Peds Hesi Study guide

Chamberlain College of Nursing NR322 ESE Study Guide Peds Hesi Study guide Medication calculations (IM, mg & ml; IV-gtt/min) Growth & Development Tables H 182-184 Infant (birth to one year) • Developmental milestones o Birth weight doubles by 6 months ▪ Triples by 12 months o Birth length increases by 50% at 12 months o Posterior fontanel closes by 8 weeks o Social smile occurs at 2 months o Head turns to locate sounds at 3 months o Moro reflex disappears around 4 months o Steady head control is achieved at 4 months o Rolls from abdomen to back and back to abdomen at 5-6 months o Plays peek-a- boo after 6 months o Transfers objects from hand to hand at 7 months o Develops stranger anxiety at 7-9 months o Sits unsupported at 8 months o Crawls at 10 months o Fine pincer grasp appears at 10 -12 months o Waves bye bye at 10 months o Walks with assistance at 10-12 months o Says a few words in addition to “mama” or “dada” at 12 months o Explores environment by motor and oral means • Erickson’s theory: developing a sense of trust ( trust vs mistrust) • Nursing implications o During hospitalization the infants emerging skills may disappear o If the parents are not bale to be with the infant the baby may be inconsolable due to separation anxiety o The nurse should plan to have the parents be part of the infant’s care and should encourage them to do so o Respect the infant’s schedule at home by assessing and implementing components as possible o Preparation and teaching should be directed to the family however the nurse should always speak to the infant especially while performing painful or stressful procedures o Toys for hospitalized infants include: ▪ Mobiles ▪ Rattles ▪ Squeaking toys ▪ Picture books ▪ Balls ▪ Colored blocks ▪ Activity boxes Toddler (1-3 years) • Developmental milestones o Birth weight quadruples by 30 months o Achieves 50% of adult height by 2 years o Growth velocity slows o Appears to be bowlegged and potbellied o All primary teeth (20) are present o Anterior fontanel closes by 12-18 months o Throws a ball overhand at 18 months o Kicks a ball at 24 months o Feeds self with spoon and cup at 2 years o Daytime toilet training can usually be started around 2 years o Two to three word sentences are spoken by 2 years o Three to four word sentence spoken by 3 years o Own first and last name can be stated by 2 ½ to 3 years o Temper tantrums are common • Erikson’s theory: developing a sense of autonomy ( autonomy vs doubt and shame) • Nursing implications o Give simple brief explanations before procedures keeping in mind that a 1 year old does not benefit from the same explanation as that given to a 3 year old o During hospitalization enforced separation from parents is the greatest threat to the toddler’s psychological and emotional integrity o Security objects or favorite toys from home should be provided for a toddler o Teach parents to explain their plans to the child o Respect the child’s routine and implement when possible o Expect regression like bed wetting o Toys for hospitalized toddlers include board and mallet, push pull toys, toy telephones, stuffed animals, story books with pictures, depending on the reason for hospitalization. Toddlers benefit form being taken to the hospital playroom when able because mobility is very important to their development o Toddlers are learning to name body parts and are concerned about their bodies o Very basic explanations should be given to toddlers about procedures o Autonomy should be supported by providing guided choices when appropriate Preschool child (3-6 years) • Developmental milestones o Each year a child gains about 5 lbs and grows 2 ½ to 3 inches o A child stands erect with more slender posture o A child learns to run jump skip and hop o A 3 year old can ride a tricycle o Handedness is established o A child uses scissors at 4 yrs o A child ties shoelaces at 5 yrs o A child learns colors and shapes o Visual acuity approaches 20/20 o Thinking is egocentric and concrete o A child uses sentences of five to eight words o A child learns sexual identity (curiosity and masturbation are common) o Imaginary playmates and fears are common o Aggressiveness at 4 yrs is replaced by more independence at 5 years • Erikson’s theory: developing a sense of initiative (initiative vs guilt) • Nursing implications o Nursing care for hospitalized preschoolers should emphasize understanding of the child’s egocentricity. Explain that he or she did not cause the illness and that painful procedures are not a punishment for misdeeds o The child’s questions should be answered at the child’s level use simple words that will be understood by the child o Therapeutic play or medical play that allows the child to act out his or her experiences is helpful o Fear of mutilation by procedures is common a band – aid may be quite helpful in restoring body integrity o Toys and play for the hospitalized preschooler include coloring books, puzzles, cutting and pasting, dolls, building blocks, clay and toys that allow the preschooler to work out hospitalization experiences depending on the reason for hospitalization o The preschooler needs preparation for procedures he or she should understand what is and what is not going to be “fixed” simple explanations and basic pictures are helpful let the child handle equipment or models of the equipment. School aged child (6-12 years) • Developmental milestones o Each year a child gains 4-6 lbs and about 2 inches in height o Girls may develop menarche o Loss of primary teeth and eruption of most permanent teeth occurs o Fine and gross motor skills mature o A child is able to write a script at 8 yrs o A child can dress self completely o Egocentric thinking is replaced by social awareness of others o A child learns cause and effect relationships o Socialization with peers becomes important o Molars ( 6 yrs erupt) • Erikson’s theory: developing a sense of industry (industry vs inferiority) • Nursing implications o The hospitalized school age child may need more support from parents than they wish to admit o Maintaining contact with peers and school activities is important during hospitalization o Explanation of all procedures is important they can learn from verbal explanations pictures and books and by handling equipment o Privacy and modesty are important and should be respected during hospitalization ( close curtains during procedures allow privacy during baths) o Participation inc are and planning with staff fosters a sense of involvement and accomplishment o Toys for this stage include board games, card games, and hobbies such as stamp collecting puzzles and video games Adolescent (12-19 years) • Developmental milestones o Girls’ growth spurts during adolescence begin earlier than boys’ ( may begin as early as 10 for girls) o Boys catch up at around 14 and continue to grow o Girls finish growth at around 15 boys at around 17 o Secondary sex characteristics develop o Adult like thinking begins around 15 they can problem solve and use abstract thinking o Family conflicts develop • Erikson’s theory: developing a sense of identity (identity vs role confusion) • Nursing implications o Hospitalization of adolescents disrupts school and peer activities they need to maintain contact with both o They should share a room with other adolescents o Illness treatment and procedures that alter the adolescent’s body image can be viewed by the adolescent as being devastating o Teaching about procedures should include time without the parents being present when parents are present direct questions to the adolescent not the parents o The age of assent for making medical decisions in children and adolescents ranges from 7-14 years parental consent is also needed for treatment o For prolonged hospitalizations adolescents need to maintain identity ( own cloths posters and visitors) a teen room or teen night is very helpful parents rooming in is discouraged o Some assessment questions should be asked without parents’ presence o When teaching adolescents the focus should be on the here and now “ how will this affect me today?” Hesi: • When does birth length double : 4 years • When does the child sit unsupported: 8 months • When does a child achieve 50% of adult height: 2 years • When does a child throw a ball overhand: 18 months • When does a child speak two to three word sentences: 2 years • When does a child use scissors: 4 years • When does a child tie his or her shoes: 5 years • Be aware that a girl’s growth spurt during adolescence begins earlier than a boy’s as early as 10 years of age • Temper tantrums are common in the toddler • Be aware that adolescence is a time when the child forms his or her identity and that rebellion against family values is common for this age group. • Knowledge of normal growth and development is used to evaluate interventions and therapy for example what behavior would indicate that thyroid hormone therapy for a 4 month old is effective? o You must know which milestones are accomplished by a 4 month old one correct answer would be has a steady head control which is an expected milestone for a 4 month old and indicates that replacement therapy is adequate for growth • Use facts and principles related to growth and development in planning teaching interventions o What task could a 5 year old diabetic boy expect to accomplish by himself? ▪ Let him choose the injection site this is possible for a preschooler to do and gives the child some sense of control. • School age children are in erikson’s stage of industry meaning they like to do and accomplish things peers are also becoming important for children of this age. • Age groups concepts of bodily injury o Infants: after 6 months their cognitive development allows them to remember pain o Toddlers: they fear intrusive procedures o Preschoolers: they fear body mutilation o School age children: they fear loss of control of their bodies o Adolescents: their major concern is change in body image • Accidents are major cause of death in children and adolescents teach parents and children developmental appropriate safety and accident prevention techniques Communicable Diseases Types H 190 B 638-647 Rubeola (measles) • A highly contagious viral disease that can lead to neurologic problems or death • Transmitted by direct contact with droplets from infected person • Contagious mainly during the prodromal period which is characterized by fever and upper respiratory symptoms • Classic symptoms o Photophobia o Koplik spots on the buccal mucosa ( white with blue centers inner cheek) o Confluent rash that begins on the face and spreads downwards o 1st have fever and dry cough for 2-3 days • Isolate for 5 days after rash immunize infants if in 72 hrs • Airborne precaution • Vaccine Available Varicella (chickenpox) • Viral disease characterized by skin lesions • Lesions that begin on the trunk and spread to the ace and proximal extremities • Progresses through macular, popular vesicular and postural stages • Transmitted by direct contact droplet spread or freshly contaminated objects • Communicable prodromal period to the time all lesions have crusted • Incubation period is 14-21 days most contagious day 1 and 2 before the rash actually appears. Will continue to be contagious un till al lesions are crusted over. • Airborne precaution , isolate the child from other children use oatmeal aveeno baths to sooth the itching • Keep pts nails short • Clinical manifestations: o Raised red/ pink bumps (papules) o Fluid filled blisters (vesicles) don’t scratch them o Crusted over/ scabbed vesicles o Fever o On back face scalp chest worse in throat eyes and vagina • Vaccine is available Rubella (German measles) • Contagious viral infection characterized by a red rash • Common viral disease that has teratogenic effect on the fetus during the first trimester of pregnancy • Transmitted by droplet and direct contact with infected person • Discrete red maculopapular rash that starts on the face and rapidly spreads to entire body • Rash disappears within 3 days • Droplet precaution ! • Clinical manifestations: o Rash with low grade fever o Rash starts on face and spreads rapidly • Keep in isolation until 5 days after rash started • Vaccine Available Pertussis (whooping cough) • Acute infectious respiratory disease usually occurring in infancy • Caused by gram negative bacillus • Begins with upper respiratory symptoms • Paroxysmal stage characterized by prolonged cough and crowing or whooping upon inspiration lasts from 4-6 weeks • Transmitted by direct contact droplet spread or freshly contaminated objects • Treated by administering erythromycin • Complications are pneumonia hemorrhage and seizures • Nursing management: antibiotics, humidity and oxygenation during paroxysm • Droplet precaution Parmyxovirus (mumps) AKA parotitis • Incubation 14-21 days • Symptoms: o Fever o Headache o Malaise o Parotid gland swelling and tenderness • Manifestation include o Submaxillary and sublingual infection o Orchitis o Menigoencephalitis • Transmitted by direct contact or droplet spread • Analgesics used for pain and antiseptics for fever • Bed rest maintained until swelling subsides • Vaccine available • Give soft foods and encourage fluids Nursing care for children with communicable disease • Isolate child during period of communicability • Treat fever with nonaspirin products • Report occurrence to the health department • Prevent child from scratching skin (cut nails apply mittens and provide soothing baths) • Administer diphenhydramine HCL (Benadryl) as prescribed for itching • Wash hands after caring for child and handling secretions or child’s articles Hesi • Children with German measles pose a serious threat to their unborn siblings the nurse should counsel all expectant mother especially those with young children to be aware of the serious consequences of exposure to German measles during pregnancy • Common childhood problems are encountered by nurses caring for children in the community or hospital settings the child’s age directly influences the severity and management of these problems Diarrhea H919 B • Increased number or decreased consistency of stools • Diarrhea can be a serious or fatal illness especially in infancy o Mild: slightly increased in number and have a more liquid consistency o Moderate: several loose or watery stools usually self limiting o Severe : watery stools are continuous will have fluid and electrolyte imbalances • Causes include but are not limited to o Infections bacterial or viral o Malabsorption problems o Inflammatory diseases o Dietary factors • Conditions associated with diarrhea are: o Dehydration o Metabolic acidosis o Shock • Assessment: o Usually occurs in infants o History of exposure to pathogens contaminated food or dietary changes o Signs of dehydration ▪ Poor skin turger ▪ Absence of tears ▪ Dry mucous membranes ▪ Weight loss ( 5-15%) ▪ Depressed fontanel ▪ Decreased urinary output increase specific gravity o Laboratory signs of acidosis ▪ Loss of bicarbonate (serum pH <7.35) ▪ Loss of sodium and potassium through stools ▪ Elevated hematocrit (hct) ▪ Elevated blood urea nitrogen (Bun) o Signs of shock ▪ Decreased blood pressure ▪ Rapid weak pulse ▪ Mottled to gray skin color ▪ Changes in mental status • Nursing plans and interventions o Assess hydration status and vital signs frequently o Monitor I/O o Do not take temperature rectally o Rehydrate as prescribed with fluids and electrolytes o Calculate IV hydration to include maintenance and replace fluids o Collect specimens to aid in diagnosis of cause o Check stools for pH glucose and blood o Administer antibiotics as prescribed o Check urine for specific gravity o Institute careful isolation precautions wash hands o Teach home care of child with diarrhea ▪ Provide child with oral rehydration solution such as pedialyte or lytren ▪ Child may temporarily need lactose free diet ▪ Child should not receive antidiarrheals ( Imodium AD) ▪ Do not give child grape juice orange juice apple juice cola or ginger ale these solutions have high osmolality o Emphasize on good hygiene for the patient and to provide proper skin care after each movement of bowel. Hesi • Add potassium to IV fluids only with adequate urine output Burns H 191 * NOT COVERED IN CLASS • Tissue injuries caused by heat electricity chemicals or radiation • 2nd leading cause of accidental death < 15 y/o • It is estimated that 75% of burns are preventable • Children under 2 ys have a higher mortality rate due to o Increased mortality <2 y/o b/c of greater body surface are o A greater pare of their body surface area is concentrated in the head and trunk compared to an older child or an adult therefore the younger child is most likely to have serious effects from burns to the trunk and head o Greater fluid volume (proportionate to body size) o Less effective cardiovascular responses to fluid volume shift • In childhood a partial thickness burn is considered a major burn if it involved more than 25% of the body surface • A full thickness burn is considered major if it involved more than 10% of body surface • Because of the changing proportions of the child especially the infant the rules of nines cannot be used to assess the percent of the burn • Use Lund-Browder for determining surface area and fluid replacement o Takes into account the changing proportion of the child should be used o Fluid needs should be calculated from the time of the burn • The formula for calculating fluid replacement and maintenance is based on the child’s body surface area and should include volume for burn losses and maintenance • Adequacy of fluid replacement is determined by evaluating urine output • Specific gravity should be less than 1.025 HESI • Urinary output for infants and children should b 1-2 ml/kg/hr Respiratory Important signs in children • Normal pulse and respiratory rates Age Pulse Respiratory Nursing Implications Newborn 100-160 30-60 These ranges are average only and vary with the sex age and condition of child always note whether the child is crying febrile or in some distress 1-11 months 100-150 25-35 1-3 years 80-130 20-30 3-5 years 80-120 20-25 6-10 years 70-110 18-22 10-16 years 60-90 16-20 • Signs of respiratory distress in children o Cardinal signs of respiratory distress ▪ Restlessness ▪ Increased respiratory rate ▪ Increased pulse rate ▪ Diaphoresis o Other signs of respiratory distress ▪ Flaring nostrils ▪ Retractions ▪ Grunting ▪ Adventitious breath sounds ( or absent breath sounds) ▪ Use of accessory muscles head bobbing ▪ Alterations in blood gases: decreased PO2 elevated PCO3 ▪ Cyanosis and pallor • Nursing implications o A pediatric client often goes into respiratory failure before cardiac failure o The nurse should know the signs of respiratory distress Obstructive Cystic fibrosis H 196-198 B 892-902 • Autosomal recessive disease that causes dysfunction of the exocrine glands (chromosome 7) • Tenacious mucus production obstructs vital structures • Multiple problems result from the exocrine dysfunction o Lung insufficiency ( most critical problem) o Pancreatic insufficiency o Increased loss of sodium and chloride in sweat • Pancreas ducts become damaged resulting in failure to secret the natural enzyme necessary to digest fats and protein food is poorly digested and thick mucus is also found in the intestines. • Assessment o Usually found in a white infant or child o Meconium ileus at birth (10-20 % of cases) o Recurrent respiratory infection o Pulmonary congestion o Steatorrhea (excessive fat greasy stools) o Foul smelling bulky stools o Delayed growth and poor weight gain o Skin that tastes salty when kissed (caused by excessive secretions from sweat glands) FIRST SIGN!! o Later: cyanosis, nail bed clubbing congestive heart failure (CHF), constipation, intestinal obstruction, rectal prolapse o Infant and children can have delayed bone age short stature and delayed onset of puberty o Usually have chest pain o Chronic, productive cough, crackles, wheeze • Nursing plans and interventions o Two positive sweat examinations o Genetic testing o Monitor respiratory status o Assess for signs of respiratory infection o Administer IV antibiotics as prescribed manage vascular access usually only for 14 days o Administer pancreatic enzymes ▪ Cotazym-S, Pancrease for infants with applesauce rice or cereal for an older child with good o Administer fat soluble vitamins ( A D E K) in water soluble form o Administer O2 and nebulizer treatment ( recombinant human (DNase) or dornase alfa (Pulmozyme) ) as prescribed ▪ Administration of oxygen • Oxygen hood: used for infants • Nasal prongs: provide low to moderate concentrations of oxygen • Tents: provide mist and oxygen Monitor child’s temperature keep edges tucked in keep child try ▪ Measurement of oxygenation • Pulse oximetry measures oxygen saturation of arterial hemoglobin noninvasively via a sensor that is usually attached to the finger or to or in an infant to sole of foot • Nurse should be aware of the alarm parameters signaling decreases SaO2 (usually < 95% ) • Blood gas evaluation is usually monitored in respiratory clients through arterial sampling • Norms : Po2- 80-100 mm Hg, PCO2 35-45 mmHg for children ( not infants and newborns) o Evaluate effectiveness of respiratory treatments o Teach family percussion and postural drainage techniques HESI o Teach dietary recommendations: high in calories high protein moderate to high in fat ( more calories per volume and moderate to low in carbohydrates ( to avoid an increase in CO2 drive) o Provide age appropriate activities o Refer family for genetic counseling o Chest physiotherapy is usually performed on to three times per day before meals to facilitate the removal of secretions from the lungs as coughing may stimulate vomiting o Oscillating vest for 30 minutes twice a day rather than chest physiotherapy • A child needs 150% of the usual calorie intake for normal growth and development Bronchiolitis H1h98 B 864-866 • Viral infection of the bronchioles that is characterized by thick secretions • Bronchiolitis is usually caused by respiratory system virus (RSV) and is found by readily transmitted by close contact with hospital personnel, families and other children. • Bronchiolitis occurs primarily in young infants • Assessment o History of Upper respiratory symptoms o Irritable distressed infant o Paroxysmal coughing o Poor eating o Nasal congestion o Nasal flaring o Prolonged expiratory phase of respiration o Wheezing rales can be auscultated o Deteriorating condition that is often indicated by shallow rapids respirations • Diagnosis o Chest x-ray to see hyperinflation patchy atelectasis and other signs of inflammation o Immunofluroscent or enzyme immunoassay techniques o Viral Culture • Nursing plan and Intervention o Isolate child (isolation of choice for RSV is contact isolation) o Assign nurses to clients with RSV who have to responsibility for any other children (to prevent transmission of the virus) o Monitor respiratory status observe for hypoxia o Clear airway of secretion using a bulb syringe for suctioning o Provide care in mist tent administer oxygen as prescribed o Maintain hydration (oral and IV fluids) o Monitor antiviral agents, ribavirin aerosol, if prescribed o Evaluate response to respiratory therapy o Administer palivizumb (synagis) to provide passive immunity against RSV in high risk children ( less than 2 years of age with history of prematurity, lung disease, or congenital heart disease) HESI • Is planning and providing nursing care a patent airway is always the priority of care regardless of age. Asthma H196 * LOOK IN BOOK!!! P 878-892 • Inflammatory reactive airway disease that is commonly chronic • Airways become edematous • The airway becomes congested with mucus • The smooth muscle of the bronchi and bronchioles constrict • Air trapping occurs in the alveoli • Assessment o History of asthma in the family o History of allergies o Home environment containing pets or other allergens o Tight cough ( nonproductive cough) o Breath sounds: coarse expiratory wheezing rales crackles o Chest diameter enlarges (late sign and symptom) o Increased number of school days missed during the past 6 months o Signs of respiratory distress • Nursing plan and intervention o Monitor carefully for increasing respiratory distress o Administer rapid acting bronchodilators and steroids for acute attacks o Maintain hydration ( oral fluids or IV) o Monitor blood gas values for signs of respiratory acidosis o Administer oxygen or nebulizer therapy as prescribed o Monitor pulse oximetry as prescribed ( > 95 % is normal) o Monitor theophylline levels (10-20 mcg. Ml is desired level) beta adrenergic agonists ( second generation sympathomimetic agents such as albuterol cromolyn sodium (intal) levalbuteral 9xopenex) budesonide (pulmicort) are the most common used medications o Administer cromolyn sodium prophylactically to prevent inflammatory response o Teach home care program including ▪ Identifying precipitating factors ▪ Reducing allergens in the home ▪ Use metered dose inhaler ▪ Monitoring peak expiratory flow rate at home ▪ Doing breathing exercises ▪ Monitoring drug actions dosages and side effects ▪ Managing acute episode and when to seek emergency care o Refer child and family for emotional and psychological counseling Drug/ route Indications Adverse reactions Nursing implications Epinephrine HCL Rapid acting Tachycardia Give subq , IV via (susphrine) / INH SUBCUT IM IV bronchodilator Drug of choice for acute asthma attack Hypertension Tremors Nausea nebulizer May repeat in 20 minutes Theophylline PO or Bronchodilator used Tachycardia Auscultate lungs IV in asthma to reverse Irritability before and after bronchospasm Palpitations administration Hypotension Monitor blood Nausea levels Vomiting Epiglottitis H 198 B 860-861 • Severe life threatening infection of the epiglottis, an inflammation of the tissue surrounding the epiglottis the long narrow structure that closes off the glottis during swallowing • Progresses rapidly causing acute airway obstruction • The organism usually responsible for epiglottis is haemophilus influenzae ( type B) • 2-8 years of age are those who are at risk • EMERGENCY !! – need intubation and culture is obtained during this time. • Assessment o Sudden onset o Restlessness o High fever o Sore throat dysphagia o Drooling o Mufflied voice o Child assuming upright sitting position with chin out and tongue protruding ( tripod position) o Distressed respiratory effort with inspiratory stridor • Diagnosis is usually based on a lateral neck radiograph with hyperextension • Visual inspection of the mouth and throat is contraindicated in child suspected of this. • Nursing plans and interventions o Encourage prevent with HIB vaccine o Maintain child in upright sitting position o Prepare for intubation or tracheostomy o Administer antibiotic as prescribed o Prepare for hospitalization in ICU o Restrain as needed to prevent extubation o Employ measures to decrease agitation and crying ▪ Provide a quiet environment with as little stress as possible to decrease anxiety and crying o It is important to reassure the parents that the child’s voice loss is temporary and to explain the need for the various pieces of equipment. • Step 1: Mild Intermittent Asthma o Symptoms < 2 times a week o Nighttime symptoms < 2 times a month o PEF > 80% of predicted value o (SABA prn) • Step 2: Mild Persistent Asthma o Symptoms: >2 a week, but <1 per day o Nighttime symptoms > 2 times a month o PEF is > 80% of predicted value o (LABA and ICS with SABA prn) • Step 3: Moderate Persistent Asthma o Daily symptoms o Nighttime symptoms > 1 night/week o PEF 60% - 80% of predicted value o (LABA and ICS - ?oral steroids) • Step 4: Severe Persistent Asthma Hesi Hint: o Continual symptoms o Frequent nighttime symptoms o PEF is < 60% of predicted value o (LABA, ICS, oral steroids, hospital?) • Do not examine the throat of a child with epiglottis ( do not put a tongue blade or an object into the throat) because of the risk of obstructing the airway completely Croup B 856 -860 • Also known as laryngotracheobronchitis • Is an upper respiratory infection • Boys are more affected than girls, greatest concerns in infants and children under the age of 6 years because of potential airway obstruction. • Clinical Manifestations: o Happens at Night or after extubation o Barking cough, hoarseness o Inspiratory stridor o Runny nose tachypnea o Have been ill for a couple of days with an upper respiratory symptoms • Diagnostic o Never do a throat culture o Pulse oximetry used to detect hypoxia o Radiograph of the upper airway may be taken to show a tapered symmetric subglottic narrowing called (steeple sign)in some children • Treatment Plan: o Inhaled racemic (nebulized) epinephrine o Corticosteroids o Antibiotics if bacterial o Antipyretics o Cool mist humidification ▪ Decreases spasm but NOT proven o Hydrate to thin mucous o Maintain patient airway o Asses respiratory status for nasal flaring sternal retraction and inspiratory strider o Monitor for cyanosis o Elevate head of the bed o Encourage and provide fluids either oral or IV o Avoid cough syrup and cold medicines which may dry and thicken secretions Infective RSV Tonsillitis H 199 B 830-831 • Inflammation of the tonsils • Tonsillitis may be viral or bacterial • Tonsilltitis may be related to infection by a streptococcus species • If related to strep treatment is very important because of the risk for developing acute glomerulonephritis or rhematic heart disease • Assessment o Sore throat HESI o Fever o Enlarged tonsils ( may have purulent discharge on tonsils) o Breathing may be obstructed ( tonsils touching, called kissing tonsils) o Throat culture to determine viral or bacterial cause • Nursing plans and interventions o Collect throat culture if prescribed o Instruct patient in home ▪ Encourage warm saline gargles ▪ Provide ice chips ▪ Administer antibiotics if prescribed ▪ Manage fever with acetaminophen o Provide surgical care if indicated ▪ Provide preoperative teaching and assessment ▪ Monitor for signs of postoperative bleeding • Frequent swallowing • Vomiting fresh blood • Clearing throat o Encourage soft foods and oral fluids ( avoid red fluids which mimic signs of bleedings) do not use straws o Provide comfort measures: ice collar helps with pain and with vasoconstriction o Teach that the highest risk for hemorrhage is during the first 24 hours and 5-10 days after surgery • Children can experience ear pain after tonsillectomy • Child should take a lot of liquid soft foods gelatin applesauce frozen juice pops and mashed potatoes DO NOT GIVE: citrus juices can cause a burning sensation • The nurse should be sure PT and PTT have been determined prior to a tonsillectomy. More important the nurse should ask whether there has been a history of bleeding prolonged or excessive and whether there is a history of any bleeding disorders in the family. Otitis media H 199 B 809-813 • Inflammation disorder of the middle ear • Otitis media may be suppurative or serous • Anatomic structure of the ear predisposes young child to ear infections • There is a risk of conductive hearing loss if untreated or incompletely treated • Assessment o Fever pain infant may pull at ear o Enlarged lymph nodes o Discharge from ear ( if drum is ruptured) o URI o Vomiting diarrhea • Nursing plans and interventions o Administer antibiotics if prescribed o Reduce body temperature ( can be very high with risk for seizures) ▪ Tepid baths ▪ Acetaminophen (Tylenol) if prescribed o Position child on affected side o Provide comfort measure: warm compress on affected ear o Teach home care: ▪ Teach to finish all prescribed antibiotics ▪ Encourage follow up visits ▪ Monitor for hearing loss ▪ Teach preventative care (smoking and bottle feeding when child is in supine position are predisposing factors) Hesi hint: • Respiratory disorders are the primary reason most children and their families seek medical care. Therefore these disorders are frequently tested on the NCLEX-RN knowing the normal parameters of respiratory rates and the key signs of respiratory distress in children is essential I DON’T KNOW WHAT THIS IS !! • Assessment with focus on lung sounds, color, positioning and VS (include nasal flaring) • Diagnostics • Nursing interventions/teaching Obstructive ▪ Medications (bronchodilators, etc) Infective Cardiovascular Congenital Heart disorders • Heart abnormalies that develop in utero and manifest at birth or shortly thereafter • Congenital heart disorder occur in 4-10 children per 1000 live births • They may be categorized as o Acyanotic ( VSD, ASD, PDA, coarctation of aorta , aortic stenosis ) ▪ Left to right shunts or increased pulmonary blood flow ▪ Obstructive defects o Cyanotic ( Tetralogy of fallot truncus arteriosus trnapsosition of the great vessels ▪ Right to left shunts or decreased pulmonary blood flow ▪ Mixed blood flow o Hemodynamic classification maybe used ▪ Increased pulmonary blood flow defects ( ASD, VSD, PDA) ▪ Obstructive defects (coarctation of aorta , AS) ▪ Decreased pulmonary blood flow defects (tetralogy of Fallot) ▪ Mixed defects (TGV, TA) Acyanotic heart defects H 200-201 B table 26-7 • Ventricular septal defect (VSD, increased pulmonary blood flow) o There is a hole between the ventricles o Oxygenated blood from left ventricle is shunted to right ventricle and recirculated to the lungs o Small defects may close spontaneously o Large defects cause Eisenmenger syndrome or congestive heart failure and require surgical closures • Atrial Septal Defect (ASD increased pulmonary blood flow) o There is a hole between the atria o Oxygenated blood from the left atrium is shunted to the right atrium and lungs o Most defects do not compromise children seriously o Surgical closure is recommended before school age. It can lead to siginifcant problems such as congestive heart failure or atrial dysrhythmias later in life if not corrected • Patent ductus Arteriosus (PDA, increased pulmonary blood flow) o There is an abnormal opening between the aorta and the pulmonary artery o It usually closes within 72 hours after birth o If it remains patent oxygenated blood from the aorta returns to the pulmonary artery o Increased blood flow to the lungs causes pulmonary hypertension o It may require medical intervention with infomethacin (idocin) administration or surgical closure • Coarctation of the Aorta (obstruction of blood flow from the ventricle) o There is an obstructive narrowing of the aorta o The most common sites are the aortic valve and the aorta near the ductus arteriosis o A common finding is hypertension in the upper extremities and decreased or absent pulses in the lower extremities o It may require surgical correction • Aortic stenosis ( AS obstruction of blood flow from the ventricle ) o It is an obstructive narrowing immediately before at or after the aortic valve ( it is most commonly valvular) o Oxygenated blood from the left ventricle into systemic circulation is diminished o Symptoms are caused by low cardiac output o It may require surgical correction Cyanotic heart defects B table 26-8 H 202 • Traditional three T’s of cyanotic heart disease o Tetraolgy of Fallot is a combination of four defects ▪ VSD ▪ Aorta placed over and above the VSD (overriding aorta) ▪ Pulmonary stenosis (PS) that obstructs right ventricular outflow ▪ Right ventricular hypertrophy ( the severity of the pulmonary stenosis is related to the degree of right ventricular hypertrophy and the extent of shunting o TA in which one artery (truncus) rather than two arteries (aorta and pulmonary artery) arise from both ventricles o TGA in which the pulmonary artery leaves the left ventricle and the aorta exits from the right ventricle • Tetralogy of Fallot ( decreased pulmonary blood flow) o Tetraology of fallot consits of four defects ▪ PS ▪ VSD ▪ Overriding aorta ▪ Right ventricular hypertrophy o Cyanosis occurs because unoxygenated blood is pumped intot he systemic circulation o Decreased pulmonary circulation occurs because of the PS o The children experiences “tet” spells of hypoxic episodes they are relieved by the child’s squatting or being placed in the knee chest position o Tetralogy of fallot requires stages surgery for correction • Truncus arteriosus o Pulmonary artery and aorta do not separate o One main vessels receives blood from the left and right ventricles together o Blood missed in right and left ventricles through a large VSD resulting in cyanosis o Increased pulmonary resistance results in increased cyanosis o This congenital defect requires surgical correction only the presence of the large VSD allows for survival at birth • Transposition of the great vessels (mixed blood flow) o The great vessels are reversed o The pulmonary circulation arises from the left ventricle and the systemic circulation arises from the right ventricle o This is incompatible with life unless coexisting VSD, ASD and or PDA is present o The diagnosis is a medical emergency the child is given prostaglandin E (PGE) to keep the ducts open Rheumatic fever H205 NEVER COVERED IN CLASS B 956-957 • Inflammatory disease • Is the most common cause of acquired heart disease in children it usually affects the aortic and mitral valves of the heart • Associated with an antecedent beta hemolytic streptococcal infection • Is a collagen disease that injures the heart blood vessels joints and subcutaneous tissues • Assessment o Chest pain shortness of breath (carditis) o Tachycardia even during sleep o Migratory large joint pain o Chorea (irregular involuntary movements) o Rash (erythema marginatum) o Subcutaneous nodules over bony prominences o Lab findings ▪ Elevated erythrocytes sedimentation rate (ESR) ▪ Elevated ASO (antistreptolysin O) titer • Nursing plans and interventions o Monitor vital signs (every 4 hours) o Asses for increasing signs of cardiac distress o Encourage bed rest ( as needed during febrile illness) o Assist with ambulation o Reassure child and family that chorea is temporary o Administer prescribed medications ▪ Penicillin or erythromycin ▪ Aspirin for anti-inflammatory and anticoagulation actions o Teach home care program ▪ Explain the necessity for prophylactics • Antibiotics taken either orally or IM ( oral penicillin BID) • IM penicillin G each month ▪ Inform dentist and other health care providers of diagnosis so they can evaluate the necessity for prophylacic antibiotics Druge/ route Indication Adverse reactions Nursing implications Penicillin G - prophylaxis for - Allergic reaction - Penicillin G is (bicillin) IM recurrence of ranging from rashes released very slowly rheumatic fever to anaphylactic over several weeks shock and death given sustained levels of concentration - Have emergency equipment available wherever medication is administered - Always determine existence of allergies to penicillin and cephalosporins check chart and record and inquire of client or family Caring for children with congenital heart disease (CHD) • Manifestations of CHD o Murmur (present or absent thrill or rub) o Cyanosis , clubbing of digits (usually after age 2) o Poor feeding poor weight gain failure to thrive (FFT) o Frequent regurgitaiton o Frequent respiratory infections o Activity intolerance fatigue • The following are assessed o Heart rate and rhythm and heart sounds o Pulses (quality and symmetry) o Blood pressure (upper and lower extremities) o History of maternal infection during pregnancy • Nursing Plan and interventions o Provide care for the child with cardiovascular dysfunction ▪ Maintain nutritional status feed small frequent feedings provide high calories formula ▪ Maintain hydration (polycythemia increased risk for thrombus formation) ▪ Maintain neutral thermal environment ▪ Plan frequent periods of rest ▪ Organize activities as to disturb child only as indicated ▪ Administer digoxin and diuretics as prescribed ▪ Monitor or signs of deteriorating condition or CHF ▪ Teach family the need for prophylactic antibiotics prior to any dental or invasive procedures due to risk of endocarditis o Assist with diagnostic tests and support family ▪ ECG ▪ Echocardiograph o Prepare family and child for cardiac catheterization (conducted when surgery is probable or as intervention for certain procedures) ▪ Risk of catheterization are similar to those for a child undergoing cardiac surgery • Arrhythmias • Bleeding • Perforation • Phlebitis • Arterial obstruction at the entry sites ▪ Children requires reassurance and close monitoring post catheterization • Vital signs • Pulses • Incision site • Cardiac rhythm ▪ Prepare family and child as able for surgical intervention if necessary HESI ▪ Prepare child as appropriate for age • Show to ICU • Explain chest tubes IV lines monitor dressings and ventilator • Show family and child waiting area for families • Use a doll or a drawing for explanations • Provide emotional support • Basic difference between cyanotic and acyanotic defects: o Acyanotic: has abnormal circulation however all blood entering the systemic cirulation is oxygenated o Cyanotic: has abnormal circulation with unoxygenated blood entering the systemic circulation o CHF is more often associated with acyanotic defects • Polycythemia is common in children with cyanotic defects • The heart rate of a child increases with crying or fever • Infants may require tube feeding to conserve energy infants being tube fed need to continue to satisfy sucking needs Managing digoxin Administration Toxicity • Prior to administering digoxin nurse must take child’s apical pulse for 1 minute to asses for bradycardia. Hold dose if pulse if below normal heart rate for child’s age • Therapeutic blood levels are 0.8-2.0 ng/mL • Families should be taught safe home administration of digoxin o Administer on regular basis do not • Nurse must be acutely aware of the signs of digoxin toxicity a small child or infant cannot describe feeling bad or nauseated • Vomiting is common early sign of toxicity this symptom is often overlooked because infants commonly “spit up” • Other GI symptoms include anorexia diarrhea and abdominal pain • Neurological signs include fatigue skip or make up for missed dose o Give one hour before or 2 hours after meals do not mix with formula or food o Take child’s pulse prior to administration and know when to call the care giver o Keep in safe place muscle weakness and drowsiness • Hypokalemia can increase digoxin toxicity Neurological Down’s syndrome H 206 • Most common chromosomal abnormality in children • Evidence by various physical characteristics and by mental retardation • Results from trisomy of chromosome 21 and in less then 5% of cases a translocation of chromosome 21 • Also associated with maternal age over 35 • Assessment o Common physical characteristics ▪ Flat broad nasal bridge ▪ Inner epicanthal eye folds ▪ Upward outward slant of eyes ▪ Protuding tongue ▪ Short neck ▪ Transverse palmar crease (simian) ▪ Hyerextensible and lax joints (hyptonic) o Common associated problems ▪ Cardiac defects ▪ Respiratory infections ▪ Feeding difficulties ▪ Delayed developmental skills ▪ Mental retardation ▪ Skeletal defects ▪ Altered immune function ▪ Endocrine dysfunctions • Nursing plans and interventions o Assist and support parents during the diagnostic process and management of child’s associated problems o Assess and monitor growth and development o Teach use of bulb syringe for suctioning nares o Teach signs of respiratory infections o Assist family with feeding problems o Feed to back and side of mouth o Monitor for signs of cardiac difficulty or respiratory infection o Refer family to early intervention program o Refer to other specialists as indicated nutritionist speech therapist physical therapist and occupational therapist HESI • The nursing goal in caring of a child with down syndrome is to help the child reach his or her optimal level of functioning Spina bifida H 207 B • Malformation of the vertebrae and spinal cord resulting in varying degrees of disability and deformity • Spina bifida occulta is a defect of vertebrae only. No sac is present and it is usually a benign condition although bowel and bladder problems may occur • With meningocele and myelomeningocele a sac is present at some point along the spine • Meningocele contains only meninges and spinal fluid and has less neurologic involvement than a myelomeningocele • Myelomeningocele is more severe than meningocele because the sac contains spinal fluid meninges and nerves • The severity of neurologic impairment is determined by the anatomic level of the defect • Every child with a history of spina bifida should be screened for latex allergies • Prevention: folic acid 0.4 mg is taken daily at least 3 month prior to pregnancy those dose is increased to 0.6 mg/day when pregnant • Assessment o Spina bifida occulta: dimple with or without hair tuft at base of spine o Presence of sac in myelomeningocele is usually lumbar or lumbosacral o Flaccid paralysis and limited or no feeling below the defect o Head circumference at variance with norms on growth grids o Associated problems ▪ Hydrocephalus (90% with myelomeningocele) ▪ Neurogenic bladder poor anal sphincter tone ▪ Congenital dislocated hip ▪ Club feet ▪ Skin problems associated with anesthesia below the defect ▪ Scoliosis • Diagnostics o MRI and CT of spine • Nursing intervention o Preoperative: place infant in prone position ▪ Keep sac free of stool and urine ▪ Cove sac with moist sterile dressing ▪ Elevate foot of bed and position child on his or her abdomen with legs abducted ▪ Measure head circumference at least every 8 hours or every shift check fontanel ▪ Assess neurologic function ▪ Monitor for signs of infection ▪ Empty bladder using crede method or catheterized if needed ▪ Promote parent infant bonding o Postoperative : place infant in prone position ▪ Make same assessments as preoperatively ▪ Asses incision for drainage and infection ▪ Assess neurologic function o Long term ▪ Teach family catheterization program when child is young ▪ Help older children to learn self catherterization ▪ Administer pro banthine or urecholine as prescribed to improve continence ▪ Develop bowel program • High fiber diet • Increased fluids • Regular fluids • Suppositories as needed ▪ Asses skin condition frequently ▪ Assist in ROM exercises, ambulation and bracing if client is able ▪ Coordinate with team members: neuro, othopedist, urologist, PT and nutritionist o Support independent functioning of child o Assist family to make realistic developmental expectations of the child. Hydrocephalus H209-210 B • Is the body’s response to an imbalance between the production and absorption of the CSF leading to increase in the CSF volume • Commonly associated with myelomeningocele – spinal fluid filled meningeal sac that contains a portion of the spinal fluid and nerves protruding through the vertebral defect • Noncommunicating is the one most associated with children o Come from an obstruction in the ventricular system that impedes the flow of the CSF and prevents it from entering the subarachnoid space • Assess head circumference from birth until the age of two in all well visits. • Assessment o Older children classic signs of ICP ▪ Change in LOC ▪ Irritability ▪ Vomiting ▪ Headache on awakening ▪ Motor dysfunction ▪ Unequal pupil response ▪ Seizures ▪ Decline in academics ▪ Change in personality o Signs of increased ICP in infants ▪ Irritability lethargy ▪ Increasing head circumference ▪ Bulging fontanels ▪ Widening suture lines ▪ “Sunset eyes” ▪ High pitched cry • Nursing plan and interventions o Prepare infancy and family for diagnostic procedures o Monitor for S/S of increased ICP o Maintain seizure precautions o Elevate head of the bed o Prepare parent for surgical procedure ▪ Shunt is inserted into ventricles ▪ Tubing is tunneling through skin to peritoneum where it drains excess of CSF o Postoperative ▪ Asses of signs of shunt malfunctions • Infants o Changes in size signs of bulging tenseness and separation in fontanels and suture lines Hesi: o Irritability lethargy or seizure activity o Altered vital signs and feeding behavior • Older children: increase ICP o Change in LOC o Complaint of headache o Changes in customary behavior (sleep patterns, developmental capabilities) ▪ Assess for signs of infection (meningitis) ▪ Monitor I and O closely o Teach home care program ▪ Teach to watch for signs of increased ICP or infection ▪ Note that child will eventually outgrow shunt and show symptoms of difficulty ▪ Note that child will need shunt revision ▪ Provide anticipatory guidance for potential problems with growth and development. o Medication to give is: acetazolamide • The signs of increased intracranial pressure are the opposite of those of shock: o Shock: increased pulse decreased blood pressure o Increased ICP: decreased pulse increased blood pressure • Baseline data on the child’s usual behavior and level of development are essential so changes associated with increased ICP can be detected early • Do not pump shunt unless specifically prescribed the shunt is made up of delicate valves and pumping changes the pressure within the ventricles Seizures H 210-211 B • Uncontrolled electrical discharges of neurons in the brain • Seizures are more common in children under the age of 2 • Seizures can be associated with immaturity of the CNS fever infection neoplasms cerebral anoxia and metabolic disorder • Seizures are categorized as o General seizures ▪ Tonic clonic (grand mal) consciousness is lost • Tonic phase generalized stiffness of entire body • Clonic phase: spasm followed by relaxation ▪ Absence (petit mal) momentary loss of consciousness posture is maintained has minor face eye hand movements ▪ Myoclonic: sudden brief contractures of muscle or group of muscles no postictal state may or may not be symmetrical or include loss of consciousness o Partial seizures arise from a specific area in the brain and cause limited symptoms examples are focal and psychomotor seizures • Assessment o Tonic clonic (grand mal) ▪ Aura ( a warning sign of impending seizure) ▪ Loss of consciousness ▪ Tonic phase: generalized stiffness of entire body ▪ Apnea cyanosis ▪ Clonic phase: spasms followed by relaxation ▪ Pupils dilated and nonreactive to light ▪ Incontinence ▪ Postseizure: disoriented sleepy o Absence seizures (petit mal) ▪ Usually occur between 4-12 years of age ▪ Last 5-10 seconds ▪ Child appears to be inattentive day dreaming ▪ Poor performance in school • Diagnostics o History of having any form of seizures • Nursing intervention o Maintain airway during seizure: turn client on side to aid ventilation Hesi o Do not restrain client o Protect client from injury during seizure and support head (avoid neck flexion) o Document seizure noting all data in assessment o Maintain seizure precaution ▪ Reduce environmental stimuli as much as possible ▪ Pad side rails or crib rails ▪ Have suction equipment and oxygen quickly accessible ▪ Tape oral airway to the head of the bed o Support diagnostic tests EEG CT scan o Support during workup for infections such as meningitis o Administer anticonvulsant medication ▪ For tonic: phenytoin (dilantin) carbamazepine (tegretol) ohenobarbital (Luminal) fosphenytoin (verebyx) ▪ For absence: ethosuximide (zarontin) valproic acid (depakene) o Monitor therapeutic drug levels o Teach family about drug administration dosage action and side effects • Medication noncompliance is the most common cause of increased seizure activity • Do not use tongue blade padded or not during a seizure it can cause traumatic damage to oral cavity Reye’s syndrome H212 B • Acute rapidly professing encephalopathy and hepatic dysfunction • Causes include antecedent viral infections such as influenza or chickenpox • Occurrence is often associate with aspirin use • Disease is staged according to the clinical manifestations to reflect the severity of the condition • Assessment o Usually occurs in school aged children o Lethargy rapidly progressing to deep coma (marked cerebral edema) o Vomiting o Hypoglycemia • Diagnostics o Elevated SGOT/ AST SGPT ALT lactate dehydrogenase serum ammonia decreased PT • Nursing intervention o Provide critical care early in syndrome o Monitor neurologic status frequent noninvasive assessments and invasive ICP monitoring o Maintain ventilation o Monitor cardiac parameters ( invasive cardiac monitoring system) o Administer mannitol if prescribed to increased blood osmolality o Monitor I/O accurately o Care for foley catheter o Provide family with emotional support Muscular dystrophy H 213 • Inherited disease of the muscles causing muscle atrophy and weakness • The most serious and most common of the dystrophies is Duchene muscle dystrophy an X linked recessive disease affecting primarily males • Duchenne muscle dystrophy appears in early childhood ( ages 3-5 ) it rapidly progresses causing respiratory or cardiac complications and death usually by 25 years of age • Assessment o Waddling gait lordosis o Increasing clumsinees muscle weakness o Gowers sign : difficulty rising to standing position has to “walk” up legs using hands o Pseudohypertrophy of muscles (especially noted in calves) due to fat deposits o Muscle degeneration especially the thighs and fatty infiltrates (detected by muscle biopsy) cardiac muscles also involved o Delayed cognitive development o Later in disease: scoliosis respiratory difficulty and cardiac difficulties o Eventual wheelchair dependency confinement to bed • Diagnostics o Elevated CPK and SGOT/AST • Nursing intervention o Provide supportive care o Provide exercises (active and passive) o Prevent exposure to respiratory infection o Encourage a balanced diet to avoid obesity o Support family’s grieving process o Support participation in the Muscle dystrophy association o Coordinate with health care team Brain tumor H 212-213 • Second most common cancer in children • Most pediatric brain tumors are infratentorial making them difficult to excise surgically • Tumors usually occur close to vital structures • Gliomas are the most common childhood brain tumors • Assessment o Headache o Vomiting (usually in the morning) often without nausea o Loss of concentration o Change in behavior or personality o Vision problems tilitng of head o In infants widening sutures increased frontal occipital circumference tense fontanel • Diagnostics • Nursing intervention o ID baseline neurologic functioning o Support child and family during diagnostic workup and treatment o If surgery is treatment of choice provide preoperative teaching ▪ Explain that head will be shaved ▪ Described ICU dressings IV lines etc ▪ ID child’s developmental level and plan teaching accordingly o Assess family’s response to the diagnosis and treat family appropriately o After surgery position client as prescribed by the HCP o Monitor IV fluids and output carefully overhydration can cause cerebral edema and increased ICP o Administer steroids and osmotic diuretics as prescribed o Support child and fmailty to promotw optimum duncitoning postoperatively Hesi • Headache on awakening is the most common presenting symptom of brain tumors • Most postoperative clients with infratentorial tumors are prescribed to lie flat or turn to either side a large tumor may require that the child not be turned to operative side • Suctioning coughing straining and turning cause increased ICP Bacterial meningitis H 211 B • Bacterial inflammatory disorder of the meninges that cover the brain and spinal cord • Meningitis is usually caused by haemophilus influenzae type B strep pneumoniae and neisseria meningitides • The usual source of bacterial invasion is the middle ear or the nasopharynx • Other sources of bacteria from wounds include fractures of the skull lumbar punctures and shunts • Assessment o Older children ▪ Classic signs of increased ICP ▪ Fever, chills ▪ Neck stiffness opisthotonos ▪ Photophobia ▪ Positive kernig sign ( inability to extend leg when thigh is flexed anteriorly in hip) ▪ Positive brudzinski sign (neck flexion causing adduction and flexion movements of lower extremities o Infants ▪ Absence of classic signs ▪ Ill with generalized symptoms ▪ Poor feedings ▪ Vomiting irritability ▪ Bulging fontanel ( IMPORTANT) ▪ Seizures • Diagnostics o Lumbar puncture shows ▪ Increased WBC ▪ Decreased glucose ▪ Elevated protein ▪ Increased ICP ▪ Positive culture of meningitis • Nursing intervention o Administer antibiotics (usually ampicillin penicillin or chlormphenicol) and antipyretics as prescribed o Isolate for at least 24 hours o Monitor vital signs and neurological signs o Keep environment quiet and darkened to prevent overstimulation o Implement seizure precautions o Position for comfort head of the bead slightly elevated with client on side if prescribed Hesi o Measure head circumference daily in infants o Monitor I/O closely o Administer HIb vaccine • Monitor hydration status and IV therapy carefully with meningitis there may be inappropriate ADH secretions causing fluid retention (cerebral edema) and dilutional hyponatremia Celebral palsy H • Nonprogressive injury to the motor centers of the brain causing neuromuscular problems of spasticity of dyskinesia (involuntary movements) • Associated problems may include mental retardation and seizures • Causes include o Anoxic injury before during or after birth o Maternal infections o Kernicterus o Low birth weight (major risk factor) • Assessment o Persistent neonatal reflexes 9moro tonic neck) after 6 months o Delayed developmental milestones o Apparent early preference for one hand o Poor suck tongue thrust o Spasticity ( may be described as “difficulty with diapering” by mother or caregiver) o Scissoring of legs (legs are extended and crossed over each other feet are plantarflexed a common characteristic of spastic CP) o Involuntary movements o Seizures o • Diagnostics o Clinical findings • Nursing intervention o Identify Cp through follow up of high risk infants such as premature infants o Refer to community based agencies o Coordinate with PT, OT , speech, nutritionist, orthopedic surgeon and neurologist o Support family through grief process at diagnosis and throughout the child’s life caring for severely affected children is very challenging o Administer anticonvulsant medication : phenytoin (dilantin) o Administer diazepam (Valium) for muscle spasms Hesi • Feed infants or child with CP using nursing interventions aimed at preventing aspiration position child upright and support the lower jaw ADD/ADHD H 207 • Attention Deficit Disorder = CNS processing aberration • Attention Deficit Hyperactivity Disorder CNS Processing aberration with impulsivity and hyperactivity • M 4 x > F 25% - 1st degree relative • + family stress, poverty, decreased nutrition, prenatal stress or decreased oxygen • ADD - Difficulty concentrating – “river” “machines” - cannot organize, loses things, forgets, failure to listen when spoken directly to, forgets to finish activity, feels different from others, isolated • ADHD – above + blurts out answers before finished, impulsive, driven by a motor – go!, aggressive (boys), mood swings (girls) • Ritalin + simplify environment, behavior modification, self esteem, community caring Renal Acute glomerulonephritis (AGN) H214 B • Immune complex response to an antecedent beta hemolytic streptococcal infection of the skin or pharynx, antigen antibody complexes become trapped in the membrane of the glomeruli causing inflammation and decreased glomerular filtration • Assessment o Recent streptococcal infection o Mild to moderate edema ( often confined to face) o Irritability lethargy o Hyerptension o Dark colored urine (hematuria) o Slight to moderate proteinuria • Diagnostics o Elevated sntistrptolysin (ASO) titer o Elevated BUN and creatinine • Nursing interventions o Provide supportive care Hesi o Monitor vital signs ( especially blood pressure) frequently o Monitor I/O closely o Weight daily o Provide low sodium diet with no added salt low potassium if oliguric o Encourage bed rest during acute phase ( usually 4-10 days) o Administer antihypertensives if prescribed o Monitor for seizures (hypertensive encephalopathy) o Monitor for signs of CHF and renal failure (uncommon) • Decreased urinary output is the first sign of renal failure UTI H 215 B • Bacterial infection anywhere along the urinary tract ( most ascend) • Poor hygiene or uncircumcised males are at risk • Assessment o Infants ▪ Vague symptoms ▪ Fever ▪ Irritability ▪ Poor food intake ▪ Diarrhea ▪ Vomiting ▪ Jaundice ▪ Strong smelling urine o Older children ▪ Urinary frequency ▪ Hematuria ▪ Enuresis ▪ Dysuria ▪ Fever o Adolescent ▪ Often as a result of sex encounters often deny symptoms o Escherichia coli in urine cultures • Diagnostics o Clean catch U/A Method Description for Children and infants Clean Catch - Best obtained by using a urine bag to catch the specimen - Apply from side to side or front to back. Diaper should be applied over the bag - Check child frequently to note urination Catheterization - sterile feeding tube is often used to catheterize small children and infants Sterile Specimen - in small infants it is best collected by the physician performing a bladder tap. Urine is aspirated through needle inserted directly into the bladder the nurse is responsible for making sure infant is appropriately hydrated and restrained during the procedure • Nursing interventions o Suspect and assess for UTI in infants who are ill o Assess for recurrent urinary tract infections in infants and young boys, UTI may indicate structural abnormalities of the urinary system o Collect clean voided or catheterized specimen as prescribed. o Administer antibiotics as prescribed o Teach home program ▪ Instruct to finish all prescribed medication ▪ Note that follow up specimens are needed ▪ Teach to avoid bubble baths ▪ Teach to increase acidic oral fluids ( apple cranberry) ▪ Instruct to void frequently ▪ Teach to clean genital area from front to back ▪ Note symptoms of recurrence ▪ Avoid caffeine, different sex partners s