Family Centered Pediatric Care

Question 1

checking V/S in children

Answer 1

• RR: count 1 minute
  
  • look at WOB, color, visualize and auscultate respirations
• apical pulse: count 1 min
  
  • radial pulse not accurate until after age 2
• temp: rectal, oral, axillary
• BP: may use upper arm, lower leg, or upper leg

Question 2

taking temperature of a child

Answer 2

• can be rectal, oral, axillary
• sometimes rectal is contraindicated–>less than 1 mos, bleeding concerns, etc
• rectal temp may be ordered if core temp is desired, but it is rare
• temp range: 36.5-37.6 deg C

Question 3

what can be a sign of illness in neonates that is not common in older children and adults?

Answer 3

• hypothermia rather than hyperthermia/fever

Question 4

HTN in children

Answer 4

• affecting more and more children due to inc in childhood obesity
• often secondary to an underlying pathological process
• make sure BP cuff is appropriate size

Question 5

screening for HTN in children

Answer 5

• all children 3 yo and older should be screened at all healthcare encounters
• children younger than 3 yo with comorbid conditions should also be screened:
  
  • prematurity or NICU stay
  • CHD, kidney dz, GU abnormality
  • family hx of CKD
  • transplant or malignancy
  • meds assoc with HTN SEs

Question 6

tx of children with HTN

Answer 6

• stage 1: lifestyle changes (diet, activity)
  
  • no evidence of organ damage, diabetes, and those who are asymptomatic
  • after 6 mos of lifestyle changes, need re evaluation and if still HTN, move to stage 2
• stage 2: anti HTN meds
  
  • children who are symptomatic, HTN secondary to meds, diabetes, or evidence of organ damage
  • many meds have not been tested long term in children

Question 7

neurological assessment of children

Answer 7

• fontanels
• LOC: how much stimulation to get them awake and keep them awake?
• following commands
• motor milestones
• cognitive and social development
• response to environment
• infant reflexes

Question 8

Babinski reflex

Answer 8

• normal until about 2 yo

Question 9

Moro reflex

Answer 9

• strongest during first 2 mos
• if present after 4 mos, it is indicative of brain damage
  
  • could indicate infantile spasms
• absence could indicate hearing impairment

Question 10

Palmar reflex

Answer 10

• should disappear by 3-4 mos

Question 11

Rooting reflex

Answer 11

• disappears by 3-4 mos
  
  • may persist up to 12 mos when the child is sleeping
• absence is indicative of severe neurological disorder

Question 12

Sucking reflex

Answer 12

• reflex persists throughout infancy
• weak or absent reflex indicates developmental delay or neurological abnormality

Question 13

when should an infant develop good head control?

Answer 13

• by 4 mos
  
  • as long as they had tummy time to develop muscle strength in neck and shoulders

Question 14

when does birth weight double? triple?

Answer 14

• doubles by 6 mos
• triples by 1 yr

Question 15

when does an infant reach 50% of their adult height?

when does an infant reach double their birth height?

Answer 15

• reaches 50% of adult height by 2 yo
• double birth height by 4 yo

Question 16

assessment of child development

Answer 16

• ongoing as the child grows: assessed with well child visits
• need to know the norms or major milestones to assess development
• use Erikson for comparison
• standardized tests:
  
  • Denver is broad screening tool used often–>assesses psychosocial and psychomotor development

Question 17

assessment of child growth

Answer 17

• all plotted on growth charts
• height/length and weight
  
  • on all visits
  • use centimeters and kilograms
• measure head circumference up to 36 mos
  
  • measure above the pinna and right at/above the eyebrows

Question 18

body mass index

Answer 18

• best indicator of healthy weight
• BMI=kg/m²
• considered overweight if BMI is at or exceeds 85%
• don’t do until after 2-3 yrs

Question 19

what BMI is considered obese? overweight?

Answer 19

• obese: at or over 95%
• overweight: 85-94%

Question 20

comorbidities that exist with childhood obesity

Answer 20

• asthma
• obstructive sleep apnea
• HTN
• type 2 diabetes
  
  • fasting blood sugar for children 10 yrs or older if BMI is >85th percentile with:
    
    • family hx of type 2 DM
    • race or ethnicity assoc with an inc risk of DM
    • clinical features of insulin resistance
• hyperlipidemia: fasting lipid profile

Question 21

assessment of childhood obesity

Answer 21

• measure and determine BMI
• skin fold thickness and waist circumference has not been shown to be useful
• obtain diet hx and activity hx
• obtain FH and PMH

Question 22

prevention of childhood obesity

Answer 22

• counsel non obese pts to establish weight friendly and healthy lifestyle
• breast feed first 6 mos and continue for at least the first year
• 5 or more fruits and veggies a day
• limit sugar sweetened beverages
• prepare more meals at home
• eat at table as family 5-6 times a week with TV off
• healthy breakfast every day
• involve the whole family in lifestyle changes
• parents should avoid overly restricted feeding behaviors
• diet rich in calcium

Question 23

tx of childhood obesity

Answer 23

• weight mgmt programs that involve the family and include the family and include frequent visits to the PCP
• physical activity recommendations
• dietary instruction
• meds:
  
  • no weight loss meds are approved for use in children younger than 12 yo
• surgery

Question 24

what is failure to thrive?

Answer 24

• inadequate growth
• no universal definition
• weight less than 5th percentile for age
• persistent deviation from growth curve

Question 25

types of failure to thrive

Answer 25

• inadequate caloric intake
• inadequate absorption: CF, hepatic dz, vitamin/mineral deficiencies
• increased metabolism: CHD, hyperthyroidism, immunodeficiency
• defective utilization: metabolic or genetic anomaly

Question 26

mgmt of FTT

Answer 26

• dx: exam, growth charts, diet hx, rule out organix causes, family assessment, home assessment
• mgmt:
  
  • reverse malnutrition
  • catch up growth
  • tx co-existing problems
• prognosis:
  
  • related to cause

Question 27

nursing care of FTT

Answer 27

• nurse:
  
  • assessment of weight, growth
  • documenting food intake, feeding behavior, interactions
• feeding:
  
  • sufficient calories, feed on schedule, persistence, eye contact
  • quiet, non stimulating feeding environment
• parent:
  
  • supporting relationship
• child:
  
  • developmental stimulation b/w feeds

Question 28

PKU

Answer 28

• genetic: autosomal recessive
• inability to metabolize phenylalanine
  
  • lacks enzyme to metabolize it
  • phenylalanine is an essential AA found mainly in proteins, grains, fruits/veggies
• high phenylalanine can cause severe cognitive impairments and erratic behavior
  
  • degenerates white and gray matter

Question 29

PKU: manifestations

Answer 29

• growth failure, vomiting, irritability, erratic behavior, spasticity, seizures, cognitive impairments
• best outcomes if tx started before 3 weeks
• dx: screening mandatory in all 50 states
  
  • dx and tx aimed at prevention of cognitive disabilities
  • test close to newborn discharge by before 7 days old
  • need sufficient exposure to milk to test (at least 24 hours)

Question 30

tx of PKU

Answer 30

• low phenylalanine formula/solution is only source of protein through adolescence
• breast feeding MAY be okay if mother’s intake is low in phenylalanine
• diet allows for 20-30 mg/kg/day of phenylalanine
• need to maintain blood level at 2-8 mg/dL–cognitive deficits occur at 10-15
  
  • even with good control, could be some degree of intellecual impairment
  • females wanting to get pregnant should go back on the diet before the pregnancy to prevent fetal brain damage

Question 31

what is the single most important health measure in pediatrics?

Answer 31

immunizations: ask about immunization status at each health care visit

Question 32

vaccine refusal

Answer 32

• most do not vaccinate due to parental concerns on vaccine safety
• most commonly cited concerns:
  
  • thimerisol–>very few contain it
  • not closely regulated–>monitored by FDA and CDC
  • dz is not a risk–>international travel inc risk
  • receive too many vaccines at once–>loads of antigens in a single vaccine component have dec over time

Question 33

recommended vs required vaccines

Answer 33

• required: determined by state for school attendance
• recommended: entire schedule recommended by the American Academy of Pediatrics

Question 34

haemophilus influenzae type B

Answer 34

• given IM
• protects against:
  
  • bacterial meningitis
  • epiglottitis
  • pneumonia
  • sepsis

Question 35

MMR vaccine

Answer 35

• live, attenuated vaccine
  
  • given subQ
• common SEs: rash (looks like measles) 7-10 days after the injection
• do NOT give to pregnant women
• measles: viral and can have complications of laryngotracheitis or encephalitis
• mumps: viral and can have complications such as encephalitis, deafness, sterility
• rubella (german measles): viral–biggest risk is teratogenic effects on fetus

Question 36

how are live vaccines given?

Answer 36

subQ

Question 37

varicella (chicken pox) vaccine

Answer 37

• highly contagious viral illness
• live attentuated vaccine, give subQ
• common SEs: rash (like chicken pox) at the injection site 7-10 days after the injection
• store frozen
• not recommended for pregnant women
• given due to complications of chicken pox that can include encephalitis and serious secondary infections
• may get mild case of chicken pox if exposed

Question 38

vaccine administration

Answer 38

• site/equipment
  
  • 1 inch, 25 G needle for IM–nice place to start
  • vastus lateralis OR ventrogluteal for infant/young child (<12 mos)
    
    • may want to avoid ventrogluteal M b/c sciatic n
  • deltoid for preschool or older than 2 yo
• safety
  
  • good restraint
  • okay to give multiple injections, but dfferent sites
  • correct storage, reconstitution
  • do not combine unless it came as a combo vaccine
• developmental approach: younger they are, the closer to the actual event we talk abou it
• document: vaccine info site, lot number, consent

Question 39

IM injections

Answer 39

• vastus lateralis, ventrogluteal, deltoid in older children
• immunizations and meds (usually abx)

Question 40

SC injections

Answer 40

• arm for immunizations
• used for insulin, hormone replacement, allergy shots, some vaccines
• all are IM, except live vaccines (MMR & Varicella)

Question 41

contraindications for vaccine administration

Answer 41

• severe febrile illness (over 38 deg)
• past SERIOUS ADRs tothe vaccine or vaccine component
• long term (>2 weeks) use of systemic steroids
• pregnancy: no live vaccines
• recent blood, plasma, or IgG for live virus vaccines–wait a minimum of 3 months
• seizure w/in several days of receiving a prior dose of vaccine
• immunosuppression:
  
  • transplant: generally no live virus vaccine if undergoing immunosuppression therapy
  • HIV: can receive live vaccine if asymptomatic
  • AIDS: not an asymptomatic state
  • chemo: wait 3 mos usually to restart vaccine schedule

Question 42

when it is okay to give a vaccine?

Answer 42

• mild to moderate local rxn to past vaccine
• mild, acute illness with or without low grade fever
• current abx therapy
• prematurity: may have to adjust schedule slightly
• family hx of seizure, SIDS, or ADRs of vaccines
• breast feeding or household contact with pregnant women
• CNA receive if HIV+ and asymptomatic

Question 43

giving oral meds to children

Answer 43

• use the correct dosing device–>carefully measure it
• don’t sneak meds into food–>do not put in a bottle
• administer into the cheek pocket
• mix in the smallest amount possible
  
  • may need to crush it and make it a liquid
  • can flavor it
• some meds you may repeat and others you may not if the kid spits it out
  
  • do not always assume you repeat it if they spit or vomit it

Question 44

evaluation of fever in children

Answer 44

• any infant less than 2-3 mos old is evaluated immediately if febrile
  
  • less than 28 days usually receive a complete septic workout–>CBC w/ diff, blood cultures, LP (then start abx)
  • up to 90 days of age the “key” is if they appear toxic
• any child with fever >105 is evaluated immediately
• a child that looks or acts very sick is evaluated immediately
• fever 104-105, younger than 2 yrs, fever >3 days, fever gone for 24 hours and then returns, or parental concerns–>should be evaluated in 24 hours

Question 45

what can you give for fever in children?

Answer 45

• tylenol at any age
  
  • ibuprofen not until 6 mos b/c of liver immaturity

Question 46

treatment of fever

Answer 46

• aimed at relieving discomfort
• meds: to lower the set point
  
  • acetaminophen: 10-15 mg/kg per dose
  • ibuprofen: 5-10 mg/kg per dose (after 6 mos of age)
  • no aspirin–>Reye’s syndrome risk
• home tx:
  
  • light clothing, air circulation, sponging (don’t want them chilling)
• oral intake: only enough needed to make sure kidneys perfusing
• parental support
• education: when to follow up, correct meds dosing, correct home care

Question 47

febrile seizure

Answer 47

• affect about 3-5% of children and usually occur b/w the ages of 6 mos and 3 yo
  
  • unusual after age 5 yo
• cause is uncertain
• temp usually exceeds 38.8 C (101.8 F)
• concern is to protect the airway!
• tonic clonic seizure occurs during the temperature rise
• follow up:
  
  • initial episode should be evaluated by pediatrician
  • complicated episodes may need further evaluated by neuro

Question 48

varicella zoster

Answer 48

• chicken pox
• transmitted airborne and direct contact
• communicable 5 days prior to rash and until last vesicle crusted over
• manifestations: fever, malaise, HA, itching, vesicular rash

Question 49

tx of varicella

Answer 49

• supportive:
  
  • tylenol
  • fluids
  • comfort for itching (baths)
• immunization to prevent
• tx of secondary infections:
  
  • cellulitis
  • meningitis
  • Reye’s Syndrome
  • illness more severe if on oral steroids

Question 50

nursing implications for Varicella

Answer 50

• monitor for complications:
  
  • neuro
  • infection
• home care:
  
  • tx of rash
  • comfort
  • fluids
  • OTC meds
• isolation if in hospital
  
  • monitor visitors

Question 51

erythema infectiosum

Answer 51

• transmission: respiratory secretions and blood
• manifestations:
  
  • HA, malaise, body aches
  • maybe low grade fever
  • 1 wk later: slapped cheek rash

Question 52

nursing implications for 5th’s disease (erythema infectiosum)

Answer 52

• supportive care:
  
  • home care for itchy rash (usually not itchy)
  • fluids
  • rest
  • keep out of sun with rash
• avoid contact w/ pregnant women
  
  • contagious prior to symptoms
• can cause aplastic crisis in children with hemolytic conditions

Question 53

impetigo

Answer 53

• bacterial infection of the skin:
  
  • often spread by auto inoculation
  • young children often affected–hand to mouth/nose
  • often seen around the nose–can be anywhere though
  • “honey crusted” lesions

Question 54

impetigo nursing care

Answer 54

• handwashing
• abx
• razors discarded
• bleach kills it on surfaces

Question 55

accident prevention

Answer 55

• injuries are number 1 mortality
• take a developmental approach to prevention:
  
  • poor planning, “top heavy,” awkward, impulsive, curious
• situations that lead to injury:
  
  • weather extremes
  • saturdays
  • overcrowded areas
  • tension in home
  • alcohol/drug use

Question 56

ingestions

Answer 56

• developmental characteristics predispose children to poisonings: curiosity, oral experimentation, imitation
• prevention:
  
  • lock up!
  • keep out of sight
    
    • throw out old drugs, don’t let young kids see adults take, keep meds in safe areas
  • keep in original containers
    
    • don’t put in food containers, don’t refer to as candy
  • keep poison control number handy

Question 57

home tx of ingestions

Answer 57

• assessment: what did they take, how much, when?
• empty mouth
• take child and container to phone
• call poison control

Question 58

charcoal for ingestion

Answer 58

• absorbs cpds
• poses risk for aspiration, intestinal obstruction, electrolyte imbalances
• mix with diet soda as sweetener to reduce absorption quality

Question 59

cathartics for ingestion

Answer 59

• stimulate evacuation of the bowel decreasing intestinal absorption
• use is controversial

Question 60

antidotes for ingestion

Answer 60

• mucomist for tylenol
  
  • tylenol is #1 drug used to commit suicide
• narcan for opiates

Question 61

lead poisoning

Answer 61

• known health hazard–absorbed by ingestion, inhalation, placental transfer
• absorbed by the body and not fully eliminated
• sometimes can be a part of cultural traditions
• the child:
  
  • young children absorb 50% of what they are exposed to
  • highest risks: ages 1-5, PICA, high fat diet, iron deficiency, developmentally delayed, increased oral activity

Question 62

pathological effects of lead

Answer 62

• heme: anemia: lead competes w/ iron in making hgb
• renal: damage to renal tubules causes excretion of glucose, protein, amino acids, and phosphate (Fanconi Syndrome)
• CNS: MOST SIGNIFICANT
  
  • cerebral edema, encephalopathy, inc ICP, seizures, MR, blindness, paralysis, death
  • developing brain is esp vulnerable
  • CNS effects are nonreversible

Question 63

treatment of lead poisoning

Answer 63

• tx home environment
• chelation starts around levels of 44-45
  
  • need to give meds that will bind to lead and then will be excreted
  • MUST make sure child is adequatley hydrated so they can excrete it
  • DMSA, EDTA, BAL

Question 64

long term effect of lead

Answer 64

• some effects are reversible
• effects on CNS leave child with cognitive impairments, behavior changes, SZ
• even low dose exposure may leave permanent effects on distractibility, impulsivity, and learning disabilities
• nursing implications:
  
  • education
  • assessment of development

Question 65

risk factors for abuse

Answer 65

• drug and ETOH abuse
• psychiatric disorders
• environmental stressors
  
  • poor parenting experiences
  • marital/partner stressors
  • social isolation
  • inappropriate expectations of child

Question 66

signs of abuse

Answer 66

• unexplained burns, bruises, fxs
• fading bruises or burns
• bruises or welts in shapes or patterns
• child “shrinks” in approach to adults
• child is overtly compliant
• caretaker with conflicting story
  
  • look at the story vs. developmental age vs. injury
• look at anyone that hurts animals–>every serial killer starts by hurting animals

Question 67

nursing implications w/ regard to child abuse

Answer 67

• dx: H&P, labs, hematogram: total body XR to look at old fxs or healing fxs
• nursing implications:
  
  • reassurance of the child: tat this is nothing they’ve done
  • nursing assessment: does hx fit evidence?
  • mandated reporter

Question 68

physical red flags for child maltreatment

Answer 68

• inconsistent hx
• hx and exam mismatch
• withholding hx
• no knowledge of circumstances
• claims of self infliction
• blaming of siblings or other parent/adult
• delay in seeking care
• hx of other injuries
• ER shopping
• inappropriate rxn to severity of injury
• partial confession

Question 69

what should hot water heater be set at?

Answer 69

no higher than 120 deg F

Question 70

bruise color scale

Answer 70

• reddish blue/purple: immediate 24 hours
• dark blue/purple: 1-5 days
• green: 5-7 days
• yellow: 7-10 days
• brown: 10-14 days
• resolution (cleared): 2-4 weeks

Question 71

parental behavior patterns seen in abuse

Answer 71

• lack of concern or detachment about the injury
• lack of response to child in pain
• overly concerned about trivial injury
• demonstrates unrealistic expectations of child (esp potty training)
• parents themselves have a hx of dru or alcohol addiction or psychosis
• lack of trust in health professionals

Question 72

consider the possibility of physical maltreatment when the child

Answer 72

• has unexplained burns, bite, bruises, broken bones, or black eyes
• has fading bruises or other marks noticeable after an absence from school
• seems frightened of the parents and protest or cries when it is time to home
• shrinks at the approach of adults
• reports injury by parents or another adult caregiver

Question 73

consider the possibility of physical abuse when parent or other caregiver:

Answer 73

• offers conflicting, unconvincing, or no explanation for the child’s injury
• describes child as evil or in some other negative way
• uses harsh physical discipline with child
• has a hx of abuse as a child

Question 74

skin and soft tissue injury

Answer 74

• bruises on face, lips, mouth, torso, back, buttocks, thighs
  
  • bruises in various stages of healing
  • degree of bruising is greater than expected for child’s activity level
  • dating bruises by color scale

Question 75

types of sexual abuse:

incest

molestation

exhibition

Answer 75

• incest: b/w family members, not necessarily blood
• molestation: indecent liberties–touching, fondling
• exhibition: indecent exposure
• child porn

Question 76

consider possibility of sexual abuse when child:

Answer 76

• has difficulty walking/sitting
• suddenly refuses to change for gym or to participate in physical activities
• reports nightmares or bed wetting
• experiences a sudden change in appetite
• demonstrates bizarre, sophisticated, or unusual sexual knowledge
• becomes pregnant or contracts STD before age 14
• runs away
• reports sexual abuse

Question 77

consider possibility of sexual abuse when parent:

Answer 77

• is unduly protective of child or severely limits child’s contact w/ other children, esp of opposite sex
• is secretive and isolated
• is jealous or controlling w/ family members

Question 78

what is pedophilia?

Answer 78

• a form of child sexual abuse is an abnormal interest in children that is based on the intention by the perpetrator to be sexually aroused by children

Question 79

Munchausen by Proxy

Answer 79

• an illness that one person (usually mom who has some health care experience) fabricates or induces in another person
• type of mental illness

Question 80

nursing responsibilities in child maltreatment

Answer 80

• identification:
  
  • nurses should perform thorough physical exams
• care of child–depends on injury
• protection of child
• prevention of abuse
• reporting–mandatory
  
  • if written report is done, report must be in common terms, not medical terms. If medical term is used, must be an explanation
  • parents are told that report is being made and social service will interview them
• testifying in court

Question 81

what is one thing you may see that is not considered child maltreatment that may look like it at first glance?

Answer 81

• Cao Gio (Coining)
  
  • involves rubbing a coin along area to release “bad wind”
    
    • if red purple discoloration appears, the tx is considered successful
  • used by Vietnamese and other Asian Pacific groups