WCC NUR 106: Exam Study Guide for Modules G4, G6, and G10 - Pediatric Nursing Essentials

WCC NUR 106: Exam Study Guide for Modules G4, G6, and G10 - Pediatric Nursing Essentials -failure to thrive -spitting up, regurgitation -constipation - -Impaired functional integrity -nausea, vomiting -diarrhea -GI track anomalies - -GI losses of fluid; absorption disorders The passage of black , tarry stools suggestive of bleeding from the upper GI tract - -melena is Bleeding from the perianal area, hemorrhoids, or lower GI tract would be bright red - -Rectal bleeding is 60-70% water - -Dehydration -diarrhea -sweating -fever -DKA -renal disease, cardiac anomalies -drugs -trauma - -Conditions in which dehydration can develop quickly are Clues to the extent of dehydration - -What do clinical signs of dehydration provide -appropriate for use when the child is alert, awake, and not in danger -treats mild to moderate dehydration in children -management at home for mild cases of dehydration *Ondansetron known as Zofran to reduce emesis - -Oral rehydration management or oral rehydration therapy -initiated when child is unable. To ingest sufficient amounts of fluid and electrolytes -treats pts with severe dehydration- uncontrolled vomiting, unable to drink, severe gastric distention -example:Pedialyte - -Parenteral Fluid Therapy sudden increase in frequency and change in consistency of stools -*the leading cause of illness in children younger than 5yrs of age - -Acute diarrhea The most common viral pathogen to cause acute diarrhea in children - -Rotavirus Parasite that causes acute diarrhea - -Giardia lamblia -glucose intolerance-watery, explosive stools -foul smelling, greasy, bulky stools- fat malabsorption -diarrhea developing after introducing cow's milk, fruits, or cereal-enzyme deficiency or protein intolerance -neutrophils or RBCs in the stool- indicate bacterial gastroenteritis or IBD - -Chronic diarrhea diagnostic evaluations -oral rehydration solutions 1st then moderate dehydration -administered in small quantities at frequent intervals - -Chronic diarrhea therapeutic management No!!!! - -Are antidiarrheal meds recommended for acute diarrhea? -rotavirus vaccine -teach personal hygiene *Most diarrhea is spread by the fecal-oral route Make sure water supply is clean and protected from contamination and prepare food carefully - -Chronic diarrhea prevention -accurate I/O measurement -provide perianal skin care -avoid taking temp rectally; this stimulates the bowel, increasing passage of stool -educate family about proper hand washing and disposal of solid diapers, clothes, and bed linens - -Chronic diarrhea nursing considerations Person to person transmission most common in children - -ProtozoaGiardiasis Cramps and diarrhea - -Protozoa- Giardiasis clinical manifestations -Metronidazole or Flagyl, Tinidazole or Tindamax -Encourage meticulous sanitary practices -Discourage infected children or those with diarrhea from swimming in pools or lakes until they are infection free - -Protozoa-Giardiasis therapeutic management -crowded conditions, such as in classrooms or daycare centers -infection begins when the eggs are ingested or inhaled - -Helminths or Pinworms patho Tape test to obtain la specimen for fecal smear - -Clinical manifestations of helminths -Mebendazole or Vermox -all bed linens and clothes must be washed in hot water -encourage hand washing after toileting and before eating, keeping a child's fingernails short, daily showering rather than tub - -Helminth therapeutic tx An alteration in frequency, consistency, or ease of passage of stool -may be secondary to other disorders -idiopathic constipation has no known cause -chronic constipation may be due to environmental or physiological factors - -Constipation patho -antacids -diuretics -antihistamines -opioids -iron supplements - -What meds may cause constipation? First meconium should be passed within 24 to 36 hours of life; if not, assess for Hirschsprung disease Hypothyroidism Meconium plug or meconium ileus (cystic fibrosis) - -Constipation in Newborn Period Often related to diet Constipation in exclusively breastfed infants is almost unknown *Breastfed infants may have decreased stools because of more complete digestion of breast milk with little residue *Formula fed infants may develop constipation *Add or increase the amount of cereal, vegetables, and fruit in the infant's diet - -constipation in infancy Onset at this age is often the result of environmental changes, stresses, and changes in toileting patterns -Encopresis is inappropriate passage of feces, often with soiling -may result from stress -relationship to UTIs - -Constipation in Childhood -increase dietary fiber and fluids -establishing a bowel routine -stool softeners such as Docusate or Lactulose may be helpful -polyethylene glycol or MIralax also an effective laxative - -Constipation in childhood tx Also called congenital a ganglion if megacolon -Mechanical obstruction from inadequate motility of the intestine -absence of ganglion cells in colon - -Hirschsprung Disease patho -foul smelling ribbon like stool -failure to pass meconium within 24-48hrs after birth -refusal to feed, abdominal distention, constipation - -Hirschsprung Disease clinical manifestations X-ray, barium enema Confirm diagnosis with rectal biopsy - -Hirschsprung Disease diagnostic evaluation -surgical removal of the aganglionic portion of the bowel to relieve obstruction, restore normal motility and preserve the function of the external anal sphincter - -Hirschsprung Disease therapeutic management -empty bowels with saline enemas -decrease bacterial flora with antibiotics -prepare child psychologically- especially when a colostomy is performed and the child is of at least preschool age, explain in concrete terms with visual aids - -Hirschsprung Disease pre-op care -fluids -may need auntiemetic drugs - -Vomiting Therapeutic management -Give ad lib amts of glucose-electrolyte solution to an alert child to restore water & electrolytes - Include carbohydrates to spare body protein & avoid ketosis - Small, frequent feedings of food or fluids are preferred - Place vomiting child on side or semireclining position to prevent aspiration - Emphasize need for child to brush their teeth or rinse their mouth after vomiting - -Vomiting nursing management Defined as transfer of gastric contents into the esophagus Occurs throughout the day, most frequently after meals and at night Usually resolves spontaneously by 1yr of age - -gastroesophegeal reflux -Vomiting - Chronic cough - Feeding refusal (infants) - Abd pain (older children) - -Clinical manifestations of gastroesophageal reflux Weight control, small frequent meals -thickened feedings and feeding in an upright position in infants -contnuous NG feedings for infants with severe reflex and failure to thrive -pharmacological therapy-Tagment, Pepcid, Prevacid, Nexium, Prilosec, Protonix -surgical treatment for children with severe complications; Nissan fundoplication - -Therapeutic management of ger -Pt should sleep on spine or supine to sleep -avoid feeding before bedtime -provide education regarding meds -offer small frequent feedings of formula combined with 1tsp of rice cereal per ounce of formula - -Nursing management for ger -Inflammation of the vermiform appendix -Most common cause of emergency abdominal surgery in childhood - -Acute Appendicitis patho -first symptoms is periambilical pain followed by nausea, RLQ pain, later vomiting with fever -most intense site of pain may be at McBurney point -rebound tenderness is not a reliable sign and is extremely painful to the child - -Acute appendicitis clinical manifestations -early recognition is essential is essential to prevent complications -removal of appendix, rehydration, antibiotics -ruptured appendix and peritonitis *IV fluids, systemic antibiotics, NG suction; preoperative *Postoperative IV fluids, antibiotics, and NG suctioning for abdominal decompression *Wound may be left open or closed after irrigation of abdominal cavity - -Therapeutic management of acute appendicitis AVOID applying heat to the area or administering laxatives or enemas - may stimulate bowel motility and increase the risk of perforation Allow child to assume position of comfort when having abdominal pain, usually with legs flexed Be aware of signs of perforation and peritonitis • Subsequent increase in pain (usually diffuse and accompanied by rigid guarding of the abdomen) • Progressive abdominal distention • Tachycardia, rapid, shallow breathing, pallor, chills, irritability *Fever, sudden relief from pain after perferation - -Acute Appendicitis Nursing Considerations Facial malformations that occur during embryonic development - May appear separately or together - -Cleft Lip & Cleft Palate Apparent at birth May elicit severe emotional reactions in parents Severity of the CP has an impact on feeding - may be unable to create adequate suction - -Diagnostic evaluation Cleft lip and cleft palate Multidisciplinary approach Closure of the cleft, prevention of complications, and facilitation of normal growth and development in the child Must provide ___________________________ prior to surgical repair through the use of specialized nipples for feeding and/or breastfeeding if able - -Therapeutic management of Cleft Lip and Cleft Palate Closure of the lip defect precedes correction of the palate - between 2 and 3 months of age ProtectthesuturelinewithaLoganboworothermethods - -Surgical Correction of Cleft Lip Typicallydonebetween6and12monthsofage Effect on speech development May require multiple surgeries for revisions May require speech therapy and orthodontics to correct malposition of teeth - -surgical correction of cleft palate Feeding • Position infant with CP in an upright position with the head supported - allows gravity to assist with the flow of liquid so it is swallowed instead of flowing through the nose • Provide support and encouragement for the mother who wishes to breastfeed; Specialty bottles available also for feeding PostoperativeCare • Elbow immobilizers may be used to prevent infant from rubbing suture line, place in elevated supine or side-lying position (the side opposite of repair) • Cleanse the suture line after feedings • Avoid placing objects in child's mouth (pacifiers, tongue depressors, thermometers, etc.) • Older child may be sent home on a soft diet - instruct parents to avoid allowing the child to eat hard foods (toast, potato chips, etc.) that can damage the palate - -Nursing care management cleft lip and/or cleft palate Failure of the esophagus to develop as a continuous passage separate from the trachea May occur separately or in combination Cause is unknown - -Esophageal Atresia & Tracheoesophageal Fistula congenital absence of part of the esophagus - -esophageal atresia abnormal passageway pertaining to the trachea and esophagus - -tracheoesophageal fistula Protrusion of a portion of an organ through an abnormal opening Typically,inguinalorumbilicalhernia Rarely,diaphragmatichernia Danger of incarceration or strangulation Incarcerated hernia- hernia that cannot be reduced easily Strangulation hernia-hernia in which the blood supply to the herniated organ is impaired • Signs include vomiting, pain, and an irreducible mass - -Hernias Constriction of the pyloric sphincter with obstruction of the gastric outlet - -Hypertrophic Pyloric Stenosis (HPS) -projectile vomiting Visiblegastricperistalsis Weight loss or failure to gain weight -distended upper abdomen -palpable olive-like mass when the stomach is empty Noevidenceofpainordiscomfort- only chronic hunger signs Metabolic alkalosis - -Hypertrophic Pyloric Stenosis clinical manifestations If present, correct metabolic alkalosis preoperatively with IV fluids; Immediate surgical revision if no fluid/electrolyte imbalance Gastric decompression IV fluids post-op and feedings introduced slowly - -Hypertrophic Pyloric Stenosis Therapeutic management Preoperative • Monitor for fluid & electrolyte imbalance and restore hydration • Stomach decompression with orogastric tube and suction Postoperative • Monitor I&O • Small feedings begun soon after surgery with clear liquids (Pedialyte), then formula or breastmilk as tolerated • Encourage parents to remain involved in child's care - -Hypertrophic Pyloric Stenosis Nursing management Telescoping (invagination) of one portion of the intestine into another - typically occurs from age 3 months to 3 years - -Intussusception Telescoping (invagination) of one portion of the intestine into another - typically occurs from age 3 months to 3 years - -Intussusception Abdominalpain,abdominalmass,bloodystools Suddenacuteabdominalpain Childscreaminganddrawingkneestochest Vomiting Lethargy *Passage of red, currant jelly-like stools (stool with blood and mucus) Tender,distendedabdomen Palpable sausage-shaped mass in RUQ Empty lower right quadrant - -Intussusception Clinical Manifestation Radiologist guided air enema or ultrasound guided saline enema - successful 80% of time Surgery necessary if not successful - -Intussusception Therapeutic management Monitor for passage of stool • Passage of a normal brown stool usually indicates that the intussusception has reduced itself - this is immediately reported to the practitioner, who may choose to alter the plan of care - -Intussusception Nursing management Fungus - -Oral Candidiasis (Thrush) White, adherent patches on the tongue, palate, and inner aspects of cheeks Infant may refuse to suck due to pain in the mouth Possibility that lesions can spread to the larynx, trachea, bronchi, lungs, and along the GI tract - -Oral Candidiasis (Thrush) Clinical Manifestations Topical application of 1 ml Nystatin or Mycostatin (antifungal) to oral cavity is usually sufficient to prevent spread - -Oral Candidiasis (Thrush) Therapeutic Treatment Rinse infants mouth with plain water after each feeding Medication administration • Give Nystatin after feedings • Distribute the medication over the surface of the oral mucosa and tongue with an applicator or syringe • Remainder of dose is deposited in mouth to be swallowed by the infant to treat any GI lesions Boil reusable nipples and bottles for 20 minutes after a thorough washing Boil pacifiers for at least 20 minutes once daily -If infant is breastfeeding treat mom as well - -Oral Candidiasis (Thrush) Nursing Care Management A sign of inadequate growth resulting from an inability to obtain or use calories required for growth Failure to thrive (FTT) Inadequatecaloricintake Inadequateabsorption Increasedmetabolism Defectiveutilization Diagnostic Evaluation Diagnosisinitiallymadef - -Growth Failure (Failure to thrive) Diagnosis initially made from evidence of growth failure • Early FTT - weight is below accepted standards or 5th percentile • Late FTT - weight and height are low, indicating chronic malnutrition Also important to look at dietary intake, health history, assessment of family, mealtime behaviors and rituals, and childparent behavior - -Growth Failure (Failure to Thrive) Diagnostic Evaluation Provide sufficient calories to support "catch-up" growth - a rate of growth greater than the expected rate for age Treat coexisting medical problems Behavior modification aimed at mealtime rituals (or lack thereof) Make referrals to welfare agencies or supplemental food programs as needed - -Growth Failure (Failure to Thrive) Therapeutic Management Provide a positive feeding environment • Establish a positive feeding routine • Talk to the child by giving directions about feeding ("take a bite") - helps maintain focus • Hold infants while feeding and maintain a face-to-face posture • Place older children at a table Teach parents successful feeding strategies Supporting the child and family - -Growth Failure (Failure to Thrive) Nursing Care Management Abdominal pain Cramping Loud crying! Crying "3's" • Crying for more than 3 hours per day for more than 3 days a week for more than 3 weeks Drawing up legs to abdomen Self-limiting and in most cases resolves as the infant matures, usually around 12 to 16 weeks Not one "cure" for all infants - -Colic Clinical Manifestations Reassure parents that they're not doing anything wrong & that the infant is not experiencing any physical or emotional harm - allow them to verbalize their feelings - -Colic - nursing care management Most cases of poisoning occur in children younger than age 6 years Pharmaceuticals Cosmetics and personal care products Cleaningproducts Plants Foreignbodies,toys,andmiscellaneoussubstances Hydrocarbons(gasoline) - -Ingestion of Injurious Agents Callfirst,beforeinitiatinganyinterventions - -Principles of Emergency Treatment Poison control center: 800-222-1222 Induce vomiting, absorb toxin, or use gastric lavage, depending on the agent ingested • Syrup of ipecac no longer recommended for routine treatment of poison ingestion • Activated charcoal (AC) Odorless, tasteless, fine black powder that absorbs many compounds Mixed with water or saline - resembles black mud - therefore, to increase the child's acceptance of AC, the nurse should mix it with diet soda and serve it through a straw in an opaque container with a cover • Gastric lavage only recommended in certain emergency situations due to risk of serious complications - -Gastric decontamination • N-acetylcysteine for Acetaminophen poisoning • Oxygen for carbon monoxide inhalation • Naloxone for opioid overdose • Digibind for digoxin toxicity • Antivenin for poisonous bites - -Gastric decontamination Antidotes available to counteract the poison Lead ingestion is most common Etiology • Peeling lead-based paint in older homes • Microparticles of lead contaminate bare soil • Food and water contamination • Pottery and dishes; folk remedies • Impoverished, urban area; older rental homes • Can be inhaled or ingested Desperole=Antidote - -Heavy Metal Poisoning Rarely symptomatic but affects renal, neurologic, and hematologic systems (bone marrow) Diagnosis is based only on the lead testing of a venous blood specimen from a venipuncture Screening for lead poisoning at age 1 and 2 years in high-risk areas - -Lead Poisoning Diagnosis Treatment based on blood lead level Chelation therapy • Removing lead from circulating blood and some lead from organs and tissues • Does not counteract effects of the lead on the body • Adequate hydration is essential - chelates excreted through kidneys - -Lead Poisoning Therapeutic Management Prevent the child's initial or further exposure to lead! • Provide extensive education to families Monitor I&O during chelation therapy When administering chelation therapy (deep IM injections), local anesthetic procaine is given with the drug; may also apply EMLA cream to reduce pain - -Lead Poisoning Nursing Care Management Generally idiopathic, but may be caused by tumors or hereditary Must be monitored for other pituitary hormone deficiencies Short stature but proportional height and weight Not all children with short stature have GHD Familial short stature Constitutional growth delay - usually boys They generally grow normally for the first year & then slow on the growth curve to below the 3rd percentile Delayed epiphyseal closure Delayed or crowded dentition - -Hypopituitarism: Growth Hormone Deficiency Somatropin- growth hormone How? SQ When? @ bedtime Why? To mimic normal growth hormone production - -GHD treatment excess growth hormone before closure of epiphyseal plates results in overgrowth of the long bones; reaches height of 8 feet or more, weight is generally in proportion to height, vertical growth accompanied by rapid and increased muscle development - -Gigantism- longer bones excess growth hormone after epiphyseal plates close; typical facial features include overgrowth of the head, lips, nose, tongue, jaw, sinuses; separation and malocclusion of the teeth in the enlarged jaw; increased facial hair, thickened, deeply creased skin - -Acromegaly-thicker bones • One of the most common endocrine problems in childhood • May be congenital or acquired (d/t thyroidectomy or radiation) • Increased TSH • Decreased T3, T4 • May have decelerated growth, myxedema, constipation, lethargy and mental decline - -Hypothyroidism • One of the most common endocrine problems in childhood • May be congenital or acquired (d/t thyroidectomy or radiation) • Increased TSH • Decreased T3, T4 • May have decelerated growth, myxedema, constipation, lethargy and mental decline - -Hypothyroidism -Synthyroid -Levathyroid *Take on an empty stomach; whatever brand of medication pt is started on they should remain on -a normal child's lab results may be abnormal due to hypothyroidism - -Hypothyroidism Treatment Graves's Disease • Often runs in families • Girls > boys - -What is the most common type of hypothyroidism in childhood? -inadequate feature description -thin hair -dry skin -puffy eyes - -Hypothyroidism characteristics Iodine - -What is needed for thyroid function? irritability, hyperactivity, short attention span, tremors, insomnia, emotional lability, poor concentration, nervousness, palpitations, exophthalmos - -Graves's Disease s/s Decreased TSH=Increased T3, T4 - -Graves' disease lab info • Treatment may include anti-thyroid meds, subtotal thyroidectomy or radioactive ablation • Thyrotoxic crisis (thyroid crisis or storm): acute onset of irritability, HTN, sever tachycardia and prostration ... delirium, coma and death are possible - -Graves's Disease tx Provide clustered care, reduce stimulation - -Nursing Interventions for Graves's Disease Either an insulin deficiency or insulin insensitivity inhibits the metabolism of carbohydrates needed to be used as fuel for the body Genetics -predisposition to Type 1 or 2 Toxins - destroying beta cells Viruses - destroying beta cells Obesity, Inactivity - lead to insulin resistance and Type 2 Autoimmune - Type 1 Idiopathic - -Diabetes Mellitus Age of Onset: >20 Sex: Males>Females Ethnicity:caucasians Nutrition:underweight Therapy:insulin Ketoacidosis:common Complications:>80% - -Type 1 diabetes Age of Onset:any Sex: Females>Males Ethnicity: African Americans, Hispanics, Native Americans Nutrition:overweight Therapy:oral meds, diet, exercise, insulin Ketoacidosis: uncommon Complications:varies - -type 2 diabetes 70-120mg/dl - -Normal glucose levels ▪ 8 hr fasting glucose > 126 mg/dL ▪ Random BS > 200 with s/s DM ▪ Oral GTT > 200 ▪ HbA1c>8.5(Toddler/Preschool) ▪ HbA1c>8(SchoolAge) ▪ HbA1c>7.5(Adolescent) - -DM diagnostic tests Polyphagia-frequent hunger Polydipsia- frequent thirst Polyuria-frequent urinating - -3 Ps -anxiety, irritability -tachypnea, palpitations -strange feelings -difficulty concentrating -slurred speech -seizure leading to coma - -Hypoglycemia <60 s/s -thirst, flushed skin -confusion -acetone, fruity smelling breath -rapid deep respirations Kussmauls - -Hyperglycemia >200 s/s MUST be a MULTIDISCIPLINARY approach Child and family Pediatrician Pediatric endocrinologist Diabetes nurse educator Nutritionist Teachers School Nurse Coach Friends - -Management of Type 1 Diabetes entire family incorporate changes into their lifestyle. This will include diabetes education, family guidance and emotional support. - -The complexity of type 1 DM requires that Pork or Human preparations Rapid, intermediate or long acting Packaged 100units/mL SQ injection 1-5x/day Insulin Pump - -Insulin Therapy Lissipro, Asparrt, Glulisine Onset of Action: 15-30 mins Peak Action: 30-90 mins Duration of Action: 3-5 hrs - -Rapid Acting Insulin Humulin R, Novolin R Onset of Action: 30 mins Peak of Action: 1-4 hrs Duration of Action: up to 8hrs - -short Acting Insulin NPH Onset of Action: 1-4hrs Peak Action: 4-14hrs 5.5hr mean Duration of Action: up to 24hrs but generally 12-16hrs - -Intermediate Insulin 70/30s glargine, detemir Onset of Action: 60-120 mins Peak Action: glargine relatively flat; detemir 6-8hrs Duration of Action: 24hrs - -Long acting insulin Nutrition - balance intake, activity, medication Activity / Sick Days Glucose Monitoring: Continuous vs Fingerstick Medication Administration • Injection Procedure - return demonstration • Injection Sites • Injection Rotation Hypoglycemic episode: Simple carb - Complex carb/protein Health Information • Eyes • Nails • Feet - -Diabetes Education Nutrition -hyperglycemia 330mg/dl can occur at 200mg/dl - -Diabetic Ketoacidosis (DKA) -acidosis pH7.35 BiCarb 15 -breakdown of body fat for energy -ketones in blood, urine and lungs - -glycosuria s/s -insufficient insulin -acute stress -acute illness -marco vascular damage- coronary artery disease, cerebrovascular disease, peripheral artery disease -micro vascular- nephropathy, neuropathy - -Diabetic Ketoacidosis (DKA) causes Principal disorder of pituitary hypo function ... Results from UNDER secretion of ADH(vasopressin) Leading to uncontrolled diuresis, excessive thirst and water intake Treatment is DDAVP Common initial sign in children is enuresis after being potty trained - -Diabetes Insipidus Humulin R, Novolin R Onset of Action: 30 mins Peak of Action: 1-4 hrs Duration of Action: up to 8hrs - -short Acting Insulin NPH Onset of Action: 1-4hrs Peak Action: 4-14hrs 5.5hr mean Duration of Action: up to 24hrs but generally 12-16hrs - -Intermediate Insulin 70/30s glargine, detemir Onset of Action: 60-120 mins Peak Action: glargine relatively flat; detemir 6-8hrs Duration of Action: 24hrs - -Long acting insulin Do NOT mix long acting insulin with any other insulin Do NOT aspirate DO rotate injection sites DO draw of short acting first, then longer acting; clear to cloudy - -DO's and DON'T's of Insulin