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NUR331 Exam 2 Flashcards

1
Q

How can we promote infant development?

A

Trust vs Mistrust
- place a child to where they can see their hands
- talk about things in the room
- touch, swaddle, talk to them
- smile, put your face in their field of vision
- try to simulate home routine
- try to assign the same nurse
- keep frightening objects away from their view
- pay attention to light and sound stimulation
- hold them for feedings*
- provide toys

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2
Q

How to prepare infants for procedures?

A
  • keep mom and dad calm
  • sensory and soothing strategies
  • cuddles, hugs
  • safe restraints
  • out of view for procedure
  • security objects from home
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3
Q

Fears for Toddlers

A

fears loss of body control
loss of routine
separation

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4
Q

How do we promote toddler development?

A
  • follow/develop rituals
  • security objects
  • praise
  • provide mobility and outlets for aggression
  • make sure they have access to finger foods
  • allow for exploring
  • offer guided choices
  • talk through all patient care
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5
Q

How to prepare toddlers for procedures

A
  • kiss
  • egocentric
  • include what they will see/smell/feel
  • praise
  • “mommy and daddy will be here waiting”
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6
Q

Fears of Preschoolers

A
  • mutilation
  • abandonment
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7
Q

What causes stress in infants?

A

absence of parent
unfamiliar persons
anxiety their parents face
loss of needs being met (food and sleep)

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8
Q

What to expect from a hospitalized preschooler

A
  • may become overly aggressive or withdrawn
  • may bring an imaginary playmate
  • may refuse to take meds or cooperate
  • like to take ownership of things in the environment
  • have little understanding of time
  • may regress on toilet training
  • enjoy silly humor
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9
Q

How do we promote preschooler development?

A
  • use specific language and look directly at them
  • be aware of distracting noises in room
  • make silly mistakes and let them catch you
  • speak using socially acceptable words
  • make sure they have their transitional object
  • encourage to promote cooperation
  • let them throw and catch objects
  • use routines
  • read out loud
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10
Q

How to prepare a preschooler for a procedure

A
  • simple explanations with diagram or doll
  • play with stethoscope, doll
  • vocalize that it is not for punishment
  • medical play
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11
Q

Fears of school age children

A

loss of control

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12
Q

What to expect of school-age children

A
  • like to take risks (IV pumps)
  • like adults to be involved when making decisions
  • enjoy contact with others their age
  • want alone time
  • want rules
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13
Q

How do we promote school age development?

A
  • encourage continuation of school work
  • give realistic and truthful explanations
  • allow quiet and private time
  • use a lot of language
  • involve them in making things
  • promote collection of things
  • make a game out of normal routine
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14
Q

How do we prepare school age children for procedures?

A
  • use simple medical terminology
  • use diagrams and pictures
  • explain the “why”
  • explain equipment
  • allow the child to play with the equipment
  • allow time for questions
  • suggest ways to develop control
  • allow them to be responsible
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15
Q

What are the fears of an adolescent?

A

altered body image, loss of control, and separation from peers

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16
Q

Things to understand about a hospitalized adolescent

A
  • they may not like becoming dependent and depersonalized
  • they enjoy being personally related to
  • understand psychological pain and physical pain
  • stage - identity vs role confusion
  • may be dating/engaged
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17
Q

How can nurses promote adolescent development?

A
  • teach them at a realistic level
  • involve them with different staff members - discuss concerns about the future
  • ask them how much they would like their parents to be involved
  • have high expectations for appropriate behavior and spell them out
  • help them maintain their identity
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18
Q

How to prepare adolescents for procedures

A
  • explain it to them - they are capable of abstract thought and reasoning
  • understand they will have fears about their appearance
  • they are more concerned about the present time rather than the future
  • allow independence
  • peer relationships are very important
  • suggest ways that they can maintain control
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19
Q

How may parents react to their child becoming hospitalized?

A

initial disbelief, anger, guilt, fear, frustration, depression

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20
Q

How can nurses work effectively with hospitalized children’s parents?

A
  • encourage visitation and staying the night with the patient
  • allow parents to be present during procedures
  • acknowledge their importance
  • provide them info
  • offer support and peer groups
  • provide respite
  • discuss arrangements for the care of other family at home
  • model appropriate parenting
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21
Q

What do children who are vulnerable when hospitalized look like?

A
  • have a difficult temperament
  • have a lack of connection with their parents
  • between 6 months and 4 years typically
  • typically male
  • have multiple stressors
  • rural home
  • passive
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22
Q

What are the stages of separation anxiety?

A

protest, despair, and detachment

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23
Q

Strategies to decrease the effects of separation anxiety

A
  • have a primary nurse
  • maintain a thorough history
  • maintain parental contact
  • teach parents to be honest about where they’re going
  • make their surroundings more familiar
  • soften medical equipement
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24
Q

What will a child look like when returning home from the hospital?

A
  • most will adapt fairly quickly
  • infants-preschoolers may adapt slower
  • children may reject caregiver when going home
  • they may regress in their development (potty training)
  • consider the pain that they will experience
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25
Q

Advice for returning home from the hospital for parents

A
  • don’t plan big trips after they get home
  • focus on reestablishing routines
  • try not to fill up the days with activities
  • encourage the children to tell their own story
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26
Q

What are the respiratory differences between adults and children?

A
  • children have a smaller airway size
  • infants rely on abdominal breathing
  • larynx and glottis are higher in the neck with children
  • children have more distance between structures which allows infections to spread more easily
  • children have eustachian tubes
  • there is pliability of ribs and sternum
  • ribs are more horizontal
  • fewer alveoli
  • higher metabolic rate
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27
Q

How to do a respiratory assessment on a child

A
  • assess LOC
  • assess RR
  • assess effort
  • assess skin and mucous membranes
  • listen to breath sounds
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28
Q

What is the normal RR of infants, children, and adolescents?

A

infants 30-40
children 20-24
adolescents 16-18

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29
Q

What are cardinal signs of respiratory distress in children?

A
  • tachypnea
  • tachycardia
  • change in LOC - restlessness, irritability, anxious**
  • cyanosis
  • increased WOB - grunting, nasal flaring, and retractions
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30
Q

What RR contraindicates feeding a child?

A

> 60

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31
Q

Mild distress- retractions

A

isolated to the intercostals

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32
Q

moderate distress- retractions

A

subcostal, suprasternal, and subclavicular

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33
Q

severe distress- retractions

A

subcostal, suprasternal, supraclavicular, and use of accessory muscles in the neck

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34
Q

other signs of respiratory distress

A
  • adventitious breath sounds
  • absent breath sounds
  • expiratory grunting
  • inspiratory stridor
  • expiratory wheeze
  • cough (note whether forceful or weak)
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35
Q

respiratory diagnostic studies

A
  • ABG
  • pulse ox
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36
Q

Respiratory Goals for Nursing Care

A
  • child will exhibit normal respiratory efforts
  • child will receive adequate rest
  • child will not spread infection to others
  • child will maintain normal hydration and nutrition
  • child lists steps to take if their breathing becomes impaired
  • parents demonstrate correct techniques for performing RT at home
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37
Q

General Respiratory Nursing Measures

A
  • ease respiratory efforts
  • promote rest and comfort
  • prevent the spread of infection
  • promote hydration and nutrition
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38
Q

How to ease respiratory efforts

A
  • positioning
  • warm or cool mist
  • mist tents
  • saline nose drops with bulb suctioning
  • bedrest or quiet activities
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39
Q

How to prevent the spread of infection

A
  • handwashing
  • teaching
  • judicious patient room assignments
  • immunizations
  • abx
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40
Q

How to promote hydration and nutrition

A
  • high cal fluids
  • avoid caffeine
  • allow children to self regulate diet
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41
Q

Specific therapies to improve oxygenation

A
  • coughing and deep breathing
  • suctioning
  • aerosol nebulizer medications
  • percussion and postural drainage
  • chest physiotherapy
  • supplemental oxygen
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42
Q

clinical manifestations of respiratory infections in infants and children

A
  • fever
  • meningismus (h/a, neck stiffness, photophobia)
  • anorexia
  • v/d
  • nasal blockage and discharge
  • respiratory sounds
  • sore throat
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43
Q

etiology of lowered respiratory defenses

A
  • age
  • frequent exposure to organisms
  • concurrent illness
  • malnutrition
  • fatigue
  • drying of mucous membranes
  • anemia
  • body chilling
  • second or third hand smoke
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44
Q

nasopharyngitis

A

“common cold”
etiology - rhinoviruses, adenovirus, influenza, para-influenza virus

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45
Q

CM of nasopharyngitis

A
  • younger child - fever, irritability, restlessness, sneezing, v/d
  • older child - dryness and irritation of nose and throat, sneezing, chilling, muscular aches, cough, edema and vasodilation of mucosa
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46
Q

therapeutic management of nasopharyngitis

A
  • no OTC cough and cold meds
  • antipyretics for high fever and discomfort
  • rest
  • older children - decongestants, cough suppressants, avoid antihistamines, abx, and expectorants
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47
Q

Tonsillitis

A
  • commonly viral, treat symptomatically, no abx necessary
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48
Q

Strep - Pharyngitis

A
  • group A beta-hemolytic streptococci
  • CM - sudden onset, sore throat, headache, fever, vomiting, lymphadenopathy, abdominal pain, beefy red throat
  • risk if untreated for rheumatic fever and acute glomerulonephritis
  • treatment - abx for 10 days
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49
Q

nursing considerations for strep

A
  • encourage people with a sore throat to seek medical attention
  • obtain swabs
  • patient teaching
  • comfort
  • no school
  • highly communicable with saliva (stand to their side when completing a strep test)
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50
Q

tonsillectomy

A
  • indicated only if documented recurrent strep, peritonsillar abscess, or sleep apnea
  • contraindicated - cleft palate, acute infections, uncontrolled systemic disease or blood dycrasias, age less than 4
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51
Q

nursing considerations for tonsillectomy

A
  • observe for s/s of excessive bleeding
  • avoid suctioning if possible, drooling is okay
  • discourage straws, coughing, laughing, or crying
  • clear liquid diet with no milk products
  • watch for stridor or airway compromise
  • comfort with ice collar and cool mist vaporizor
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52
Q

external otitis

A
  • inflammation and infection of the outer ear (auricle or canal)
  • caused by bacteria or dermatitis
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53
Q

CM of external otitis

A
  • disproportionate pain that increases with movement
  • drainage that is serosanguineous or purulent
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54
Q

Types of OM

A
  • acute
  • recurrent
  • OM with effusion (serous, mucoid, purulent)

one type can become another

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55
Q

OM

A

infection of the middle ear associated with fluid or pus

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56
Q

RF of OM

A
  • anatomical structure
  • boys and younger children
  • usual lying-down position of infants
  • exposure of cigarette smoke, many people, bottles in bed, unimmunized, and winter*
  • pacifier use beyond infancy
  • family history of otitis media
  • allergic rhinitis
  • acquired immune deficiences
  • cranofacial anomalies
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57
Q

CM of OM

A
  • ear pain (otalgia)
  • infants get irritable
  • child holds or pulls at ear
  • may roll head from side to side
  • fever up to 104
  • ruptured tympanic membrane
  • can lead to hearing loss if chronic*
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58
Q

therapeutic management of OM

A
  • teach parents to prevent occurrence
  • abx therapy (amoxicillin)
  • antipyrine or benzocaine-otic for ear pain
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59
Q

chronic OM treatment

A

myringotomy with pressure equalization tympanovstomy tubes
- no diving, jumping, or prolonged submersion
- no swimming in lakes or rivers
- avoid pressure postoperatively

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60
Q

croup

A

swelling or obstruction in the region of the larynx
- hoarseness, barky cough
- inspiratory stridor
- varying degrees of respiratory distress

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61
Q

acute laryngotracheobronchitis

A
  • viral croup
  • inflammation of the mucosal lining of the larynx, trachea, and bronchi causing narrowing of the airway
  • infants and children <5 years old
  • slowly progressive - may develop with influenza or bronchiolitis
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62
Q

CM of stage I croup

A

fever, fear, hoarseness, brassy cough, inspiratory stridor when disturbed

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63
Q

CM of stage II croup

A

continuous stridor, lower lip retraction, retraction of soft tissue of the neck, use of accessory muscle of respiration, labored breathing

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64
Q

CM of stage III croup

A

signs of anorexia and CO2 retention, restlessness, anxiety, pallor, sweating, rapid respirations

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65
Q

CM of stage IV croup

A

cyanosis, cessation of breathing

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66
Q

therapeutic management of croup

A

ABC*
- high humidity with cool mist
- humidified oxygen
- adequate oxygen intake
- comforting measures
- avoid cough syrups and cold medicines
- racemic epi (watch for rebound*)
- corticosteroids
- bronchodilators and abx may not work

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67
Q

croup nursing considerations

A
  • observation
  • respiratory assessment
  • measures to conserve energy
  • measures to decrease anxiety (parents at bedside)
  • assess for and prevent dehydration
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68
Q

signs of increasing croup severity

A
  • increased respiratory rate
  • increased agitation, restlessness, anxiety, decreased LOC
  • cyanosis
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69
Q

epiglottitis

A
  • bacterial croup
  • serious life threatening obstructive inflammatory process*
  • usually between 2-5
  • caused by flu or strep
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70
Q

CM epiglottitis

A
  • abrupt onset, starts with sore throat
  • high fever, mouth open, tongue protruding, drooling, agitation
  • looks sick, insists on sitting upright
  • sore red inflamed throat, difficulty swallowing
  • muffled voice, inspiratory stridor, no spontaneous cough
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71
Q

epiglottitis interventions

A
  • maintain airway
  • avoid x ray and transport
  • let parents be with the child
  • prepare for sedation and intubation
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72
Q

bacterial tracheitis

A
  • similar symptoms to epiglotitis
  • fever
  • interventions: maintain the airway (no tongue blades, avoid x ray and transport, let parents be with the child, prepare for sedation and intubation)
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73
Q

bronchiolitis

A
  • acute viral infection resulting in inflammation of the smaller bronchioles, characterized by thick mucous
  • mostly in children under 2
  • caused by adenovirus, parainfluenza virus, and mainly RSV*
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74
Q

pathophysiology of RSV

A
  • epithelial cells swell and protrude into lumen, then lose cilia
  • bronchiolar mucosa swells
  • lumina fills with mucous and exudate
  • walls of bronchi and bronchioles are infiltrated with inflammatory cells
  • peribronchiolar interstitial pneumonitis develops
  • dead luminal epithelial cells are shed into bronchioles
  • small airway obstruction leads to hyperinflation
  • obstructive emphysema
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75
Q

transmission of RSV

A
  • direct contact with respiratory secretions
  • survives for hours on surfaces and half an hour on skin
  • 5-8 day incubation period
  • increased incidence in fall and winter (not in spring)
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76
Q

s/s of RSV

A
  • apnea may be first sign in infancy
  • rhinorrhea
  • pharyngitis
  • coughing/sneezing
  • wheezing, crackles, decreased breath sounds
  • possible eye and ear infection
  • intermittent low grade fever
  • difficulty feeding
  • irritability
  • **may progress to: tachypnea, air hunger, retractions, cyanosis
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77
Q

diagnostic evaluation of RSV

A
  • rapid immunofluorescent antibody-direct fluorescent antibody staining (DFA)
  • enzyme linked immunosorbent assay (ELISA)
  • qualitative reverse transcription (polymerase chain reaction*)
  • viral culture (SNOG**)
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78
Q

therapeutic management for RSV

A
  • primary goal: airway maintenance*
  • symptomatic treatment*
  • meds: antivirals (ribavirin), bronchodilators, corticosteroids (controversial)
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79
Q

NC for RSV

A
  • contact isolation
  • consistent hand-washing*
  • encourage parental participation
  • supportive care
  • measures to keep airway open*
  • saline drops and bulb suction
  • increased humidity
  • adequate fluid intake
  • rest
  • humidified oxygen
  • antipyretics
  • monitor O2
  • monitor hydration, encourage PO intake of clear fluids
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80
Q

RSV prevention

A
  • palvizumab (Synagis)- vaccine for at risk infants and children under 2
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81
Q

pneumonias

A
  • inflammation of the alveoli, may be primary or secondary
  • etiology - viral, mycoplasma, bacterial, aspiration, inhalation, or blood stream
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82
Q

pneumonia CM

A

fever, chest pain, dullness to percussion, non-productive cough, rhonchi or fine rales, decreased breath sounds, respiratory distress

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83
Q

complications of bacterial pneumonia

A

empyema
pyoneumothorax
tension pneumo
PE

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84
Q

nursing care of pneumonia

A
  • humidified O2, bronchodilators
  • may need CPT or postural drainage
  • rest, hydration
  • elevate HOB, allow them to be comfortable
  • observe for signs of respiratory distress
  • monitor pulse ox
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85
Q

pertussis

A

“whooping cough”
- common in unimmunized children between 4-10
- infants less than 6 months will have apnea
- infants older than 6 months will have paroxysmal cough
- older people have persistent cough

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86
Q

therapeutic management of pertussis

A
  • erythromycin
  • less than 6mo will need vent
  • humidified O2
  • maintain hydration
  • watch for and prevent pneumonia
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87
Q

TB

A
  • transmission occurs by micro-droplet inhalation when an infected person coughs or sneezes
  • high risk with heredity, girls have higher mortality, infancy or adolescence, stress states, nutritional deficits, or concurrent infection
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88
Q

will a person always have a positive mantoux after having one?

A

YES

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89
Q

NC for TB

A

isolation
med adherence
adequate nutrition*

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90
Q

apnea of infancy

A
  • can be life threatening
  • happens mainly with infants who were over 37 weeks gestation
  • combination of apnea >20 seconds, cyanosis or pallor, marked change in muscle tone, choking or gagging
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91
Q

apparent life threatening event with apnea of infancy

A
  • half idiopathic, half are symptoms of other disorders
  • risk of SIDS
  • evaluate with cardiopneumogram, HR, RR, O2, and polysymnography
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92
Q

ALTE NC and management

A
  • continuous cardiac and pulmonary monitoring under episode free for 6 months
  • methylxanthine use
  • education of caregivers: CPR, emergency numbers on phones
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93
Q

SIDS

A
  • sudden death of an infant under 1 year that occurs during sleep and remains unexplained after postmortem exam
  • leading cause of infant death
  • RF - 2-4 months, native american, african american, and hispanic, males, lower SES, winter
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94
Q

infant characteristics of SIDS

A
  • race and gender
  • premature or low birth weight
  • multiple births
  • low apgar score
  • CNS disturbances and respiratory disorders
  • later birth order
  • overheating
  • unsafe sleep arrangements
  • bottle-fed
  • maternal age
  • prenatal and postnatal smoking
  • substance abusers
  • poor prenatal care
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95
Q

asthma

A

chronic inflammatory airway disorder that consists of airway obstruction, bronchial irritability, edema of mucous membranes, congestion, and spasms of smooth muscles

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96
Q

patho of asthma

A
  • type 1 hypersensitivity
  • IgE mediated, mast cells release histamine and leukotrienes that result in diffuse obstructive and restrictive airway disease because of inflammation of mucous membranes, accumulation of tenacious secretions from mucous grands and spasms of smooth muscles of bronchi
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97
Q

how to classify asthma

A
  • frequency and severity of symptoms
  • levels of control
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98
Q

RF for asthma

A
  • age, heredity, gender, obesity, ethnicity
  • allergens, infection, tobacco, air pollution, diet
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99
Q

symptoms of asthma

A
  • dyspnea, expiratory wheezing, and cough**
  • diaphoresis
  • hacking and nonproductive cough at onset, becomes rattle and productive
  • prolonged expiratory phase
  • anxious expression, restlessness
  • coarse rhonchi
  • sitting position
  • nasal flaring, cyanosis, intercostal retractions
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100
Q

dx of asthma

A

H&P
lab results
PFT
PEFR

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101
Q

therapeutic management of asthma

A
  • control dust mites, pillows and mattress in impermeable covers, roach control, dust control, remove animals from home, avoid kerosene or wood heat
  • avoid triggers - smoking
  • humidity 35-50%
  • air conditioners
  • CPT
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102
Q

drug therapy for asthma

A
  • controllers: corticosteroids, LAB2AA, mast cell stabilizers, leukotriene inhibitors
  • relievers: SAB2AA, methylxanthines
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103
Q

PEFT directions

A

80-100 is personal best
50-79 is add a med
less than 50 should go to ER

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104
Q

NC for asthma

A
  • high fowlers position
  • O2
  • teach child to use diaphragm to pull in and expel air
  • control panic
  • administer rescue drugs
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105
Q

exercise induced bronchospasm

A
  • self-terminating airway obstruction that develops during or after vigorous activity
  • peaks in 5-10 mins
  • symptoms - cough, SOA, chest pain, tightness, endurance problems
  • pre medicate
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106
Q

CF

A
  • most common lethal inherited disease in caucasians
  • autosomal recessive
  • disrupts normal functions of the exocrine glands related to sodium and chloride transport via the CFTR protein
  • results in impaired fluid secretion and abnormally thick exocrine secretions
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107
Q

pulmonary effects of CF

A

repeated episodes of bronchitis
generalized obstructive emphysema
S/S - wheezy cough, increase dyspnea, thick rattle, productive cough, cyanosis, pneumonia, polyps in nose, clubbed fingers, chronic sinusitis

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108
Q

GI tract effects of CF

A
  • intestinal obstructions of SI
  • degeneration of pancreas causes pancreatic achylia which causes malabsorption syndrome and DM
  • s/s - appetite changes, steatorrhea, azotorrhea, weight loss, tissue wasting, distended abdomen, sallow skin, anemia
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109
Q

hepatic effects of CF

A
  • biliary fibrosis causes biliary cirrhosis and portal HTN
  • s/s - ascites, GI bleeding, jaundice
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110
Q

random effects of CF

A

delayed puberty, infertility
loss of electrolytes, dehydration, hyponatremia, and heat stroke

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111
Q

dx of CF

A

prenatal - DNA analysis
new born screening
pilocarpine electrophoresis
stool for fecal fat

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112
Q

prognosis of CF

A
  • decreased life expectancy
  • maximize health potential (pulmonary hygiene, nutrition, prevention/early and aggressive treatment)
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113
Q

goals of CF therapy*

A
  1. prevent infection
  2. nutrition
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114
Q

medical management of CF

A
  • aggressive airway clearance BID
  • oxygen therapy
  • bronchodilators
  • chloride channel activators and sodium channel blockers
  • abx
  • pancreatic enzymes by mouth
  • high fat diet, fat soluble vitamins
  • NaCl tabs added in hot weather
  • oral iron
  • monitor BS
  • flu shot
  • lung transplant
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115
Q

NC for CF

A
  • respiratory assessment, vigilance on chest PT
  • constant assessment of IV site and admin of abx
  • enzyme replacement
  • exercise
  • high cal food and shakes
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116
Q

types of extracellular fluid

A

interstitial
intravascular
transcellular

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117
Q

developmental differences of children and adults

A
  • increased body surface area to BMI
  • higher metabolic rates
  • higher body water content
  • increased fluid intake and output relative to size
  • larger quantities of ECF
  • immature kidney function
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118
Q

what 3 things does meeting fluid requirements include?

A

maintenance - normal ongoing loss of fluid and electrolytes
deficit - total amount of fluids and electrolytes lost from illness
ongoing losses - loss from third space, diarrhea, blood loss

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119
Q

factors that increase maintenance fluid requirements

A
  • fever over 99
  • tachypnea
  • increased temp of environment
  • burns
  • ongoing diarrhea losses, vomiting, NG, high output, kidney failure
  • DKA, DI
  • shock
  • radiant warmer
  • phototherapy
  • post op bowel surgery
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120
Q

factors that decrease maintenance fluid requirements

A
  • skin: mist tent, incubator, swamp bed
  • lungs: humidified vent
  • renal: oliguria, anuria
  • hypothyroid
  • CHF
  • increased intracranial pressure
  • SIADH
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121
Q

causes of electrolyte imbalances

A

intake is greater than output
excretion failure

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122
Q

s/s of electrolyte imbalance

A

edema, slow bounding pulse, crackles in lungs, lethargy, hepatomegaly, weight gain, seizures, coma

123
Q

NC of electrolyte imbalance

A
  • limit intake
  • diuretics
  • monitor VS
  • monitor neuro status
  • seizure prec.
124
Q

causes of fluid depletion

A

lack of oral intake
abnormal losses

125
Q

types of dehydration

A

isotonic - Na is 135-145
hypertonic - Na is 145+
hypotonic - Na is <135

126
Q

therapeutic management of dehydration

A

correct imbalance
treat underlying cause
oral rehydration therapy
parental fluid therapy

127
Q

3 phases of rehydration

A
  1. expand ECF volume quickly to improve circulatory and renal function
  2. replace electrolytes
  3. introduce oral feedings
128
Q

mild dehydration

A
  • increased thirst, slightly dry mucous membranes
  • given fluids
  • continue breast feeding and formula if tolerated, continue regular diet if receiving solid food
129
Q

moderate dehydration

A
  • loss of skin turgor, dry mucous membranes, sunken eyes and fontanels
  • given fluids
  • continue breast feeding and formula if tolerated, continue regular diet if receiving solid food
130
Q

severe dehydration

A
  • signs of moderate dehydration with one of the following: rapid pulse, cyanosis, rapid breathing, lethargy, or coma
  • given fluids until pulse and LOC return to baseline
  • continue breast feeding and formula if tolerated, continue regular diet if receiving solid food
131
Q

causes of hyponatremia

A
  • fever
  • increased water intake without electrolytes
  • decreased Na intake
  • DKA
  • burns and wounds
  • SIADH
  • malnutrition
  • cystic fibrosis
  • renal disease
  • v/d, NG tube
132
Q

CM of hyponatremia

A
  • neurogenic - behavioral change, irritability, lethargy, h/a, dizziness, apprehension
  • cardiovascular - increased HR, decreased BP, cold and clammy skin
  • muscle cramps
  • nausea
133
Q

causes of hypernatremia (147+)

A
  • water loss or deprivation
  • high Na intake
  • DI
  • diarrhea
  • fever
  • hyperglycemia
  • renal disease
  • increased insensible loss
134
Q

CM of hypernatremia

A
  • increased thirst
  • oliguria
  • agitation
  • flushed skin
  • peripheral and pulmonary edema
  • dry and sticky mucous membranes
  • n/v
  • severe CNS symptoms if 150+ (seizures, hyperirritability)
135
Q

causes of hypokalemia

A
  • stress
  • starvation
  • malabsorption
  • excess fluid loss
  • diuretics
  • IV fluids without K
  • corticosteroids
  • DKA
136
Q

CM of hypokalemia

A
  • muscle cramping and weakness
  • CVS - weak or irregular pulse, tachycardia, bradycardia, cardiac arrhythmias, hypotension
  • GI - ileus, decrease in BMs
  • CNS symptoms - irritability, fatigue, paralysis, weakness
137
Q

causes of hyperkalemia

A
  • increased intake of K
  • decrease urine excretion
  • kidney failure
  • metabolic acidosis
  • hyperglycemia
  • PSD
  • dehydration
  • rapid IVF
  • burns
138
Q

CM of hyperkalemia

A
  • irritability, anxiety
  • twitching
  • hyperreflexia
  • weakness
  • flaccid paralysis
  • nausea
  • diarrhea
  • bradycardia
  • cardiac arrest
  • apnea, respiratory arrest
139
Q

causes of hypocalcemia

A
  • inadequate calcium intake
  • vitamin D deficiency
  • renal insufficiency
  • calcium loss
  • alkalosis
  • hypoparathyroidism
140
Q

CM of hypocalcemia

A
  • nervous system, numbness and tingling in fingers and toes, nose, ears, and circumoral area
  • hyperactive reflexes
  • muscle cramps and tetany
  • laryngospasm
  • poor feeding in neonate
  • trousseau’s and chvostek’s
  • hypotension and cardiac arrest
141
Q

causes of hypercalcemia

A
  • milk alkali syndrome
  • excessive IV or oral calcium admin
  • acidosis
  • prolonged immobilization
  • hypoproteinemia
  • renal disease
  • hyperparathyroidism
  • hyperthyroidism
142
Q

CM of hypercalcemia

A
  • lethargy, weakness,
  • anorexia, thirst
  • itching
  • behavioral changes
  • stupor, confusion
  • n/v/c
  • bradycardia, cardiac arrest
143
Q

hypotonic fluids

A
  • less solutes than intracellular fluid
  • .45NS, 2.5D5W, .33NS
  • fluid shifts INTO the cells
  • used for cellular hydration
  • watch for low BP
  • contraindicated for low BP, increased ICP, stroke, neuro pt, liver pt, trauma, surgery, burns
144
Q

isotonic fluids

A
  • same tonicity as intracellular fluids
  • NS, LR, D5W
  • no fluid shifts
  • used for fluid and electrolyte replacement
  • monitor for FVE, edema, and diluted labs
  • contraindicated in FVE
145
Q

hypertonic fluids

A
  • more solutes than intracellular fluid
  • D5 1/5, D5NS, D5LR
  • fluid shifts OUT of the cells
  • used for hypovolemia, increased NaCl, extravasations, cellular dehydration, hyperglycemia
  • contraindicated in renal and cardiac pts, dehydrated patients
146
Q

What size needle is preferred for IV infusions in peds?

A

22-24g

147
Q

What gauge of needle is used for small scalp veins?

A

23-25g

148
Q

What is normal urine output in children?

A

1-2mL/kg/hr

149
Q

When weighing a diaper, what is the g to mL ratio?

A

1:1

150
Q

What are some indications for strict I/O measurement?

A
  • receiving IV therapy
  • after major surgery
  • with severe burns or thermal injuries
  • with CHF
  • dehydration
  • DM
  • oliguria
  • diuretic therapy
  • corticosteroid therapy
  • respiratory distress
151
Q

meconium

A

green/brown sticky stool that occurs after birth (not having this in the first day or two is a red flag)

152
Q

What are the differences in GI in adults and kids?

A
  • immature digestion at birth (don’t have enzymes to digest carbs)
  • swallowing is an automatic reflex until 6 weeks
  • by 6 months a child can control their swallowing
  • stomach is round until 2 and elongates at 7
  • stomach capacity is small at birth and rapidly increases
  • stomach acid is not fully developed until 6 months
  • LES is more relaxed in kids (why they spit up a lot)
  • stomach pain can be psychosocial
153
Q

growth of an infant’s stomach

A

day of birth - size of marble
day 3 - ping pong ball
day 10 - large egg
adult - softball

154
Q

failure to thrive

A

inadequate growth resulting from inability to obtain or use calories required for growth
weight below the fifth percentile or persistent deviation from an established growth curve

155
Q

failure to thrive classifications

A

organic FTT - physical cause, underlying condition
non-organic FTT - likely a psychosocial factor, poverty and addicted parents
idiopathic FTT - idiopathic

156
Q

clinical features of FTT

A
  • height and weight below fifth percentile
  • persistent deviation from established growth pattern
157
Q

contributing factors to non-organic FTT

A

caregiver inability to perceive needs
poverty
health beliefs
inadequate nutritional knowledge
family stress or crisis
feeding resistance
insufficient breast milk

158
Q

therapeutic management of non-organic FTT

A

catch up growth
multidisciplinary growth (dietary, speech)
correct nutritional deficiencies
treat underlying cause
educate parents or primary caregivers

159
Q

feeding guidelines for non-organic FTT

A
  • consistency of staff
  • quiet and non-stimulating environment
  • maintain calm
  • give child directions for eating
  • be persistent
  • face to face posture
  • introduce new foods slowly
  • follow child’s rhythm of feeding
  • follow a structured routine
160
Q

nursing interventions for NFTT

A
  • accurate IO
  • DW
  • model proper infant care
  • supply the parent with emotional support without fostering dependency*
  • promote the parent’s self-respect and confidence
161
Q

cleft lip/cleft palate

A
  • involves abnormal openings in the lip and or palate
  • unilateral or bilateral
  • etiology - multifactoral inheritance, teratogens, maternal smoking
162
Q

CM of cleft lip/palate

A
  • difficulty feeding
  • mouth breathing, which results in more air swallowed causing distended abdomen and pressure on diaphragm
  • increased risk of infection (aspiration pneumonia)
163
Q

therapeutic management of cleft lip/palate

A

cleft lip - z plasty in first weeks of life
cleft palate - obturators, closure between 12-18 months

164
Q

pre-op NC for cleft lip/palate

A

promote bonding - encourage expression of grief and fears, emphasize the positive, express optimism
breast feeding is more difficult
feeding - upright position, special nipples, simulate suck reflex, rest, burp frequently

165
Q

post-op cleft lip/palate NC

A
  • protect airway
  • if palate repair, can place on belly
  • monitor for hypothermia
  • prevent infection
  • protect suture line - elbow restraints
  • pain management
  • avoid objects in mouth, suction with caution**
166
Q

long term consequences of cleft lip/palate surgery

A
  • altered speech
  • altered dentition
  • hearing problems
167
Q

discharge teaching after cleft lip/palate surgery

A
  • good oral care
  • watch their ears
  • promote speech development
168
Q

esophageal atresia (EA) and tracheoesophageal fistula (TEF)

A
  • failure of esophagus to develop as a continuous passage and or failure of the trachea and esophagus to separate
169
Q

CM of EA and TEF

A

frothy saliva in mouth and nose
choking and coughing
feedings return through the nose and mouth
may become cyanotic and apnic

170
Q

what are the 3 c’s of TEF?

A

choking coughing cyanosis

171
Q

diagnosis of EA and TEF

A
  • passage of radiopaque catheter until obstruction is encountered
  • NC for preop- early detection, maintenance of airway, prevention of pneumonia, gastric of blind pouch decompression, abx, do not feed if suspected
172
Q

post op NC of EA and TEF surgery

A
  • careful suctioning
  • upright position
  • pacifier for non-nutritive suctioning
  • NG to low wall suction
  • high humidity environment
  • prevent pneumonia
  • chest tube care
  • maintain nutrition
  • provide comfort and physical contact
  • discharge teaching - s/s of resp distress, tracheomalacia, GERD, and constriction of the esophagus
173
Q

tracheomalacia

A

loose trachea that makes sounds when they are fed

174
Q

NC for anorectal malformations

A
  • preop - GI decompression, IV fluids
  • postop - scrupulous perineal care, supine with legs flexed, colostomy care, nutrition
175
Q

omphalocele

A

herniation of the abdominal contents through the umbilical ring, intact perineal sack

176
Q

gastroschisis

A

herniation of the abdominal contents right of the umbilical ring, no peritoneal sack

177
Q

therapeutic management of abdominal wall defects

A
  • loosely cover with saline soaked pads and plastic drape
  • IV fluids
  • abx
  • surgical correction
  • NC - sterile technique, careful handling, monitor for ileus
178
Q

gastroenteritis

A
  • second leading cause of death worldwide
  • commonly contributes to diarrhea (stool weight 200g+ per day, 3 or more loose or watery stools per day)
  • alteration in normal bowel movement characterized by increased frequency and decreased consistency
  • less than 14 days duration
179
Q

etiology of gastroenteritis

A

viral - mainly in developed countries
bacteria - responsible for most cases of severe diarrhea
protozoan - less than 10

180
Q

viral gastroenteritis

A
  • rotavirus and norovirus are most common
  • s/s - low grade fever, nausea, vomiting, abd cramps, watery diarrhea
  • viral shedding for weeks after symptoms resolve
181
Q

bacterial diarrhea

A
  • all age groups
  • fecal oral transmission
  • s/s - bloody diarrhea, severe cramping, and malaise
182
Q

treatment of diarrhea

A
  • oral rehydration solution - infalyte, pedialyte, naturalyte, or rehydralyte
  • avoid fruit juices, colas, sports drinks
  • normal diet with rehydration for mild to moderate
  • IV for moderate to severe
183
Q

nursing management of diarrhea

A
  • restore f/e balance
  • prevent the spread of infection
  • prevent skin breakdown
  • provide adequate nutritional intake
  • reduce fear and anxiety
  • infection control
  • provide health education for prevention and home management
184
Q

constipation etiology and management

A
  • structural disorders, hypercalcemia, lead poisoning, spinal cord lesions, mainly functional*
  • management - diet (applesauce, juices, prunes), stool softeners
185
Q

encopresis

A
  • chronic constipation with soiling, stool around impaction
  • etiology - psychological trauma, voluntary withholding
  • management - purge the bowel, stool softeners, bowel retraining
  • NC - teaching, support compliance with long term therapy, empower the child, positive reinforcement
186
Q

Hirschsprung disease

A
  • congenital anomaly
  • patho - absence of autonomic parasympathetic ganglion cells in one or more segments of the colon, causes enlargement of the bowel proximal to defect, results in mechanical obstruction from inadequate motility of part of the intestine
  • most dangerous complication is enterocolitis, bloody diarrhea, fever, lethargy
187
Q

CM of hirschsprung disease

A
  • newborn - failure to pass meconium within 48 hours, food refusal, bilious vomiting, abdominal distention
  • infancy - poor weight gain, constipation, abdominal distention, episodes of diarrhea and vomiting
  • childhood - constipation, ribbonlike foul smelling stools, palpable fecal mass, abdominal distention, poor appetite and growth
188
Q

therapeutic management of hirschsprung disease

A
  • dx - barium enema, rectal biopsy, anorectal manometry
  • treatment is based on relieving chronic constipation
  • surgery: temporary ostomy, then pull through
  • prognosis - good, may have an anal stricture and incontinence postop
189
Q

preop for hirschsprung disease

A
  • note first BM on all babies
  • measure abdominal girth daily
  • bowel prep
  • monitor hydration, f/e status
  • teach enema techniques: avoid tap water, 1 tsp salt and 1 pint water
190
Q

postop for hirschsprung disease

A
  • NG to suction
  • I/O to include NG losses and ostomy drainage
  • hydration and f/e balance
  • abdominal assessment
  • ostomy care
191
Q

GERD

A

passive transfer of gastric contents into the esophagus and inappropriate relaxations of the LES
causes CNS problems, developmentally exaggerated enteric reflex or abdominal pressure

192
Q

RF for GERD

A

prematurity, bronchopulmonary dysplasia, esophageal scar tissue, neurogenic disorders, scoliosis, asthma, cystic fibrosis, some meds

193
Q

S/S of GERD in infants

A

spitting up a lot, may be foreceful, intermittent vomiting, hematemesis and melena, irritability, classic back arching, ALTE or apnea, persistent aspiration, pneumonia

194
Q

S/S of GERD in children

A

heartburn, anemia, persistent aspiration pneumonia, chronic cough, difficulty swallowing, abdominal pain

195
Q

therapeutic management of GERD

A

diagnosis - UGI, 24 hour pH probe, endoscopy, labs
meds - antacids or histamine receptor antagonists, PPI, prokinetic meds

196
Q

surgical procedure for GERD

A

nissen fundoplication

197
Q

NC for GERD

A
  • HOB 30, wedge under mattress, harness
  • small frequent feedings with thickened formula
  • avoid fatty foods, chocolate, tomato products, carbonated liquids
  • educate patients
  • burp frequently
198
Q

hypertrophic pyloric stenosis

A
  • circular muscle of the pylorus becomes thickened causing obstruction of the gastric outlet
  • etiology - unknown, genetic component
  • males 5x>females
  • develops in the first few weeks of life, edema and inflammation increases the obstruction
199
Q

hypertrophic pyloric stenosis CM

A
  • projectile vomiting without bile
  • hunger and irritability progressing to lethargy
  • dehydration and weight loss
  • visible gastric peristalsis
  • olive shaped mass
  • commonly FTT
200
Q

hypertrophic pyloric stenosis therapeutic management

A

dx - H&P, abdominal x-rays, ultrasound, labs show metabolic alkalosis, hyponatremia, hypokalemia, pyloromyotomy

201
Q

pyloromyotomy

A

correct dehydration and acid base balance prior to surgery
therapeutic management of hypertrophic pyloric stenosis

202
Q

NC of hypertrophic pyloric stenosis

A
  • observation for clinical features
  • regulation of fluid therapy
  • preop - NPO, strict IO, monitor IV fluids, NG
  • postop- pain control, titrate PO feedings
203
Q

intussusception

A
  • invagination or telescoping of one portion of the intestine into another
  • most common in first year
  • 2x more common in males
  • 90% idiopathic
204
Q

complications of intussesception

A

obstruction, inflammation, edema, ischemia, perforation, peritonitis, shock

205
Q

CM of intussesception

A
  • severe paroxysmal abnominal pain
  • screaming and drawing knees up to chest
  • vomiting bile or fecal stained
  • palpable sausage shaped mass RUQ
  • current jelly like stool
  • abdomen becomes tender and distended
206
Q

therapeutic management of intussusception

A
  • dx - H&P, flat plate for free air followed by barium enema
  • non-surgical hydrostatic reduction
  • surgical reduction and resection
207
Q

NC for intussusception

A
  • recognize symptoms and refer for treatment
  • NG for decompression
  • monitor for shock
  • administer abx
  • routine post op care
  • family support
208
Q

celiac disease

A
  • chronic inflammation of SI mucosa which may result in varying degrees of atrophy to intestinal villi, malabsorption and a variety of CM
  • triggered by an inability to digest gluten
  • results in accumulation of a toxic substance that damages the mucosal surface and interferes with the absorption of nutrients
209
Q

CM of celiac

A
  • no symptoms for at least 6 months
  • major symptoms appear between 1-5 years
  • progressive malnutrition, anorexia, muscle wasting, abdominal pain, distention
  • secondary deficiency - anemia, rickets
  • watery pale foul smelling stool
  • vomit, constipation
  • celiac crisis - severe dehydration
210
Q

therapeutic management of celiac

A

dx - jejunal biopsy, abnormally elevated levels of endomysial and anti tissue transglutaminase antibodies
- eliminate wheat, rye, barley, oats
- diet high in cal and protein, low fat
- supplemental vitamins and iron
- increased risk of malignant lymphoma of SI

211
Q

NC celiac

A

promote compliance with dietary restrictions
teach parents to read food labels
stress long-term complications

212
Q

short bowel syndrome

A
  • malabsorptive disorder that occurs as a result of decreased mucosal surface area
  • etiology - congenital anomalies, ischemia, trauma, long segment resection
  • decreased intestinal surface area for absorption of fluid, electrolytes, and nutrients
  • increased and disorganized transit time for intestinal contents
213
Q

therapeutic management of SBS

A

preserve as much bowel as possible
maintain optimum nutrition
stimulate intestinal adaptation
minimize complications

214
Q

complications of SBS and TPN admin

A
  • CVC infections
  • metabolic complications - electrolyte disturbances, hyperglycemia, hypoglycemia, hyperlipidemia, cholestasis, liver dysfunction
  • bacterial overgrowth
  • gastric acid hypersecretion
215
Q

NC of SBS

A
  • enteral feedings, non-nutritive sucking, check placement, daily stools for occult blood
  • teach home care
  • skin care - chronic diarrhea
  • promote development
216
Q

acute appendicitis

A
  • inflammation of the vermiform appendix
  • uncommon before age 2-years, associated with increased complications and mortality
  • rapidly progresses to perforation and peritonitis
  • etiology - obstruction of the lumen of the appendix, hardened fecal material, foreign bodies, microorganisms, parasites
217
Q

CM of acute appendicitis

A
  • colicky abdominal pain and tenderness RLQ
  • guarding of the abdomen
  • rebound tenderness*
  • n/v, anorexia
  • low grade fever, 102+ means perforation
  • sudden relief of pain and other signs of peritonitis
218
Q

therapeutic management of acute appendicitis

A
  • diagnosis, h&p, CBC, abdominal ultrasound
  • appendectomy*
  • preop fluids and antibiotics
  • peritonitis - fluids, antibiotics, NG tube, delayed closure to prevent abscess formation
219
Q

NC for acute appendicitis

A
  • assessment
  • avoid enemas and heating pads
  • prep for surgery, psychological and physical
  • post op care
  • not ruptured - not a big deal
220
Q

meckel diverticulum

A
  • fibrous connecting the small intestine to the umbilicus
  • most common congenital malformation of the GI tract
  • complications - bleeding from peptic ulceration or perforation, obstruction, inflammation
221
Q

CM of meckel diverticulum

A
  • painless rectal bleeding
  • abdominal pain
  • s/s of obstruction
  • hematochezia
  • intussusception
222
Q

therapeutic management of meckel diverticulum

A

dx - h&p, radionuclide imaging
surgical removal, correct shock or infection first
prognosis - full recovery if treated early, small mortality rate if untreated

223
Q

NC for mekel diverticulum

A
  • psychosocial support
  • bleeding - monitor for shock, bed rest, record blood loss in stools
  • post op - IV fluids, NG
224
Q

bacterial (infective) endocarditis

A
  • an inflammatory process resulting from infection of the valves and inner lining of the heart
  • increased susceptibility with CHD or acquired heart disease
  • increased risk following dental procedures, surgery, and intracardiac lines
  • most commonly from strep
225
Q

patho of bacterial IE

A
  • organisms enter bloodstream from an area of localized infection and grow on the endocardium
  • vegetations, fibrin deposits, and platelet thrombi form
  • lesions may invade adjacent tissues or break off and embolize elsewhere
226
Q

clinical manifestations of bacterial IE

A
  • low grade intermittent fever
  • anorexia
  • malaise
  • weight loss
  • joint pain
  • positive blood culture
  • new heart murmur or a change in an existing murmur
  • petechiae of mucous membranes
  • janeway spots
  • osler nodes
  • splinter hemorrhages under nails
227
Q

therapeutic management of bacterial IE

A
  • IV abx for up to 2-8 weeks
  • surgical removal of significant emboli and or valve replacement
  • prevention - prophylactic abx 1 hr before risky procedures
228
Q

NC for bacterial IE

A
  • teach prophylactic abx therapy
  • teach family to give IV abx at home
  • symptomatic relief
  • monitor for emboli
229
Q

rheumatic fever

A
  • a systemic inflammatory disease that follows a group A beta hemolytic strep infection
  • aschoff bodies - inflammatory hemorrhagic bullous lesions that are formed and cause swelling, fragmentation, and alterations in connective tissue
  • may develop into rheumatic heart disease, causing damage to the mitral valve
  • most often in school age children
  • antecedent upper respiratory infection 2-6 weeks prior to symptom appearance
  • more frequent in males, late winter or early spring
  • diagnosis based on modifications of the jones criteria (one major and one minor)
230
Q

clinical manifestations of RF

A
  • major - polyarthritis, carditis, chorea, erythema marginatum, subcutaneous nodules
  • minor - arthralgia, low grade fever, elevated ASO titer, antistreptolysin, abdominal pain
231
Q

therapeutic management of RF

A
  • eradication of beta hemolytic streptococci
  • prevent cardiac damage and relieve symptoms
  • aspirin therapy, steroids, bedrest
  • prevent recurrence and endocarditis
232
Q

NC of RF

A
  • prevent the disease
  • encourage compliance with drug regimens especially prophylactic antibiotics
  • facilitate recovery, rest, adequate nutrition, pain management
  • provide emotional support
233
Q

kawasaki disease

A
  • acute systemic vasculitis of unknown etiology
  • thought to have an infectious component
  • pre-pubertal children usually boys under 2 years old
  • more frequent in winter and spring
  • usually self-limited and resolves without cardiac treatment, 20% develop serious cardiac sequelae
234
Q

CM of KD - acute phase

A
  • fever
  • pruritic polymorphic rash
  • cervical lymphadenopathy
  • dry, red, cracked lips
  • strawberry tongue
  • bilateral conjunctivitis, inflammation without exudate
  • erythema and swelling of palms and soles
235
Q

CM of KD - subacute phase

A
  • begins with resolution of fever and lasts until all clinical signs have disappeared
  • vasculitis
  • desquamation of toes, feet, fingers, and palms
  • arthritis
  • thrombocytosis
236
Q

CM of KD - convalescent or recovery phase

A
  • symptom free
  • this phase is complete when all blood valves have returned to normal
  • this is the most dangerous phase because they are not monitored, can lead to MI and emboli**
237
Q

s/s of MI in children

A
  • abdominal pain
  • vomiting
  • restlessness
  • inconsolable crying
  • pallor
  • shock
238
Q

therapeutic management of KD

A
  • salicylates for anti-inflammatory and anti-platelet effects (high dose ASA for 72 hours, then low dose ASA)
  • high dose IVIG - has to be given within 10 days of fever starting
239
Q

nursing considerations for KD

A
  • monitor cardiac status carefully
  • watch for signs of MI
  • safely administer IVIG - blood product with normal precautions
  • symptomatic relief - skin discomfort, mouth care, clear liquids and soft stools, irritability
  • discharge teaching - accurate information regarding progression, immunizations, possibility of MI, take aspirin, no varicella vaccine with ASA
240
Q

hypertension in children

A
  • consistent elevation of blood pressure beyond the upper limits of normal
  • based on age, gender, and height
  • major categories: essential or primary (no identifiable cause), secondary (due to identifiable cause) which comes in mild, significant, or severe
241
Q

etiology of HTN in children

A
  • primary: unknown (rare)
  • secondary: renal disease, coarction of the aorta (HTN in upper extremities), oral contraception, steroids, obesity, adrenal disorders
242
Q

CM of HTN in children

A
  • high BP
  • frequent headaches
  • dizziness
  • vision changes
243
Q

therapeutic management of HTN in children

A

identify and treat underlying cause
monitor if mild
combination of pharm and non-pharm therapy

244
Q

NC for HTN in children

A
  • detection - calm the child and use a proper fitting cuff
  • teach - how to monitor child’s BP, diet and exercise, precautions with antiHTN (for orthostatic hypotension), avoid alcohol, stay on prescribed diet, no oral contraceptives
245
Q

HL in children

A
  • pre-symptomatic phase of atherosclerosis
  • selective screening for those with a family history or are overweight
  • total cholesterol <170 is considered acceptable
  • fat intake is never limited between birth and 2
246
Q

therapeutic management of HL in children

A
  • dietary, step diet in moderation
  • pharmacologic: cholesyramine or colestipol
  • screen, educate, and support
247
Q

dysrhythmias in children

A
  • diagnose - 24 hr holter monitor, EKG, transesophageal recording
  • bradydysrhythmias - sinus brady, AV block
  • tachydysrhythmias - sinus tach, SVT
248
Q

SVT

A
  • rapid and regular heart rate (200-300bpm)
  • treat with vagal maneuvers (do not try at home*)
  • adenosine impairs AV conduction, rapid IV push
  • synchronized cardioversion or esophageal overdrive pacing
  • radio-frequency ablation, digitalis
  • educate - avoid decongestants, digi precautions
249
Q

sinus arrhythmias

A
  • regular irregularity
  • normal in school age child
  • have the child hold their breath and it should regulate
250
Q

cardiomyopathy

A
  • myocardial abnormalities which impair the cardiac muscle’s ability to contract
  • types: dilated, hypertrophic, and restrictive
251
Q

dilated cardiomyopathy

A

ventricular dilation with greatly decreased contractility leading to CHF

252
Q

hypertrophic cardiomyopathy

A

increase in heart muscle mass without an increase in cavity size, usually the LV

253
Q

restrictive cardiomyopathy

A

restriction to ventricular filling caused by endocardial or myocardial disease or both (CHF)

254
Q

etiology of cardiomyopathy

A
  • 5% of cardiac deaths in children
  • caused by genetics, infection, deficiency states, metabolic abnormalities, and collagen vascular diseases
  • most cases are idiopathic
255
Q

CM of cardiomyopathy

A

CHF, dysrhythmias, syncope, sudden death

256
Q

therapeutic management of cardiomyopathy

A

digoxin, diuretics, beta blockers, CCB, anticoags
will ultimately need a transplant

257
Q

NC for cardiomyopathy

A
  • the hardest thing for active children is adjusting to failing heath and the need for restricted activity
  • include the child in discussions and decisions
  • teaching - psychological preparation for transplant and post op care
258
Q

how to assess cardiac function in children

A
  • history - parental concerns, mother’s heath and pregnancy
  • inspection - nutritional state (know weight), color, chest deformities, unusual pulsations, respiratory excursion, digital clubbing (late sign)
  • palpate and percuss - chest, abdomen, peripheral pulses
  • auscultate - heart rate and rhythm, blood pressure, character of heart sounds
  • chest xray, EKG, CBC, echo, ABGs, heart cath
259
Q

how is a heart cath done in kids?

A

right side is more common because it is safer and there are structural defects may allow access to the left side of the heart

260
Q

pre procedure care for heart cath

A
  • nursing assessment
  • NPO for 4-6 hours, IV fluids needed in young children
  • developmentally appropriate psych prep
  • educate that they will have to be flat
261
Q

post heart cath care

A
  • observe for complications- color and LOC, vital signs and respiratory status, distal extremities (pulses distal to the site can be weaker the first few hours), dressing for bleeding, fluid intake (encourage fluid to flush out dye), hypoglycemia
  • pressure dressing for 24 hours
  • no tub baths for 48 hours
  • rest at night and then resume normal activities
  • tech sings and symptoms of infection
262
Q

cardiac developmental considerations

A
  • ventricles are equal in size at birth
  • less compliance - during infancy the heart is less developed and less organized
  • normal O2 is 95-100
  • infants and small children have thin chest walls with little subq fat and muscle
263
Q

How does fetal circulation differ from adult circulation?

A
  • liver and lungs are bypassed via shunts
  • oxygenation and filtration of impurities are conducted by the mother
  • fetal circulation ensures that the most vital organs and tissues receive the max concentration of blood
264
Q

ductus arteriosus

A

bypass the lungs

265
Q

foramen ovale

A

bypass the lungs

266
Q

ductus venosus

A

bypass the liver

267
Q

fetal shunts

A

all close at birth or shortly after because of
- decreased maternal hormone prostaglandin E
- increased O2 sat
- pressure changes within the heart

268
Q

general clinical findings for cardiac defects

A
  • dyspnea
  • feeding difficulty and FTT
  • stridor and choking spells
  • HR over 200, RR about 60
  • recurrent respiratory tract infections
  • in the older child, poor physical development, delayed milestones, and decreased exercise tolerance
  • cyanosis and clubbing of fingers and toes
  • squatting or knee-chest position
  • heart murmurs
  • excessive perspiration
  • signs of HF
269
Q

acyanotic defects

A
  • atrial septal defect
  • ventricular septal defect
  • patent ductus arteriosis
270
Q

cyanotic defects

A
  • tetralogy of fallot
  • tricuspid atresia
  • transposition of the great vessels
  • hypoplastic
  • trunctus arteriosis
271
Q

what are the two principal clinical consequences that can occur from congenital heart defects?

A
  • CHF - caused by defects that result in left to right shunting of blood
  • hypoxemia - caused by defects that result in decreased pulmonary blood flow
272
Q

clinical consequences that occur with increased pulmonary blood flow

A
  • the systemic pressure is greater than the pulmonary pressure, so left to right shunting occurs*
  • increased blood volume on the right side of the heart increases pulmonary blood flow at the expense of systemic blood flow
  • clinically - s/s of CHF (defects that result in left to right shunting of blood cause symptoms of HF)
273
Q

CHF

A

the inability of heart to pump enough to meet the heart’s demands

274
Q

CHF can be caused by

A
  • FVE
  • pressure overload
  • decreased contractility
  • high cardiac output demands
275
Q

in children, CHF occurs more frequently with

A

congenital heart defects in which structural abnormalities result in a volume load or pressure load on the ventricles

276
Q

CM of CHF

A
  • pulmonary venous congestion - tachypnea, wheezing, crackles, retractions, cough, dyspnea on exertion, grunting, nasal flaring, cyanosis, feeding difficulties, irritability, fatigue with play
  • systemic venous congestion - hepatomegaly, ascites, edema, weight gain, NVD
  • impaired myocardial function - tachycardia, weak peripheral pulses, hypotension, gallop, cooler extremities, oliguria, fatigue, restlessness, enlarged heart, sweating
  • high metabolic rate - FTT, slow weight gain, perspiration
277
Q

therapeutic management of CHF

A
  • improve cardiac function
  • remove an accumulated fluid and sodium
  • decrease cardiac demands
  • improve tissue oxygenation and decrease oxygen consumption
  • furosemide, ACE inhibitors, digitalis
278
Q

rules for digitalis admin

A
  • regular intervals
  • 1 hour before or 2 hours after eating
  • check apical heart rate for 1 minute before giving
  • do not mix with food or fluid
  • give behind teeth or brush teeth after administering
  • missed dose - if less than 4 hours, give it, if more than 4 hours, withhold, if 2 doses are missed notify HCP
  • if child vomits - do not repeat dose
  • in hospital - check K levels before giving, hold if theyre low
279
Q

s/s of digoxin toxicity

A

n/v, bradycardia, anorexia, neurologic and visual disturbances

280
Q

NC for digoxin toxicity

A
  • monitor closely for dysrhythmias
  • digiband can be administered (watch for rapid drop in K levels
281
Q

NC for CHF

A
  • promote adequate rest
  • prevent crying
  • group activities
  • short intervals of play, cuddling
  • provide neutral thermal environment
  • may have normal O2 of 70-80
  • anticipate hunger, smaller, more frequent feedings, feed no longer than 30 mins at a time
  • feed in relaxed environment
  • semi-erect position for feeding
  • burp before, during, and after feeding
  • formula with increased cals per ounce
  • soft preemie nipple with moderately large opening
  • assess RR
  • position to encourage maximum chest expansion
  • avoid constriction
  • humidified supplemental O2, during bouts of crying or invasive procedures
  • avoided crowded public places, good hand washing, screen visitors
  • accurate I/O, daily weight, assess for edema, maintain fluid restriction if ordered, provide good skin care, change position frequently
  • developmentally appropriate toys, infants do catch up
282
Q

family education for CHF

A
  • teach s/s of worsening clinical status
  • information on how to give meds
  • stress importance of good nutrition
  • immunizations - stay up to date - if less than 2, need RSV prophylaxis
  • promote growth and development
283
Q

arterial septal defect

A
  • defect stems from a patent foramen ovale of failure of a septum to completely develop between the right and left atria
  • CM - may be asymptomatic, heart murmur, CHF, increased risk for dysrhythmias with pulmonary vascular disease and emboli later in life
  • treatment - mild defects may close spontaneously, open heart surgery and dacron patch closure, may be closed using devices during heart cath
284
Q

ventricular septal defect

A
  • septum fails to completely form between the right and left ventricles
  • CM - CHF, moderate to severe, cyanosis, characteristic murmur, right ventricular hypertrophy, FTT< fatigue, recurrent respiratory infections
  • treatment - pulmonary artery banding, may close spontaneously by age 3, interventional heart cath with septal occluder or surgical correction with a patch and repair of AV valve tissue
285
Q

patent ductus arteriosus

A

the fetal structure fails to close, blood is shunted from the aorta to the pulmonary artery
- CM - machine-like murmur, can be asymptomatic, or CHF
- treatment - indomethacin, interventional heart cath with coil, left thoracotomy or VATS

286
Q

clinical consequences of obstructive lesions

A
  • blood exiting the heart meets an area of anatomic narrowing causing obstruction of blood flow
  • obstruction usually occurs near the valve as in aortic and pulmonic stenosis
  • either shunting or back up of blood on the right side
  • increased pulmonary congestion
  • signs of CHF
287
Q

coarctation of the aorta

A

narrowing of the aortic arch, usually distal to the ductus arteriosus and beyond the right subclavian artery that results in increased pressure proximal to the defect and decreased pressure distal to the defect
- either preductal or postductal
- clinical consequences - l to r shunting, increased pulmonary blood flow leading to CHF, increased blood flow to head and upper extremities, decreased blood flow to trunk and lower extremities
- management - prostaglandin E to maintain PDA, balloon angioplasty, surgery within first 2 years

288
Q

aortic stenosis

A
  • narrowing or fusion of aortic valves with interferes with left ventricular outflow. blood backs up into right side of heart and right side of heart enlarges
  • results in decreased cardiac output, left ventricular hypertrophy, pulmonary vascular congestion
  • serious defect** - obstruction tends to be progressive, sudden episodes of myocardial ischemia, low cardiac output, can result in sudden death, only defect where activity is limited, surgical repair rarely results in normal valve
  • CM - infants have faint pulses, hypotension, tachycardia, poor feeding, children have exercise intolerance, chest pain, and dizziness when standing for long periods
  • treatment - ballon dilation or surgery (aortic valvotomy or replacement, mortality is high for older kids)
  • activity level is restriced in children with aortic stenosis even though the chance of sudden death is very rate
  • children are not on bedrest, but activity level is restricted
  • curtail strenuous activities
289
Q

pulmonic stenosis

A
  • defect that involves narrowing or constriction of valves of the pulmonary artery interfering with right outflow
  • pulmonary atresia
  • CM - may be asymptomatic, some have mild cyanosis or CHF, murmur
  • treatment - balloon angioplasty, surgery
290
Q

pulmonary atresia

A

extreme form, total fusion resulting in no blood flow to lungs

291
Q

cyanotic defects def

A
  • caused by defects that result in deceased pulmonary blood flow
  • in cyanotic the pressure is greater on the pulmonic side so blood shunts from the right to left
  • mixed oxygenated and deoxygenated blood flows to the systemic circulation resulting in hypoxia
292
Q

cyanotic defects symptoms

A

cyanosis, polycythemia, digital clubbing, altered ABG

293
Q

general interventions for cyanotic heart defects

A
  • provide good skin care
  • supplemental O2
  • monitor for and prevent dehydration
  • developmentally appropriate prep for procedures
294
Q

NC for cyanotic defects

A
  • alteration is oxygenation
  • anxiety caused by cyanosis
  • dehydration
  • prevention and accurate assessment of respiratory infections
295
Q

tetralogy of fallot

A

combination of 4 defects (pulmonic stenosis, right ventricular hypertrophy, overriding aorta, ventricular septal defect)
CM - heart murmur with a thrill, polycythemia, hypoxic episodes, metabolic acidosis, poor growth, clubbing, exercise intolerance
- improved quality of life and longevity with surgery, done in stages

296
Q

squatting position in tetralogy of fallot

A

reroutes blood
increases vascular resistance
decreases blood return from legs
divert more blood to pulmonary artery

297
Q

guidelines for hypercapnia spells

A
  • employ calm comforting speech
  • knee chest position
  • 100 oxygen by face mask
  • give morphine
  • Iv fluid replacement and volume expansion if needed
  • repeat morphine as needed
298
Q

tricuspid atresia

A
  • failure of the tricuspid valve to develop resulting in no communication between right atrium and ventricle resulting in severe right hypoplasia or absence of the right ventricle
  • CM - cyanosis
  • treatment - prostaglandin E to maintain foreman ovale, digi and diuretics, palliative surgical repair to increase pulmonary blood flow
299
Q

transposition of great arteries

A
  • pulmonary artery arises from left ventricle and the aorta arises from the right ventricle. no communication between the systemic and pulmonary circulations
  • s/s - increasing cyanosis as foramen ovale closes
  • treatment - arterial switch procedure in the first few weeks of life, IV prostaglandin E to keep foramen ovale open and or balloon atrial septostomy
300
Q

truncus arteriosus

A

pulmonary artery and aorta fail to divide during embryotic development, one single large vessel empties both ventricles
- CM - cyanosis, CHF, heart murmur
- treatment - surgical repair during the first few months of life
- digoxin and diuretics

301
Q

hypoplastic left heart syndrome

A

aortic valve atresia, mitral atresia or stenosis, small or absent left ventricle, severe hypoplasia of the ascending aorta and aortic arch
- underdevelopment of left side of the heart
- descending aorta receives blood via the PDA
- S/S - cyanosis, weak peripheral pulses, cool extremities, respiratory distress, often times no murmur
- management - prostaglandin E to keep PDA, fontan procedure, norwood procedure, transplant*

302
Q

fontan procedure

A

direct blood flow to pulmonary artery from RA

303
Q

norwood procedure

A

anastomosis of main PA to aorta, shunt from RV to PA

304
Q

complications of heart surgery

A
  • CHF
  • dysrhythmias
  • cardiac tamponade
  • atelectasis, pneumothorax, pulmonary edema, PE
  • cerebral edema and brain damage
  • hemorrhage or anemia

NSG (12 decks)

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