Pediatric Unit Exam Review

PED Unit exam review 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Communicating with 6 y/o (preschooler) to express emotional status  Drawing Adolescent sextual history. How to ask her? “Are you sexually active with anybody?” Nonpharmacologic pain management. How does it work? Reduce pain reception PCA control analgesia for 6 y/o . What kind of dosage does it deliver? Baseline in bolus  Patient-controlled analgesia o Self-administration of pain med o Can be basal, bolus, or combination o Has lockout to prevent overdosing  Family-controlled analgesia o Same concept as PCA o Parent or caregiver manages the child’s pain Using opioid long period. Increasing dosage to control pain. Child is relatively pain free. What is the next stop? Tapper off dosage. Iron absorption  Cast iron, Vit-C Cow’s milk sensitivities  Colic is paroxysmal abdominal pain that generally occurs in infant under 3 month of age. Loud, intense crying, pull legs up against their abdomen. Face become red, flushed. Fist clench,  Infants who are changed to cow’s milk before 1 year of age should receive a supplementary form of vitamin C and iron and possibly fluoride to make up for the deficiency of these components in cow’s milk. However, the practice of switching to cow’s milk is not recommended because the protein in it is difficult for an infant to digest, possibly leading to such intestinal irritation that slight but continuous gastrointestinal bleeding occurs, which results in anemia. never use honey as a sweetener because it may contain botulism spores and never use cow’s milk because it can cause microscopic intestinal bleeding.  If a milk allergy is present, a soy-based formula can be substituted.  The problem, called baby-bottle syndrome (decay), is most serious when the bottle is filled with sugar water, formula, milk, or fruit juice. Eczema (Atopic dermatitis)  Lesions are extremely pruritic.  The common sites for lesions change as the child grows and develops dexterity. Infants usually present with rash on the face, neck, and extensor surfaces (Fig. 42.7). Infants with atopic dermatitis will rub their face, arms, and legs to relieve the intense itching. As children develop dexterity, they focus on flexural folds of the extremities and neck. Because the lesions feel so uncomfortable, children with infantile atopic dermatitis become fussy and irritable. They may not eat well because of this generalized discomfort. The combination of poor sleep patterns, poor intake, and an increase need of energy to repair damaged skin can result in a decrease in nutritional status Overdose of ASA  Vitamin K Breast-feeding. What food is common causing allergy? Peanut, Fish  The most common foods that cause immediate allergy symptoms include peanut, egg whites, milk, wheat, soy, seafood, and tree nuts. If children are allergic to milk, caution them 11. 12. 13. 14. 15. 16. 17. that they are allergic to milk products such as ice cream, yogurt, and cheese as well. Children who are allergic to eggs often cannot eat any foods that contain eggs, such as egg noodles or mayonnaise. Activated charcoal is supplied as a fine black powder that is mixed with water for administration. Adding a sweet syrup to the mixture can make it more palatable. Caution parents that, as the charcoal is excreted through the bowel over the next 3 days, stools will appear black so they do not mistake the color for blood.  Charcoal is antidote for acetaminophen poisoning  Using a straw Lead screening p819  Symptoms of lead poisoning: irritability, HA, fatigue, abdominal pain,  Blood screening is essential  . The CDC (2012b) recommends screening for all children between the ages of 9 and 12 months at least once and again at 18 or 24 months of age. A small amount of blood taken by a finger prick is analyzed. A positive result (over 5 μg/dl) must be confirmed by further testing. The long-term effects of lead poisoning and therapy are discussed in. Levels as low as 5 μg/dl can cause learning and behavioral problems (CDC, 2012b). High levels may result in seizures, cognitive challenges, coma, and even death. Although 10 μg/dl was the standard to define lead toxicity for the past decade, the new lower level of 5 μg is proposed as the best way to help prevent minimal damage Late signs of ICP pg. 1384  Bradycardia, widened pulse pressure, bradypnea. Mononucleosis (kissing disease, Mono) pg 1215  Epstein-Barr infection  Presence of virus in saliva  The classic symptoms of EBV infection include several days of prodromal symptoms of anorexia, chills, and malaise with fever in 90% and enlargement of the cervical nodes and tonsils. Pharyngitis with palatal petechial and periorbital edema and found with splenomegaly is present in about 5% (Pinninti et al., 2016) (Fig. 43.10). If the mesenteric lymph nodes enlarge, children may experience abdominal pain so sharp that it simulates appendicitis. On a blood smear, atypical lymphocytosis is seen and a total elevation of the lymphocyte count peaks between 2 and 3 weeks of illness. Herpes zoster: posterior root ganglia pg 1208  Herpes zoster is a reactivation of the VZV. The herpes viral family has viral latency, which means that once you develop varicella, the virus lies latent in the posterior dorsal root ganglia (Alter et al., 2015). The reactivation of the VZV occurs during aging as well as during times of immunosuppression. Occasionally wetting the bed 6 y/o. what age night time bed wetting usually stop?  Enuresis pg1306 : Enuresis is involuntary passage of urine past the age when a child should be expected to have attained bladder control (Fleming, 2012). Because this is expected at 2 to 3 years of age for daytime and age 4 to 6 years for nighttime, enuresis is said to occur at approximately 7 years. Children with enuresis who are older than 5 years of age need an evaluation to determine whether there is an organic cause for the disorder. Down syndrome has experience sexual intercourse. How to educate pt?  Children with Down syndrome are usually cognitively challenged to some degree. The challenge can range from an IQ of 50 to 70 to a child who is profoundly affected (IQ less than 18. 19. 20. 21. 22. 23. 24. 20). The extent of the cognitive challenge is not evident at birth, but the fact the brain is not developing well is usually evidenced by a head size smaller than the 10th or 20th percentile at well-child healthcare visits. It’s important for children with Down syndrome to be enrolled in early educational and play programs so they can develop to their full capacity.  Health professionals who care for children with cognitive disabilities must be especially watchful to protect these vulnerable children from sexual maltreatment 15 y/o hasn’t started menstrual period yet. The onset Secondary sexual characteristic has started about 2 years ago. Pg 887, pg1326  Delayed puberty, as the name implies, is the failure of pubertal changes to occur at the usual age. The family history of many of these children reveals a family tendency for late maturation. If so, the child needs a thorough physical examination to disclose whether some secondary sex characteristics are present or endocrine stimulation is beginning.  Most girls worry considerably about delayed menstruation, but, once reassured that their development is merely delayed, they are usually willing to wait for menarche to occur on its own. If girls have not begun to menstruate by age 17 years and pathology has been ruled out, menstrual cycles can be initiated by administering estrogen. Chlamydial infection  S/S: watery, heavy, gray-white vaginal discharge, vulvar itching.  Incubation period is 1-5 weeks  Doxycycline, azithromycin  Required to report to the health department and usually tested for gonorrhea as well.  Sexual partner should receive the same treatment Genital wart caused by HPV (human papillomavirus) increased risk which of the following?  HPV infections are serious because they are associated with the development of penile and cervical cancer later in life. Anorexia nervosa pg 1548 - wanna be perfect.  is characterized by refusal to maintain a minimally usual body weight because of a disturbance in perception of the size or appearance of the body  Children or teens with the disorder think of themselves as overweight even though their weight is adequate and thus severely limit their intake, begin excessive exercise, or use emetics, laxatives, enemas, or diuretics (purging) to better reduce their weight to what they envision their weight should be .  It may be genetically based and includes three separate features: self-induced starvation to a significant degree, a relentless drive for thinness, and medical signs and symptoms resulting from starvation.  Specific characteristics of a child or teen with anorexia nervosa that are usually present include: Severely distorted body image o BMI less than 17.5 kg/m2 or less than 85% of expected weight o Intense fear of gaining weight or becoming fat even though underweight o Refusal to acknowledge seriousness of weight loss 4 y/o boy. Very angry, kicking, what would the nurse do?  Let him cry CNS stimulates. What kind of dependency? Pg 902 Child is feeling guilt for misbehaviors  Magical thinking  Preschooler 3 -6 age  May believe illness and hospitalization are punishment 25. Negativism – “No”  offer option. Choices. 26. Separation anxiety  It begin around 4 to 8 month  Stage o Protest: screaming, clinging, aggression toward strnagers o Despair: withdrawal from others. Depression, regression o Detachment: interacting with strangers, forming new relationship, happy appearance. 27. Acute diarrhea pg 1262  Increase BUN, increase Hct  Metabolic acidosis: diarrhea.  Metabolic alkalosis: vomiting 28. 12 y/o Leukemia – Cytoxan  Cyclophosphamide (Cytoxan): alkylating agent  SE: bone marrow depression, anorexia, nausea, vomiting, mucositis, alopecia, cystitis (hemorrhagic), hepatoxicity.  Encourage fluid intake 29. Fluid shift. Burn injury  Intravascular space. Where the fluid is moving next? 30. 31. 32. 33. First sign of overwhelming sepsis? AMS periorbital edema  when is the last time urinate? UTI secondary Vasco urinatal reflux  Empty bladder completely. Nephrotic syndrome. Lab. Fluid Shifts in First 24 Hours Remobilization of Fluid After 48 Hours Burn Edematous tissue surrounding burn area ↓ ↓ Increased capillary permeability Intravascular compartment ↓ ↓ Hypoproteinemia Hypervolemia Hyponatremia Hypernatremia Hyperkalemia Hypokalemia Hypovolemia    Increased specific gravity Proteinuria The four characteristic symptoms of nephrotic syndrome are proteinuria, edema, hypoalbuminemia (low serum albumin level), and hyperlipidemia (increased blood lipid level) 34. HUS- Hemolytic uremic syndrome pg 1314  With hemolytic-uremic syndrome, the lining of glomerular arterioles becomes inflamed, swollen, and occluded with particles of platelets and fibrin. The child’s red blood cells and platelets become damaged as they flow through the partially occluded blood vessels. As the damaged cells reach the spleen, they are destroyed by the spleen and removed from circulation, leading to a hemolytic anemia.  E.coli infection can cause it  S/S: dehydration, fever, oliguria, proteinuria, hematuria, urinary cast in urine follows, increased Creatinine, BUN, Edema, pale, easy bruising, petchiae, thrombocytopenia 35. Croup pg 1110 - increase fluid  Croup (inflammation of the larynx, trachea, and major bronchi) is a frightening illness in childhood, although complications are rare for caregivers. In children between 6 months and 3 years of age, the cause of croup is usually a viral infection such as parainfluenza virus.  With croup, children typically have only minimal signs at bedtime. Temperature is normal or only mildly elevated. They may develop a barking cough (croupy cough), inspiratory stridor, and marked retractions from inflammation of the larynx, trachea, and major bronchi. 36. Acute otitis media – taking gentamycin  Kidney function – monitor I&O 37. Pneumonia  Antibiotic 38. Acute asthma episode  Albuterol (short-acting) 39. 3 y/o hospitalization  parent, favorite toys, blankets, 40. Methotrexate toxicity?  Methotrexate (MTX)  SE: mucositis, bone marrow depression, nausea, vomiting, alopecia, hepatotoxicity, nephrotoxicity,  Administer salicylates often follow by leucovorin to decrease toxicity. 41. Preschool  magical thinking 42. 6 y/o Hepatitis A. How to care pt?  Chicken pox  Teach infection control, hand hygiene. 43. 2 y/o . Cardiac cath  Check allergies  iodine, shellfish, contrast 44. Cardiac defect  Shunt left from right heart.  Symptoms? Complication? CHF 45. Obstructed blood flow. What defect?  Stenosis 46. Factor A administration. What color of skin will turn?  Risk for hepatitis  Yellowish skin 47. Rheumatic fever  CRP – C reactive protein ( inflammation process) 48. Kawasaki disease (vasculitis)  high-dose aspirin therapy has demonstrated a reduction in the appearance of coronary artery ectasia and aneurysms due to their anti-inflammatory properties. 49. ACE inhibitor 50. Blood transfusion – develop dyspnea, dry cough  Fluid overload 51. Rheumatic fever – Bed rest, activity restriction. What outcome ?? HR 52. Moderate hemophilia A. What is the main therapy?  Factor VIII deficiency  Factor VIII is an intrinsic factor of coagulation; its absence causes the intrinsic system for manufacturing thromboplastin to be incomplete. 53. Acquired hematologic disorder. What is the condition when there is excessive destruction of platelet? Pg 1250  Idiopathic thrombocytopenic purpura (ITP) is the result of a decrease in the number of circulating platelets in the presence of adequate megakaryocytes (precursors to platelets). The cause is unknown, but it is thought to result from an increased rate of platelet destruction due to an antiplatelet antibody that destroys platelets, making this an autoimmune illness.  Laboratory studies reveal marked thrombocytopenia. The platelet count may be as low as 20,000/mm3. Bone marrow examination reveals a normal number of megakaryocytes. 54. Head injury. Very first signs the nurse asses? LOC 55. Sickle cell anemia  Sickle turbidity screening does not differentiate trait from disease  Hemoglobin electrophoresis is definitive diagnosis. 56. Seizure safety measure 57. Aplastic anemia. Teaching plan pg 1238  Depression blood component  Aplastic anemias result from depression of hematopoietic activity in the bone marrow. The formation and development of WBCs, platelets, and RBCs can all be affected  immediately discontinue any drug or chemical suspected of causing the bone marrow dysfunction and removing the substance from the child’s environment to avoid exposure.  hematopoietic stem cell transplantation  Limit the number of blood-drawing procedures; combine samples whenever possibl  Use a blood pressure cuff instead of a tourniquet to reduce the number of petechiae.  Apply pressure to any puncture site for a full 5 minutes before applying a bandage.  Minimize the use of adhesive tape to the skin (pulling for removal may tear the skin and cause petechiae).  Pad side and crib rails to prevent bruising. Assess the need for routine blood pressure determinations because tight cuffs can lead to petechiae.  Protect intravenous sites to avoid numerous reinsertions. Administer medication orally or by intravenous infusion when appropriate to minimize the number of subcutaneous or intramuscular injection sites.  Assess that the child is using a soft toothbrush and is offered foods that can be chewed without irritation (e.g., avoid toast crusts).  Check toys for sharp corners, which may cause scratches. Urge the child to be careful with paper because paper cuts can bleed out of proportion to their size.  Distract the child from rough play; suggest stimulating but quiet activities to minimize risk of injury. 58. Growth hormone. When is the best time to administer? At night time.  14 y/o Humurs Fx  Epiphyseal plate (growth plate) Injury to this area in a growing child is always potentially serious because it may halt growth, stimulate abnormal growth, or cause irregular or erratic growth. 59. Ankle injured. Teaching? Ice compression  A strain is a muscle–tendon injury. A sprain is a ligament injury. Strained or sprained ankles are common and slow-to-heal childhood injuries  If the injury is recent, apply an ice pack for approximately 20 minutes to reduce edema at the site; repeat this for 4 to 7 days at home. The child may be fitted for crutches to limit weight bearing for the next 3 or 4 days or fitted with a supportive medical boot. Make certain the parents understand how the elastic bandage is applied so that it can be rewrapped if it loosens and be certain the child is using the crutches or boot properly before being discharged from the emergency department. 60. Swollen ankle, popping sound, painful  ???? 61. Sprains – ice, rest, elevated legs 62. Legg clave perthes disease pg 1446.  Legg-Calvé-Perthes disease is avascular necrosis (a lack of blood flow resulting in destruction) of the proximal femoral epiphysis,  In children older than 6 years of age, reconstructive surgery (an osteotomy to center the femur head in the acetabulum followed by cast application) is most often prescribed.  younger than 6 years of age usually focuses on pain reduction with nonsteroidal antiinflammatory drugs (NSAIDs) plus keeping the head of the femur within the acetabulum by a containment device 63. JRA – Juvenile idiopathic arthritis pg 1454. Teaching? Medication?  Because JA is a long-term illness, therapy includes a balanced program of exercise, rest, and medication administration to relieve pain, restore function, and maintain joint mobility  Using an elevated toilet seat  Heat application  NSAIDs such as ibuprofen (Motrin) or naproxen (Naprosyn)  Because taking so many NSAIDs can cause gastrointestinal upset and bleeding, be certain parents know to always give the medication with food.  Slow-acting antirheumatic drugs (SAARDs), also called disease-modifying antirheumatic drugs (DMARDs), can be used if NSAIDs are ineffective.  Methotrexate, a cytotoxic drug, is the second drug usually prescribed. Steroids, such as prednisone, are only added to the drug therapy if the disease is extremely severe or is an incapacitating systemic disease that has not responded to other antiinflammatory agents.  tumor necrosis factor (TNF) inhibitors, such as etanercept (Enbrel) or infliximab (Remicade) 64. Tetanus (Lockjaw) pg 1222  Tetanus occurs worldwide causing an acute, spastic paralytic illness caused by neurotoxin produced by Clostridium  It is a highly fatal disease if untreated and is caused by an anaerobic, spore-forming bacillus found in soil and the excretions of animals. It enters the body through an open wound. If the wound is deep, such as a stab wound, where the distal end of the wound is shut off from an oxygen source, tetanus bacilli begin to reproduce. The organism may also enter through a burn site, which crusts, thus creating an anaerobic environment. As the bacilli grow, they produce exotoxins that cause the disease symptoms by affecting the motor nuclei of the central nervous system (Arnon, 2016). The onset of the disease occurs gradually over 1 to 7 days with severe muscle spasm stimulated by external stimuli and autonomic dysfunction causing arrhythmias, tachycardia, and diaphoresis. 65. Head injury just came to the ER. Parent is asking how bad it is  not sure yet. 66. Spinal cord injury. Cervical 3 TABLE 49.4 FUNCTIONAL ABILITY AFTER SPINAL CORD INJURY Injury Highest Key Functions Site Still Present Effects and Possible Interventions C1–C3 Head and neck muscles intact Respiratory paralysis from loss of phrenic nerve innervation; will need ventilatory assistance No voluntary motion below chin; possibly able to learn to use mouth to control pen for writing and mouth stick to reach objects C4 Diaphragm intact Loss of motor function of upper and lower extremities and trunk; able to learn to use abdominal muscles to breathe independently C5 Shoulder control; biceps, deltoid function Able to feed self and operate wheelchair if fitted with self-care aids C6 Forearm pronation; wrist extension Use of upper extremities for self-care; can transfer to wheelchair and so have increased independence C7 Triceps function Able to transfer to wheelchair readily; increasing independence C8 Thumb and finger function Able to do fine motor tasks; increases selfcare ability T1–T7 Intercostal muscles (able to Full use of upper extremities but is still breathe with chest, not dependent on wheelchair abdominal, muscles) Possibly able to drive car with hand controls Possibly able to have high leg braces fitted for standing T10–12 Abdominal muscles Use of long leg braces and four-point crutch to ambulate L2–L4 Hip flexion Leg extension Use of long or short leg braces to ambulate L5–S1 Gluteus maximus muscle function Able to walk without aids S4 Bladder and anal sphincter control Able to control bladder and bowel function Penile erection and ejaculation possible 67. Pseudohypertrophic Muscular Dystrophy (Duchenne Disease)- Duchenne disease, the most common form of muscular dystrophy, is inherited as a sex-linked recessive trait. Therefore, it occurs only in boys, although a mother who carries the gene may demonstrate some symptoms. Symptoms are usually apparent by 3 years of age. Pg 1459  reach milestone later than does the average.  By about 3 years of age, symptoms become acute and obvious as boys develop a waddling gait and have difficulty climbing stairs  They can rise from the floor only by rolling onto their stomachs and then pushing themselves to their knees  To stand, they press their hands against their ankles, knees, and thighs (they “walk up their front”), called a Gower sign.  They may walk on their toes, which leads to the development of a short heel cord. Speech and swallowing become difficult.  It may be awkward to lift a young child with this condition by placing your hands under the axillae because the child seems to slip through your hands due to the lax shoulder muscles. In contrast, calf muscles are hypertrophied (measure larger than normal) because the muscles become so degenerated they are replaced by fat and connective tissue.  Scoliosis of the spine and fractures of long bones may occur from abnormal muscle tension and lack of muscle support.  By junior high school age, most boys become wheelchair dependent. Tachycardia can occur as the heart muscle weakens and enlarges. Pneumonia develops easily as the child’s cough reflex becomes weak and ineffective. Death from pulmonary dysfunction tends to occur at about 20 years of age. 68. Blowing bubble – Incentive spirometer  Expiratory time and expiratory pressure? 69. Constipation can cause UTI – large stool mass prevent complete emptying of the bladder 70. Crhon’s disease pg 1285  The symptoms of CD depend on the severity and location of the inflammation. Abdominal pain, diarrhea with or without blood, and weight loss may be present. The inflamed area may become narrowed causing a stricture of the bowel, and a bowel obstruction may develop if this goes untreated.  When food is reintroduced after the resting period, a high-protein, highcarbohydrate, and high-vitamin diet is prescribed to replace nutrients. Children may 71. 72. 73. 74. 75. 76. 77. eat cautiously at first to avoid reintroducing diarrhea, so assess intake and output carefully. Closed head injury  best position? Pg 1383  Placing a child in a semi-Fowler’s position (use an infant seat for babies) or administering a corticosteroid such as dexamethasone (Decadron) can effectively reduce cerebral edema and its accompanying pressure.  When a parent is burping an infant after a feeding, caution them to be careful not to put pressure on the jugular veins because this is another action that increases ICP. acute glomerulonephritis pg 1308  Glomerulonephritis, inflammation of the glomeruli of the kidney, may occur as a separate entity but usually occurs in children as an immune complex disease after infection with nephritogenic streptococci (most commonly subtypes of group A betahemolytic streptococci) where complement, a cascade of proteins activated by antigen–antibody reactions, plugs or obstructs glomeruli.  sudden onset of hematuria and proteinuria  Urinary sediment will contain white blood cells, epithelial cells, and hyaline, granular, and red blood cell casts.  hild’s urine appears tea-colored, reddish-brown, or smoky.  oliguria. Specific gravity of urine becomes elevated. Hypertension from hypervolemia occurs. The child may have abdominal pain, a low-grade fever, edema, anorexia, vomiting, or headache.  There may be cardiac involvement such as orthopnea, cardiac enlargement, enlarged liver, pulmonary edema, a galloping heart rhythm, or heart failure because of the difficulty in managing the excessive plasma fluid.  If blood pressure reaches 160/100 mmHg as part of the expanding circulatory volume, encephalopathy may occur, with symptoms of headache, irritability, seizures, vomiting, coma or lethargy, and perhaps transitory paralysis, symptoms all caused by cerebral ischemia (vasoconstriction of cerebral vessels that occurs to reduce cranial pressure). Hearing loss . distortion sound and problem in discrimination?????????????????????????? Diphtheria pg 1220 - treatment?  Treatment involves a single dose of equine antitoxin based on clinical suspicion, and this can be obtained through the CDC (AAP, 2015).  children are given penicillin or erythromycin intravenously  Complete bed rest  Droplet precautions must be followed until cultures are negative.  endotracheal intubation may be necessary. Sickle cell – why no symptoms occurs early? Pg 1243.  Because fetal hemoglobin contains a γ, not a β, chain, the disease usually will not result in clinical symptoms until a child’s hemoglobin changes from the fetal to the adult form at approximately 6 months. However, the disease can be diagnosed prenatally by chorionic villi sampling or from cord blood during amniocentesis. If these were not done, it will be identified at birth by neonatal screening Addison disease ??????????? Ewing Sarcoma (bone cancer) pg1522 management?  therapy consists of a combination of surgery to remove the primary tumor, radiation, and chemotherapy  The drug regimen often used includes vincristine, dactinomycin, cyclophosphamide, doxorubicin, etoposide, and ifosfamide.