Family Centered Pediatric Care Flashcards
(81 cards)
1
Q
checking V/S in children
A
- 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
2
Q
taking temperature of a child
A
- 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
3
Q
what can be a sign of illness in neonates that is not common in older children and adults?
A
- hypothermia rather than hyperthermia/fever
4
Q
HTN in children
A
- 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
5
Q
screening for HTN in children
A
- 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
6
Q
tx of children with HTN
A
- 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
7
Q
neurological assessment of children
A
- 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
8
Q
Babinski reflex
A
- normal until about 2 yo
9
Q
Moro reflex
A
- 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
10
Q
Palmar reflex
A
- should disappear by 3-4 mos
11
Q
Rooting reflex
A
- disappears by 3-4 mos
- may persist up to 12 mos when the child is sleeping
- absence is indicative of severe neurological disorder
12
Q
Sucking reflex
A
- reflex persists throughout infancy
- weak or absent reflex indicates developmental delay or neurological abnormality
13
Q
when should an infant develop good head control?
A
- by 4 mos
- as long as they had tummy time to develop muscle strength in neck and shoulders
14
Q
when does birth weight double? triple?
A
- doubles by 6 mos
- triples by 1 yr
15
Q
when does an infant reach 50% of their adult height?
when does an infant reach double their birth height?
A
- reaches 50% of adult height by 2 yo
- double birth height by 4 yo
16
Q
assessment of child development
A
- 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
17
Q
assessment of child growth
A
- 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
18
Q
body mass index
A
- 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
19
Q
what BMI is considered obese? overweight?
A
- obese: at or over 95%
- overweight: 85-94%
20
Q
comorbidities that exist with childhood obesity
A
- 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
- fasting blood sugar for children 10 yrs or older if BMI is >85th percentile with:
- hyperlipidemia: fasting lipid profile
21
Q
assessment of childhood obesity
A
- 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
22
Q
prevention of childhood obesity
A
- 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
23
Q
tx of childhood obesity
A
- 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
24
Q
what is failure to thrive?
A
- inadequate growth
- no universal definition
- weight less than 5th percentile for age
- persistent deviation from growth curve
25
types of failure to thrive
* inadequate caloric intake
* inadequate absorption: CF, hepatic dz, vitamin/mineral deficiencies
* increased metabolism: CHD, hyperthyroidism, immunodeficiency
* defective utilization: metabolic or genetic anomaly
26
mgmt of FTT
* 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
27
nursing care of FTT
* 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
28
PKU
* 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
29
PKU: manifestations
* 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)
30
tx of PKU
* 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
31
what is the single most important health measure in pediatrics?
immunizations: ask about immunization status at each health care visit
32
vaccine refusal
* 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
33
recommended vs required vaccines
* required: determined by state for school attendance
* recommended: entire schedule recommended by the American Academy of Pediatrics
34
haemophilus influenzae type B
* given IM
* protects against:
* bacterial meningitis
* epiglottitis
* pneumonia
* sepsis
35
MMR vaccine
* 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
36
how are live vaccines given?
subQ
37
varicella (chicken pox) vaccine
* 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
38
vaccine administration
* 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
39
IM injections
* vastus lateralis, ventrogluteal, deltoid in older children
* immunizations and meds (usually abx)
40
SC injections
* arm for immunizations
* used for insulin, hormone replacement, allergy shots, some vaccines
* all are IM, except live vaccines (MMR & Varicella)
41
contraindications for vaccine administration
* 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
42
when it is okay to give a vaccine?
* 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
43
giving oral meds to children
* 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
44
evaluation of fever in children
* 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
45
what can you give for fever in children?
* tylenol at any age
* ibuprofen not until 6 mos b/c of liver immaturity
46
treatment of fever
* 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
47
febrile seizure
* 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
48
varicella zoster
* 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
49
tx of varicella
* 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
50
nursing implications for Varicella
* monitor for complications:
* neuro
* infection
* home care:
* tx of rash
* comfort
* fluids
* OTC meds
* isolation if in hospital
* monitor visitors
51
erythema infectiosum
* transmission: respiratory secretions and blood
* manifestations:
* HA, malaise, body aches
* maybe low grade fever
* 1 wk later: slapped cheek rash
52
nursing implications for 5th's disease (erythema infectiosum)
* 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
53
impetigo
* 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
54
impetigo nursing care
* handwashing
* abx
* razors discarded
* bleach kills it on surfaces
55
accident prevention
* 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
56
ingestions
* 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
57
home tx of ingestions
* assessment: what did they take, how much, when?
* empty mouth
* take child and container to phone
* call poison control
58
charcoal for ingestion
* absorbs cpds
* poses risk for aspiration, intestinal obstruction, electrolyte imbalances
* mix with diet soda as sweetener to reduce absorption quality
59
cathartics for ingestion
* stimulate evacuation of the bowel decreasing intestinal absorption
* use is controversial
60
antidotes for ingestion
* mucomist for tylenol
* tylenol is #1 drug used to commit suicide
* narcan for opiates
61
lead poisoning
* 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
62
pathological effects of lead
* 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
63
treatment of lead poisoning
* 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
64
long term effect of lead
* 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
65
risk factors for abuse
* drug and ETOH abuse
* psychiatric disorders
* environmental stressors
* poor parenting experiences
* marital/partner stressors
* social isolation
* inappropriate expectations of child
66
signs of abuse
* 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
67
nursing implications w/ regard to child abuse
* 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
68
physical red flags for child maltreatment
* 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
69
what should hot water heater be set at?
no higher than 120 deg F
70
bruise color scale
* 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
71
parental behavior patterns seen in abuse
* 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
72
consider the possibility of physical maltreatment when the child
* 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
73
consider the possibility of physical abuse when parent or other caregiver:
* 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
74
skin and soft tissue injury
* 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
75
types of sexual abuse:
incest
molestation
exhibition
* incest: b/w family members, not necessarily blood
* molestation: indecent liberties--touching, fondling
* exhibition: indecent exposure
* child porn
76
consider possibility of sexual abuse when child:
* 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
77
consider possibility of sexual abuse when parent:
* 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
78
what is pedophilia?
* 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
79
Munchausen by Proxy
* an illness that one person (usually mom who has some health care experience) fabricates or induces in another person
* type of mental illness
80
nursing responsibilities in child maltreatment
* 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
81
what is one thing you may see that is not considered child maltreatment that may look like it at first glance?
* 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
