaches a level of 5g100mL usually because of desaturation of arterial blood in children with congenital defects c When the child is anemic the 02 saturation must be very low before cyanosis is observed because there s less overall circulating hemoglobin d Occurs in a hypercyanotic spell as well 8 What causes RHEUMATIC FEVER a In ammatory connective tissue disorder that follows strep infection i Affects heart joints brain and skin tissue ii Can be autoimmune response in a genetically predisposed child b Manifestations carditis murmurs arthritis subcutaneous nodules skin rash aimless movements c Treatment antibiotics penicillin sulfadiazine erythromycin aspirin for fever arthritis arthralgias 9 Care of the child post CARDIAC CATHETERIZATION a Chest radiography EKG CBC and electrolyte levels may be down preop b Child is NPO except for meds arrives at cardiac cath lab 12 hours before and voids and is given oral sedatives get baseline VS c Post op monitor for complications like arrhythmias bleeding hematoma development thrombus formation and infection i No bleeding should occur at cath site ii Child usually on anticoagulants afterward iii Assess VS CMS checks of lower extremities pressure dressing over cath site every 15 min for 1 hour and every 30 min for 1 hour 1 Should match preop and remain stable 2 Check under butt if blood is oozing under child 3 Monitor lO because contrast media may cause diuresis iv If on diuretics monitor for dehydration and replace uid if excessive excretion occurs v After catheters and guidewires are removed at the end of the procedure direct pressure must be applied for 15 minutes a pressure dressing is then applied for 6 hours vi Regular assessment of the cath site and distal extremity is performed for several hours after procedure vii Child is kept on bed rest for 6 hours with effort to keep legs straight for several hours 1 Avoid elevating the HOB as exion of the hip is bad 2 Activity is limited for 24 hours 3 Provide quiet activities to keep the child occupied viii Encourage intake of small amount of clear uid initially and progress 1 Maintaining hydration is important because of diuretic effect of contrast medium 10 Care of the child with KAWASAKI39S DISEASE a Acute febrile systemic in ammatory illness that affects small and midsize arteries that can result in stenosis leading to reduced blood ow and potential infarcts leading cause of acquired heart disease i Exaggerated immune response in a susceptible child ii Typically think its related to viral illness maybe strep URI 9 preceded by it b 3 phases i Acute phase lasts 1 to 2 weeks 1 High temperature 104105 for more than 5 days 2 Strawberry tongue bumpy rough look 3 Maculopapular or erthyma multiformelike rash on trunk and perineal area 11 h 4 Unilateral enlargement of cervical lymph nodes diarrhea hepatic dysfunction 5 lrritability conjunctival hyperemia but no drainage 6 Red throat swollen hands and feet ii Subacute phase lasts 2 to 4 weeks 1 Dry cracked lips and ssures painful 2 Skin on hands and feet sloughs off 3 Fever joint pain cardiac disease thrombocytosis iii Convalescence stage lasts 6 to 8 weeks after disease onset 1 Return back to normal with lingering signs of in ammation Diagnosed on just these sign and symptoms because there is no blood test for it i Creactive protein and ESR may be elevated but very general Treatment i If caught in rst stage HIGH DOSE ASPIRIN 1 Thins blood and decreases in ammation ii Also get IV gamma globulin to help decrease in ammation and increase immune system on rst day Concerned about residual cardiac defects At risk poststrep infection post heart surgery congenital heart defects Nursing Role i Before diagnosis prevent infection assess signs ii After diagnosis Assess CHF ensure rest manage complications Monitor for side effects of aspirin GI upset and bleeding Run immunoglobulin slowly and watch for reactions Promote comfort keep clean and dry lubricate lips use cool compresses and tepid sponges Give frequent small feedings Passive ROM exercises to facilitate joint movement 7 Encourage parental involvement iii Teaching 1 Administer aspirin and watch for side effects GI bleeds GI upset 2 Child needs to avid contact sports and limit strenuous activity 3 Take temperature daily and report fever 4 Postpone measles and varicella vaccine for 11 months after immunoglobulin administration 5 Should get in uenza vaccine because risk for Reyes syndrome since on aspirin gtUUI 39 9 How can BACTERIAL ENDOCARDITIS be prevented Highest risk are kids who have had surgery for an obstruction of pulmonary ow or valve replacement Antibiotic prophylaxis amoxicillin ampicillin gentamycin Prophylaxis prior to professional teeth cleaning dental procedures tonsillectomy adenoidectomy bronchoscopy and surgery on the respiratory GI and GU system Maintenance of good oral hygiene and regular dental care 12 e Discourage kids at high risk from getting body piercing and tattoos Discussing with parents regarding PLAY and the child with a CONGENITAL HEART DEFECT 13 14 a b c d e 0390 0390 an Encourage parent to treat child as normally as possible Children with mild cyanotic lesions do not need to adjust activity The child with moderate to severe disease should be able to tolerate crying for a few minutes without difficulty Place child in chest knee position Encourage rest periods Nursing care of the child with RHEUMATIC FEVER Most common cause of acquired heart disease in children Affects aortic and mitral valves Related to untreated strep throat Care of the child with KAWASAKI39S DISEASE Acute febrile systemic vascular in ammatory disease Strawberry tongue conjunctivitis high fever rash peeling of hands and feet are a late sign Treatment lblg and high dose aspirin 5 principle features i Conjunctivis without exudate ii Red throat strawberry tongue iii Cervical lymphadenopathy iv Erythema of palms and soles desquamation after 2 wks or so Immunizations 1 How do children develop immunity a Passively from mom s breast milk natural immunity i Passive immunity antibodies produced in another host human or animal given when the child needs antibodies faster than the body can make them 1 Include immunoglobulin 2 Do NOT confer lasting immunity child will need vaccine in future b Actively from vaccines i Active immunity antibody production stimulated by vaccine antigens without causing clinical disease c Disease exposure humoral immunity destroys bacterial antigens B lymphocytes are produced in bone marrow and produce antibodies 2 How do most children become infected with infectious diseases a Environmental contact sneezing coughing i Children don t have the best hand hygiene and put everything in their mouth ii Caregivers don t always use proper hand hygiene b Fecaloral routes respiratory more common forms of direct and indirect transmission in children c Slides said immature immune system limited prior exposure to communicable disease d Immune system is not fully mature at birth have a lot of B and T lymphocytes but not exposed to antigens i IgG is passed from mother through placenta ii IgA IgE IgD IgM are not transferred through placenta 3 What can parents do to prevent infection with infectious diseases a Hand hygiene soap and water when visibly dirty alcoholbased hand sanitizer when not visibly soiled b Standard precautions wear gloves when in contact with blood body uids secretions excretions nonintact skin or mucous membranes Wear additional PPE if body uid splashes may occur c Avoid exposure to infected individuals keep sick kids home from school don t share utensils dispose of diapers Q Promote immunizations e Decreaseeliminate pathogens disinfecting hard surfaces wash dishes and hands before food do not kiss pets f Limit the spread of infection Isolate from other children if sick clean shared items maintain a high level of suspicion when numerous individuals with similar signs and symptoms are seen g Consult HCP can t keep kid awake fever down respiratory distress constant vomiting 0 U0 child not playing 4 What should you tell parents who refuse immunizations goom Bene ts outweigh the risk Insurance covers the cost Vaccine impact on diseases has essentially wiped them out Parents have the right to refuse vaccines for their children but if there is a disease outbreak the nonimmunized child must be kept out of school or childcare DOCUMENT the refusal MISINFORMATION CORRECT INFORMATION Vaccine preventable diseases have been eliminated Most diseases are never completely eliminated Travelers may reintroduce the disease from a country or another area where the disease still exists Immunization weakens the immune system Multiple vaccines overload the immune system and cause harmful effects Vaccination uses the body s immune system to prevent a future einfection Child s immune system recognizes the foreign substance inactivated or attenuated virus or bacteria to create antibodies to protect against it Infants are capable of generating protective immune responses to multiple vaccines given simultaneously Thimerosal use in vaccines may cause mercury poisoning Thimerosal a bacteriostatic agent that contains ethyl mercury was used to sterilize vaccines in multidose vials Now vaccine manufaturers have eliminated thimerosal from the majority of vaccines while maintaining their sterility It would be better to let the child get the disease than get immunized Many diseases can cause suffering permanent disability and even death Vaccines do not No vaccine is 100 effective and immunity does work Children can wane over time leading to the need for a 2nCI still get the immunization disease 5 Discuss the risks and bene ts of vaccines a Risk i Pain at injection site redness and swelling common 1 Ice pack acetaminophen to reduce fever and swelling ii Fever joint pain muscle aches or fatigue within hours to days after the vaccine is given 1 Acetaminophen or ibuprofen iii Mild allergic reaction hives 1 Call 911 if severe allergic reaction have them lay on back and raise legs to promote blood return iv Contraindications moderate to severe acute illness with or without fever hypersensitivity to vaccine components eggs neomycin gelatin immune globulin therapy in last 36 months cancer tx pregnancy b Bene ts builds immune system prevents infection i Prevents diseases that initially killed other children 6 How is fever treated in children with infectious diseases a In general you want to assess the child s hydration status and uid intake vital signs comfort level and appetite i Observe for seizures and toxic appearance lethargy poor perfusion hypoventilation hyperventilation and cyanosis behavior irritable and restless tful sleep and nonspeci c muscular pain ii Common symptoms fatigue malaise weakness decreased responsiveness skin rash poor appetite vomiting diarrhea body aches b Check temperature Q4H i Lower temperature with acetaminophen or ibuprofen NO ASPIRIN 9 REYES 1 Drops are 3x more concentrated than syrup do not alternate increases risk of overdose ii Acetaminophen 1015 mgkg temperature rises again after 4 hours iii Ibuprofen 410 mgkg temperature rises again after 6 hours iv If antibiotics are given make sure they take the whole amount and know if it needs to be taken with food Oral rehydration clear uids Remove all clothing except one light layer if sponging child give medication rst and then use tepid water to sponge the child NOT alcohol e High calorie high protein diet 0 7 Know how to read the immunization table ie what immunizations can be given at birth Which ones can be given after age 1 year only a b an D lReaammendedl Immunization Eehedlulle liar liarsans ned Through E Views United States 12 For ii39i SE who faill behind or start late see the catch up schedule Vaccine 139 Age y 1 7 2 gm i i h s ii munths A IE manlliis months mamhsg manihsgmunihs years years wrungquotqquotuu Junta unr uplunmunu i 15 i19 23 7 23 146 39 I 1 r M a 1 I r Influenza blamingmam Measles iliunips Rubella y Valhalla irlvepali lis ii i IiiiiitiilitliiuiFt tusff i W Diff Villa Haeimphiiisinfiigrimeiiipaly H j N 2 see minaretquot see Martiniquot Birth Hepatitis B Bangle 2i remmmended 39 as far all children quotI PEII IZQE Di remmmended aegis far ceriain iii i ii gains i Note Hep B is given at birth before discharge 2nCI dose given at either 1 or 2 monhts of age the lasr dose is given no earlier than 24 weeks of age 1 month Hepatitis B 2 months Hepatitis B if 2nOI dose was not given at 1 month Rotavirus RV Diphtheria Tetanus Pertussis DTaP Haemophilus In uenzae Type B HIB Pneumococcal PCV inactived polivirus IPV Vaccines given only after one year I Minimum age 12 months MMR Varicella Hep A ll Minimum age 2 years Meningococcal MCV iii iv vaccine DTaP V Minimum age 9 years Human papillomavirus HPV Minimum age 10 years Tetanus Diptheteria acellar pertussis Minimum age 11 or 12 meningococcal conjugate MCV 8 Which immunizations should children with HIVAIDS NOT receive In uenza live attenuated for intranasal use should NOT be used in HIV children that are severely immunocompromised MMR not if severely immunocompromised PRV rotavirus not if severely immunocompromised Category A mildly symptomatic with 2 or more of the following but none listed in Category B or C i Lymphadenopathy hepatomegaly splenomegaly dermatitis parotitis recurrent or persistent URI sinusitis or otitis media Category B moderately symptomatic with conditions other than those listed in Category A or C that are attributed t HIV infection i Anemia bacterial meningitis pneumonia sepsis thrush cardiomyopathy cytomegalovirus infection diarrhea chronic or recurrent hepatitis HSV stomatitis HSV bronchitis or a an pneumonia Herpes zoster nepropathy leiomyosarcoma neoplasm of smooth muscle 9 Know when immunizations should be administered vs not administered a Cancer and HIV do not administer especially varicella and MMR b Minor illness can still administer vaccine hospitalized children might not be administered vaccines c Give combinations of vaccines at the same visit d Contraindications to vaccine administration i History of anaphylactic reaction to the vaccine or one of it s components egg ii Moderate to severe acute illness like in hospitalization iii For speci c vaccine pregnancy or allergy to some components GlGU 1 Dif culties children with CLEFT LIP and palate experience a Main concern is aspiration i Always feed slowly in an upright position ii Burp frequently iii Use widebased nipplesusually able to breastfeed 2 Discharge instructions for CELIAC DISEASE Genetic chronic malabsorption syndrome Gluten intolerance BROW barley rye oats and wheat lmpairs absorption in the small intestine Fatty stools SS diarrhea vomiting abdominal pain bloating weight loss growth impairment f Usually diagnosed between 918 months mapsm 3 Presentation and treatment of INTUSSUSCEPTION a Telescoping of one part of the intestine into the other b Peyer s patches rough areas inside of the intestines c Abrupt severe abdominal pain In a healthy infant d Bilious emesis e Currant jelly stools are a very late sign f Treated with a barium or air enema i If patient passes a brown stool the treatment worked 4 Assessment care and treatment of PYLORIC STENOSIS GE REFLUX and HIRSCHSPRUNG39S DISEASE a Pyloric Stenosis i Thickening of the pyloric canal ii More common in rstborn white males iii Symptoms become evident 28 weeks after birth 1 Projectile vomiting 2 Infant is hungry irritable and fails to gain weight the food is not getting to the intestines 3 Olive sized mass in the upper right quadrant 4 Visible peristaltic waves iv Diagnosed with an ultrasound v Surgically corrected 1 Burp frequently 2 Pedialyte for 46 hours b Gastroesophageal Re ux Disease GERD i More common in premature males ii GER is treated medically H2 antagonistszantac Pepcid or PPls prevacid Prilosec iii SS Poor weight gain recurrent vomiting irritability refusal to eat arching of the neck apnea coughing pneumonia and cough iv Thicken feedings burp frequently hold infant upright after feedings c Hirschsprung Disease i Lack of ganglion cells in rectum and colon so there is no peristalsis and colon becomes a megacolon ii No BM in rst 2448 hrs iii Ribbon like stools in older children iv Distended abdomen with chronic constipation and alternating diarrhea 5 Assessment care and treatment including teaching of VOLVULUS APPENDICITIS and TEF a Volvulus i Most dangerous ii Twisting of the intestine iii Bilious vomitingspinach green stools iv Surgical emergency b Appendicitis i Common between 1019 ii McBurney s point pain between umbilicus and right iliac crest iii Pain when gas moves up the abdomen from laproscopy iv Sudden relief of paingtperforationgt728 days of IV antibiotics c Esophageal atresia and trachoesophageal stula TEF iv foregut fails to separate and form esophagus and trachea Excessive salivation drooling sneezing respiratory distress Three Classic Signs of TEF Three C s 1 Cyanosis 2 Choking 3 Coughing Diagnosis NG tube resistance Xray ultrasound Medical emergency
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