Exam 4 Flashcards
My friends call me lazy
I blame it on my friend’s strabismus and ptosis
I cause one eye not to see so good
I cause an asymmetrical corneal light reflex
Playing pirates for several hours a day and vision therapy make me better
Amblyopia
Amblyopia Therapeutic Management
Patching (the stronger eye) for several hours a day OR Atropine drops in the stronger eye daily
Vision therapy
Eye muscle surgery
I block light from entering the eye
I am a leading cause of visual impairment & blindness
You won’t see a red reflex with me
Surgery makes me go away-the earlier the better
Congenital Cataracts
Congenital Cataract Patho
Opacity of the optic lens preventing light from entering into eye - will lead to severe amblyopia if not treated
Congenital Cataract assessment cues and management
Surgical removal of cataract and placement of implantable lens
Post-op care: Eye patching, Elbow restraints
Antibiotic & steroid drops (parent education)
Patching of normal eye after surgical eye has healed to strengthen vision
Sunglasses when outside to protect against UV rays
I make the ear feel full
Making air bubbles is my specialty
I make the TM look dull, orangish and have decreased movement
I can make you say “Huh?”
I usually go away on my own
Otitis Media With Effusion (OME) Non-infectious
Otitis Media With Effusion (OME) Non-infectious Assessment Cues and Management
Antihistamines, steroids, and decongestants do not help resolve
Usually spontaneously resolves but should be rechecked every 4 weeks
Do not feed in a supine position and avoid bottle propping
If OME persists for >3 months, refer to ENT and assess carefully for hearing loss or speech delay
It can also cause balance disturbance
I can visit infants and young children often, usually with my neighbor URI
I cause rubbing and pulling of ears
I cause the TM to look dull, red and bulging
I can cause hearing difficulties & speech delays if I visit often
Acute Otitis Media
Acute Otitis Media Assessment Cues and Management
Symptomatic management of otalgia and fever
* Acetaminophen and ibuprofen -mild to moderate pain
* Narcotics for severe
* Benzocaine (Auralgan) drops may also be prescribed for pain if the TM is not ruptured
Warm heat or cool compresses may be effective
Antibiotic therapy - Amoxicillin, Amoxicillin-clavulanate (Augmentin), Azithromycin – PO (10-14 days)
Pneumatic otoscope- used to visualize the TM and assess its movement
Conductive Hearing Loss
Transmission of sound through the middle ear is disrupted (i.e. frequent OM)
Sensorineural Hearing Loss
Damage to the hair cells in the cochlea or along the auditory pathway (i.e. ototoxic medication, meningitis, CMV, rubella, excessive noise)
Mixed Hearing Loss
attributed to both conductive and sensorineural problem
I take the pressure off
I am needed when OM visits often
I allow the infection to get out
I fall out on my own
Tympanostomy Tubes
Tympanostomy Tubes Management and Education
Myringotomy (~15 minute surgery) uses general anesthesia; PACU recover, discharged home same day
*Post Op pain is not common
Teach ear drop administration if prescribed post-op and tubes remain in place for several months; usually fall out spontaneously (~8-18 months)
Ear plugs recommended when swimming; if water enters ear, allow it to drain out
Report drainage
I like to get in the way of the aqueous humor flow
I cause optic nerve damage and vision loss
You may see a gray or green light reflex in only one eye
Surgery makes me go away
Infantile glaucoma
Infantile glaucoma Physical Cues
Keeping eyes closed
Frequent eye rubbing
Spasmodic winking
Corneal clouding
Enlargement of eyeball
Excessive tearing or conjunctivitis
Red reflex may appear gray or green
Infantile glaucoma Management/Education
Surgical intervention is first-line treatment – 3-4 surgeries may be needed
Post-op Care - Protect surgical site: Elbow restraints, maintain eye patch and bedrest; provide distraction activities
Discharge teaching: Teach parents how to administer eye medications; No rough-housing or contact sports for 2 weeks
Nursing care for Visual Impairment
Use child’s name to gain attention; Identify your presence first before touching child
Name and describe people/objects to make child more aware of what is happening
Discuss upcoming activities
Use touch and tone of voice appropriate to the situation
Use simple and specific directions
Use parts of the child’s body as reference points for location of items
Encourage exploration of objects through touch
Symptoms of hearing loss of infants
Wakes only to touch, not room noise
Does not babble by 6 months
Symptoms of hearing loss for Young Child
Does not speak by age 2 years
Communicates needs through gestures
Focuses on facial expressions when communicating
Does not respond to doorbell or telephone
Symptom of hearing loss for Older child
Often asks for statements to be repeated
Inattentive or daydreams
Poor school performance
Monotone speech
Proper ear drop administration
For children under 3: Hold ear lobe and gently pull down and back.
For children 3 and over: Hold upper part of ear and gently pull up and back.
Fe+ supplements
Place behind teeth to avoid teeth stains
Cause constipation – increase fluids and may need stool softeners
Cause dark, green stools – this is normal
Iron Deficiency Anemia
Iron Deficiency Anemia PhysicaL cUES
Irritability, HA
Unsteady gait, weakness,fatigue
Dizziness, sob, pallor skin, mm, conjunctiva assess for difficulty feeding, pica spooning of nails
Iron deficiency anemia lab cues
Decrease
RBC, Hgb, Hct, MCV, MCH, and Ferritin
Increase
RDW
Iron deficiency Diagnostic Findings
Peak at 12-24 month and adolescence
Low RBC, Hgb, Hct, MCV, MCH (mean cell hgb), RDW (red cell distribution width), and ferritin
Iron Deficiency Management
Feed only formula fortified with Fe+, supplementation by 4-5 months
Mothers increase Fe+ in their diet
Limit cow’s milk in children >1yr. to 24oz/day
Nutrition (Fe+ rich food): Red meant, tuna, salmon, eggs, tofu, enriched grains, dried beans and peas, dried fruits, leafy green vegetables, and Fe+ fortified cereal
Fe+ supplement
Put behind teeth to avoid teeth stains, can cause constipation, and cause dark, green stool (normal)
Give with vitamin C, do not give with milk, color stools and black urine may be normal, stain teeth, drink with straw, and may cause constipation
Overproduction of immature lymphoblast cells (WBC) with infiltration of organs and tissues
Acute Lymphoblastic Leukemia
Acute Lymphoblastic Leukemia Physical Cues
Low-grade fever, signs of infection, pallor, bruising/petechiae/purpura, leg pain, joint pain, enlarged liver, lymph nodes, headache, N/V, abdominal pain
Acute Lymphoblastic Leukemia Lab Cues
Bone Marrow Aspirate (BMA) - most definitive test, determines lymphoid or myeloid and cell types, and prolific quantities of blasts. (Determine MLL or ALL)
CBC - Low Hgb, Low Hct, Low RBCs, low/normal/high WBCs
Blood Smear - may reveal blasts
LP – whether leukemic cells in CNS
CXR – to detect PNA or mediastinal mass
Deficiency of Factor VIII which is essential to activate factor X, which converts prothrombin to thrombin, without it, platelets cannot make clots
Hemophilia
Hemophilia Physical Cues
Joint swelling, pain, bruising, bleeding (nose, gums, hemoptysis, hematemesis, heavy menstrual); chest or abdominal pain (internal bleeding)
Hemophilia Lab Cues
CBC – possible low Hgb & Hct
Coags – PTT prolonged; normal PT & Platelets
Hemophilia Management/Treatment of Bleeding Episodes
FIRST - Factor VIII administration (slow IV push)
Then; aply direct pressure to external bleeding; if joint bleeding, apply ice or cold compresses and elevate extremity unless contraindicated by causing further injury
Desmopressin (DDAVP) (in mild cases) – triggers the endothelium of bld vessels to release Factor VIII
18 month-old presents with…
Reports of watery diarrhea
Asymmetric abdomen
Nontender mass in right abdomen
Proptosis in right eye
Elevated HVA & VMA levels
Arises from embryonic neuroblasts (nerve cells)
Neuroblastoma
Neuroblastoma Patho
A malignancy that occurs in the adrenal gland, sympathetic chain of the retroperitoneal area, head, neck, pelvis, or chest.
Neuroblastoma Physical Cues
Most commonly occurs unilateral in the abdomen (mainly in the adrenal gland) and sometimes in chest or retroperitoneal space
Swollen asymmetric abdomen, proptosis, bruising, watery diarrhea, and enlarged nodes firm and nontender
Neuro deficits, bone pain and limp
Neuroblastoma Diagnostics findings
24-hour urine for elevated homovanillic acid (HVA) and vanillylmandelic acid (VMA)
CT/MRI, CXR, bone scan, BMA, BX, and skeletal survey
A 16-year-old presents with…
Painless, enlarged cervical lymph nodes
Fever & reports of night sweats
20% weight loss
Lymphoma - Hodgkin Disease
Lymphoma - Hodgkin Disease - Physical Cues
Main symptoms: Painless, enlarged supraclavicular or cervical lymph nodes (“sentinel nodes”)
Classified A (Asymptomatic) or B (Fever, night sweats, >10% weight loss, cough, abdominal discomfort, enlarged liver or spleen)
Lymphoma - Hodgkin Disease - Diagnosis/Biopsy Results
Reed-Sternberg Cells
Malignancy of the lymph system primarily involves lymph nodes that often metastasize to spleen, liver, bone marrow, lungs, heart and its vessels, trachea, esophagus, thymus
15-year-old presents with…
Complaints of dull right leg pain
Erythema & swelling around the right knee
Limited ROM in right knee; limped into exam room
Bone scan results: mass in right distal femur
Osteosarcoma
Osteosarcoma Common Sites
Most common sites are proximal humerus, tibia and distal femur (50% of cases)
Osteosarcoma Assessment Cues
Dull bone pain for possibly several months, limp, or limited ROM; Inspect for erythema and swelling
Palpate for tenderness and size of any soft tissue masses
Osteosarcoma Treatment
Chemotherapy
Amputation (depends on size of tumor)
Limb-sparing procedures of the affected extremity – tumor removed by wide local excision & tissue & bone removed and replaced with bone graft or artificial bone implant
Common Cancer Treatment
Mucosal ulceration, skin breakdown, neuropathy, pain, NV, loss of appetite, hemorrhagic cystitis, alopecia, cardiomyopathy (late), and cognitive defects.
Chemotherapy and RT AE/Management
Anemia
Limit blood draws
Fe-rich foods
Use of synthetic Erythropoietin (Epoetin)
Thrombocytopenia
Avoid rectal temps & meds
Avoid IMs or LPs
Avoid ASA & NSAIDS – give Acetaminophen instead
Neutropenia
Private room
Meticulous hand hygiene before and after care
Prophylactic antibiotics
Absolute Neutrophil Count (ANC) <1000
Nausea/Vomiting/Anorexia
Offer bland, dry foods
Offer small, frequent meals
Offer ice, carbonated drinks, popsicles throughout day
Complementary remedies (relaxation, guided imagery)
Radiation Therapy AE/Common Complication/Management
Altered Skin Integrity
Wash skin with mild soap & water
Avoid lotions/powders/ointments
Avoid sun or heat exposure
Diphenhydramine or hydrocortisone cream for itching
Antimicrobial cream to desquamation
Moisturize with aloe vera
Preventing hemorrhage, preventing infection, preventing anemia, and managing nausea, vomiting, and anorexia.
Radiation Management
Assess for skin irradiated areas, moisturize, antimicrobial cream, and itching cream (diphenhydramine or hydrocortisone)
Patient teaching: do not wash off marks for target areas, use mild soap and water, do not apply ointment on irradiated areas, avoid sun exposure to affected area, and use loose soft clothing.
When the circulation of blood vessels is obstructed by abnormally shaped RBCs causing ischemia & infarction
Sickle Cell Disease
Sickle Cell Disease Physical/Labs Cues
Physical Cues
Extreme fatigue or irritability
Pain: abdomen, thorax, joints, digits
Dactylitis
Cough, ↑WOB, fever, tachypnea, hypoxia (ACS s/s)
Splenomegaly
Jaundice (from hemolysis) or pale conjunctiva, palms, soles, and skin
Labs
↓ H&H, ↑ Platelets (SC increases plt activation), ↑reticulocyte count
Sickle Cell Disease Management
Pain Control
Standard child pain scale for age with frequent assessments
Opioid medication for moderate to severe pain on a regular schedule or via PCA
NSAIDs or acetaminophen for less severe pain combined with distraction
Apply warm compresses to inflamed joints
Hydration
Provide up to double maintenance fluid requirements (150ml/kg/day) either orally or IV; Maintain F/E balance; monitor electrolytes
Hypoxia
Encourage incentive spirometry use to decrease incidence of ACS
O2 via NC if SpO2 is <92% (O2 given in the absence of hypoxia may inhibit erythropoiesis)
BM Aspirate Procedure and Monitoring
Prone position
Posterior or anterior iliac crest is most common bone used; may use tibia in infants
BM procedure tray/needle equipment
Medication: Local/topical anesthetic and conscious sedation meds (Fentanyl/Versed)
Pre-procedure priorities
Explain procedure, comfort, infection prevention
Post-procedure priorities
Hold pressure/pressure dressing and monitoring for bleeding and infection
Apply pressure for 5-10 minutes then apply pressure dressing; Monitor for bleeding
General Neutropenic Precaution
Private room
Meticulous hand hygiene before and after care
VS Q4H and assess for signs of infection Q8H and PRN
Avoid rectal temps, enemas, suppositories, urinary catheters, and invasive procedures
Restrict visitors
No raw fruits, vegetables, fresh flowers, or live plants in room
Mask on child when outside room
Soft toothbrush
Types of skin Lesions
Macule - circular, flat discoloration <1cm
Papule – superficial, solid, elevated <0.5 cm
Annular – ring-like with central clearing
Vesicle – circular collection of free fluid < 1 cm
Pustule – vesicle containing pus
Macule
Circular, flat discoloration <1cm
Papule
Superficial, solid, elevated <0.5 cm
Annular
Ring-like with central clearing
Vesicle
Circular collection of free fluid < 1 cm
Pustule
Vesicle containing pus
Skin Common Lab and Diagnostics test
Blood Tests:
Complete blood count (CBC)
Erythrocyte sedimentation rate (ESR) (shows inflammation)
Immunoglobulin E (IgE)
Culture and sensitivity of wound drainage
Potassium hydroxide (KOH) prep
Patch or skin allergy testing
Woods Lamp
Skin Biopsy (less common)
I come in many different shapes & sizes
Mom says this, Dad says that of how I came to be
Poverty, prematurity & chronic illness can lead to me
The buttocks, back & thighs are hiding places of thee
Pattern markings can be key
Skin injuries
Skin injuries Types and Risk Factor
Types
Abrasion, laceration, bites, bruises, and burns
Risk Factors
Poverty, prematurity (<1 yr), chronic illness, intellectual disability, parent w/ abuse history, unrelated partner, alcohol/substance abuse, and extreme stressor
Skin Injuries Suspicious cues
Injuries in uncommon locations, bruises in infants <9 months (not able to walk or be active), multiple injuries other than lower extremities, frequent ED visits (or delayed in seeking care), inconsistent stories, and unusual caregiver-child interaction.
Location can be determined based on location of injury
I’m busiest in the summertime
15 or higher is the best # to be
Broad spectrum & Oxybenzone free is the best kind of me
I do my best work before and during fun in the sun
Sunscreen/Sunburn Prevention
Sunscreen/Sunburn Prevention Prevention and Education
Infants <6 months out of direct sunlight, minimal sunscreen use
Hats, sun shirts
Limit sun exposure between 10 am – 4 pm
Sunscreen:
Broad spectrum (screens out both UVB & UVA rays)
Fragrance and oxybenzone-free
SPF 15 or higher; Zinc oxide products for nose, cheeks, ears, shoulders
Apply 30 minutes prior to sun activity, reapply at least every two hours or every 60-80 minutes while in the water
Use on sunny & overcast days
Atopic Dermatitis (eczema) Physical Cues
Extreme itching
Erythema, inflammation
Variety of lesions/rash (plaques, papules, scaling, vesicles) on face, scalp, wrists or arms, elbows/antecubital, knees/popliteal areas
Atopic Dermatitis Diagnostic Findings
Elevated IgE levels
Presence of wheezing (asthma is common)
Temperature changes and sweating makes me come out to play
I can make you wiggle and scratch all day & night
Sometimes I bring my friend wheeze
I make IgE levels rise
Atopic Dermatitis
Atopic Dermatitis (Eczema) Management
Medications: Topical corticosteroids & Immunomodulators-tacrolimus
Avoid hot water and bathe 2X/day in warm water
Avoid soaps containing perfumes, dyes, or fragrances (Dove, Caress, Cetaphil, Aquanil)
Pat skin dry and leave moist while apply moisturizers (Eucerin, Aquaphor, Vaseline, Crisco) multiple times daily
100% cotton clothing and bed linens, avoiding synthetics and wool; Keep fingernails short
Antihistamines at HS may assist with itching; Behavior modification during waking hours (clickers, distraction, reward)
Diaper Dermatitis Physical Cues
Non-candida – red, shiny; affects skin on buttocks, thighs, abdomen & waist, usually not creases or folds
Candida – deep red color, scaly with patches outside of diaper area, usually affects creases & folds
May also have thrush in mouth
Does not improve with standard diaper cream
Diaper Dermatitis Management
Change diapers frequently
Avoid rubber pants, harsh soaps, and baby wipes with fragrance or preservatives
Skin barriers (zinc oxide); Antifungal (Nystatin) if Candida albicans
Allow the infant or child to go diaperless for a period of time daily to allow healing
Blow-dry the diaper area/rash area with the dryer set on the warm (not hot) setting for 3-5 minutes Candida
Non-candida - Skin barriers (zinc oxide, A,D & E ointments, petroleum)
Candida - Antifungal (Nystatin)
Diaper-less for a period of time daily to allow healing
Blow-dry the diaper area/rash area with the dryer set on the warm (not hot) setting for 3-5 minutes
Bacterial Skin Infection Physical Cues
Impetigo (can turn into papules and vesicles)
Cellulitis (localized inflammation)
Staphylococcal scalded Skin Syndrome (burn-like appearance - leaves red, weeping surface)
Bacterial Skin Infection Therapeutic Management
Usually cause by Staphylococcus aureus or MRSA
Impetigo: Antibiotic ointment or oral antibiotic (soak and clean impetigo before applying antibiotics)
Cellulitis: oral or parenteral antibiotic, rest and immobilize affected areas
SSSS: Mild (oral antibiotics), Severe (IV antibiotics, fluid management, and burn tx)
When Staph aureus or MRSA come to town that’s when I come around
My favorite hang outs are around the nose and mouth
My spots fill up with fluid then erupt
Some say I look like the color of honey
Impetigo
Impetigo Physical Cues
Common infection of superficial layers of epidermis - primary or secondary. Papules → vesicles or pustules w/honey-colored exudate/crusts; itchy or painful
Impetigo Management/Education
Soak impetigo lesions in appropriate solution before applying antibiotics
Treat topically with antibiotic ointment or oral antibiotics; hygiene/linens, avoid contact
Staph aureus is my name and producing toxin is my game
I can make babies’ skin weep and peel
I sometimes look like a bad sunburn
Staphylococcal scalded Skin Syndrome (SSSS)
SSSS Cues
S.aureus produces a toxin that causes the skin to exfoliate causing diffuse erythema and tenderness and a burn-like appearance – leaves red, weeping surface (face, neck, axillary, groin)
SSSS Treatment
Mild: Oral antibiotics
Severe: IV antibiotics, fluid management, burn treatment
Cellulitis Patho
Localized infection or inflammation; Firm, swollen, red area of skin and subcutaneous tissue (red, warm, swollen, pain, tenderness) & possible systemic effects (fever, malaise)
Cellulitis Treatment and Education
Oral or parenteral antibiotics
Rest and immobilize affected area
Viral Skin Infection - Varruca Physical Cues
Verruca (warts) (human papillomavirus)
Elevated, rough, gray-brown firn papules, single or in groups.
Treatment: Surgical removal, electrocautery, cryotherapy, laser
Viral Skin Infection
Molloscum contagiosum (Poxivurs)
Flesh-colored papules on stalks (extremities, face, and trunk)
Resolves spontaneously in 18 months
Complicated cases: remove pox chemically or with curettage, cryotherapy or electro dissection
Tinea (Fungal) infection Diagnostic
Presence of skin lesions, type, distribution, and any rashes
Skin scrapings, KOH preparations, and hair plucking
Pedis
Feet
Corporis
Arms or legs
Versicolor
Hypopigmented areas on neck, trunk, proximal arms
Capitis
Scalp, eyebrows, or eyelashes
Cruris
Inguinal creases and inner thighs
Tinea capitis - Therapeutic Management
Oral griseofulvin for 4-6 weeks; Hair will regrow in 3-12 months after TX initiated; No school for 1 wk after tx started
Tinea corporis - Therapeutic Management
Contagious; Topical antifungal (clotrimazole) at least 4 weeks; May return to school or daycare once TX began
Tinea pedis - Therapeutic Management
Topical antifungal cream, powder, spray; Keep feet clean and dry; May use water with vinegar solution for soaking; Cotton socks only; Flip-flops/slides around pools and in locker rooms
Tinea Versicolor - Therapeutic Management
Selenium sulfide shampoo weekly x 4 wks or topical antifungal cream; Skin pigmentation will return to normal in several months
Tinea Cruris - Therapeutic Management
Topical antifungal cream x 4-6 weeks; Cotton underwear, loose clothing should be worn with good hygiene
Topical antifungal cream
Powder, spray; Keep feet clean and dry; Vinegar solution for soaking; Cotton socks only; Flip-flops/slides around pools and in locker rooms
Topical antifungal (clotrimazole)
At least 4 weeks; Linens and clothing must be washed in hot water to reduce spread.
Acne History and Physical Cues
Onset of lesions and family HX (Begins as early as age 7, affecting 85% of adolescents)
Use of any medications that may exacerbate (steroids, androgens, lithium, phenytoin, isoniazid)
HX of endocrine disorder
Date of LMP for females (worse 2-7 days prior to start of menses)
Presence of comedones (papules – blackheads or whiteheads), pustules, nodules, and hypertrophic scarring (occurs on face, chest and back)
Note oily skin/hair
Acne Management
Education: Avoid oil-based cosmetics and hair products; Headbands, helmets/hats may exacerbate; balanced diet
Clean skin with mild soap and water BID; shampoo hair regularly * Avoid picking/squeezing comedones
Use topical medications as prescribed; may take 4-6 weeks for improvement
Tretinoin – interrupts abnormal keratinization that causes microcomedones
Benzoyl peroxide (OTC products) – inhibits growth of P. acnes
Topical antibacterials (Clindamycin); Oral – Tetracycline, Erythromycin
Isotretinoin – for severe cases, dermatologist prescribed, teratogenic
Oral contraceptives – decreases endogenous androgen production
Emotional counseling if acne is severe
Complications: Infection & Cellulitis
