NURS 211 Final Module Exam Guide Graded A

Traction: Essential Components - -Traction -Countertraction: -Frictional force: Attention-Deficit/Hyperactivity Disorder ADHD - Inattention, impulsiveness, and hyperactivity Typical onset is before 7 years of age Learning Disability - A heterogenous group of disorders with difficulties in acquisition and use of listening, speaking, reading, writing, reasoning, mathematical, and/or social skills Diagnostic Evaluation of ADHD and LD - -Quality of motor activity -Developmentally inappropriate inattention, impulsivity, and hyperactivity -Wide variation of severity -Diagnostic criteria have been developed by the American Psychiatric Association Battery of tests for ADHD and LD - -IQ -Hand-eye coordination -Visual and auditory perception -Comprehension -Memory Therapeutic management of ADHD - Classroom Family education and counseling Behavioral therapy and/or psychotherapy for the child Environmental manipulation Medication Medications for ADHD - Not all children benefit from pharmacologic therapy Stimulants: Dextroamphetamine (Dexedrine), amphetamine, and dextroamphetamine (Adderall) Methylphenidate (Ritalin) Side effects of ADHD medications - Insomnia, anorexia and weight loss, hypertension Used long term, may suppress growth Therapeutic management of LD - Primarily educational interventions Wide variation of diagnostic severity Nursing considerations for ADHD and LD - -community settings -school nurses -hospital settings Autisms Spectrum Disorders ASDs - Complex neurodevelopmental disorders of brain function: -Autistic Disorder -Asperger Syndrome -Pervasive Developmental disorder not otherwise specified. These range from mild to severe Causes of ASD - Unknown/Idiopathic -High risk of recurrence in families -No supportive evidence that ASD is caused by the measles-mumps-rubella MMR vaccine or vaccines containing thimerosal. Theories about the cause of ASD - -A link between hereditary, genetic, and medical problems -Immune and environmental factors may increase incidence Diagnostic criteria for ASD - -Qualitative impairment in social interaction -Qualitative impairment in communication -Restricted repetitive and stereotyped patterns of behavior, interests, and activities -Delays or abnormal functioning with onset before 3 years of age -American Psychiatric Association DSM-IV-TR Nursing Consideration for ASD - -Wide variation in the individual client response to treatment efforts -No cure for ASD, but many therapies used -Most promising results seem to be obtained with the use of highly structured routines and intensive behavior modification programs Family support for ASD - -ASD often becomes a "family disease" -Help alleviate parents' unwarranted feelings of guilt and shame -Stress the importance of family counseling -Autism Society of America (ASA) is a good source of information -Encouraging home care for children; assisting with long-term placement later in life Renal system assessment - Physical assessment Health history Renal system assessment Physical assessment - Palpation, percussion Renal system assessment Health history - -previous UTI, calculi, stasis, retention, pregnancy, STDs, and bladder Ca -Meds, such as ATB, anticholinergics, and antispasmodics -Urologic instrumentation -Urinary hygiene -patterns of elimination Urinary Tract Infection UTI - -One of the most common conditions of childhood 10% of kids have a febrile UTI in the first 2 yrs of life -Concept of "asymptomatic bacteria" in the urinary tract Most important factor of UTI in children - Urinary stasis Uncircumsized males - are at a higher risk of UTI Classification of UTI - -Asymptomatic bacteriuria -Symptomatic bacteriuria -Upper tract infection -Lower tract infection Asymptomatic Bacteriuria - Significant bacteriuria with no clinical symptoms Symptomatic Bacteriuria - Bacteriuria with physical signs, such as dysuria, suprapubic discomfort, hematuria, and fever Upper tract Infection UTI - Infection involving the renal parenchyma, pelvis, and ureters -Typically causes fever, chills, and flank pain Lower Tract infection UTI - Infection involves the lower urinary tract -usually no systemic manifestations Organisms that commonly cause UTIs - Escherichia coli is the most common pathogen (80% of cases) Streptococci Staphylococcus saprophyticus Occasionally, fungal and parasitic pathogens Anatomic or physical causes of UTI - Short urethra in girls Uncircumcised males Normal characteristics of urine - Color, straw to amber. Clarity, clear or transparent but can become cloudy when standing. Odor, aromatic. Specific gravity concentration, 1.005 to 1.030. pH should be 4.5 to 8 Newborn urine production - 1-2 ml/kg/hr Children urine production - 1 ml/kg/hr Normal urinalysis - pH 5 to 9. Specific gravity 1.001 to 1.035. Protein <20 mg/dl. Urobilinogen up to 1 mg/dl. None of the following: Glucose Ketones Hgb WBCs (few) RBCs Casts Nitrites Diagnostic studies of UTI - Dipstick Microscopic urinalysis culture and sensitivity clean catch specimen is preferred U-bag for collection from child Specimen obtained by catheterization or suprapubic needle aspiration has more accurate results Cryptorchordism - failure of the testicles to descend into the scrotum Considerations for Cryptochordism - Begin Descent 32-36 weeks -risk is malignancy and infertility Not palpable in scrotal sac after delivery Treatment-observation for 6 months, orchiopexy Testicular self exam-taught in adolescence Orchiopexy - surgical fixation of a testicle Hypospadias - abnormal congenital opening of the male urethra on the undersurface of the penis Epispadias - congenital defect in which the urinary meatus is located on the upper surface of the penis Hypospadias and Epispadias Considerations and treatment - Incomplete formation of the anterior urethra Treatment-Surgery repair between 6-12 months -drainage stent Neonates should not be circumsized, foreskin can be used for reconstruction Management goals for Hypospadias and epispadias - Make urinary and sexual function as normal as possible Nursing care of hypospadias and epispadias - -infant not circumsized at birth -encourage fluids -I & O -Pain -Double diaper -No tub bath -restrict activity -antibiotics -anticholinergics -urine bay be blood tinged. Nephrotic Sydrome - Most common presentation of glomerular injury in children Characteristics of nephrotic syndrome - massive proteinuria hypoalbuminemia hyperlipidemia edema Types of Nephrotic Syndrome - Minimal Change Secondary Congenital Minimal change nephrotic syndrome Common names - MCNS AKA: idiopathic nephrosis childhood nephrosis Minimal lesion nephrosis Secondary Nephrotic Syndrome - This syndrome results from a multisystem disorder such as diabetes, systemic lupus or sickle cell anemia. Minimal Change Nephrotic Syndrome - Occurs predominantly in children between the ages of 2-7 Rare in children younger than 6 months Cause of Minimal Change Nephrotic Syndrome - Cause and mechanism are not truly known, but the components are thought to be: metabolic biochemical Physiological immune mediated Pathophysiology of MCNS - Glomerular membrane -normally impermeable to large proteins -becomes permeable to proteins, especially albumin -albumin is lost in the urine (hyperalbuminuria) -serum albumin is decreased (hypoalbuminemia) -fluid shifts from the plasma to the interstitial spaces hypovolemia ascities Diagnosis of MCNS - -Suspected based on clinical manifestations Generalized edema (develops gradually or rapidly) Proteinuria 2+ on dipstick testing Hypoalbuminemia Hypercholesterolemia (in the absence of hematuria and hypertension) Low serum protein and sodium -May require renal biopsy to distinguish from other types of nephrotic syndrome Management of Nephrotic Syndrome - -Supportive care -Diet --Low to moderate protein --Sodium restrictions when large amounts of edema are present -Steroids (first line of therapy) --Dose is 2 mg/kg divided into twice-a-day doses --Prednisone is the drug of choice (least expensive and safest) -Immunosuppressant therapy (cyclophosphamide [Cytoxan]) -Diuretics Family issues with MCNS - - Chronic condition with relapses - Developmental milestones - Social isolation --lack of energy --Immunosuppression, protection --Change in appearance due to edema affects the self-image Nursing interventions for MCNS - -Aseptic technique during catheterization -Avoid unnecessary catheterization and early removal of indwelling catheters -Routine and thorough perineal care for all hospitalized patients -avoid incontinent episodes by answering call lights and frequently offering a bedpan -Ensure adequate fluid intake -discharge to home instructions -follow up urine culture Prevent Nosocomial infections - Wash hands before and after contact with pts wear gloves for care of the urinary system For MCNS Ensure adequate fluid intake does.. - -dilutes urine making the bladder less irritable -flushes out bacteria before they can colonize -avoid caffeine, alcohol, citrus juices, chocolate, and highly spiced foods because they are potential bladder irritants We do a follow up urine culture - because: recurrent symptoms typically occur 1-2 weeks post therapy encourage adequate fluids even after infection low dose, long term atb to prevent relapse or reinfection Explain rationale to enhance compliance The immobilized child - • Immobilization was once thought to be restorative for patients with illness and injury • We know now that immobilization has serious consequences - Physical - Social - Psychological Physiological effects of immobilization Muscular system - -Decreased muscle strength and endurance -Atrophy -Contractures and loss of joint mobility Physiological effects of immobilization skeletal system - -bone demineralization -negative calcium balance Physiological effects of immobilization metabolism - -Decreased metabolism -negative nitrogen balance -hypercalcemia -decreased production of stress hormones Physiological effects of immobilization cardiovascular system - -decreased efficiency of orthostatic neurovascular reflexes -diminished vasopressor mechanism -altered distribution of blood volume -venous stasis -dependent edema Physiological effects of immobilization respiratory system - -decreased need for oxygen -diminished vital capacity -poor abdominal tone and distention -mechanical or biochemical secretion retention -loss of respiratory muscle strength Physiological effects of immobility gastrointestinal - -Distention caused by poor abdominal muscle tone -difficulty feeding in the prone position -gravitation effect on feces -anorexia Physiological effects of immobility integumentary system - Decreased circulation and pressure leading to decreased healing capacity Physiological effects of immobility urinary system - -alteration of gravitational force -difficulty voiding in the supine position -urinary retention -impaired ureteral peristalsis Physiological effects of immobility psychosocial - -diminished environmental stimuli -Altered perception of self and environment -increased feelings of frustration, helplessness, and anxiety -Depression, anger, and aggressive behavior -developmental regression Fractures - Common injury in children-kids bones tend to bend vs breaking -methods of treatment are different in peds -rare in infants, except with MVA -Clavicle is most frequently broken bone in kids -In school-age kids, bike and sports injuries Types of fractures - Compound complicated comminuted greenstick Compound fractures - Open fractures Fractured bone protrudes through the skin Complicated fractures - bone fragments have damaged other organs or tissues Comminuted Fractures - small fragments of bone are broken from fractured shaft and lie in surrounding tissue Greenstick fracture - Compressed side of the bone bends but the tension side of the bone breaks causing an incomplete fracture Clinical manifestations of fractures - Generalized swelling Pain or tenderness Diminished functional use May have bruising, severe muscular rigidity, crepitus Kids and fractures - Kids recover from fractures very quickly because they are still growing Diagnostic evaluation fracture - Obtain info from person who observed injury xray is most useful tool Therapeutic management fractures - Traction and immobilization. Goals are to regain alignment and length of the bony fragments (reduction) to retain alignment and length (immobilization), to restore function to the injured parts, to prevent further injury Assessment of the 5 ps - Pain Pulse Pallor Paresthesia Paralysis The Child in a cast - Cast application techniques-assess circulation Nursing considerations Cast care at home Cast removal Skin care Pt education cast - Do not stick anything down in your cast!!! Family ensure the 5 ps are appropriate Traction - Extended pulling force -to provide rest for an extremity -To position for bone healing -to immobilize a fracture until healing is sufficient to permit casting or splinting -to help prevent or improve contracture deformity -to provide immobilization -to reduce muscle spasms-rare in children Traction component - forward force produced by attaching weight to distal bone fragment Adjust by adding or subtracting weights Counter traction component - backward force provided by body weight Increase by elevating foot of bed Frictional force component - provided by patient's contact with the bed Types of traction - Manual traction is applied to a body part by the hand placed distally to the fracture site Skin traction involves pulling mechanisms that are attached to the skin with adhesive material or an elastic bandage Skeletal traction is applied directly to the skeletal structure by a pin, wire, or tongs inserted into or through the diameter of the bone distal to the fracture Manual traction - Traction that is applied to a body part by the hand placed distally to the fracture site Skin Traction - Traction that involves pulling mechanisms that are attached to the skin with adhesive material or an elastic bandage Skeletal traction - Traction that is applied directly to the skeletal structure by a pin, wire, or tongs inserted into or through the diameter of the bone distal to the fracture Developmental Dysplasia of the hip DDH - Formerly called "congenital dislocation of the hip" and "congenital hip dysplasia In some newborns, the socket is too shallow and the ball (thigh bone) may slip out of the socket. Two types: Idiopathic-infant neurologically intact Teratologic-Neuromuscular defect Three degrees of Developmental Dysplasia of the Hip - Acetabular dysplasia Subluxation Dislocation Acetabular Dysplasia - Mildest form; osseous hypoplasia of acetabular roof Femoral head remains in the acetabulum Subluxation - incomplete or partial dislocation Dislocation - femoral head loses contact with the acetabulum and is displaced posteriorly and superiorly; ligaments are elongated and taut Therapeutic management of DDH - · Importance of early intervention · Newborn to age 6 months: Pavlik harness for abduction of the hip · Age 6 to 24 months: Dislocation is unrecognized until the child begins to stand and walk; use traction and cast immobilization (spica) · Older child: Operative reduction, tenotomy, osteotomy; difficult after 4 years Pavlik harness - keep femur in acetabulum (4-5mon) wear 24 hrs a day adjust every 2 weeks because of rapid growth Clinical manifestations of DDH Infant - -Shortened limb on affected side -Restricted abduction of hip on affected side -Unequal gluteal folds when infant prone -Positive Ortolani test -Positive Barlow test Ortalani test Barlow test Ortolani Test - put infant in frog leg position and check for hip clicks if present it is positive Barlow Test - hip flexed and thigh abducted while pushing posteriorly can feel dislocation of femur head DDH in older infant and child - Affected leg shorter than the other Telescoping or piston mobility of joint Trendelenburg sign Greater trochanter is prominent and appears above line from anterior superior iliac spine to tuberosity of ischium Marked lordosis if bilateral dislocations Waddling gait if bilateral dislocations Trendelenburg sign - Superior gluteal nerve, upper medial gluteal injection Gluteus medius/minimus injured, contralateral hip drops when he lifts his left foot off the floor lordosis - abnormal anterior curvature of the lumbar spine (sway-back condition) Nursing care for pavlik harness - Maintaining reduction-prevent the hip from coming out Teaching parents how to care for the infant and the harness Providing skin care-keep harness clean, have child wear a t-shirt Congenital clubfoot - talipes varus talipes valgus talipes equinovarus talipes calcaneus Talipes varus - Inversion, or bending inward Talipes valgus - eversion, or bending outward Talipes equinovarus - plantarflexion with the toes lower than the heel Talipes calcaneous - dorsiflexion with toes higher than the heel Classification of clubfoot - Mild or postural Teratologic Congenital idiopathic or true clubfoot Mild or postural club foot - May correct spontaneously or require passive exercise or serial casting Teratologic clubfoot - Associated with other congenital anomalies Usually requires surgical correction and has a high incidence of recurrence Congenital Clubfoot - Bony abnormality almost always requiring surgical intervention Nursing Considerations clubfoot - Casting/bracing Good skin assessment Scoliosis - abnormal curvature of the spine most common spinal deformity Three planes possible May be congenital, or develops during childhood Three planes of Scoliosis - Lateral curvature Spinal rotation causing rib asymmetry Thoracic hypokyphosis Scoliosis Considerations - Multiple potential causes; mostly idiopathic generally more noticeable after preadolescent growth spurt may have complaints of ill-fitting clothes AAP and AAOS favor scoliosis screening either in school, providers office, or nurse's clinic Scoliosis screening differences by gender - Girls need screened at age 10-12 years old Boys need screened at age 13-14 years old Scoliosis Diagnostics - Standing radiographs to determine degree of curvature Adams forward bending test Risser scale Asymmetry of shoulder height, scapular or flank shape, or hip height Often have a primary curve and a compensatory curve to align the head with the gluteal cleft Adams forward bending test - definitive clinical screening test for scoliosis Risser scale - xray to determine skeletal maturity Also shows how big the degree of curvature Therapeutic management of scoliosis - Team approach to treatment Bracing Exercise Surgical intervention for severe curvature (instrumentation and fusion): Harrington rods L-rods Nursing concerns with Scoliosis bracing - Compliance is a major concern-braces must be worn 23/24 hours daily Thoraciclumbarsinal orthotic braces common Adolescents don't want to feel weird Nursing concerns with Scoliosis post surgery - Rods can pop if curvature continues postop check vasculature and neuro and GI/GU Are the kids voiding postop? narcotic pain meds postop could be PCA pump Nursing care management of scoliosis - Concerns of body image Concerns of social isolation Concerns of prolonged treatment of condition Preoperative care Postoperative care Family issues-especially girls Juvenile Idiopathic Arthritis JIA - -Also known as juvenile rheumatoid arthritis, juvenile chronic arthritis, or idiopathic arthritis of childhood -Cause is unknown; immune and environmental causes have been hypothesizedpossible genetic components -often undiagnosed -peak ages are 1-3 years and 8-10 -Painful joints JIA Actually - A heterogeneous group of diseases Systemic arthritis Oligoarthritis Polyarthritis Systemic Arthritis JIA - Involves one or more joints with at least 2 weeks of fever, rash, lymphadenopathy, hepatosplenomegaly, and serositis Oligoarthritis JIA - One to four joints affected for the first 6 months Polyarthritis - Rheumatoid factor negative with five or more joints affected. Rheumatoid factor positive with five or more joints affected Both within the first 6 months period of time most important for diagnosis JIA other factors - 90% of kids Rheumatoid factor is negative symptoms may burn out and become inactive chronic inflammation of the synovium with joint effusion, destruction of cartilage, and ankylosis of the joints as the disease progresses Symptoms similar to adult arthritis Symptoms of JIA - Stiffness Swelling Loss of mobility in affected joints Warm to touch, usually without erythema Tender to touch in some cases Symptoms increase with stressors Growth retardation Diagnostics Evaluation of JIA - No definitive tests Elevated Sedimentation rate in some cases-inflammation Antinuclear antibodies are common but are not specific for JIA Leukocytosis during exacerbations Diagnosis is based on criteria of the American College of Rheumatology American College of Rheumatology Diagnostic Criteria for JIA - Age of onset before 16 years One or more affected joints Duration of arthritis longer than 6 weeks Exclusion of other forms of arthritis Therapeutic management of JIA - • No specific cure • Goals of therapy: preserve function, prevent deformities, and relieve symptoms • Iridocyclitis/uveitis - Inflammation of iris and ciliary body - Unique to JIA - Requires treatment by ophthalmologist Pharmacology for JIA - NSAIDs: first drugs used Slow Acting Antirheumatic drugs SAARDs: may require mos to be effective and typically work in combo w/ other drugs Corticosteroids: used for life threatening complications & incapacitating arthritis (can cause Cushings syndrome, osteoporosis, increaed infection risk, glucose intolerance, cataracts, and growth suppression) Cytotoxic Agents Immunologic modulators Management of JIA - Therapy individualized to child Pharmacologic agents may include NSAIDs, SAARDs, corticosteroids, cytotoxic agents, etc. PT, OT Nutrition, exercise Splinting devices Pain management Application of heat Man Nursing considerations JIA - Low stress exercises for the joints like yoga or aqua therapy low impact family support Cerebral Palsy CP - -A group of permanent disorders in the development of movement and posture that are attributed to nonprogressive disturbances in the developing fetal or infant brain. -May involve sensation, Perception, communication, cognition, and behavior Etiology of CP - -intrauterine hypoxia or asphyxia -preexisting prenatal brain abnormality -maternal exposure to trauma -preterm or post term birth -shaken baby -birth trauma -multipara pregnancy -carnicterus (brain damage from excessive bilirubin--jaundice) In 80% of cases there is NO identifiable cause Types of CP - spastic (pyramidal): hypotonia -- most common dyskinetic (nonspastic, extrapyramidal): athetoid, dystonic ataxic (nonspastic, extrapyramidal) mixed Spastic CP - Pyramidal: Hypotonia Most common type Dyskinetic CP - Nonspastic, extrapyramidal Athetoid Dystonic Ataxic CP - -nonspastic -extrapyramidal -repetitive movements -wide gait -inability to hold objects Mixed Type CP - manifestations of more than one clinical type of CP Diagnosis of CP - Careful assessment in early infancy (especially those with known risk factors) Use of assessment tools in the first 2 years of life Neurologic examination Caregiver history Neuroimaging: Computed tomography (CT) scan; magnetic resonance imaging (MRI) Metabolic and genetic testing Possible motor signs of CP - Persistent primitive reflexes Poor head control after age 3 months-extended head lag Stiff or rigid limbs Arching back; pushing away Floppy tone Unable to sit without support at age 8 months Clenched fists after age 3 months Possible behavioral signs of CP - Excessive irritability No smiling by age 3 months Feeding difficulties Persistent tongue thrusting Frequent gagging or choking with feedings Therapeutic goals for CP - -Establish locomotion, communication, and self-help skills -Gain an optimal appearance and integration of motor functions -Correct associated defects as effectively as possible -Provide adapted educational opportunities -Promote socialization experiences with other affected and unaffected children Interventions for CP - Surgical-tendon release Braces and supportive devices Medications (intermittent or via pump) -Antispasmodics; botox -Analgesia -Antiepileptics Family education and support -School and social supports -Dental care and physical therapy -Well-child care CP and IQ - Wide variation In 70% of CP patients, the IQ is normal Difficult to assess; requires ongoing evaluation Promotion of growth and development Rigid, atonic, and quadriparetic CP patients have the highest incidence of profound impairment Neural Tube Defects - Failed closure of neural tube May involve the entire length of the neural tube or small portion Includes ancephaly and spina bifida incidence of neural tube defects - -affects girls more than boys -occurs three times more often in caucasians and hispanics than in african americans -one of the most common birth defects in the US NTD etiology - Multifactorial Drug, chemical, or radiation exposure Maternal malnutrition; low folate levels Genetic mutation in folate pathways Syndromes such as trisomy 18, PHAVER syndrome, and Meckel-Gruber syndrome Prepregnancy maternal obesity Maternal diabetes mellitus, low maternal vitamin B12 status, maternal hyperthermia, and the use of AEDs in pregnancy Lack of folic acid Prenatal management of NTD - Treatment and prevention Supplementation with folic acid 0.4 mg/day If there is a history of NTD, 4 mg/day In 1998, the Food and Drug Administration (FDA) fortified cereal grains with folic acid Begin preconception Prenatal and antenatal assessment Antenatal surgical intervention Antenatal - During pregnancy Antenatal Diagnosis of NTD - elevated alpha-fetoprotein in amniotic fluid, tested at 6-18 weeks of gestation uterine ultrasound and genetic counseling Types of NTD - -ancephaly (no brain, only brainstem develops) -spina bifida myelomeningocele Anencephaly - Absence of cerebral hemispheres Brainstem function may be intact Incompatible with life-few hours to a few days, death due to respiratory failure Spina Bifida - Failure of the osseous spine to close Two types Spina Bifida occulta Spina bifida cystica Spina Bifida Occulta - Not visible externally Usually lumbosacral, at L5 to S1 Spina Bifida Cystica - Visible Defect External Saclike protrusion Two types Meningocele Myelomeningocele