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Exam 4 Flashcards

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1
Q

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

A

Amblyopia

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2
Q

Amblyopia Therapeutic Management

A

Patching (the stronger eye) for several hours a day OR Atropine drops in the stronger eye daily

Vision therapy

Eye muscle surgery

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3
Q

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

A

Congenital Cataracts

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4
Q

Congenital Cataract Patho

A

Opacity of the optic lens preventing light from entering into eye - will lead to severe amblyopia if not treated

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5
Q

Congenital Cataract assessment cues and management

A

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

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6
Q

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

A

Otitis Media With Effusion (OME) Non-infectious

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7
Q

Otitis Media With Effusion (OME) Non-infectious Assessment Cues and Management

A

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

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8
Q

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

A

Acute Otitis Media

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9
Q

Acute Otitis Media Assessment Cues and Management

A

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

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10
Q

Conductive Hearing Loss

A

Transmission of sound through the middle ear is disrupted (i.e. frequent OM)

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11
Q

Sensorineural Hearing Loss

A

Damage to the hair cells in the cochlea or along the auditory pathway (i.e. ototoxic medication, meningitis, CMV, rubella, excessive noise)

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12
Q

Mixed Hearing Loss

A

attributed to both conductive and sensorineural problem

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13
Q

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

A

Tympanostomy Tubes

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14
Q

Tympanostomy Tubes Management and Education

A

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

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15
Q

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

A

Infantile glaucoma

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16
Q

Infantile glaucoma Physical Cues

A

Keeping eyes closed
Frequent eye rubbing
Spasmodic winking
Corneal clouding
Enlargement of eyeball
Excessive tearing or conjunctivitis
Red reflex may appear gray or green

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17
Q

Infantile glaucoma Management/Education

A

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

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18
Q

Nursing care for Visual Impairment

A

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

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19
Q

Symptoms of hearing loss of infants

A

Wakes only to touch, not room noise

Does not babble by 6 months

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20
Q

Symptoms of hearing loss for Young Child

A

Does not speak by age 2 years

Communicates needs through gestures

Focuses on facial expressions when communicating

Does not respond to doorbell or telephone

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21
Q

Symptom of hearing loss for Older child

A

Often asks for statements to be repeated

Inattentive or daydreams

Poor school performance

Monotone speech

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22
Q

Proper ear drop administration

A

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.

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23
Q

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

A

Iron Deficiency Anemia

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24
Q

Iron Deficiency Anemia PhysicaL cUES

A

Irritability, HA
Unsteady gait, weakness,fatigue
Dizziness, sob, pallor skin, mm, conjunctiva assess for difficulty feeding, pica spooning of nails

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25
Iron deficiency anemia lab cues
Decrease RBC, Hgb, Hct, MCV, MCH, and Ferritin Increase RDW
26
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
27
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
28
Overproduction of immature lymphoblast cells (WBC) with infiltration of organs and tissues
Acute Lymphoblastic Leukemia
29
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
30
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
31
Deficiency of Factor VIII which is essential to activate factor X, which converts prothrombin to thrombin, without it, platelets cannot make clots
Hemophilia
32
Hemophilia Physical Cues
Joint swelling, pain, bruising, bleeding (nose, gums, hemoptysis, hematemesis, heavy menstrual); chest or abdominal pain (internal bleeding)
33
Hemophilia Lab Cues
CBC – possible low Hgb & Hct Coags – PTT prolonged; normal PT & Platelets
34
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
35
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
36
Neuroblastoma Patho
A malignancy that occurs in the adrenal gland, sympathetic chain of the retroperitoneal area, head, neck, pelvis, or chest.
37
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
38
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
39
A 16-year-old presents with… Painless, enlarged cervical lymph nodes Fever & reports of night sweats 20% weight loss
Lymphoma - Hodgkin Disease
40
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)
41
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
42
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
43
Osteosarcoma Common Sites
Most common sites are proximal humerus, tibia and distal femur (50% of cases)
44
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
45
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
46
Common Cancer Treatment
Mucosal ulceration, skin breakdown, neuropathy, pain, NV, loss of appetite, hemorrhagic cystitis, alopecia, cardiomyopathy (late), and cognitive defects.
47
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)
48
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.
49
When the circulation of blood vessels is obstructed by abnormally shaped RBCs causing ischemia & infarction
Sickle Cell Disease
50
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
51
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)
52
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
53
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
54
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
55
Macule
Circular, flat discoloration <1cm
56
Papule
Superficial, solid, elevated <0.5 cm
57
Annular
Ring-like with central clearing
58
Vesicle
Circular collection of free fluid < 1 cm
59
Pustule
Vesicle containing pus
60
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)
61
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
62
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
63
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
64
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
65
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
66
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
67
Atopic Dermatitis Diagnostic Findings
Elevated IgE levels Presence of wheezing (asthma is common)
68
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
69
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)
70
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
71
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
72
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)
73
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)
74
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
75
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
76
Impetigo Management/Education
Soak impetigo lesions in appropriate solution before applying antibiotics Treat topically with antibiotic ointment or oral antibiotics; hygiene/linens, avoid contact
77
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)
78
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)
79
SSSS Treatment
Mild: Oral antibiotics Severe: IV antibiotics, fluid management, burn treatment
80
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)
81
Cellulitis Treatment and Education
Oral or parenteral antibiotics Rest and immobilize affected area
82
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
83
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
84
Tinea (Fungal) infection Diagnostic
Presence of skin lesions, type, distribution, and any rashes Skin scrapings, KOH preparations, and hair plucking
85
Pedis
Feet
86
Corporis
Arms or legs
87
Versicolor
Hypopigmented areas on neck, trunk, proximal arms
88
Capitis
Scalp, eyebrows, or eyelashes
89
Cruris
Inguinal creases and inner thighs
90
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
91
Tinea corporis - Therapeutic Management
Contagious; Topical antifungal (clotrimazole) at least 4 weeks; May return to school or daycare once TX began
92
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
93
Tinea Versicolor - Therapeutic Management
Selenium sulfide shampoo weekly x 4 wks or topical antifungal cream; Skin pigmentation will return to normal in several months
94
Tinea Cruris - Therapeutic Management
Topical antifungal cream x 4-6 weeks; Cotton underwear, loose clothing should be worn with good hygiene
95
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
96
Topical antifungal (clotrimazole)
At least 4 weeks; Linens and clothing must be washed in hot water to reduce spread.
97
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
98
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

Peds (4 decks)

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