Final Flashcards
Erikson’s 8 stages of social-emotional development
Trust vs Mistrust (Birth -12 months)
Autonomy vs Shame and Doubt (12-36 months)
Initiative vs Guilt (preschool 3-5 years)
Industry vs Inferiority (school age)
Identity vs Role Confusion (12-18 years)
Intimacy vs isolation (18–25 years)
Generativity versus self-absorption and stagnation (25–65 years)
Integrity versus despair (65 years–death)
Piaget’s 4 stages of cognitive development
- Sensorimotor (birth to 2 years)
- Preoperational (2 to 7 years)
- Concrete operations (7 to 11 years)
- Formal operations (11 to 15 years)
Expected Findings for child with Autism (5)
- Delays in social interaction and imaginative play before age 3 years (no immitation)
- Avoidance of eye and physical contact
- Short attention span
- Rhythmic movements
- Attached to routines
Interventions for autism (7)
- Early screening and intervention to maximize their social skills (at 18 and 24 months)
- Behavior Modification i.e. Limit setting
- Decreasing environmental stimuli
- Introduce new situations slowly
- Involve parents b-c warm up to new people slowly
- Promote consistency in caregiving
- Ensure safety (May have poorer safety cues)
Age appropriate toys: infants
- nesting toys
- teething rings
- rattles
- mobile
- high contrast (0-6m)
Psychosocial Development: Infant
Trust Development (2 )
Mistrust Development (2)
Social behaviors (2)
Trust
- Feeding
- Stimulation and Comfort (quality care)
Mistrust
- when gratification of needs is delayed
- when needs met before infant asks (does not learn delayed gratification)
Social modifications
- Grasping (pleasurable tactile)
- Biting (first conflict is biting w/ breastfeeding)
Age-specific difficulties: Infants
2 notes and age ranges
- separation anxiety b/w 4-8 months
(insecure attachment disorders form here if failure to learn object permanence and discriminate parent from others) - stranger fear b/w 6-8 months
(nurse should be soft, eye-level, stay safe distance and avoid sudden invasive gestures; child may refuse to play with strangers)
Sleep: infants
SIDS prevention (5)
- back to sleep (tummy time in daytime to prevent plagiocephaly)
- sleep in crib w/ firm mattress in same room as parents
- no loose objects, crib bumpers, soft toys, and bedding out of baby’s sleep area
- avoid letting baby overheat at night
- breastfeed first 6 months
- use pacifier
5 safety concerns for infants - Preschool (and recommendations)
ASPIRATION- check for small objects, feed sitting up, small food bites, avoid pits and bones
SUFFOCATION- “Back to sleep”, avoid extra blankets and pillow, avoid unsafe sleep, crib slats, 6cm apart, no crib bumpers, remove bibs, avoid bags, balloons, and buckets
DROWNING- supervise baths, fence pools, keep bathroom doors closed, keep appliances shut; teach toddlers and up how to swim and not go in water too deep
FALLS-crib rails, car seats, supervise when on furniture, avoid scatter rugs, fence the stairs, keep furniture away from the window.
BODILY DAMAGE-Secure furniture, supervise with animals, keep away sharp items, walk w/ scissors down
Emergency Care for Poisoning (4)
- always assess child (ABCs)- (oxygen, intubate, pulse ox, sodium bicarb for metabolic acidosis)- shock is common
- call poison control (1-800-222-1222)
- Terminate exposure to poison (empty mouth, flush w/ water, remove clothes; keep child side-lying
- identify poison (environmental cues, witnessess, victim)
Poisoning Safety Promotion: Infants - School age (6)
- check paint for furniture and toys- no lead
- All toxic substances on high shelf
- Keep plants out of reach
- Child safe caps and all meds stored out of reach (SAFETY LOCK FOR TODDLERS; do not take meds in front of child)
- Give medications as a drug, do not call it “candy”
- Carbon monoxide detector in home
Burns Safety Promotion: Infants- School age (9)
- Smoke detectors
- Check temperature of all formula and bath waters
- Water heater set under 120 degrees
- Avoid cigarettes/ashes near child
- Flame retardant clothes
- Store all candles, matches, lighters in high place
- Caution with sun exposure, use sunscreen
- Safe cooking (microwave and pot handles turned inward)
- Do practice fire drills
Psychosocial development: Toddler
6 concepts related to Autonomy vs Shame and Doubt
- Independence (differentiate self from others; accept separation from others, control bodily functions)- risk for injury r/t increased independence and mobility
- Negativism (negative responses; so reduce opportunities to say no)
- Ritualism (provides them comfort)
- Transitional objects
- Animism
- Centration- focus on one thing
Age-appropriate activities: toddlers (7)
- Blocks
- Books
- Push/pull toys
- Balls
- Large piece puzzles
- Finger paints/thick crayons
- Imagination (Boxes, kitchen pots/spoons)
What is the purpose of play?
What kind of play do different ages engage in?
- relief of stress, energy, tension (a way to cope)
- intellectual and social development
Infants- sensory affective and solitary play
Toddlers - parallel play (usually do not share)
Preschool- associative play (group play w/o rigidity)
School age- cooperative and competitive
3 Age-specific Difficulties: Toddlers and preschoolers
What are they? (3 concerns)
How to manage them?
Temper Tantrums (kicking, screaming, holding breath)
- manage w/ consistent expectations, ignore noninjurious behavior, time outs
- normal part of development (problem if > 15 mins, > 5x per day, or after 5 yrs
Sibling rivalry (upset by dethronement; preschoolers may act out)
- manage by preparing child before the birth
Regression (during stress or discomfort)
- manage w/ ignoring and praising appropriate behavior
Motor Vehicle Safety Promotion: All ages (9)
- all children in rear seat until 13 yrs
- rear-facing carseat until 2 yrs
- front-facing carseat until 4 yrs/ 40 pounds
- booster seat until 80 pounds or 4 ft 9 in
- keep trunk closed
- do not leave child unattended in car
- seat belt use
- no phone, alc, or drugs while driving (for adolescents)
- do not add extra padding to car seats
Psychosocial Development: Preschool (Initiative vs guilt
When does conflict occur?
Tasks (2)
- guilt due to consequences of misbehavior
Tasks
- develop consciousness
- magical thinking (b-c I thought it, it happened)
Typical Age-specific difficulties: Pre-school (2)
- fear of bodily harm (dark, animals, procedure; think broken skin = insides will come out) until 5-6 yrs
- Aggression due to frustration (thwart self-satisfaction), modeling (parent aggressive), and reinforcement (get attention)– usually normal
Age-appropriate activities: Preschool (6)
- Tricycles, wagons, sports equipment
- alphabet or number flash cards AND books
- Electronic games and educational TV for learning
- Paints, crayons
- musical toys
- Imaginative or dramatic play such as dress up clothes, dolls, housekeeping, puppets, Construction sets
Social Development: School age (4)
- self-concept (concious awareness of self and ideals) develops and is influenced by others
- peer pressure (need to conform and belong; may need to bullying)
- clubs (groups w/ rigid rules)
- dyadic relationships w/ same-sex i.e. best friends
Psychosocial Development: School Age
Industry criteria (2)
Inferiority criteria (2)
Industry
- sense of accomplishment (competitions, meaningful work)
- extrinsic motivation (rule follower, like to win, rewards)
Inferiority
- fear ridicule by peers
- unable to excel in areas (all children must learn that they can not master everything)
Age-appropriate activities: School Age (5)
- Teams (Clubs and peer groups; organized sports)
- Hopscotch, jump rope
- Ride bicycles
- Quiet activities (Building models, Crafts, board games)
- Collections (rocks, stamps, cards, coins, stuffed animals)
Bicycle Safety: Preschool-Adolescent (5)
- Wear helmets when riding bike, motorcycle, ATV, skateboards, scooters
- Learn rules of road (Ride with direction of traffic away from parked cars, use hand signals)
- Walk bike if busy area
- Use lights and reflectors, light clothes at night
- Don’t ride double unless equipped
Bodily harm Safety: School age- adolescent (5)
- protective equipment during sports
- locked firearms
- window guards to prevent falls
- teach address, phone, and stranger safety
- no trampoline in under 6 yr olds
Cognitive development: Adolescence
Formal Operations Concepts (5)
- Abstract thinking/ imaginative
- use analytical thinking to make decisions
- Able to think through more than 2 variables concurrently
- Evaluate own thinking and others (Able to understand how actions/factors influence others)
- Idealistic
Psychosocial development: Adolescence
Identities developed (3)
Concepts (1)
Identities
- Personal sense of identity (coherent picture of past, present, future; autonomy from parents)
- Group identity with peer group (best friends, rejection of adult group; very important)
- sexual identity (Increased interest in romantic relationships, may experiment, body image))
Concepts
- View themselves as invincible
Age-appropriate activities: Adolescence
- Non-violent video games and music
- Social Media
- Sports
- pets
- Career training programs
- Reading
- Social events- dances, movies, football games
Mental Health Concerns: Adolescence
4 signs
- Poor school performance
- Lack of interest/ Social isolation
- Sleep or appetite disturbances (should get 9 hrs)
- Expression of suicidal thoughts (suicide 3rd leading cause of death; screen ALL)
Body Surface Area
Equation
Units
Equation: √((ht (cm) x wt (kg))/3600))
Units: m2
Normal Temperature for children
36.7-37.5
Normal Heart Rates for 3mo-2 yrs, 2yrs-10yrs, and 10 yrs+
Resting (awake)
Resting (sleeping)
3mo-2 yrs
Resting (awake): 80-150 beats/min
Resting (sleeping): 70-120 beats/min
2yrs-10 yrs
Resting (awake): 70-110 beats/min
Resting (sleeping): 60-90 beats/min
10 yrs+
- 60-100 beats/min
Normal Respiratory rates:
1-11 mo
2-6 yrs
8-10 yrs
1-11 mo: 30-60 breaths/min
2-6 yrs: 21-25 breaths/min
8-10 yrs: 19-21 breaths/min
Normal blood pressure:
1-2 yrs
5 yrs
10 yrs
14 yrs
What may discrepancy of lower and upper extremity BP indicate?
1-2 yrs: 90/56 mm hg (measured starting at 3 routinely OR for critical care)
5 yrs: 95/56 mm Hg
10 yrs: 102/62 mm Hg
14 yrs: 110/65 mm Hg
Discrepancy: Coarctation of the Aorta
Pediatric Exam
General Tips (7)
- Warm, child-friendly room
- Include time to play and become acquainted
- auscultate heart, abdomen lungs early before child disturbed (infants- toddlers)
- Perform distressing procedures near the end of the exam (ears and mouth; areas of pain; temp and BP)
- offer choices if they exist
- be quick and efficient but do not rush
- record in head to toe but perform in developmentally appropriate sequence
Pediatric Exam: Health history (2)
- able to participate by age 7 yrs
- most of information is obtained from adult present (dont assume person is mom or dad)
Pediatric Exam: Infant Tips (3)
- perform with child on parent’s lap (or hold confidently
- assess mouth while crying
- talk in quiet, unhurried, nonthreatening voice (may need high-pitched voice and smiling)
Pediatric Exam: Toddler tips (6)
- Allow to sit on parent’s lap or stand near parent
- Use play- count fingers, tickle toes, who can i see in here today (ears)
- Introduce equipment slowly (let them play with it first; hide scary equipment)
- Have parent remove outer clothing, leave underwear on until needed to remove
- Explain things concretely and short sentences
- Praise for cooperative behavior and use rewards
Pediatric Exam: Pre-schooler tips (5)
- Prefer parent’s closeness (Can be standing and/or sitting)
- If cooperative (usually like to please), can examine head to toe
- Request self-undressing. Leave underpants.
- Demonstrate and let child examine equipment
- Paper doll technique (demonstrate first on doll then child)
Pediatric Exam: School age and adolescent tips (6)
- Examine head to toe, genitalia last
- Self-undressing, keep on underwear, provide a gown
- Explain exam and findings to the child (include long-term benefits for adolescents)
- Teach about body functions and care (esp sexual development)
- Respect need for privacy/modesty (May or may not want parent present)
- encourage them to share feelings and ask questions
Physical Exam: Infant Reflexes
7 and when they disappear
What does it mean if reflexes persist?
Stepping-0-4 weeks,
Sucking/rooting, palmar grasp, Moro (startle), tonic neck (fencing), 3-4 months
Plantar grasp-0-8 months
Babinski- 0-1 year (fanning of toes)
If they do not disappear, sign of CNS impairment
Physical Exam: fontanels
How should they feel?
When are they bulging (3)?
When are they sunken
Normal: feel soft and flat
Bulging w/ crying, vomiting, increased ICP
sunken w/ dehydration
Physical Exam: Ear
Expected Findings (3)
Unexpected Findings (2)
Procedures (3)
Expected Findings
- cerumen in ear
- newborn blinks to sound
- infant turn to sounds
Unexpected Findings
- foreign bodies in ear
- ear infections (more common than in adults b-c close proximity
Procedure
- pinna down and back if under 3 (up and back if older than 3)
- examine hearing in children with speech delays
- use whisper test up until preschool
Physical Exam: Eyes
Expected finding (3)
Procedures (4)
Expected
- depth perception around 7-9 months (mature around 2-3 yrs)
- binocularity around 6 wks (esp by 4 months)
- visual acuity 20/40 in toddlers
Procedures
- visual screening for 3 and up (non-letter alternative to snellen for young children)
- corneal light reflex test AND cover-unconver test for strabismus
- check for red reflex
- hold head for H test in young children
Physical Exam: Cardiac
Expected Findings (3)
Unexpected Findings (2)
Tips (3)
Expected Findings
- sinus arrhythmia (HR increases w/ inspiration, sleep, waking)
- S2 split on inspiration
- apical pulse at 4th ICS for under 7 yrs, 5th ICS for over 7 yrs
Unexpected Findings
- weak lower pulses (COA)
- murmurs (range from innocent (no problem) to organic (physiological conditions))
Tips
- evaluate while sitting and lying down
- always use apical HR for 60 seconds if < 2 yrs (best while sleep for infants)
- radial pulse okay after 2 yrs
Physical Exam: Respiratory
Expected Findings (5)
Unexpected Findings (2)
Tips (3)
Expected Findings
- obligatory nose breathers (up till 4 months)
- diaphragmatic breathing (children under 6-7 yrs)
- irregular rhythm in infants
- 1:2 AP to lateral ratio by 6 yrs (barrel and 1:1 in infancy)
- Hiccups
Unexpected Findings
- s/s of respiratory distress
- allergic salute in allergy season
Tips
- take RR for 60 seconds
- hold feeds if newborn > 60 breaths/min
- take RR at end of each cry if crying b-c takes deep breath
Physical Exam: Abdomen
Expected Findings (2)
Unexpected Findings
Tips (2)
Expected Findings
- protuberant abdomen (large liver= fast metabolism/drug usage in toddlers)
- umbilical hernia in infants
Unexpected findings
- sunken abdomen may be dehydration or malnutrition
Tips
- ticklish so place your hand over theres at first
- flex knees to relax abdomen
Physical Exam: Musculoskeletal
Expected Findings (2)
Unexpected Findings (2)
Procedures (2)
Expected Findings
- genu varum (bow legged) in infancy till 18 months
- genu valgum (knock kneed) around 2-7 yrs
Unexpected Findings
- scoliosis (screening school age and beyond via leaning forward w/ knees straight)
- hip dysplasia ( seen in infants via ortolani sign and barlow signs)
Procedures
- For leg discrepancy, compare level of malleoli OR child trendelenburg sign (place hands on illiac crest from behind and should be level)
- Romberg test (child close eyes and remains standing straight for 20 sec) for coordination
Physical Exam: Integumentary
Expected Findings (3)
Unexpected Finding (2)
Tips (2)
Expected
- bruising on legs when learning to walk
- cyanotic extremities in newborn for first few hrs
- thin skin in young children (use tape w/ caution)
Unexpected
- bruising on padded areas (abdomen)
- diaper rash
Tips
- turgor on above clavicle for school age
- turgor on abdomen for infants-preschool
Respiratory System Variations for children (3)
- smaller and shorter airway
- short straight eustachian tube
- increased infections from 3-6 m when maternal antibodies leave and waiting for infant antibodies
Signs of Respiratory Distress (8)
- Retractions
- Irregular sounds: wheezes (high pitched), stridor
- Head bopping
- Nasal flaring (unable to breath w/ an occluded nostril)
- Mucus-y poops
- Gargled speech
- excessive crying
- nonproductive cough
Asthma: Pathophysiology (3)
- Inflammatory response -> airway remodeling
- Accumulation of secretions -> hypoxemia
- Bronchoconstriction (Spasm of bronchi and bronchioles) -> respiratory acidosis
Asthma: Clinical Manifestations (7)
- Hacking, paroxysmal, irritative and nonproductive Cough (especially at night or early morning due to bronchial edema)
- Frothy, clear, gelatinous sputum (as secretions increase)
- Coarse and loud breath sounds (sonorous crackles, rhonchi, wheezing)
- Prodromal itching at front of neck or upper back (seen in some children)
- absent air movement and air hunger (no breath sounds, chest tightness)- medical emergency b-c sign of ventilatory failure
- limited speech (unable to say more than 5 words) and anxiety
- barrel chest (if repeated)
Asthma: Management Priorities (6)
- frequent assessment (esp pulse ox, lung sounds, breathing)
- give oxygen (nasal cannula, face mask, blow by)
- Calm environment and reassurance
- encourage deep breathing (via games like blow out candles or big bad wolf)
- give medications (bronchodilators then steroids; use spacer for better coordination)
- suction as needed (mouth then nose)
Asthma: Classifications (4)
- Intermittent <= 2 days a week
- Mild persistent: > 2 days a week, but not daily
- Moderate persistent: daily, night-time symptoms 3-4 times a week
- Severe persistent: several times a day, continual symptoms, night-time symptoms more than once a week less than 5 or nightly greater than 5; Use beta agonist several times a day
Asthma: Diagnostics (4)
- Chest x-ray (may show hyperinflation or infiltrates))
- Pulmonary Function Test (includes spirometry (5 yrs +), bronchoprovocation (direct exposure to antigens), exercise tolerance)
- Allergy Testing (skin, Eosinophilia levels, IgE levels)
- ABG
Peak Flow meters
What is it?
Three levels
- Peak flow meter (used in 5+ to manage asthma by measuring max flow of air forcefully exhaled in 1 second)
Levels
Green– keep doing regular acitivities
Yellow- may need extra treatment
Red- call provider or EMS
Prevention of Asthma exacerbation (7)
- Avoid triggers ( house and outdoor allergens, smoke, temp extremes)
- Adherence to preventive medications (anti-inflammatories and LABA)
- Exercise (best is swimming)
- Hyposensitization/ allergen immunotherapy
- Breathing exercises
- Peak Flow Meters
- use dehumidifiers or air conditioners
Asthma: anti-inflammatories
Important notes for all following:
- Mast cell stabilizer (Cromolyn sodium, necromil) - 1
- Glucocorticoids (Prednisolone, Methylprednisolone)- 3
- Anti-leukotrienes (montelukast sodium) - 1
- Monoclonal antibodies (omalizumab) - 2
Cromolyn sodium
- maintenance for 2+
Glucocorticoids (Prednisolone, Methylprednisolone)
- first line for 5 yr +
- usually inhaled for maintenance; systemic for acute exacerbation
- may cause thrush or stunt growth
Anti-leukotrienes (montelukast sodium)
- for moderate persistent asthma in 12m _
Monoclonal antibodies (omalizumab)
- for moderate to severe persistent in 12 yr +
- black box warning for anaphylaxis so monitor for 2 hrs
Asthma: bronchodilators
SABAs (Albuterol, Terbutaline)- 1
LABAs (Salmeterol)- 1
Anticholinergics (ipratropium, atropine)- 2
SABAs (Albuterol, Terbutaline)
- for acute relief or prevent EIB
LABAs (Salmeterol)
- never monotherapy, use w/ corticosteroid
Anticholinergics (ipratropium, atropine)
- anticholinergic effects (dry mouth, no secretions, blurry vision)
- for acute relief
Nasopharyngitis/ Common Cold
Causative agent
Key s/s (2)
Treatment
- Do’s (4)
- Don’ts (2)
Cause: viral
Key s/s: open mouth breathing (up to 3 yrs), chilling sensations
The Do’s
- supportive care b-c no cure (raise HOB, suctioning, vaporization, acetaminophen)
- reassure family colds are common till age 5
- monitor for complications (fever, dehydration, ear infection)
- rule out strep
The Don’ts
- OTC cough suppressants (dextromethorphan w/ caution in 6 yrs and up)
- Expectorants, antibiotics, antihistamines are not used
Bronchiolitis/RSV
Basic Pathophysiology
Key s/s (3)
Prevention
The Dont’s of treatment (4)
Patho: small airways become obstructed -> emphysema and patchy atelectasis at bronchiolar level
Key s/s:
- rhinorrhea
- apnea (first sign in infants under 1 months besides lethargy and irritability)
- low fever
Prevention-palivizumab (monoclonal antibody) once a month IM (given in NICU)
The Dont’s of treatment
- avoid Routine chest percussion and drainage
- Fluids by mouth may be contraindicated
- Bronchodilators rarely beneficial
- no antibiotics b-c viral
Acute Pharyngitis/ strep throat
Causative Agent
Key S/s (3)
Main risks (2)
Causative Agent: GABS
S/s
- pharyngitis (inflamed tonsils)
- cervical lymphadenopathy
- scarlet fever (erythematous sandpaper-like rash)
Main risks
- rheumatic fever (inflammatory of heart, CNS, joints)– within 18 days
- acute glomerulonephritis– within 10 days
Tonsillectomy
Contraindications (4)
The Do’s of Post-op care (5)
Contraindications: bleeding disorders, cleft palate, acute infection, under 3-4 yrs (b-c hypertrophy of lymphoid tissue possible)
Post-op care
- Pain management-meds (always give PO meds before IV meds run out) and ice collar
- Observe for complications (s/s of hemorrhage)- such as frequent swallowing, tachycardia, pallor, bright red emesis
- position for fluid drainage (prone, side lying)
- expect dark brown emesis (bright red is active bleeding)
- full recovery in 1-2 weeks
Bronchitis
Key S/s
Diagnostic
Treatments (3)
Key S/s: coarse, dry, hacking cough worse at night
Diagnostics: previous URI
Treatments
- symptomatic (rest, analgesics, antipyretics, humidity)
- antibiotics if bacterial
- cough suppressants (allow rest at night but interfere w/ secretion clearance)
Cystic Fibrosis
Basic Pathophysiology
Etiology
Basic pathophysiology: thick, sticky mucus due to exocrine gland dysfunction
Etiology: autonomic recessive (1 in 4 chance each pregnancy if both parents are carriers)
Cystic Fibrosis: Diagnosis (4)
- newborn screen w/ sweat chloride > 60 mEq/L (normal is 40)
- absence of pancreatic enzyme
- stool fat analysis (72 hr)
- family history
Cystic Fibrosis: Airway clearance Therapy (6)
- usually BID
- chest physical therapy (percussion, postural drainage, flutter/handheld percussor)
- Positive expiratory therapy (PEP) - Breathing against resistance to keep airway open and get around mucus so it can be expectorated)
- High-frequency chest compressions (HFCC)–vibration vest assists mucus breakdown and clearance)
- Exercises (stimulate mucus excretion, muscle development, pulmonary vital capacity, and sense of well-being)- encourage sports
- breathing exercises (deep breathing, bubbles)
Cystic Fibrosis: Medication
Things to know
Mucolytics (Dornase alfa) - 2
Antibiotics - 2
Bronchodilators -1
Oxygen -1
Mucolytics (Dornase alfa)
- decreases mucus viscosity
- side effects are laryngitis and minor voice alts
Antibiotics
- long course so need PICC or implanted port
- IV vancomycin, inhaled tobramycin
Bronchodilators
- give before Airway clearance therapy
Oxygen
- w/ caution b-c often have CO2 retention
Cystic Fibrosis: Diet (6)
- high-protein, high-caloric diet
- decreased fat
- increased sodium
- needs replacement of fat soluble vitamins
- may need gastric feedings at night (growth failure despite PN may = deterioration)
- remain upright post-feed to prevent Gerd
Cystic Fibrosis: Effects in Respiratory system
3 common
3 special concerns
- chronic pneumonia (thick sputum)
- emphysema (barrel chest, clubbed fingers)
- recurrent URI due to bronchial obstruction
Severe
- pneumothorax and atelectasis
- hemoptysis (from recurrent infection, emergency if > 250 ml/24 hr)
- nasal polyposis (due to chronic inflammation, may need irrigation or corticosteroids)
Cystic Fibrosis: effects in GI/Endocrine system (7)
- meconium ileus (intestinal obstruction) or constipation – need stool softeners
- malabsorption syndrome in pancreas (leads to steatorrhea (bulky frothy stools) and azotorrhea (foul smelling stools w/ putrefied protein))
- Reduced digestive enzymes
- Cystic-fibrosis Diabetes (common and need insulin)
- Portal hypertension in bile and liver (due to biliary cirrhosis)
- rectal prolapse - simple use lubricated finger to put back
- Chronic GERD - use H2 antagonist and GI motility
Cystic Fibrosis: Effects in
Musculoskeletal (2)
Reproduction (2)
Musculoskeletal
- Failure to Thrive due to malnutrition
- bone health concerns due to pancreatic insufficiency and steroid use – may need growth hormones
Reproduction
- most males are sterile
- mucus blocks cervix in females but pregnancy possible (higher risk for complications)
Croup: Epiglottis
Causative Agent
Key S/s (5)
Main risk
Diagnostic
Causative Agent: bacterial (abrupt onset)
Key S/s:
- Absence of cough
- Drool (painful swallowing)
- Agitation
- Tripod position (sitting upright and leaning forward w/ mouth open, chin out, and tongue protruding)
- stridor
Main risks: severe respiratory distress
Diagnostics: cherry red epiglottis
Croup: Acute Laryngotracheobronchitis
Causative Agent
Key S/s (4)
Main risk
Causative Agent: most common croup, viral
Key S/s
- barky, brassy cough and horseness (worse at night and w/ crying)
- stridor
- prior URI
- Dyspnea (due to narrow airway from inflamed mucosal lining)
Main risks: respiratory acidosis -> respiratory failure
Croup: Acute Spasmodic Laryngitis
Causative Agent
Key S/s (3)
Treatments (2)
Causative Agent: viral w/ allergic component
Key S/s
- recurrent paroxysmal nocturnal attacks of laryngeal obstruction (awakes in middle of night w/ barking cough that subsides the next day)
- hoarseness may remain next day
- no fever
Treatments
- humidity or cool night air
- epinephrine for severe
Croup: Bacterial Tracheitis
Causative Agent
Key S/s (4)
Treatments (4)
Causative Agent: bacterial of trachea
Key S/s
- large, thick secretions
- stridor in every position
- no response to LTB therapy
- no drooling
Treatments
- intubation
- suctioning (endoscopy w/ HCP)
- antibiotics (erythromycins)
- antipyretics
Speaking Child Language
Words to avoid (5)
- Shot, bee sting — say poke
- Deaden
- Take your blood pressure
- Stool
- Test
Procedure management
NPO and fluid restriction tips (6)
- have clear liquids >2 hours
- breast milk >4 hours and infant formula >6 hours before procedure (keep eye out for dehydration)
- serve liquid in small container to give illusion of a lot
- keep mouth moist w/ atomizer or ice chips
- keep close eye on older children who may try to sneak liquids
- do not leave fluids at bedside
Alternative Feeding: Gavage Feeding (5)
- give by gravity
- check placement w/ x-ray, pH, measure mark
- use 5 or 8 french tip
- do in quiet calm environment
- use nonnutritive sucking to improve digestion
Medication Administration: 9 rules
- Do not give a child a choice of the medication.
- Allow choices the child can have some control over
- Do not lie, saying it won’t hurt or taste bad
- Give worst meds last (prednisone = bad taste)
- Give brief explanations
- Tell the child is ok to be scared.
- Always include the child and parent when talking during med administration.
- Be confident and positive when approaching the child (Do not use baby talk, you can just change your intonation)
- The younger the child the shorter time between explanations and administration.
Involve the parent.
Medication Administration: Oral
Tips (8)
- orange tips = oral syringe
- use nipple for infants to suck
- chewables are good for preschoolers
- give capsules w/ small amount of food or liquid
- never mix in bottle b-c may not drink it all or not want to drink if nasty
- place syringe on side of mouth (spraying at back can cause aspiration)
- chase bad tasting w/ water, juice, ice pop (nondairy)
- small puff in face can cause swallow reflex
Medication Administration: IM
What is needle recommended gauge?
What is the needle size (length) AND max amount to administer in the following areas:
- vastus lateralis and ventrogluteal
- Deltoid
Gauge: 22-25
Vastus lateralis and ventrogluteal
Size: 5/8 - 1 inch
Max volume: 0.5 for infant, 2 ml small child
Deltoid
Size: 1/2 - 1 inch
Max volume: 0.5-1 ml
Medication Administration: IV (7)
- assess site q1-2 hrs
- use 22-24 gauge for small veins
- usually by IV pump ( if bolus, 20 ml/kg okay)
- children 5 and up can use PCA pump (family version available too)
- Use superficial hand, wrist, forearm, foot, or ankle veins in small infants
- Avoid foot veins in children learning to walk or walking
- Use scalp veins in infants up to 9 months after other sites have failed
Medication Administration
- Enema (4)
- Intraosseous
Enema
- done if NPO due to vomiting or mental status
- contraindicated in immunosuppressed or thrombocytopenia
- max volumes (120-240 for infant, 240-360 small child)
- No soapsuds
Intraosseous
- done in pediatric resuscitation if IV not possible after 3 attempts or 90 seconds
Vital Signs: Temperature
4 tips
- Axillary preferred in infant to 2 years
- Rectal temps if accuracy needed (age over 1 month)
- 2-5 years axillary or TM
- Can take orally when child can hold under tongue (5+)
Pain assessment
Scales (and appropriate ages) - 5
- NIPS- Neonatal Infant Pain Scale-birth -1 month
- FLACC Pain Scale- 2 month -7 years
Face Legs Arms/Activitiy Crying Consolability
For non-verbal child - Oucher Scale 0-5 scale; have child place faces in order then choose
- Faces Pain Scale- 3 years and older
- Numeric Pain Scale- Children 5 -7 years and older
Pain Assessment
Infants (3)
Toddlers (3)
Infants
- Pre-verbal (physiologic response, crying, difficulty sleeping, feeding, relaxing)
- Facial expression most reliable
- Older infant may push or pull away
Toddlers
- loud cry
- words that indicate pain
- stay very still
Pain Assessment
Preschooler (6)
- verbal report as young as 3 yrs for pain, location, and degree
- Views pain as a punishment for thoughts/behavior
- Regression to earlier behaviors (bed wetting, thumb sucking, crying, kicking)
- Denies pain – fear of pain relieving measures “shots”
- Avoid telling child to be “brave” or good boy or girl after procedure
- Fears body mutilation (Need all their parts; Band-aids are important, magical thinking)
Pain Assessment
School age (3)
Adolescent (2)
School-age
- Describes pain and can quantify intensity (if scale is explained in simple terms)
- Awareness of death
- Bargains or tries to “make a deal” (I’ll let you change my dressing after this tv show)
Adolescent
- understands cause and effect
- quantifies and describes pain
Pain Management: Reducing Needle Stick Pain (8)
- Ice
- Vapocoolant Sprays (may cause some constriction or may not be liked)
- TENS units (stimulate nerves above location)
- EMLA (eutectic mixture of lidocaine) cream- or Lidocaine- apply 60 minutes before poke)
- Shot Blocker or buzzy (yellow thing which blocks some of the nerves or (distracts nerves)
- sedation for infants or young children sometimes
- change needle if pierced rubber stopper
- apply pressure 10 sec before
Pain Management: Nonpharmacological
Infants (2)
Toddlers and preschoolers
School age and adolescents (2)
Infants
- Nonnutritive sucking (pacifier, Sweet ease)
- touch, holding, rocking
Toddlers and preschoolers
- distraction (books, videos, music, bubbles–use child life)
School-age and Adolescents
- guided imagery
- breathing exercises
Informed consent and children
Who can give informed consent?
Who can give assent?
- emancipated minors or parents of children give informed consent
- assent given by children over 7 which says they permit and understand the procedure but this is not legally binding
7 Tips for immunizations and IM injections
- Use calm and neutral words (here I go vs here comes the sting)
- Do not give in Dorsogluteal site (potential for nerve damage and less immunity)
- give multiple immunizations at same time in separate sites or at least 1 inch apart
- Do not manually stimulate injection site
- children do not need to restart series after dose missed, just continue where they left off
- vastus lateralis (preferred) or ventrogluteal (okay for 2m+)
- wake up sleeping children or may fear going back to sleep
Bright Futures Areas to Assess in Well-Child Visits (5)
- Emotional well-being (coping, mood regulation, mental health, sexuality, Suicidal ideation)
- Physical growth and development (physical and dental health, body image, healthy nutrition, physical activity)
- Social and academic competence (relationships with peers and family, school performance, interpersonal relationships)
- Risk reduction (tobacco, alcohol, other drugs, pregnancy, STIs)– important in adolescence b-c risk taking behavior
- Violence and injury prevention (safety belt and helmet use, substance abuse and riding in a vehicle, interpersonal violence, bullying)– encourage safe driving
Respiratory Interventions: Ease Respirations at home (6)
- Moisturized air (useful with hoarseness or laryngeal involvement) for 10-15 minutes
- Steamed vaporizers, kettles, and boiling water are discouraged
- Steam in shower is good method
- Use nasal aspiratory or bulb syringe for young infants before feeding and sleeping
- Saline nose drops (1/2 tsp salt, 1 cup water) useful
- Topical vapor rub for 2 yrs and older ( never give orally or under the nose)
Tonsillitis
Causative Agent
Key S/s (4)
Treatments (3)
Causative Agent: viral or bacterial, often w/ pharyngitis
S/s
- edematous tonsils (difficult breathing, swallowing, hearing (if adenoids))
- snoring and mouth breathing (noctural dyspnea)
- foul mouth odor
- persistent cough
Treatments
- Saline gargles, lozenges, non opioid pain meds
- soft to liquid diet
- If severe and not resolved by other methods, tonsillectomy or adenoidectomy
Acute Pharyngitis/ strep throat
Diagnostics
Treatments (4)
Diagnostics: rapid test to screen for strep and do throat culture if screen negative
Treatments
- Warm saline gargles
- Penicillin or macrolide antibiotic (infectious for 24 post initiation of antibiotic; no longer contagious after 24 hrs so can return to school) - unless viral
- cool drinks and foods (ice cream, ice chips)
- chloraseptic or acetaminophen or ibuprofen, for pain (liquid or chewable)
Tonsillectomy
The Dont’s of Post-op care (5)
The Dont’s Post-op
- Avoid fluids until child alert and can swallow
- Citrus juice can cause discomfort
- Milk, ice cream and pudding not offered until clear tolerated because can cause child to clear throat
- Avoid gargle, coughing, suctioning, straws, nose blowing
- No red products or red dyes in fluids
Infectious Mononucleosis (Mono)
Causative Agent
Key S/s (3)
Main risk
Severe S/s to report (4)
Causative Agent: EBV, viral
Key S/s:
- Sore throat (Exudative pharyngitis w/ petechiae)
- Lymphadenopathy
- Hepatosplenomegaly
Main risks: neurological (meningitis, seizures),
Severe S/s to report to HCP
- severe sore throat (unable to eat or drink)
- severe abdominal pain
- difficulty breathing
- respiratory stridor
Infectious Mononucleosis (Mono)
Diagnostics (3)
Treatments (5)
Diagnostics
- heterophil antibody test (positive up to 6m post exposure in 4 yrs and up)
- mono spot test (earlier diagnosis)
- increased WBC (atypical leukocytes)
Treatments
- symptomatic (mild elixir analgesic, gargles, troches, warm drinks)
- corticosteroids
- avoid strenuous activities (contact sports until splenomegaly resolved)
- contagious (just don’t share hygiene products and drinks)
- viral so no antibiotics
Croup: Epiglottis
Treatments (7)
Prevention
Treatments
- maintain airway (prep for intubation)
- keep calm (in parent’s lap)
- give IV cephalosporins (Ceftriaxone/cefotaxime or vancomycin )
- do not examine throat if suspected (need provider and resuscitation equipment prior to throat exam)
- Humidified oxygen via mask or blow-by to reduce agitation
- Corticosteroids (can reduce edema early)
- Droplet precautions 24 hrs after initiation of antibiotics
Prevention: Hib vaccine
Croup: Acute Laryngotracheobronchitis
Treatments (6)
Treatments
- Cool mist (or cool car ride if no stridor at rest)
- Racemic Epinephrine Tx (short-term relief for moderate or severe croup—rapid onset but short duration)
- Frequent assessment
- Corticosteroids (dexamethasone PO)—standard treatment
- Heliox (helium with oxygen): moderate to severe croup
- Avoid aggravating child b-c can worsen respiratory distress
Bronchiolitis/RSV
The Do’s of treatment (7)
- Contact or droplet Isolation- lives 1 hr on hands
- Ribavirin-antiviral agent- inhalations (VERY DANGEROUS so limited use)
- Heated high-flow nasal cannula (HHFNC)- extra humidity with oxygen administration and CPAP
- CPAP, BiPAP, or intubation required if respiratory acidosis present)
- Suctioning (Nasal aspiration with aspirator to remove secretions; best treatment)
- IV fluids for acute phase
- Nebulized Hypertonic (3%) saline for those hospitalized more than 3 days to help w/ mucociliary clearance
Status Asthmaticus
What is it?
S/s (3)
Treatment (4)
Status Asthmatics: an episode of severe asthma that does not respond to normal treatment.
S/s: profuse sweating, sitting upright and refuses to lie down
Treatment
- same as asthma (cardiorespiratory and pulse oximetry monitoring, humidified oxygen, Inhaled SABA, systemic corticosteroid, anticholinergic)
- IV magnesium sulfate (Muscle relaxant to decrease inflammation and improve pulmonary function)
- Heliox (helium and oxygen)- decreases airway resistance and work of breathing via nonrebreathing face mask
- Ketamine (Dissociative anesthetic causes smooth muscle relaxation)
Cystic Fibrosis: Medication
Things to know:
Pancreatic Enzymes (Pancrease) -2
Nebulized hypertonic saline -2
CFTR -2
Pancreatic Enzymes (Pancrease)
- enteric-coated given at every meal and snack (powder form in applesauce for infants)
- increase dose if fatty stools
Nebulized hypertonic saline
- only for 6 yrs + and severe b-c may cause bronchospasms
- increases mucus clearance and airway hydration
CFTR Modulator (cystic fibrosis transmembrane conductance regulator)– Ivacaftor
- for 2 yrs and up w/ specific mutation
- reduces likelihood of sticky mucus development
Medication Administration
- Optic (4)
- Otic
- Nasal
Optic
- put pressure on lacrimal duct after administration for 1 minute to wash tear duct and prevent medicine from draining into body
- ointment goes inner to outer canthus
- give drops prior to ointment (3 mins apart)
- if eyes clenched, put in nasal corner and it will go in once eyes open
Otic
- warm to room temp to prevent vertigo
Nasal
- hyperextend head to prevent strangling sensation from trickling
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
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)
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
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
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)
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)
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)
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
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)
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
