Peds Exam 1 Flashcards
Care Prioritizing
Life threatening -> limb threatening -> new problem -> chronic problem
Maslow’s Hierarchy of Needs
Physiological (food, water, sleep) Safety (of body, employment) Love/Belonging (family, friends) Esteem (confidence, respect by others) Self-Actualization (morality, creativity)
Newborn skin permeability
Increased skin permeability, increased penetration of medication, greater risk of toxicity
Newborn gastric emptying
Reduced gastric emptying and intestinal motility, increased time to reach therapeutic concentrations
Newborn proportion of body water
Increased body water, important to consider when administering water soluble drugs (reach adult values by 12)
Newborn proportion of body fat
Lower proportion of body fat, lower doses of lipophilic drugs are required
Newborn glomerular filtration and tubular secretion rates
Decreased glomerular filtration and tubular secretion. Gradual increase in renal function, reach adult values for 1-2 years.
Things to check if respiration rate of child is too high?
Fever, room too hot, if child has a chronic condition, if child is “comfortably tachypnic”. Fast breathing children have higher aspiration risk.
Kids are abdominal breathers until…
age 7
Pre-hypertension in peds
Average systolic and diastolic pressure are in the 95th percentile from 3 separate readings. Will likely turn hypertensive in 1-2 years, monitor closely.
When to take pediatric BPs
Annually starting at 3, sooner if demonstrate htn symptoms. If hospitalized or in ED will always get BP. Always get BP if hospitalized or in ED.
Fever Parameters
Newborn - 3 months: over 38
3 - 36 months: over 38.9
Children: over 40
When can children fixate visually?
3 months
Corner of eye should line up with….
Top of ear
Child under 3 pull pinna…
down and back
Child over 3 pull pinna…
up and back
Infants are obligate _____ breathers
Nose. Can have feeding difficulties if nose is clogged with secretions.
Report to provider if tonsils are…
swollen, red, or white patches. Leave tonsil exam to end of assessment because kids don’t like it.
Toddler risk factors for anemia
Cows milk not a good source of iron, contains substances that bind to iron and impair absorption
Adolescent risk factors for anemia
Poor eating habits, rapid growth rate
IgG
80% of the antibodies in the system. Crosses the placenta. Newborn levels similar to mother’s, but disappear by 6-8 months.
IgA
Prevents colonization fo bacteria, not present at birth, normal levels by ~6 years. Children at 6 tend to be ill more often due to lack of full complement of immunoglobulins
IgE
Binds to allergens. Not present at birth, normal values achieved ~6 years
Cardiovascular considerations for peds
Immature heart is more sensitive to volume changes or pressure overload. If giving fluids monitor infants for fluid in lungs, HR changes.
Respiratory considerations in peds
Smaller nares = easily occluded
Smaller oral cavity and larger tongue = higher risk of obstruction
Epiglottis still floppy = increased risk of swelling
Cartilage of thyroid, cricoid, trachea is immature, collapses more easily when neck is flexed
Fears of hospitalized children
Unknown Punished Isolation Pain Needles Death
Infant - 18 months Erickson
Trust vs mistrust
18 months - 3 years Erickson
Autonomy vs shame/doubt
3 years - 5 years Erickson
Initiative vs guilt
5 years - 13 years Erickson
Industry vs inferiority
13 years - 21 years Erickson
Identity vs role confusion
Glasgow Coma Score
Max 15, Min 3, at 7 or below consider respiratory support
Manifestations of ICP in Infants/Young Children
Bulging anterior fontanel High pitched cy Increased head circumference Irritabliity/restlessness Change in feeding Unconsolable Sunset eyes
Manifestations of ICP in Older Children
Headache Vomiting (not diarrhea!) Cognitive/personality/behavioral changes Diplopia and blurred vision Anorexia/nausea/weight loss Seizures
Late Manifestations of ICP
Decreased LOC
Decreased motor response
Abnormal sensation to painful stimuli
Decerebrate/decorticate posturing
Decerebrate vs Decorticate
Decerebrate: flexing, arms inward. Acute but less severe
Decorticate: rigid extension, head tilted back. More acute.
Signs of Brain Herniation
Major LOC Fixed/dilated pupils Cushing's Triad: -Bradycardia -Irregular respirations -Increased SBP, widening pulse pressure
Hydrocephalus Communicating vs Non-Communicating
Non-Communicating is more common, blockage in ventricles prevents CSF form being reabsorbed, causing accumulation in the brain.
Communicating: free flowing CSF, not absorbed
Post-op care for hydrocephalus surgical shunt
Keep child flat for 24 hours, VS, euro checks, observe dressing, head circumference
Status Epilepticus
Continuous seizure lasting more than 5 minutes. Maintain ABC, IV admin of antiepileptic agents (diazepam, loraeepam, loading dose of phosphenytoin). If at home diastat or intranasal midazolam.
Meningococcemia
Systemic form of meningitis. Mortality nearly 100% in children, 17-60% in adults
Meningitis Symptoms in Babies
Tense or bulging soft spot High temperature Very sleeping/too slow to wake up Breathing fast/breathing difficulty Extreme shivering Pin prick rash, purple bruises, anywhere on the body Diarrhea (sometimes) Vomiting/refusing to feed Irritable High pitched or moaning cry Blotchy skin, getting purple or turning blue. A stiff body with jerky movements, or floppy and lifeless Cold hands and feet
Meningitis Assessment
Glasgow Coma score Signs of increasing ICP Meningeal signs Focal signs - hemiparesis, abscess, ischemic areas Systemic signs of infection
Meningitis Nursing Interventions
Isolation Antibiotics Watch for increased ICP Monitor for euro changes Supportive care
Strategies to decrease ICP
Keep head midline, head above 30 degrees, low stimulus environment
Reyes Syndrome
Aspirin when given for a viral infection can cause massive unexplained cerebral edema with high ICP in children, which requires aggressive treatment. Changes in hepatic and liver function. Supportive care, ventilator. Sometimes resolves with time, sometimes does not.
Retractions
Most common area is subcostal. Subcostal/intercostal/substernal are less severe, severity increases as you go up the body, suprasternal and supraclavicular very severe
Pharyngitis/Tonsillitis
Group A Strep responsible for 30% of tonsillitis cases. Pharyngitis is usually the trigger sign of a URI, is self limiting. Viral.
Post-tonsillectomy priorities
Maintain airway
Do not suction
Any frank bleeding, pallor, emesis of blood, tachycardia, spitting blood = call provider stat
Relieve pain
Asthma triggers
Exercise Seasonal pattern Viral respiratory illness Weather changes Animal dander Roaches/dust mites Smoke/aerosols Emotional
Peak Flow
Drops as bronchospasm increases. Should be measured as a baseline. Measure while standing, do 3 times and record highest. Always at the same time every day.
Cystic Fibrosis
Exocrine system not working properly, over producing mucous. Try to minimize pulmonary complications, ensure nutrition for growth, encourage physical activity
Acute Otitis Media
Rapid onset of signs and symptoms of middle ear inflammation. History of rapid onset ear pain, earache, tugging, rubbing, holding ear, excessive crying, irritability, changes in sleep, behavior, or appetite.
Treat with antibiotics, can consider tympanostomy tubes inserted surgically. Prophylactic antibiotic therapy NOT recommended. Reduce paci use, encourage breastfeeding, avoid tobacco exposure, avoid supine feeding (bottle propping)
Severe AOM
Acute Otitis Media w/presence of severe ear pain and fever over 39C
Recurrent AOM
3 or more documented and separate AOM episodes in preceding 6 months, or 4 in 12 months
AOM considerations
Assure AOM resolves, esp in cognitively delayed patients. Complications can include leading to meningitis, recurrent infections, hearing complications, pneumonia, URIs, bacteremia, cellulitis, continued paint and fever, sleep disruption.
Otitis Media with Effusion (OME)
Fluid in middle ear w/out signs of acute ear infection. Usually resolves spontaneously, but if lasts over 3 months consider tympanostomy tubes for kids under 4, over 4 adenoidectomy and/or tympanostomy tubes.
OME Complications
Complications include hearing loss, balance and coordination problems, poor academic performance, behavior problems, ear discomfort, recurrent AOM, speech delays.
Tympanostomy complications
Rare damage to ear drum. Tubes will fall out 12-18 months, may need replacement, can occasionally leave a hole. Kids can still take baths, swim in pool, air travel.
Acute Laryngotrachealbronchitis
Croup. Viral. Upper airway. Whooping, barking cough. Stridor. Supportive care. Reposition, O2, ensure hydration and comfort. Mild = outpatient, significant = hospitalization for hydration and oxygen
Supraglottitis
Medical emergency! Bacterial. Rapid onset (3-6 hours), high fever, drooling, history of very sore throat. Look of fear on kid’s face.
Absolute Neutrophil Count (ANC)
Measure of the number of neutrophil granulocytes
Type of WBC that fights infection
Below <1,000 = neutropenic (normal: 3-5,000)
Mild to Moderate Dehydration Classifiers
3-4% weight loss
2 of 4: capillary refill >2 s; absent tears; dry membranes; ill appearance
Mild to Moderate Dehydration Symptoms
Weight
Fatigued, restless or irritable; thirsty/eager to drink; normal to increase HR, RR; decreased quality of pulses, tears, urine output; eyes slightly sunken; dry mucus membranes
Mild to Moderate Dehydration Treatment
Maintain normal diet
ORT
Want to treat at home
Gatorade is not a good rehydration (too much sugar)
Watch for changes in mental status (if worsen go to ER)
Severe Dehydration Classification
> 9% weight loss
Severe Dehydration Symptoms
Weight
Apathetic, lethargic; drinks poorly or unable to; tachycardia; weak thready pulse; deep breathing; deeply sunken eyes; absent tears; minimal urine output
Severe Dehydration Treatment
Pt is NPO – once Pt is in a moderate state can start ORT
Maintain skin integrity
Return child to normal status
Rotavirus
Causes more severe diarrhea than other pathogens
Fever and vomiting followed by diarrhea
Symptoms appear 2 days after exposure
Vaccine for young children to prevent severe rotavirus
Constipation
Pebble-like hard stools for 2+ weeks; firm stools less that 2/week for 2+ weeks. Consider other things going on (childhood – do they not want to go at school)
Constipation Treatment
Diet, fluid management, behavior modification
Increase: water; raw fruits/veggies; ¼ cup apple, pear, prune juice; oatmeal; bran
Decrease: cheese; milk >3 servings; processed foods; sodas; high sugar foods
Pyloric Stenosis
Hypertrophic obstruction of the circular muscle of the pyloric canal
Projectile non-bilious vomit
Olive-sized RUQ mass
Irritable, poor weight gain, small stools
Peristaltic waves from left to right across the epigastrium
Hunger even after vomiting. Need surgical treatment: pyloromyotomy
Intussusception Definition
Bowel folds back on itself
Most common in 3mo-3y
Most common site: ileocecal valve
Sudden acute abdominal pain; inconsolable crying; bilious vomiting; lethargy
Classic Triad (late): abdominal pain; palpable sausage sized mass; currant jelly-like stools
Intussusception Treatment
Air or barium enema
Passage of brown stool indicates spontaneous reduction
Surgery required if enema doesn’t work
Crohn Disease
May affect any part of the GI tract
Skipping lesions
Inflammation can burrow through the thickness of the bowel wall
Moderate to severe diarrhea; pain; anorexia and weight loss may be severe; anal/perianal lesions and fistulas are common
Crohn Disease Treatment Considerations
Steroid treatment causes moon face – big body image effect
Antibiotics cause diarrhea – can make school difficult
Ulcerative Colitis
Only the inner most lining of the colon, mucosa, becomes inflamed (limited to colon and rectum)
Presentation may vary depending on extent of inflammation
Rectal bleeding; severe diarrhea; moderate anorexia and weight loss
Ulcerative Colitis Considerations
Steroid treatment causes moon face – big body image effect
Antibiotics cause diarrhea – can make school difficult
Appendicitis
Inflammation of the vermiform appendix (McBurney point)
Periumbilical pain that descends to RLQ
Fever (not sensitive or specific)
N&V after onset of pain. Peak incidence 10-12y (higher rupture <4y)
Cleft Lip/Palate
Incomplete fusion of lip and/or palate. If cleft palate – aspiration risk!
Keep fed and dry – do not want to pop sutures
Cleft Lip/Palate Considerations
Nutrition (feeding devices? Distress?)
Feeding positions; impaired parent/infant bonding
Post-op: assess suture line, provide pain control and prevent crying
Esophageal Atresia (EA) & Tracheoesophageal Fistula
Failure of the esophagus to develop as a continued passageway
Failure of trachea and esophagus into distinct structures
Profuse drooling, cyanosis, choking, coughing; feeding returns through nose/mouth; abdominal distension with cry; unable to pass NG tube
Aspiration Risk
EA is not a surgical emergency
Esophageal Atresia (EA) & Tracheoesophageal Fistula Treatment
Low intermittent or continuous suction of upper pouch
Side lying or prone with Trendelenburg
Complications: aspiration, reflux, pneumonia, feeding difficulties (may have lacking oral stimulation); esophagus motility
Omphalocele
Abdominal contents herniate through the umbilical ring with peritoneal sac. Infection risk.
Gastroschisis
Bowel herniates through the defect to the right of the umbilical cord and through rectus muscle. Infection risk.
Gastroschisis Treatment
Cover bowel with saline soaked gauze and place in bag
Replogle to low continuous wall suctions for bowel decompression
Prevent mal-rotation
Hirschsprung Disease
Absence of autonomic parasympathetic ganglion cells in the colon prevents peristalsis
Internal sphincter fails to relax – always contracted
Lack of stools or explosive stools; bilious vomiting; stools may be ribbon-like or foul smelling; abdominal distention; palpable fecal mass
Hirschsprung Disease Treatment
Barium enema; rectal biopsy; rectal manometry
Cerebral Palsy
Group of permanent non-progressive abnormalities that lead to disorders of movement and posture, causing activity limitation and functional impact
May impede cognitive function, language and achievement of normal development
Can occur pre/post-natal (TBI, meningitis, hypoxic encephalopathy) . Scoliosis and kyphosis may affect breathing
May see contractures
Pt may not be able to speak, but can understand – don’t talk about them like Pt is not there
Levels of Respiratory Distress
Mild: tachypnea; tachycardia; diaphoresis
Moderate: flaring; retractions; grunting; wheezing; anxiety; irritability; confusion; mood changes; headaches; HTN
Severe: dyspnea; bradycardia; stupor, coma; cyanosis
Respiratory Distress Interventions
Reposition Pt Assure airway patency Administered oxygen (humidified) Administer appropriate meds Promote expectoration of secretions
Respiratory Failure
Respiratory system fails in one or both of its gas exchange functions: O2 and CO2 elimination
Unable to compensate; respirations are ineffective and decreased
Leads to arrest
Bronchitis
Usually URI and viral
Bacteria can trigger
Persistent dry cough
Bronchiolitis
Usually virus (RSV) Labored breathing (apnea <6mo); poor feeding; wheezing; fever; nasal secretions Seasonal (fall-winter).
Bronchiolitis Treatment
Isolation (usually contact) O2, may be NPO; maintenance fluids If wheezing: bronchodilators Antibiotics if uncertain dx Steroids not recommended
Pneumonia
An acute inflammation of the lungs resulting from the invasion and replication of an infection agent
Community acquired v. nosocomial
Pneumonia Treatment
Isolation? Antibiotics IV maintenance fluids Pulmonary toilet (get all secretions out) Antipyretics?
