peds final exam study guide

Administration of growth hormone for growth hormone deficiency sub Q at night  Use of Glasgow coma scale – level of consciousness, alertness The pediatric GCS consists of three components of assessment: eye opening, motor, and auditory/visual responses. When performing an assessment using the pediatric GCS, the nurse assigns a numeric value to each of the levels of response (1–15). •Score of 9–15 (unaltered state of consciousness) •Score of 8–4 (state of coma) •Score of 3 or below (deep coma) The nurse carefully monitors, measures, and documents vital signs, LOC, reflexes, and pupil reaction as prescribed by the health-care provider or as dictated by facility policy. The frequency of vital sign measurement is dependent on the etiology, neurological status, and cerebral involvement. Any change in vital signs needs to be evaluated because the child's condition can deteriorate rapidly. The child's vital signs may need to be assessed every 15 minutes or more often if the neurological state or physical state is unstable. If the child's condition is stable, vital signs are measured every 2 hours.  Assessment findings in meningitis Signs and symptoms o Patient may initially appear to be only mildly ill o Signs and symptoms are often vague or subtle:  Fever  Headache  Stiff neck  Lethargy and/or irritability  Nausea and/or vomiting Kernig’s sign Brudzinski’s sign  SIADH signs pathophysiology, signs and symptoms, complications and treatment Characterized by excessive secretion of antidiuretic hormone (ADH). ADH normally causes the kidneys to conserve water. (water retention, water intoxication) Increase water so it dilutes the salt = hyponatremia = seizures Look for crackles Signs and symptoms Neuro changes (sodium) = irritability, combative, coma, hallucinations, confusion High BP N/V Seizures Headache Muscle cramps Weakness 2 Tx: Fluid restriction Irrigate all oral tubes with normal saline rather than water Monitor child’s nutritional status (diet high in sodium and protein) Continually assess level of consciousness  Hypothyroidism s/s and treatment Indefinite treatment If left untreated, can lead to goiter Signs and symptoms In infants, signs and symptoms include: Prolonged newborn jaundice Poor feeding Constipation Cool, mottled skin Hypotonia Increased sleepiness Decreased crying Larger fontanels Umbilical hernia Large, thick tongue As child begins to grow and mature, manifestations may include: Short stature for age Delayed dentition Delays in major developmental milestones Weight gain Hypotonia Puffy facial features Severe mental retardation Protruding abdomen Umbilical hernia Thick, dry, scaly, pale, or mottled skin Sparse, coarse, dry, or brittle hair Nursing care Based on child’s response to the illness Focus on educating family Manage thyroid hormone replacement therapy Levothyroxine sodium (Synthroid) Iodine supplementation also appropriate in some cases  Myringotomy tubes Tube to the ears Stay in until they fall out on their own (typically 6-12 months or until they fall out) Chronic ear infections: myringotomy tubes placed in tympanic membrane for effusion drainage and pressure equilibrium 3  Cast and cast care Neurovascular checks – check for cap refill, pain, pulse Don’t put anything inside cast Don’t get it wet Tell child it gets hot when forming bc when they move etc.. and can cause pressure ulcer Cast complications Compartment syndrome (accumulation of fluid in the fascia) Cast syndrome (portion of duodenum compressed between superior and mesenteric artery and aorta) Major complication is compartment syndrome: Two assessments Neurovascular assessment Assess for “5 Ps” Pain unrelieved by narcotics Pallor Paralysis Paresthesia Pulselessness Application of ice and elevation of affected extremity can help to alleviate risk of compartment syndrome Facilitate drying of cast Promote good fluid intake and high-fiber diet Prevent itching Teach about cast removal  Meningocele vs. myelomeningocele vs. spina bifida occulta What is? Which one? What does it look like? Which ones worse? Spina bifida – neural tube defect Signs and symptoms Signs and symptoms vary depending on level of lesion and type of defect Spina bifida occulta is least severe form: • Visualization of meningocele or myelomeningocele • Weakness • Paralysis • Sensory loss Severe spina bifida: • Visualization of myelomeningocele • Neurological deficits • Hip and joint deformities • Impaired bowel and bladder function Nursing care Treatment is dependent on form of spina bifida 4 • Spina bifida occulta often does not need treatment • More pronounced spina bifida creates risk for neurological complications, including meningitis Assess defect upon delivery for type of contents in the sac and measure the defect Prevent injury of sac and assess for indications of infection • Redness • Purulent drainage • Bleeding • Necrosis • If sac ruptures and leaks CSF, patient is at risk of developing meningitis Administer medications • IV antibiotics to prevent infection pre- and postoperatively • Anticholinergics to improve urinary continence • Antispasmodics to control bladder spasms Prevent skin breakdown Laminectomy postoperative care • Monitor vitals for signs of infection • Perform dressing changes using sterile technique • Assess surgical site for redness, purulent drainage, odor, and CSF leakage • Measure infant’s head circumference as prescribed • Assess fontanels for bulging and cranial sutures for separation • Help infant maintain position that does not place pressure on surgical site • Provide pain management to avoid crying-induced intracranial pressure increases If the child has a meningocele, a protruding sac is located on the cervical, thoracic, or lumbar spine at the level of the defect and a thin layer of muscle and skin usually covers the lesion. Meninges (membranes) protrude through the defect in the spine, but no involvement of neural elements is present. Neurological functioning is usually not affected. A myelomeningocele is the most severe form of spina bifida and is evident on delivery. The meninges protrude through the defect, and the meninges contain spinal cord elements. It appears as a very pronounced skin defect, usually covered by a transparent membrane and may even have neural tissue attached to the inner surface. The higher the defect is located on the spine, the greater the loss of spinal cord function because usually no neurological function is found below the defect. The bony prominences of the unfused neural arches can be felt at the defect's lateral border. When the child is born, the membrane covering the defect may be intact or may leak cerebrospinal fluid (CSF). If the membrane is not intact, the risk for infection and neuronal damage is increased. Until the defect is surgically closed, CSF may accumulate, which results in further dilation and enlargement of the sac, and further neuronal damage may occur. The involvement of the spinal cord has greater implications for the function of the child during childhood