Exam 2 Flashcards
Three consequences of impaired intracranial regulation
Cerebral edema- increased brain size, fluid accumulation
Increased intracranial pressure- sustained pressures, trauma,
Decreased cerebral perfusion pressure (bleeding r/t hemorrhagic stroke)
Cushing Triad for increased ICP
Increased systolic blood pressure (widened pulse pressure)
Decreased pulse rate (bradycardia)
Decreased respirations (irregular)
Note: effects opposite those of shock
ICP Monitoring
Indications (4)
Care (2)
Indications
- Glasgow Coma Scale score < 8
- TBI w/ abnormal CT scan
- Deteriorating neurological condition
- Subjective judgment regarding clinical appearance and response
Care
- Do not change dressings daily
- keep drainage bag for direct ventricular pressure measurement at level of ventricles
Pediatric Glasgow Coma Scale
Three parts (and their scales)
Three parts
- Eye opening (1-4 – none; pain; speech; spontaneously)
- Motor response (1-6 – none; extension; flexion abnormal; flexion withdrawal; localizes pain; obeys commands)
- verbal response (1-5 – incomprehensible/agitated/restless; inappropriate persistent cry or words; confused/consolable cry; orientation (smiles, listens, follows)
Pediatric Glascow Coma Scale
3 score ranges
Score of 15: unaltered LOC
Score of 8 or below: coma
Score of 3: extremely decreased LOC
(worst possible score on the scale)
Head Injury
Patho (2)
- acceleration-deceleration esp due to large head to body ratio in child
- force of intracranial contents unable to be absorbed by skull so shearing forces OR force brain through tentorial opening
Types of Head Injuries (6)
- Skull fracture (requires great force)
- Contusions: visible bruising coup (at impact pt) OR contrecoup (opposite impact pt)– shaken baby syndrome
- Intracranial hematoma
- Diffuse injury
- Laceration (tearing of tissue)
- Concussion (alteration in neurologic function w/ or w/o loss of consciousness; may have amnesia/confusion but transient)
Complications of Head Trauma (3)
Epidural hemorrhage (death likely)
- Bleeding b/w skull and dura lead to tentorial herniation rapidly
Subdural hemorrhage
- Bleeding b/w dura and arachnoid membrane over brain due to vein tearing or direct trauma
- slow development
Cerebral edema
- Associated with TBI
- Increased cytotoxic or vasogenic edema leads to herniation
Types of Skull fractures (6)
Basilar: post- Battle sign (bleeding posterior neck, mastoid area), raccoon eyes, leakage of CSF from ears and nose
Diastatic: transverses the sutures and widens sutures.
Comminuted: split into multiple pieces
Linear: does not cross suture lines
Open: leads to rhinorrhea or otorrhea of CSF
Depressed: locally broken into irregular fractures
Diagnostics for Intracranial Regulation (6)
- Neuroimaging (MRI, CT) (Check for allergies if contrast dye to be used; child must be still)
- Skull radiograph
- EEG (flat = brain death)
- Brain biopsy
- Lumbar puncture (contraindicated w/ increased ICP; lie still)– diagnostic for meningitis
- Lab tests (hyperglycemia in increased ICP; low HCt, low Platelet, high WBC in head injury)
Neurological Examination: impaired?
Vital signs (3)
- cerebral hypoxia > 4 min = irreversible damage
- hypothermia = severe infection
- hyperthermia = acute infections, heatstroke, drug ingestion, hemorrhage
Neurological Examination: Impaired?
Respiratory (4)
- Slow and deep = heavy sleep after seizures, sedatives, cerebral infections
- Slow and shallow = sedatives or opioids
- Hyperventilation = metabolic acidosis, salicylate poisoning, hepatic coma
- Hypoventilation/ CO2 retention = can increase cerebral blood flow and ICP
Neurological Examination: Impaired?
LOC (2)
Skin (2)
LOC
- unable to say their name
- have parent in room to increase chance of response
Skin
- bruises, bleedings, or needle sticks
- head circumference reading till 2 yrs (daily if myelomeningocele, hemorrhage or IU infections)
Neurological Examination: Impaired?
Eyes (3)
- not PERRLA (fixation = brain damage, dilation or pinpoint = brain damage, dilation but reactive = seizure)
- doll head maneuver (rotate head, eyes should go to opposite side)
- Ice water caloric test ( only if unconscious; eyes move to side of stimulation)
S/s of Increased ICP in Infant (7)
Poor feeding
High-pitched cry, difficult to soothe, irritable
Tense, bulging fontanels
Separated cranial sutures (increased frontooccipital circumference)
Distended Scalp veins
Macewen (cracked-pot) sign (Bones of skull thin and sutures palpably separated to produce cracked-pot sound on percussion of skull
Setting-sun sign (Sclera visible above iris due to eyes being rotated downward)
S/s of Increased ICP in Child (8)
- Headache
- Forceful NV
- Seizures
- Irritability
- Diminished physical activity (drowsy, lethargy, Inability to follow simple command)
- Slurred speech
- Visual changes (diplopia, blurred vision)
- Inappropriate for age reflexes i.e. primitive and babinski)
Late signs of Increased ICP (9)
Bradycardia
Decreased motor response to a command
Decreased sensory response to painful stimuli
Alterations in pupil size and reactivity
Decortication (Rigid flexion w/ arms close to body, flexed elbows and wrists, plantar flexed feet, legs extended & internally rotated)
Decerebrate (rigid extension and pronation of arms and legs, flexed wrists, clenched jaw, extended neck; arched back)
Cushing’s triad-decreased HR. RR. & widening or increased BP (pulse pressure)
Cheyne-Stokes respirations (prolonged apnea, paradoxical chest movement, ataxic breathing, hyperventilation)
Papilledema (optic disc swelling, hemorrhages, tortuosity of vessels, absence of venous pulsations)- develops in 24-48 hrs
8 levels of consciousness
Full consciousness
Confusion: impaired decision making
Disorientation: to time and place
Lethargy: sluggish speech
Obtundation: arouses with stimulation; respond to voice or pain
Stupor: responds only to vigorous and repeated stimulation
Coma: no motor or verbal response to noxious stimuli i.e voice nor pain
Persistent vegetative state: permanent loss of function of cerebral cortex
Stages of Brain Herniation (5)
bilateral Babinski reflexes
Grasp reflex
Decortication (Rigid flexion w/ arms close to body, flexed elbows and wrists, plantar flexed feet, legs extended & internally rotated)
Decerebrate (rigid extension and pronation of arms and legs, flexed wrists, clenched jaw, extended neck; arched back)
Flaccid (when lower pons and upper medulla involveD)
Nursing Care of Unconscious child: Reduce ICP (9)
- ABC (vitals q15 mins)
- NPO
- neck stabilization(use jaw thrust vs chin lift for airways)
- minimize environmental noise, stimulation
- reduce suctioning
- position (HOB 30 degrees and avoid neck vein compression)
- Prevent straining i.e. cough, vomit, defecation, Valsalva maneuver
- Use vibration instead of cough b-c it does not increase ICP
- provide thermoregulation (light covering, antipyretics, hypothermia blanket)
Medications to reduce ICP (6)
- Stool softeners
- Analgesics (pain increases ICP but pain meds decrease LOC so controversial; acetaminophen, NSAIDs, opioids, paralytics (vecuronium)))
- IV hypertonic NS (no dextrose if on keto; avoid overhydration)
- manage SIADH (NS and diuretics) or DI (vasopressor or fluid replacement) if present
- corticosteroids (for inflammation and edema)- watch for hyperglycemia, infection; don’t give if for head trauma
- osmotic diuretic (Mannitol) - reduce ICP
Acute Care Medications to reduce ICP
4 types
Antiepileptics –phenytoin, fosphenytoin, Carbamazepine (Tegretol)
- Look for CBC changes and SJS
- used for seizures
Sedation or amnesic anxiolytics (Propofol, Lorazepam) - agitation can increase ICP
Barbiturates (controversial)- induce coma to decrease metabolic rate and protect brain when reduced cerebral perfusion pressure
Paralytic agents
Posttraumatic Syndromes: Head Injury (4)
- Post-concussion syndrome: residual symptoms after 4 weeks
- Headaches – within 1 week – 3months
- Seizures – within 24 hrs
- Structural complications i.e hydrocephalus, herniation
Hydrocephalus
Patho (3)
- Impaired absorption, production, or flow of CSF within the subarachnoid space
- Communicating or non-communicating (obstructive)
- Increased CSF in ventricles leads to dilated ventricles and compresses brain tissue
Management of Hydrocephalus: Shunt
Complications (4)
Nursing Care (6)
Complications: infection, malfunction, subdural hematoma, peritonitis
Nursing care
- keep head flat to prevent rapid drainage (flex head prior to shunt placement; place on unoperated side
- shunt is for life and revised when growth
- do not pump shunt
- educate family on name and model of shunt
- no scalp IVs
- test any drainage for glucose (CSF leak)
Management of Hydrocephalus
VA shunt (2)
VP shunt (4)
Ventriculoatrial (VA)
- drains fluid from ventricles into atria of the heart usually done when hx of abdominal surgery
- contraindicated with CHD or elevated CSF protein
Ventriculoperitoneal shunt (VP Shunt)
- drains fluid from ventricles into peritoneum
- preferred method b-c longer and allows growth
- observe for abdominal distention (s/s of peritonitis)
- contact sports prohibited
Shunt Infections
Types of infections (4)
Treatment (3)
Infections: Septicemia, Bacterial endocarditis, Wound infection, Meningitis
Treatment
- massive-dose antibiotics
- shunt externalization (at level of auditory meatus, clamp during ambulation)
- shunt removal
Bacterial Meningitis
What is it?
Seasonal Variation
Prevention
Diagnosis
Severe complications (6)
Acute inflammation of the meninges and CSF which spreads via vascular dissemination (due to Hib, GBS, Meningococcal)
Seasonal variation: late winter and early spring
Prevention: Hib vaccine; prophylaxis in pregnancy
Diagnosis: Lumbar puncture unless increased ICP then CT scan
Severe complications: seizures, subdural effusions, deafness (from CN VIII damage), sepsis, obstructive hydrocephalus, hemiparesis (r/t thrombi in veins)
S/s of meningitis (7)
- Fever, chills
- Nuchal rigidity
- Photophobia
- Brudzinski’s sign (neck stiffness causes hip and knees to flex when neck flexed)
- Kernig’s sign (unable to straighten leg >135 degrees w/o pain)
- Joint problems
- s/s of increased ICP (poor feeding, vomiting, irritability, seizures, high pitched cry)
Bacterial Meningitis
CSF color
ICP Pressure
Culture
Presence of following in CSF:
WBCs
Protein
Glucose
CSF color: cloudy, turbulent, purulent
ICP Pressure: elevated
Culture: positive
Presence of following in CSF:
WBCs: elevated esp. polymorphonuclear leukocytes
Protein: elevated
Glucose: Decreased
Viral Meningitis
CSF color
ICP Pressure
Culture
Presence of following in CSF:
WBCs
Protein
Glucose
CSF color: clear or slightly cloudy
ICP Pressure: normal or elevated
Culture: negative
Presence of following in CSF:
WBCs: elevated
Protein: normal or slight elevation
Glucose: normal
Management of Meningitis (6)
- Droplet isolation due to nasopharyngeal secretions
- 10 day Antibiotic therapy (IV) - not for viral (GIVEN ASAP TO IMPROVE PROGNOSIS)
- Control fever (hydration, antipyretics)
- Pain management- meds
- positioning (sidelying)
- Reduce ICP (elevate HOB and decreased stimulation)
Encephalitis
Causative organism
Patho
Key S/s (4)
Causative organism: virus from vector (mosquitoes and ticks)
Patho: inflammation of CNS by virus
Key S/s: stiff neck, headache, Ataxia, speech difficulties
(also fever, malaise, NV)
Epilepsy vs Seizure
Epilepsy: Two or more unprovoked seizures
Seizure: Caused by excessive and disorderly neuronal discharges in the brain r/t an underlying disease process (such as trauma, meningitis, encephalitis, epilepsy, stress, illness)– Most common neurologic dysfunction in children
Partial Seizures (focal) - 3
- Local onset and involves a relatively small location of the brain
- Simple Partial (w/o impaired awareness; may have aura)
- Complex Partial (w/ impaired awareness and automatisms)
Generalized (Grand Mal- Tonic-clonic) - 3
- Involves both hemispheres without local onset
- loss of consciousness and motor impairment at onset
- no aura
Generalized seizures: 4 types
Tonic-Clonic seizures (grand mal and most dramatic)
- Tonic (stiffening, eyes roll up)
- Clonic (intense jerking w/ rhythmic contraction and relaxation longer than tonic phase
Absence (petitt mal): Sudden onset of brief loss of consciousness (5-10 sec), blank stare and automatisms; does not fall
Atonic (drop): Sudden, momentary loss of muscle tone
Myoclonic: Sudden brief, shocklike muscle movements
Febrile Seizures (4)
- transient disorder of childhood (rare after 5 yrs of age)
- fever > 38C (100.4 C)
- treat w/ antipyretics and PRN benzos at home (alongside seizure precautions)
- call 911 if > 5 min
Infantile Spasms (4)
- clusters of Jerking of tummy, raising arms, blinks, occur every 3- 5 seconds lasting up to 30 minute
- abnormal EEG w/ hyperarrhythmia
- treat w/ ACTH (monitor for immunosuppression, glucose, hypertension) OR prednisolone
- treat w/ ketogenic diet (monitor ketones and glucose)
Management of Seizures (4)
Drug therapy (ideally monotherapy for full control; slow discontinuation)
Ketogenic diet (high fat, to preserve glucose)
Vagus nerve stimulation (palliative, generator in chest sends electrical impulse to Vagus nerve (CN X) at onset of seizure after activation w/ magnet)
Corpus Callosotomy (ligation of area via surgery)
Nursing Care for seizures (5)
- Time and record behavior surrounding Seizure
- Keep patient safe – ABCs
- Oxygen
- Seizure precautions (no restrain, nothing in mouth during, suction equipment at bedside, ease to floor, )
- aspiration precautions (post seizure NPO and suction; place on side)
S/s of acute seizure (4)
- Apnea
- Cyanosis
- Pupils dilated and non-reactive
- Incontinence
Meds for Seizures (what to know?)
- Diazepam
- Lorazepam (Ativan)
- Fosphenytoin
- phenytoin (DILANTIN)) - 2
- Levetiracetam
- Carbamazepine (Tegretol)
- Phenobarbital or propofol - 2
- Valproic Acid
Diazepam or Lorazepam (Ativan)
-oral, buccal, rectal, IV
Fosphenytoin- (form of phenytoin)
phenytoin (DILANTIN)
- Do not take w/ milk
- can cause gum hyperplasia
Levetiracetam (Keppra)
- rash and mood swings risk
Carbamazepine (Tegretol)
- SJS risk
Phenobarbital
- for status epilepticus
- take adequate vitamin D and folic acid
Valproic Acid
- liver toxicity
Craniosynostosis
What is it?
Treatment
Complications of treatment (3)
- bones join together too early and surgery separates them (posterior fontanel < 8 wks; anterior fontanel < 12-18 months)
Treatment: Surgery
Complications: Edema, Bleeding (black eyes), Infection
Reye’s syndrome
Cause
S/s (2)
Diagnosis
Complications (3)
Cause: giving aspirin or Pepto bismol to children with a viral infection
S/s: cerebral edema, liver involvement
Diagnostics: Liver biopsy (fatty liver)
Complications: Coma, Brain herniation, Death
Risk factors for Congenital Heart Defects (8)
- other anomalies (trisomies 21, 13, 18, turner, DiGeorge)
- Maternal Chronic illness (diabetes, PKU)
- Maternal Alcohol consumption, Substance abuse
- Exposure to environmental toxins
- In utero Infections (CMV, toxoplasmosis, Rubella, HIV)
- Medications (phenytoin, valproic acid, amphetamine, OCs)
- Family history of heart defects
- IUGR or HBW
S/s of congenital heart defects (9)
- Tachypnea/tachycardia
- Activity/Exercise intolerance (poor feeding, fatigue during eating)
- Developmental delay, FTT
- Frequent respiratory tract infections
- cyanosis (unresponsive to O2)
- Unusual pulsations – JVD, diminised peripheral pulses, pallor
- clubbing of fingers
- heart sounds (murmurs, distinct, muffled; irregular; thrills)
- Enlarged organs (cardiomegaly, hepatomegaly, splenomegaly)
Causes of Cyanosis
Lung vs Heart Issue
- problem?
- response to Oxygen
Primary parenchymal lung disease ( Pneumonia, meconium aspiration syndrome)
-Problem is with O2 diffusion
- Responds to increased FiO2
Primary cardiac disease
- combo of decreased pulmonary flow and intracardiac mixing of “blue” and “pink” blood
- Doesn’t respond much to increased FiO2
Cardiac Diagnostics: What are they
ECG
ECHO
Exercise/stress test
Syncope/ Tilt Table Test
Cardiac MRI
ECG - electrical activity of heart (assess child, not monitor; takes 15 min)
ECHO -ultrasound of structure, size, blood flow through heart (takes an hr and child be still)
Exercise/Stress test - monitor during exercise
Syncope/ Tilt Table Test- determine cause of fainting (normal: BP stable, HR increases w/ horizontal to vertical position; positive: Pt passes out, hypotension, bradycardia/tachycardia w/ horizontal to vertical position due to heart or BV problem
Cardiac MRI- still and moving pics of heart and major BVs to analyze structure and function (sedation for child < 7; contraindicated w/ metal implants (pacemakers, cochlear)
Cardiac Diagnostics: Cardiac cath Purposes
Diagnostic - 2
Interventional
Electrophysical
Diagnostic- prior to surgical repair
– Right and/or Left cath. Right through vein, left through artery to Helps plan for procedures
- Angiogram - visualize the arteries surrounding the heart w/ contrast dye and X-ray images
Interventional – repair or other intervention
Electrophysiology studies – evaluate and destroy (ablate) accessory pathways that cause some tachydysrhythmias
Cardiac Diagnostics: Cardiac cath
Pre-procedure care (6)
- Assess dye allergy (iodine)
- Age-appropriate teaching (informed consent from parent)
- NPO at least 4-6 hours (IV fluids for infants)
- Assessment: VS baseline cardiopulmonary, perfusion, assess and MARK all pulses, height & weight
- Sedation- oral or IV
- Assess for infection may be postponed if severe diaper rash
Cardiac Diagnostics: Cardiac cath
Post-procedure care (8)
- Monitor blood glucose (hypoglycemia possible), VS, dressing, I & O, continuous cardiac monitoring
- Bedrest for 4-6 hr, Strict.
- Keep affected extremity straight for 2hr, then limited ambulation for 3 days
- avoid baths and activity for 48-72 hrs
- HOB flat x 2 hrs, elevate 30˚ 2 hrs after completion of procedure.
- Check cath site and distal extremity pulses, color and perfusion, q15 min x 4 occurrences, then q 30 min x 4 occurrences , then q1h x 3 h,
- Pulse - normal to be weaker in affected extremity for a few hours
- remove dressing in 24 hrs
When to notify HCP post-cardiac cath (5)
- If bleeding, apply pressure at cardiac catheter entry site (2.5 cm above entry site)
- swelling
- hematoma
- arrhythmia (possible and reason for monitoring)
- fever
4 classifications of CHD
↑ Pulmonary blood flow
- Atrial Septal Defect (ASD)*
- Ventricular Septal Defect (VSD)*
- Patent Ductal Arteriosus (PDA)*
Obstruction of blood flow (out of the heart)
- Coarctation of aorta*
- Pulmonic Stenosis *
- Aortic Stenosis
↓ Pulmonary blood flow
- Tetralogy of Fallot (TOF)*
Mixed blood flow
- Transposition of Great Arteries/Vessels (TGA)*
- Hypoplastic Left Heart Syndrome (HLHS)
CHD: Increased Pulmonary Blood Flow (ASD, VSD, PDA)
Characteristics (3)
- Abnormal connection between 2 sides of heart
increased blood volume on R side - Left to Right shunt
- Decreased systemic blood flow due to increased pulmonary blood flow
CHD: Increased Pulmonary Blood Flow (ASD, VSD, PDA)
Clinical Manifestations (7)
- If small, may be asymptomatic and close spontaneously
- Fatigue (poor feeding, activity intolerance)
- Heart Murmur
- Risk for Endocarditis
- Risk for pulmonary vascular obstructive disease
- risk for CHF
- Growth delay (FTT, poor weight gain)
Atrial Septal Defect
What is it?
S/s (4)
Complications (2)
Abnormal opening b/ atria so L-R shunt
Key S/s
- usually asymptomatic
- murmur (systolic w/ fixed split-second sound)
- atrial dysrhythmias (r/t RA and RV enlargement)
- hypertrophy of right side
Complications: HF by 30-40 yrs if untreated; embolism
Atrial Septal Defect
Treatment (2)
Surgical- Pericardial/Dacron patch w/ cardiac bypass
Non-surgical- Amplatzer Septal Occluder placed by cardiac cath (need Low dose aspirin x 6 months)
Ventricular Septal Defect
What is it?
S/s (2)
Complication
Abnormal opening b/w heart ventricles (most common defect) causing higher systemic resistance and ventricle pressure
Key S/s
- Murmur (loud, harsh)– best heard at left sternal border
- right side hypertrophy
Complications: HF
Ventricular Septal Defect
Treatment (3)
Palliative- PA banding to decrease pulmonary blood flow
Surgical- Patch (large defect) or suture w/ cardiac bypass- preferred
Non-surgical- Device closure with catheterization; more risk than ASD for complete AV block
Patent Ductus Arteriosus
What is it?
S/s (3)
Complication
failure of fetal ductus arteriosus to close at birth causing shunt from aorta to pulmonary artery
S/s: Murmur (machinery like), widened pulse pressure, pulmonary arterial HTN
Complications: right sided hypertrophy
Patent Ductus Arteriosus: Treatments
Medical (2)
Nonsurgical
Surgery (2)
Medical
- prostaglandins to keep PDA if other defects present (side effect = apnea)
- prostaglandin inhibitors (Indomethacin (Indocin) or ibuprofen) in newborns closes PDA
Nonsurgical
- Coiling to occlude in cath lab for > 1 yr if small
Surgery (if large)
- Ligation of PDA with surgery (thoracotomy)
- Thoracoscopic placement of clip
Ductus arteriosus
What keeps it open? (3)
What closes it? (3)
What keeps it open:
- Low pO2/ hypoxia
- Prostaglandins
- Nitric oxide
What constricts it?
- O2
- Norepinephrine, acetylcholine, bradykinin
- Indomethacin, ASA
CHD: Coarctation of Aorta
Characteristics (3)
- Localized narrowing near the insertion of the DA
- Increased pressure proximal to defect (upper extremities); left ventricle and left atrium
- Decreased pressure distal to the defect (lower extremities)
CHD: Coarctation of Aorta
Clinical manifestations (6)
- bounding pulses in UE’s
- Weak or absent LE pulses, cool LE’s
- Heart failure (acidosis and hypotension)
- HTN in UE shows as dizziness, fainting, headaches, epistaxis in older children
- Risk for stroke
- Risk for aortic aneurysm
CHD: Coarctation of Aorta - Treatments
Medical - 1
Nonsurgical - 2
Surgical - 4 notes
Medical
- Initially, may need Prostaglandin E to maintain PDA (palliative)
Nonsurgical
- Balloon angioplasty
- stent placement for patency of aorta
Surgical
- end to end anastomosis with prosthetic graft or portion of L subclavian artery
- Cardiac Bypass not required, thoracotomy incision used
- give mechanical ventilation and inotropic support (Digoxin) pre-op
- manage HTN post-op with meds (Nitroprusside or ACE inhibitors)
CHD: Tetralogy of Fallot (TOF)
4 defects
- VSD (pressure equal in right and left ventricles)
- Overriding aorta (determines blood distribution)
- Pulmonic stenosis (decreases pulmonary blood flow)
- Right ventricular hypertrophy
CHD: Tetralogy of Fallot (TOF)
Clinical Manifestations (6)
- Mild to severe cyanosis at birth
- Murmur
- Clubbing
- Polycythemia/clot formation (emboli)
- Failure to thrive
- Tet spells (anoxia with crying, feeding – risk for seizures, loss of consciousness, emboli, death)
CHD: Tetralogy of Fallot (TOF) - Treatment
Palliative (2)
Complete Repair (2)
Palliative
- during Tet spell, put in knee-to-chest OR squat position
- BT shunt w/ subclavian artery
Complete repair
- Close VSD
- Resect pulmonary stenosis and patch pulmonary valve stenosis to enlarge right ventricle outflow via bypass and median sternotomy
CHD: Transposition of Great Arteries (TGA)
Patho (3)
- PA leaves the LV
- Aorta leaves the RV
- Must have other defect to allow for mixing (patent foramen ovale, PDA, or VSD)
CHD: Transposition of Great Arteries (TGA)
Clinical Manifestations (4)
- Severe cyanosis at birth with minimum communication of saturated and desaturated blood unless large VSD or PDA
- Symptoms of heart failure (pulmonary congestion)
- Murmur (+/-)
- Cardiomegaly within a few weeks
CHD: Transposition of Great Arteries (TGA) - Treatment
Medical - 1
Nonsurgical - 1
Surgery - 1
Medical
- Prostaglandin E to maintain PDA and O2 sat ≥75% (side effect – apnea (likely need intubation/ventilator)) - IMMEDIATELY
Nonsurgical
- Balloon Atrial Septostomy (BAS; Rashkind) - cath lab
Surgery
- arterial switch in first few weeks of life (transection of great arteries and anastomosing pulmonary artery to aorta to establish normal circulation)
Post-op care after Cardiac Surgery (8)
- Air filters on IV lines to prevent R→L shunt of air bubbles
- Monitoring (Central/Arterial lines, Cardiac monitor and pulse oximeter, Chest tube (strip only if cardiac), Pacemaker on abdomen))
- Ventilator usually via nose
- If murmur expected, you should hear it
- Strict I and O (UOP > 1 mL/kg/hr; NPO if intubated)
- Monitoring Labs (K+ (never bolus potassium!), Ca+)
- do not lift by arms until 6 weeks post-op (scoop instead)
- maintain thermoregulation (hypothermia possible post- op so use radiant heat warmer for infants
Congestive Heart Failure
What is it?
Causes (3)
inability of the heart to pump an adequate amount of blood into the systemic circulation to meet metabolic demands
Causes
- structural abnormalities r/t blood volume and pressure in heart (heart defects)
- Myocardial failure (cardiomyopathy, dysrhythmias, electrolyte imbalance (severe))
- excessive demands on heart muscle (Sepsis, severe Anemia)
S/s of Heart Failure r/t Impaired myocardial Function (7)
- restlessness
- anorexia, FTT, fatigue, weakness
- Tachycardia, gallop
- diaphoresis
- pallor or mottling (purply)
- poor perfusion (cool extremities, weak pulses, delayed cap refill, decreased urine output)
- cardiomegaly
S/s of Heart Failure r/t pulmonary congestion (5)
- Tachypnea
- respiratory distress (Crackles, cough, retractions, flaring, grunting, wheezing)
- cyanosis
- orthopnea
- activity intolerance (dyspnea)
S/s of Heart Failure r/t Systemic venous congestion (5)
Hepatomegaly
weight gain
edema (peripheral edema, periorbital edema)
ascites
neck vein distention
CHF: Decrease Cardiac Demands
Nursing Care (4)
- Prevent crying and keep them calm
- thermoregulation (radiant warmer; shivering increases demand)
- cluster care to prevent sleep interruption
- semi-fowler positioning
CHF: Digoxin
Nursing Care (4)
- Monitor apical pulse
- Hold if HR under 70 bpm in older child or 90-100 in young child/infant OR sig lower than previous reading
- Do not repeat dose if vomiting, notify health care team if misses more than 2 doses
- Give water after dosing to prevent tooth decay
CHF: Digoxin
Therapeutic Effect (3)
Toxicity (5)
Therapeutic Effect
- Increases force of contraction/contractility (+ inotrope)- prolonged PR
- Decreases HR (- chronotropic) - reduced ventricular rate
- Increases renal perfusion
Toxicity
- bradycardia
- NV
- visual changes (see halos)
- poor feeding, anorexia
- dysrhythmias
CHF: ACE Inhibitors (Captopril, Enalapril, and Lisinopril)
Therapeutic Effect (3)
Side Effects (5)
Care
Therapeutic Effect
- Vasodilation decreases PVR and SVR (preload)
- Decreased BP and afterload
- Reduces aldosterone which prevents fluid retention
Side effects: angioedema, Cough, hyperkalemia, hypotension, renal dysfunction
Care: Check BP before and after administration
CHF: Diuretics (Furosemide (Lasix), Chlorothiazide (Diurel))
Nursing Care (5)
- Monitor potassium (s/s hypokalemia = muscle weakness, irritability, drowsiness, tachy/bradycardia)
- Potassium supplements
- K+ rich foods (bran cereals, potatoes, tomatoes, bananas, oranges, leafy veggies)
- Daily weights, I & O
- give early in day
CHF: Nutrition
Nursing care (5)
- feed when well rested at first sign of hunger b-c fatigue can decrease feeding
- increased caloric needs w/ Polycose, corn oil
- Preemie nipple or enlarge opening
- Allow at least 30 minutes for feedings (then gavage remaining feeding)
- stroke jaw to encourage sucking
CHF: Improve Tissue Oxygenationand Decrease Oxygen Consumption
Nursing Care (2)
- give oxygen w/ caution b-c can cause vasoconstriction but decreases PVR
- raise HOB 45 degrees
Acute Rheumatic Fever
What is it
Incidence
Complication
Prevention of Recurrence (2)
Inflammatory condition impacting joints, heart, brain and skin after untreated Strep infection
Incidence: 2-6 weeks after a group A streptococcal infection
Complications: Rheumatic Heart Disease (mitral valve damage)
Prevention of recurrence: Penicillin or erythromycin BID; or IM penicillin q28 days for 10 yrs if carditis (5 yrs w/o carditis)
Acute Rheumatic Fever
S/s (8)
- Carditis (New murmur or valve regurgitation; Cardiomegaly; Pericardial friction rub)
- Polyarthritis (Swollen, hot, red, very painful joint pain); arthralgias
- Chorea (Sudden aimless, irregular movements of extremities, exacerbated by stress)
- Nontender SubQ nodules
- Erythema marginatum (Pink nonpruritic rash)
- Fever (> 38.5 C)
- ESR > 60 mm or SRP > 3 mg/dL
- Prolonged PR
Acute Rheumatic Fever
Treatment (4)
- Antibiotics (Penicillin)
- ASA for 2 weeks (aspirin to prevent clots, control inflammation, fever, discomfort) - prednisone if no response to aspirin
- Bedrest initially followed by quiet activities
- heart valve repair or replacement for RHD
Bacterial Endocarditis
What is it?
Transmission
Risk factor
Complications (2)
infection of valves and inner lining of heart which can damage or destroy valves, deposit fibrin and platelet thrombi
Transmission: Agents enter blood from any localized infection, brushing teeth, flossing, chewing, invasive procedures (GI, GU, dental, cardiac)
Risk factors: CHD
Complications: heart failure, dysrhythmias
Bacterial Endocarditis
Clinical Manifestations (10)
- Heart (HF, dysrhythmias, new/changed murmur)
- arthralgias
- headache
- weight loss
- Vegetations on ECHO
- inflammation signs (fever, malaise, +/- blood cultures, increased ESR, leukocytosis)
- Splinter hemorrhages (thin black lines under the nails)
- Osler nodes (red, painful intradermal notes on pads of phalanges)
- Janeway lesions (painless hemorrhagic areas on palms and soles)
- Petechiae on oral mucous membranes
Bacterial Endocarditis
What groups need prophylaxis Amoxicillin before Dental procedures? (5)
- Prosthetic heart valve repair
- History of endocarditis
- Heart transplant with history of abnormal valve function
- Cyanotic CHD not fully repaired (includes shunts or conduits) or for first 6 months after repair
- Repaired congenital heart disease with residual defects (i.e. persisting leaks or abnormal flow near prosthetic patch or prosthetic device)
Kawasaki Disease
Patho/Progression (4)
- Acute stage (inflammation of capillaries, arterioles, venules and pancarditis) esp coronary arteries
- Progression to muscular arteries (may lead to coronary artery aneurysms or MI)
- Vessels reach max enlargement in 4-6 weeks from onset of fever
- disease resolves in 6-8 weeks
S/s of Kawasaki Disease (10)
- Fever (>102.2) for 5 days
- bilateral nonexudative conjunctivitis
- cervical lymphadenopathy (unilateral)
- rash esp trunk and perineal
- mucositis (strawberry tongue, red lips)
- Swelling or erythema of palms and soles (peripheral edema)
- desquamation of skin (in 2-3 weeks; painless)
- IRRITABILITY (last up to 2 months)
- temporary arthritis, lethargy
- Inflammation of myocardium (myocarditis, valvulitis, arrhythmias)
Kawasaki Disease
Labs and Diagnostics (5)
Elevated ESR, CRP
Anemia
Leukocytosis
Do Baseline Echo
Platelet rises in 2nd week
Drug Management of Kawasaki Disease
IV Ig
- Purpose
- Nursing Care/Pt education (4)
Purpose: high dose to reduce risk of coronary artery abnormalities)
Nursing Care/Pt education
- usually 1 infusion
- same care as blood products (2 nurse check, frequent VS)
- monitor cardiac status and anaphylaxis
- avoid MMRV for 11 months after admin
Drug Management of Kawasaki Disease
Aspirin (4)
Aspirin (anti inflammatory and reduce clot formation)
- given 6-8 wks; indefinitely if cardiac abnormalities
- avoid chickenpox and flu to avoid Reye’s
- avoid contact sports b-c low platelets w/ ASA
- Warfarin, Plavix (clopidogrel), lovenox (enoxaparin) if aspirin inadequate)
Nursing Care for Kawasaki (5)
- skin (cool compress, lotion, soft cloths)
- oral care (lip lubrication, soft foods, clear liquids)
- Monitor VS, I & O, weight, ECG
- Passive ROM to increase flexibility
- environment (quiet, respite for parents)
Shock
What is it?
Consequences (3)
Inadequate tissue perfusion to meet the metabolic needs results in cellular dysfunction and organ failure
Consequences: hypotension, tissue hypoxia, metabolic acidosis
Types of Shock (3)
Hypovolemic (blood loss (Trauma, IC bleed, GI bleed), plasma loss (sepsis, acidosis), ECF loss (NVD))
Distributive (Anaphylaxis, sepsis)
Cardiogenic (post op CHD, pump failure (myocarditis, trauma, CHF), Dysthymias (SVT, AV block))
Phases of Shock
Compensated (4)
Degree of tachycardia- present
Perfusion to extremities- pallor, diminished UO,
LOC- irritable, thirsty
BP- normal, narrow pulse pressure
Phases of Shock
Decompensated (5)
Perfusion to extremities - cool and pale, decreased skin turgor, poor cap refill
LOC - confusion and somnolence
BP - low BP
Other- metabolic acidosis, tachypnea
Phases of Shock
Irreversible (3)
Perfusion to extremities - Anuria; thready, weak pulse; periodic breathing or apnea
LOC- stupor or coma
BP- hypotension
Shock
Management (6)
- VS q15 minutes; output hourly
- Ventilatory support- Early endotracheal intubation
- IV NS or LRs ( 20 ml/kg push)
- Albumin (b-c remain in system longer than NS)
- Catecholamines to improve heart pumping (Dopamine and Epinephrine)
- legs flat and above heart
Sickle Cell Anemia
Patho
Types (3)
Incidence (2)
Patho: increased RBC destruction b-c sickled hgb unable to obtain oxygen causing obstruction, inflammation (local hypoxia), adhesion
Types: homozygous HgbSS, heterozygous HgbSC, Beta thalassemia (seen in mediterranean)
Incidence: autosomal recessive seen in AA; manifests after 4-6 months when fetal Hgb disappears
Sickle Cell Anemia
Diagnosis (4)
- Mandatory screening of all newborns
- Sickledex- detects HgbS but cannot differentiate trait from disease; heel stick
- Hgb electrophoresis (definitive diagnosis)- separates various forms of Hgb via fingerprint of protein
- CBC- anemia
Sickle Cell Anemia: Vaso-occlusive crisis
S/s (8)
Vaso-occlusive crisis (ischemia and pain) – main
- Painful joints and hands/feet (dactylitis)
- Abdominal pain
- retinal (detachment, blindness or visual changes, icteric sclera)
- renal (Hematuria, dark urine, enuresis)
- Priapism
- AVN (avascular necrosis) of hip or shoulder
- lordosis or kyphosis
- leg ulcers
Sickle Cell Anemia: Sequestration crisis
S/s (3)
Sequestration crisis- RBC breaking down quickly
* Hepatomegaly (jaundice)
* Splenomegaly (fibrous or rupture; functional asplenia)– may need spleen removed
* Circulatory collapse/shock (cardiomegaly, systolic murmur, tachycardia, Fatigue)
Sickle Cell Anemia: Anemic/aplastic crisis
s/s (2)
- high reticulocyte count (reticulocytosis)
- reduced RBC production
Sickle Cell Anemia
General manifestations (4)
- Chronic Anemia (hgb 6-9 g/dl)
- Susceptibility to sepsis (r/t functional asplenia)
- Growth retardation
- Delayed sexual maturation
Sickle Cell Crisis: Triggers (6)
- Anything that increases body’s need for oxygen or alters transport of oxygen
- Hypoxia
- Fever (notify provider if > 38.5)
- Infection, trauma
- dehydration (b-c increases blood viscosity)
- Physical and emotional stress
Sickle Cell Anemia: Severe Complications
Acute Chest Syndrome (2)
Cerebral Vascular Accident (2)
Acute Chest Syndrome (ACS) - r/t pulmonary infiltrates
- Report chest pain, fever of 38.5 C or higher, congested cough, tachycardia, dyspnea, retractions, decreased O2 sat
- Call provider immediately
Cerebral Vascular Accident (CVA) - r/t HgbSS blocking BVs in brain
- Report seizures, abnormal behavior, weakness or inability to move an extremity, slurred speech, visual changes, vomiting, or severe headache
- If hx of CVA or beta thalassemia, child may get monthly chronic transfusions for prevention
Sickle Cell Anemia: Prevention of crisis (3)
- Hydration
- Hydroxyurea- ↑ Hgb F (fetal hemoglobin), lower leukocyte and reticulocyte levels
- Oxybryta (decreases # of crises in 4yrs +)
Sickle Cell Anemia: Prevention of complications (3)
- Penicillin prophylaxis – 2m to 5yrs (prevents pneumococcal sepsis)
- Vaccines (Hib, pneumococcal, meningococcal, influenza)
- Transcranial Doppler annually for children 2-16 years- Identify blood clots early via measuring intracranial vascular flow
Sickle Cell Anemia: Treatment (7)
- Rest
- Hydration -oral or IV therapy (tell parents specific amount)
- Electrolyte replacement
- Blood replacement (phoresis of blood or whole-blood exchange)
- Antibiotics for infection
- Monitoring of reticulocyte (baby RBCs) count regularly to evaluate bone marrow function
- HSCT is only potential for cure (stem cell transplant) – complications (graft rejection, immunosuppression, graft vs host disease, relapse)
Sickle Cell Anemia: Pain Management (7)
- PCA preferred
- Mild: acetaminophen, Ibuprofen, codeine, toradol
- Severe: opioids, ketorolac
- avoid meperidine (Demerol) b-c risk for seizures and product breakdown
- monitor for GI bleeds from NSAIDS
- Apply heat or massage affected area
- Avoid cold compresses (we want blood flow to area b-c pain from tissue anoxia)
Sickle Cell Anemia: Patient Education (5)
- Wear medical ID band
- Frequent rest with physical activity
- Avoid contact sports with splenomegaly
- avoid oxygen admin b-c can depress RBC production and worsen anemia
- refer to crisis as pain episode
Sickle Cell Anemia: Blood Transfusions
Indication
Risk (4)
Nursing Care (2)
Indication: during crisis or monthly if CVA risk or Beta thalassemia
Risk: infection, hyperviscosity, alloimmunization, Hemosiderosis and hemochromatosis (iron deposits with/without tissue damage)
Nursing Care
- Oral chelation agents (deferasirox, deforxamine) to remove excess iron
- oral chelation given IV or subQ over 8-10 hours (during sleep)
Hemophilia
What is it?
Incidence
Diagnosis (3)
Bleeding disorder r/t congenital deficiency of specific coagulation proteins (Factor VIII or Factor IX)
Incidence: x-linked recessive so usually boys with carrier mother
Diagnosis: Factor VIII and Factor IX assays; PTT, DNA testing
Hemophilia
Severity (3)
Severe (Factor VIII activity <1%)- spontaneous bleeding without trauma
Moderate (Factor VIII activity 1-5%)- bleeding with trauma
Mild (Factor VIII activity 5-40%)- bleeding with severe trauma or surgery
Hemophilia
S/s (7)
- excessive Bruising
- prolonged bleeding (epistaxis)
- Hemarthrosis (bleeding in joint -> bony changes and deformities) - signs: stiff, tingling, ache, inflammation signs
- hematuria
- hemorrhages (brain = fatal, GI = anemia)
- subQ and IM hemorrhages
- Hematoma (pain, swell, limited motion)
Hemophilia: Medical Management (5)
- Factor VIII Infusions -replace missing clotting factors; every other day or 3x/week for severe
- Desmopressin (DDAVP-synthetic vasopressor) (IV or nasal spray)- increases factor VIII activity for mild
- Aminocaproic acid- prevents clot destruction; give Factor infusion first
- Corticosteroids- for hematuria, acute hemarthrosis, chronic synovitis
- Cox-2 inhibitors- for hemophilic arthropathy
Hemophilia: Prevent Bleeding (6)
- Regular exercise and PT may reduce bleeding episodes
- Noncontact Sports- golf, swimming, jogging, fishing, bowling
- Oral (Soft bristled toothbrush w/ warm water)
- Electric shavers vs razors
- SubQ instead of IM injections
- Avoid aspirin or ibuprofen (NSAIDs)
Hemophilia: Control Bleeding (4)
- factor replacement
- RICE- rest, ice, compression, elevation
- Keep cold packs ready
- Only active ROM (NO PASSIVE) for hemarthrosis
Hemophilia: Patient Education (2)
- Medical ID bracelet
- teach child 8-12 yrs to give injections
Type 1 Diabetes Mellitus
Patho
destruction of pancreatic beta cells causing absolute insulin deficiency
Type 1 Diabetes Mellitus
Clinical Manifestations (12)
- Polydipsia
- Polyuria (enuresis)
- Polyphagia
- Weight loss
- Infections (Vaginitis (candida) or diaper rash)
- Fruity odor to breath
- Delayed wound healing
- Blurred vision
- Changes in LOC (very hyper, irritable, Fatigue/lethargy/ drowsy)
- Rapid respirations
- Abdominal pain
- Hot dry skin
Diagnosis of Type 1 DM
4 tests
- Fasting BG of > 126 mg/dL
- random BG of > 200 with classic signs of diabetes
- oral glucose tolerance test of > 200 mg/dL in the 2 hour sample (Balanced diet 3 days prior to test; NPO for 8 hours prior; BG levels drawn q 30 minutes x 2 hours)
- HbA1C > 6.5% ,<8 %- determines long term control (120 days) for children 6-12 yrs
Nutrition for Diabetes (6)
- Weigh/measure food for 3 months w/ progression to estimation of portion sizes
- 3 well balanced meals at regular intervals, afternoon, and night-time snack
- Allow child to participate in food choices (balanced colors)
- Extra food needs to be consumed for increased activity (10-15 g of carbohydrate for 30-45 minutes of activity)
- Avoid concentrated sweets
- Use Sugar substitutes in moderation b-c sorbitol metabolizes to fructose then glucose and can lead to osmotic diarrhea
Self-Monitoring for Diabetes Mellitus (5)
- done ac and hs at minimum
- Keep records of results with food intake and any other events such as increased activity or illness that may alter BG
- Check strips for expiration and no needle sharing
- If using pump, have backup in case it malfunctions AND change needle q48-72hrs
- teach school age to give their insulin w. pinch technique and rotate sites
Type 1 Diabetes Mellitus: Patient Education (5)
- Do not hide needles from the child (be direct, honest, show them)
- Check BG before exercise. May need decreased dose of insulin when exercising or a snack.
- wear Medic-Alert bracelet
- may need increased insulin during illness or stress
- check glucose and urine for ketones q3h when sick
S/s of hypoglycemia (7)
- Sweating/chills
- Trembling/shakiness/anxiety/nervousness
- Tiredness/ paleness/ palpitations
- Blurry vision
- Mood Changes (tearful or euphoria
- headaches/ confusion/dizziness
- Hunger
DM: Management for Hypoglycemia
Conscious (2)
Unconscious (2)
If conscious
- simple glucose (½ cup orange juice or soda; 8 oz milk, Small box raisins, 3-4 hard candies or Life Savers, 1 tsp of sugar or honey, 1 candy bar)
- give complex carb and protein afterward
If unconscious
- cake frosting or glucose paste on gums
- glucagon
DM: When to call HCP (9)
- BG >240
- Fever higher than 38.9, fever doesn’t respond to acetaminophen, or lasts over 12 hours
- urine ketones
- Disoriented or confused
- Rapid breathing
- Vomiting more than once
- Diarrhea over 5 times or more than 24 hours
- Unable to tolerate liquids
- Illness > 2 days
Growth Hormone Deficiency
Clinical Manifestations (6)
- Short stature (proportional height and weight)
- Delayed epiphyseal closure and bone age
- Increased insulin sensitivity
- Delayed dentition (crowded or mispositioned) and Underdeveloped jaw
- Delayed sexual development
- premature aging
Growth Hormone Deficiency
Diagnostic (3)
Growth curve and familial height pattern- Assess height and weight velocity on growth charts
MRI and x-ray of left hand/wrist to predict remaining growth potential
CT and skull x-rays -determine presence of tumor or other structural defects
Growth Hormone Deficiency
GH stimulation testing (4)
- draw baseline IGF-1 and IGFBP-3 (Insulin-like Growth factor) levels
- give GH-releasing hormone (levodopa, clonidine, propranolol, glucagon, insulin) or arginine
- obtain blood samples q30 x 3 hr
- NPO and limit activity 10-12 hours prior to test
Growth Hormone Deficency: Family Education (4)
- Child should wear identification bracelets
- Do note infantilize child
- Emphasis abilities and strengths vs physical size (helps develop positive self-image
- final height usually less than normal
Growth Hormone Deficiency: Medical Management
GH replacement therapy (Somatropin)
- Route
- Nursing Care (2)
Route: subQ 6-7 days/week at bedtime for GH releases 45-90 mins after sleep
Nursing Care
- Give until bone age > 14 in girls and > 16 in boys or when growth is under 1 inch/year
- Height is usually attained slower than peers
Hypothyroidism
Function of Thyroid hormone
What impacts TH synthesis?
Consequences of Delayed treatment
Function: Thyroid hormone regulates BMR and controls growth and tissue differentiation
Synthesis impacted by dietary iodine and tyrosine
Consequences of Delayed treatment: poor intellectual development and growth ( 0-3: IQ 89; 3-6 m: IQ 71; After 6 months: IQ 54)
Hypothyroidism
Diagnostic (3)
- mandatory screening of all newborns
- blood studies if positive screen
- Labs (low TH, high TSH)
Congenital Hypothyroidism: Birth
Clinical Manifestations (6)
Poor feeding
Lethargy, somnolence, sleepy
Constipation
Bradycardia
Respiratory difficulty (dyspnea on exertion)
Large Fontanels
Congenital Hypothyroidism: 6-9 wks
Clinical Manifestations (7)
Short forehead and depressed nasal bridge
Puffy eyes
Large Tongue (macroglossia)
Thick dry skin w/ yellow discoloration
Dry Coarse but sparse Hair
Abdominal Distention
Hypotension
Congenital Hypothyroidism: Older Child
Clinical Manifestations (6)
Short w/ infantile proportions
Obese
Abnormal Reflexes
Awkward Mobility (growth cessation)
Intellectual Disability
Thyromegaly
Congenital Hypothyroidism: Levothyroxine
Toxicity (6)
Nursing Care (2)
S/S of overdose/toxicity
- Tachycardia
- dyspnea
- irritability
- insomnia
- fever/sweating
- weight loss
Nursing Care
- Keep TSH levels between 0.5-2 mU/L
- given for life so compliance key
Childhood Obesity: Risks (6)
- lessens life expectancy (by 5-20 yrs)
- Psychosocial consequences (low self-esteem, depression, social isolation, anxiety)
- comorbidities (DM2, sleep apnea, HTN, dyslipidemia, asthma, gallbladder disease, metabolic syndrome, fatty liver, PCOS)
- stress incontinence (r/t bladder pressure)
- Orthopedic (knee or hip pain indicate SCFE and leg bowing i.e. Blount’s disease)
- early puberty
Obesity: Patient Education (7)
- Eat only at the table without other distractions like TV or reading a book.
- Use fruits for desserts.
- Use smaller plates, plastic utensils
- Eat slowly and put fork down between bites
- Limit “sit time” at computers, TV, video games to < 2 hrs/day
- physical activity 60 min/day
- choose low fat, low sugar, low sodium, high fiber foods
Obesity: Management (3)
- Behavior modification (Appetite regulation via positive reinforcement and peer groups)
- Pharmacological agents (ex. Orlistat)
- Surgical/ bariatric—not recommended due to many metabolic complications
Important Tips to prevent effects of immobility
Positioning - 4
Nutrition -3
Positioning
- turn q2h
- skin care regularly
- maintain proper alignment
- use active and passive ROM
Nutrition
- protein
- bone healing (calcium and vitamin D)
- adequate calories
Diagnostics for Mobility concerns- 7
- Assessment (pain, ROM, tenderness, erythema etc.; key for diagnosis)
- X-rays (Difficult to use for diagnosis because of localized swelling but accesses skeletal trauma
- CT Scans and MRI (find injuries, areas of infections, and cancer)
- Ca 2+ (varies w/ bone breakdown from immobility making hydration crucial)
- CBC, WBC and blood cultures
- ESR elevation
- Alkaline phosphatase - increases with growth
Mobility: Difference b/w the following
Contusions
Dislocation
Strain
Sprain
Contusions: damage to soft tissue, subcutaneous tissue, and muscle causes escape of blood into tissues leading to ecchymosis (black-and-blue discoloration) (s/s. Swelling, pain, disability, crush injuries)
Dislocation - Displacement of normal position of opposing bone ends or of bone ends to socket
Strain - microscopic tear in the muscles and tendons
Sprain - A ligament is torn or partially torn.
Management of Bone and muscle injuries
RICE vs ICES
RICE (rest, ice, compression, elevation)
ICES (Ice, compression, elevation, support
Difference b/w following fracture:
- Plastic deformation
- Buckle
- Simple or closed
- Greenstick
- Open or compound
- Complicated
- Comminuted
- Plastic deformation: bone is bent, not broken
- Buckle: appears raised or bulging due to compression of porous bone
- Simple or closed: does not produce a break in the skin
- Greenstick: bone is angulated beyond limits of bending; compressed side bends and tension side fails leading to incomplete fracture
- Open or compound: fractured bone protrudes through the skin
- Complicated: bone fragments have damaged other organs or tissues
- Comminuted: small fragments of bone are broken from fractured shaft and lie in surrounding tissue
Epiphyseal Injury
What is It?
Complication
Management (2)
- injury at epiphyseal plate (cartilage growth plate which is weakest point of bone)
Complication: longitudinal or angular growth deformities
Management
- frequent surveillance if type 1 (separation of growth plate)
- Surgery (open reduction and internal fixation) if type 3 (half of bone under plate broken)
Management of Fractures - 5
- RICE (no heat)
- splint (immobilize)- soft splint (pillow or folded towel) or rigid splint (rolled newspaper or magazine)
- cover wounds w/ sterile or clean dressing
- surgery (external fixation (rings to bone w/ wires), internal fixation, distraction (separate bones to encourage growth of new bones))
- calm and reassure family
Process of bone healing (3)
- Osteoblasts stimulated by break in bone and form bulging growth of new bone tissue
- Callus forms (deposition of calcium salts)
- Remodeling (smooths out irregularities produced by osteoblasts and callus)
Four goals of management fractures
- regain alignment and length of bony fragments (reduction)
- Retain alignment (immobilization) - until callus forms
- Restore function - ROM and weight bearing after site stable
- Prevent deformity or injury
Components of traction to realign fracture site (3)
Traction—forward force produced by attaching weight to distal bone fragment; HCP Adjust by adding or subtracting weights
Countertraction—backward force provided by body weight; Increased by elevating foot of bed
Frictional (patient’s contact w/ bed)
Purposes of Traction (5)
- Relieves fatigue in involved muscles
- Fatigues muscles to reduce muscle spasms (rare)
- Position distal and proximal bone ends (Realignment) to promote healing
- Prevents deformity and contractures
- Immobilize healing bone and prevent further injury
Types of traction (3)
Manual- applied by hand placed distal to the fracture site during application of a cast or for closed reduction
Skin- Buck’s (leg extended) OR Bryant (legs up 90 degree for DDH)
Skeletal - pins, wire, tongs (ex. 90-90 degree (common at hip and knee) or Halo vest (cervical)
Interventions for Traction (6)
- Diazepam (muscle relaxant for spasms)
- Provide Skin care (q2h turns, braden scale, hygiene, pressure alt mattress)
- Pin site Care daily or weekly (cover w/ rubber or padding; antiseptic (chlorhexidine) or topical antibiotic)
- NURSES DO NOT LIFT OR DISCONTINUE WEIGHTS!!!! LET THEM HANG FREELY
- prevent constipation (fluids, fiber, stool softener)
- promote circulation (ROM, bandages not restrictive)
Time frame for Bone healing and remodeling
- Neonatal period
- Early childhood
- Later childhood
- Adolescence
Neonatal period: 2-3 weeks due to thickened periosteum and more blood supply
Early childhood: 4 weeks
Later childhood: 6-8 weeks
Adolescence: 8-12 weeks
6 P’s
Which 3 are late signs?
- Pain – unrelieved by pain medication 1 hr after admin, especially w/ passive ROM
- Pulselessness - no distal pulse palpable
- Pallor - discoloration OR cyanosis; cool temp; cap refill > 3 sec
- Paresthesia - tingling or burning
- Paralysis – inability to move affected part;
- Pressure - swelling, tenseness or warmth of affected limbs and extremities
Pallor, paralysis, and pulselessness are late
Compartment Syndrome
Management - 5
- fasciotomy (cut skin and reduce pressure)
- do not elevate
- administer fluids if needed
- bivalve cast if excessive edema (i.e., cut calf in half a hold w/ elastic bandage)
- CALL HCP
Complications of Casts (3)
- infection (hot spots on dried cast or foul smell)
- Loose cast (no longer useful and can lead to skin irritation or pressure sores)
- Compartment syndrome – medical emergency
Cast Application (4)
- Plater of Paris dries in 2 to 48 hours
- Fiberglass dries in a couple of hours
- handle w/ palms until dry
- let child know some warmth may be felt but no burning
Cast Care (7)
- Elevate initially w/ pillow (do not let stay dependent for long)
- Encourage use of unaffected muscles
- No coat hangers or straws in cast
- Use fan or cool air to circulate air if high humidity (no heated air)
- for spica, use cast petaling (tape edges w/ waterproof tape around perineal)
- if open cast, cut out window to view wound AND outline any blood
- Crutches should fit properly w/ soft rubber tip to prevent slipping and well padded (support on hand grips NOT axilla)
Cast removal (6)
- reassure muscle atrophy will go away as strength regained
- avoid cold temps after removal
- use sunscreen after removal
- apply mineral oil or lotion to remove
- Soak in bathtub
- Do not pull or forcibly remove w/ vigorous scrubbing (may cause excoriation and bleeding)
Congenital Dislocation of Hip/ Developmental Dysplasia of hip
S/s (7)
- Barlow (thigh adducted, and light pressure applied to femoral head to see if slips out of acetabulum then slips back when pressure is released) - unstable hip
- Ortolani sign (abduct knees and put forward pressure behind trochanter than backward pressure; audible clunk/thunk if femoral slips forward into acetabulum meaning it is dislocated) - disappears when adduction contractures develop at about 6-10 weeks
- Galeazzi sign: Limb shortening on affected side
- Trendelenburg sign: When child stands on one foot and bears weight on affected hip, pelvis tilts downward on normal side instead of upward, as it would with normal stability
- Asymmetric thigh and gluteal folds seen when prone
- lordosis
- waddling gait (bilateral hip dislocation
3 degrees of DDH
Acetabular dysplasia - 3
- Acetabular dysplasia ( mildest form of DDH)
- neither subluxation nor dislocation
- delay in acetabular development (osseous hypoplasia of the acetabular roof that is oblique and shallow
- cartilaginous roof is intact)
3 degrees of DDH
Subluxation - 4
- Subluxation ( largest percentage of DDH)
- subluxation ( incomplete dislocation of the hip)
- femoral head remains in contact with the acetabulum
- stretched capsule and ligamentum teres cause the head of the femur to be partially displaced
- Pressure on the cartilaginous roof inhibits ossification and produces a flattening of the socket.
Degrees of DDH
Dislocation - 2
- Dislocation
- femoral head loses contact with the acetabulum and is displaced posteriorly and superiorly over the fibrocartilaginous rim
- ligamentum teres is elongated and taut.
DDH: Management of Pavlik harness (4)
- Avoid lotions and powders because they can cake and irritate the skin.
- Always place the diaper under the straps
- Gently massage healthy skin under the straps once a day to stimulate circulation
- Do not adjust harness
Management of DDH
Birth- 6month - 1
Age 6- 24 months - 3
Older child (4yrs +) - 4
Birth to age 6 months
- Pavlik harness for abduction of hip for 6-12 week continuously
Ages 6-24 months
- recognized when child begins to stand and walk
- need closed reduction and spica cast
- may use traction for full abduction of hip
Older child (4yrs +):
- need open reduction w/ preop traction
- tenotomy (lengthen contracted muscles)
- osteotomy ( construct acetabular roof)
- correction and healing is very difficult
Club foot
s/s (5)
- Affected foot or feet smaller
- shorter, empty heel bed
- midfoot medial creases
- If unilateral, affected limb shorter and calf atrophy present
- Foot pointed down (plantar flexed) and inward
Club foot
3 types
- Positional: primarily from IUGR; no bony abnormality; responds to simple passive exercise and casting
- Congenital (idiopathic): in normal child w/ wide range of rigidity & prognosis; Requires casting w/ surgical intervention (heel-cord tenotomy)
- Syndromic (teratologic): seen w/ anomalies (such as myelomeningocele or arthrogryposis); requires surgical correction and resistant to treatment
Club foot: 3 stages of management
- Correction of deformity
- maintain correction until muscle balance is regained
- frequent follow-up care to monitor for recurrence of deformity w/ x-rays
Clubfoot: Ponseti method (5)
- Weekly gentle manipulation and stretching of medial side of foot w/ serial long leg casts ideal shortly after birth
- Casting (6-10 weeks) followed by percutaneous heel-cord tenotomy (corrects equinus deformity)
- After tenotomy, long leg cast for 3 weeks
- After casting, Ponseti sandals w/ bar set in abduction to maintain correction and prevent recurrent
- surgery at 6m-1 yr if casting fails
Slipped Capital Femoral Epiphysis (SCFE)
What is it?
Incidence
Diagnosis (3)
Complications (3)
- Spontaneous movement of femoral neck from femoral head in acetabulum due to increased weight
Incidence: boys before or during rapid growth
Diagnosis: physical exam, hx, Anteroposterior and frog-leg hip x-ray
Complications: avascular necrosis, further slippage, deformity
Slipped Capital Femoral Epiphysis (SCFE)
Symptoms (6)
- Obese
- limp on affected side w/ altered gait
- internal rotation and loss of abduction of affected leg
- affected limb shortens
- groin, hip, and knee pain
- inability to bear weight
Slipped Capital Femoral Epiphysis (SCFE)
Treatment (4)
- strict bedrest and Buck’s traction immediately
- surgery within 24 hrs w/ pin placement OR surgical hip dislocation
- post-op no weight bearing to gradual weight- bearing
- Restriction from certain sports until fusion or closure of proximal femoral physis to prevent further slippage
Complications of Spinal Fusion (4)
- Neurologic injury or spinal cord injury
- hypotension from acute blood loss
- SIADH
- Superior mesenteric artery syndrome( due to duodenal compression by aorta and superior mesenteric artery leading to obstruction; causes epigastric pain, copious NV, and eructation(belch); alleviated w/ left lateral or prone position (worsened by supine)
Scoliosis
What is it?
Diagnosis
Three levels
- spinal deformity involving lateral curve, spinal rotation, thoracic hypokyphosis
Diagnosis: x-ray to determine skeletal maturity
Levels
- <10 degrees = postural variation
- 20 or less = may not require intervention; can do exercises or braces
- Greater than 40 = requires surgery
Scoliosis screening (5)
- started at School Age (Screening at 10 AND 12 yrs. for girls or at 13 OR 14 yrs. for boys)
- child in only underpants
- Child bends at waist, trunk parallel to floor, arms hanging free
- observe the back for asymmetry of hips, scapula, shoulder height, pelvic obliquity; widened angle between arm and body
- Hold hips stable and have child turn left / right to assess flexibility of curve
Scoliosis: Braces
Types - 3
Notes - 4
Types: Boston, TLSO, Milwaukee (usually for kyphosis and has neck ring)
Notes
- Braces are worn for 23 hours per day
- Not curative
- slows or stops the progression of the curvature until child reaches skeletal maturity
- discontinued once growth completed
Scoliosis: Surgery
Indication (3)
Types (3)
- depends on degree of curvature (>45-50 degrees), pain, OR if exercise & brace fails
Types
- Spinal fusion is more common and less invasive than rod insertion (via posterior or anterior approach)
- VEPTR (done for younger children with severe scoliosis via lengthening the ribs by using a prosthetic rib to enhance the breathing effort of children with scoliosis and straighten spine)
- instrumentation
Scoliosis: Surgery
Post-op care (7)
- Bed rest
- logrolling
- PCA / pain control b-c very painful surgery
- Teds / SCD’s
- frequent assessment (check for sensation and ileus (stool softeners), retention (foley))
- early mobility (usually by day 2; PT on 1st day)
- Brace may or may not be used.
Juvenile Idiopathic Arthritis (JIA/JRA)
What is it
Incidence - 2
Classification - 3
- inflammation in joints for > 6 weeks causing pain, swelling, and scar tissue (limited ROM)
Incidence: autoimmune condition in girls < 16; total remission in most by adulthood
Classification: dependent on joints affected, systemic symptoms, and presence of absence of rheumatoid factors
Juvenile Idiopathic Arthritis: Diagnostic (5)
- 10% have positive rheumatoid factor
- ESR/CRP elevated
- Leukocytosis w/ exacerbations of systemic JIA
- Antinuclear antibodies common but not specific to JIA (can identify those at risk for uveitis)
- Radiographs – best to show soft-tissue swelling and joint space widening from increased synovial fluid
Juvenile Idiopathic Arthritis
Joint signs (3)
Systemic Symptoms (5)
Joint signs
- limp
- favoring an extremity
- inflammation (pain, swelling, edema, redness)
Systemic signs
- Rash
- fever
- lymphadenopathy
- splenomegaly and hepatomegaly
- uveitis (inflammation in anterior chamber of eye; diagnosed by slit lamp eye exam)
Juvenile Idiopathic Arthritis Management
Pharmacology - and side effects (5)
- Ibuprofen (NSAIDs)- GI bleeds
- Aspirin (NSAIDs)- be wary of viral illness b-c reyes syndrome
- Methotrexate or Sulfasalazine (DMARD) - teratogenic, hepatotoxic, Bone marrow suppression
- Corticosteroids (given intra-articular) - risk for infection, adrenal insufficiency, avascular necrosis, cushingoid, osteoporosis, HTN, diabetes
- Etanercept or Adlimulmab (Biologic DMARDs) - infection risk
Juvenile Idiopathic Arthritis
Goal of therapy - 4
Goal of therapy - NO CURE
- preserve joint function
- limit abnormalities and deformity
- promote normal growth and development
- decrease the discomfort (relieve symptoms)
Juvenile Idiopathic ARthritis
Interventions (7)
- Physical therapy (strengthen joints and prevent deformities)
- pain relief (usually avoid opioids unless severe)
- moist heat ( hot pack, warm bath)
- exercise
- promote general health and nutrition (match caloric intake to energy needs)
- allow child to rest as needed
- promote independence ( parent only help when necessary)
Muscular Dystrophy
Diagnostics (4)
- DNA analysis (genetic detection of absence of dystrophin (muscle protein product due to muscle fiber degeneration)) - possible at 12 weeks gestation
- Serum CK (elevated in first 2 yrs of life)
- EMG (decreased amplitude and duration of motor unit potentials)
- Muscle Biopsy
Muscular Dystrophy
What is it?
Incidence - 2
Muscle atrophy and fatty infiltrates on extremities leads to progressive degeneration of muscle fibers
Incidence: x-linked; often wheelchair bound by 12 yrs
Muscular Dystrophy
Complications (7)
- osteoporosis and fractures
- contractures
- scoliosis
- obesity
- respiratory infection r/t reduced pulmonary vital capacity from weak respiratory muscles; also difficult clearing secretions via cough b-c weak muscles
- cardiopulmonary issues due to respiratory, oropharyngeal and facial muscle involvement (heart failure and sleep apnea)
- disuse atrophy
Muscular Dystrophy
S/S (6)
- waddles (due to weak butt muscles) causes frequent falls
- lordosis (sway back, awkwardly holds shoulders back; due to weak pelvis
- Gower’s sign (walking hands up knees and legs to stand up)
- Mild to moderate mental impairment (Decrease in verbal skills)
- Higher emotional disturbance
- fatty muscle hypertrophy (thigh, calf, upper arm)
Muscular Dystrophy: Family Education (6)
- encourage normalcy
- okay to grieve since chronic fatal disease
- Guilt from passing this to son lies on woman
- Genetic counseling for female relatives, siblings
- provide for rest periods ( child can self-regulate activity tolerance)
- prevent infections ( avoid crowds; get pneumococcal and influenza vacs)
Muscular Dystrophy: Nursing Care (4)
- Prevent contractures (passive ROM, soft casts, surgery, braces)
- Promote pulmonary function ( breathing exercises, incentive spirometer q4h; mechanically assisted coughing)
- Position changes when in wheelchair (allow for time to lie flat)
- Keep active as long as possible (don’t wheelchair confine early)
Muscular Dystrophy: Pharmacology Effects
Corticosteroids - 3
Albuterol - 2
Corticosteroids (prednisone, deflazacort)
- Increased muscle strength, bulk, power and decreased progression of weakness (Prolonged ambulation)
- decreased incidence of scoliosis and cardiomyopathy)
- Increased pulmonary function
Oral albuterol
- increase lean body mass and decrease fat mass
- no change in strength
