Peds exam 3 Flashcards
First signs of hematologic disorder or cancer in children?
Skin color changes such as pallor, bruising, and flushing are often the first signs that a problem is developing
-change in mental status (lethargy) can indicate low hemoglobin levels
Physical examination of the child with a hematologic or neoplastic disorder includes what?
inspection and observation
palpation
auscultation
general appearance and observation of child with disorder of altered cellular regulation
-thin, frail appearance
-asymmetry of body parts
-altered consciousness
-child’s response to stimuli
-bleeding gums or pale mucous membranes
-assess for rectal bleeding or vaginal discharge
-pallor in nail beds, palms, and soles
-clubbing of fingers
-assess urinary output
-assess vital signs
-assess conjunctiva
Auscultation for children with altered cellular regulation
assess for any adventitious breath sounds or heart murmurs
-assess rate, rhythms, tone
-listen to bowel sounds
Palpation with altered cellular regulation disorders
Measure BP (may change with alterations in blood volume)
Measure peripheral pulses
Assess capillary refill (may be prolonged)
Palpate lymph nodes
Palpate abdomen for splenomegaly, hepatomegaly, tenderness
Assess for swelling in any parts of the body
Assess skin temp
Assess skin elasticity (turgor)
Assess if joints are tender and if ROM is limited
Common medical treatments for cancer and altered cellular regulation disorders
Blood transfusion
Leukapheresis- Removal of the blood to collect specific blood cells. The remaining blood is returned to the body.
Hematopoietic stem cell transplantation
Supplemental oxygen
Biopsy
Splenectomy
surgical removal of tumor
Radiation
Central venous catheter
Implanted port
Benefit to acupuncture
may help to decrease nausea, vomiting, and aversion to chemotherapy.
Adverse effects of radiation therapy vs chemotherapy
radiation therapy:
include
-FATIGUE,
-nausea, vomiting,
-oral mucositis,
-myelosuppression- A condition in which bone marrow activity is decreased, resulting in fewer red blood cells, white blood cells, and platelets., and
-ALTERATIONS OF SKIN INTEGRITY at the site of irradiation
chemotherapy:
-immunosuppression –>infection, myelosuppression,
-nausea, vomiting,
-CONSTIPATION,
-oral mucositis,
-ALOPECIA, and
-PAIN
Hemopoietic stem cell transplant indications
(cases when performed)
leukemias, lymphomas, sickle cell disease, aplastic anemia, thalassemia
hemopoietic stem cell transplant considerations (what to maintain, provide, avoid)
Maintain medical asepsis and isolation (prevents infection)
Provide good oral care
Avoid rectal temps or suppositories
indications for radiation therapy (4)
before or after surgical resection
leukemia
lymphoma
solid tumors
a-fetoprotein (AFP)
-where produced
-decreased levels by what age
-elevated in what cases
-determines what
produced by fetal liver and yolk sac
decreases to very low levels by age one
-usually elevated in Hodgkin disease and other cancers
-determines tumor burden
Urine catecholamines (VMA, HVA)
-diagnosis for what
-involves what?
-levels altered by what?
catabolism of catecholamines causes elevated levels in the urine
-Diagnosis of neuroblastoma
-involves 24-hour urine collection
-levels may be altered with certain foods and vigorous exercise
MRI in evaluating cancer
can identify extent of tumor or metastatic spread
CT in evaluating cancer
can identify location of tumor or metastasis
Ultrasound in evaluating cancer
identify tumor presence, especially in abdomen or kidney
Bone marrow aspiration and biopsy
evaluation for leukemia or metastasis of other cancers in bone marrow
Bone scan
identifies metastasis of bone
chest x-ray use
identifies tumor or metastasis in the thorax
*x-ray is mainly used to monitor cancer
Anemia
is a condition in which the level of RBCs is lower than the age-appropriate normal value. Anemia may develop as a result of decreased production of RBCs or loss and destruction of RBCs.
What can cause anemia?
related to lack of dietary intake of the nutrients needed to produce the cells, alterations in the cell structure, or malfunctioning tissues (e.g., bone marrow), toxin exposure, medication, trauma
Anemias related to nutritional deficiency
-may be related to what?
iron deficiency,
folic acid deficiency, and
pernicious anemia
-maybe related to food dislikes or malabsorption issues
Anemia related to toxin exposure
example is lead poisoning
Hemolytic anemia
Anemia caused by the alteration or destruction of the RBCs
Types of hemolytic anemia
sickle cell disease
thalassemia
Therapeutic management of iron deficiency anemia
iron supplements (ferrous sulfate or ferrous fumarate)
4 to 6mg/day
-take with vitamin c
-teeth staining
-dark stools
Blood transfusions if anemia is severe
Monitor labs
sickle cell disease pathophysiology
RBCs sickle and clump together—>preventing blood flow to tissues in the area. The sickled shaped cells can’t pass through the capillaries and venules of the circulatory system–>local tissue hypoxia, ischemia
sickle cell disease therapeutic management
Manage pain (PCA if appropriate)
NSAIDs
hydration
prevent infection (prophylactic antibiotics, immunizations)
supplemental oxygen
possible blood transfusion
manage stress
What medication should not be given to patients with sickle cell crisis?
meperidine (Demerol)
first sign of sickle cell crisis?
pain
nursing interventions to prevent sickle cell crisis (4)
Managing pain, stress
immunizations, prophylactic antibiotics
Idiopathic Thrombocytopenic Purpura (ITP) value monitoring
platelets
surgery care for patient with ITP
make sure to monitor surgery sites for bleeding
signs of brain tumor
headache
altered mental status
hypertension
increased intracranial pressure
blown pupils
Delaying cord clamping
helps with iron deficiency
administering intravenous immunoglobin
hydration
watch for adverse reactions
physical assessment before administration
vital signs
stay with them for first 30 minutes
monitor for dehydration throughout administration
Therapeutic effect of immunoglobin G
hydration should improve throughout administration
HIV medications
what to educate about
MOA
educate about compliance
Helps prevent infection and spread
SLE testing
test for ANA (antinuclear antibody) presence (blood test)
Managing Myasthenia Gravis
preventing infection is important
Signs of food allergy
anaphylactic shock
rash, hives
diarrhea, vomiting, cramps, bloating, nausea
congestion, swelling of tongue or throat, runny nose, cough, wheezing, asthma
what medication to have on hand for food allergies?
epipen
Benadryl
signs of endocrine disorder
what is important
growth issues
look at health history/exams
*health history is important
growth hormone production occurs where?
pituitary gland
Dwarfism
Condition caused by insufficient growth hormone in childhood
too much growth hormone
gigantism
interventions for Addison’s
talk to school about IEP (allowing bathroom breaks)
give fluids
An Individualized Education Program is a legal document under United States law that is developed for each public school child in the U.S. who needs special education. It is created through a team of the child’s parent and district personnel who are knowledgeable about the child’s needs.
congenital hypothyroidism s/s
constipation,
weight gain,
not thriving,
fatigue
SLOOWWWW
congenital hypothyroidism interventions
promote growth
education
rest breaks
make sure environment is good
Signs of adrenal crisis
Confusion, abdominal pain, dehydration, low BP, high fever, rapid heart and breathing rate, nausea vomiting
managing adrenal crisis
education
corticosteroid use
developmental issues related to diabetes
education
educate child and parents about adherence and health promotion
education for diabetes
diet
carb counting
how to administer insulin/where to administer insulin
risk for complications (DKA, infection)
primitive vs protective reflexes
considerations with casts- what to make sure
make sure to reposition
Metatarsus adductus activity
encourage ROM
-prevent injury to other joints
developmental dysplasia of the hip
check gluteal folds
Dev hip dysplasia- pelvis drops when hip raised, thigh and gluteal folds asymmetrical, knee height is unequal, Barlow and Ortollani test positive
Rickets
lack of vitamin D
soft bones
Darker pigmented skin
Leg-Calve-Perthes Disease
what is it
what to monitor
Necrosis of the femoral head
monitor bone with x-ray
scoliosis assessment
assess compliance with brace
priority for seizures
safety
lab diagnostics for seizure
EEG
lab diagnostics for meningitis
lumbar puncture
hydrocephalus
what to monitor
abnormal accumulation of fluid (CSF) in the brain
-monitor shunt for infection (drowsiness, nausea, headache)
craniocytosis
how diagnosed
diagnosed by x-ray (out of womb)
can be diagnosed with ultrasound
-can have surgery
Brudzinski’s sign
Severe neck stiffness causes a patient’s hips and knees to flex when the neck is flexed
how to tell if antibiotics are working with bacterial meningitis?
culture
management with meningitis
try to prevent complications
warning signs of head trauma
retinal hemorrhage
fixed and dilated pupils
confusion
neurological disorder meds
phenytoin
benzos
Neurofibromatosis
complications
tumor on peripheral nerves
Complications: learning disorders, depression, pain
nursing management for neurofibromatosis
biopsy to see if it’s benign or malignant
good way to assess child for autism
see how they play
Signs of ITP
-what to assess?
increased bruising, epistaxis, or bleeding of the gums are signs of ITP
-assess for blood in the stool
-assess for petechiae on lips and buccal mucosa
Risk factors for ITP
what to assess?
-recent viral illness,
-recent MMR immunization, or
-ingestion of medications that can cause thrombocytopenia.
Inspect for petechiae, purpura, and bruising, which may progress rapidly within the first 24 to 48 hours of the illness
laboratory findings for ITP
platelets
wbc
hbg/hct
What is done to r/o leukemia?
Extremely low platelet count (less than 50,000)
normal WBC
normal hemoglobin and hematocrit
Bone marrow aspiration may be performed to rule out leukemia
Nursing management for ITP
what to use for pain?
what to avoid?
Medical treatment might not be needed, just observation
Avoid NSAIDs
Use acetaminophen (tylenol) for pain
avoid activities that may cause trauma/injury
humoral immunity
mediated by antibodies secreted by B cells
Cellular immunity
cell mediated immunity controlled by T cells
Which type of immunity is present at birth?
Which type will develop as newborn is exposed to organisms?
Cellular immunity
-humoral immunity will develop as newborn is exposed to organisms
considerations with newborn immune system
the healthy full-term infant’s immune system is still immature.
The newborn exhibits a decreased inflammatory response to invading organisms, –> increases his or her susceptibility to infection.
Thymus in young children
is quite enlarged at birth and remains so until about 10 years of age
Tonsils in young children
often enlarged
What temperature does IV immunoglobulin need to be infused at?
room temp.
Can be stored in fridge
What labs need to be assessed before administering immunoglobulin?
Assess baseline serum blood urea nitrogen (BUN) and creatinine, as acute renal insufficiency may occur as a serious adverse reaction.
preparing immunoglobulin
what not to do?
needs to be reconstituted
needs to be administered at room temp
*Do not shake bottle
What needs to occur before administering immunoglubulin?
-patient needs to be hydrated
-may need to administer diphenhydramine or acetaminophen before infusion in some cases
-baseline physical assessment and vital signs
-calculate rate
When is diphenhydramine or acetaminophen indicated for IVIG?
-children who have never received IVIG,
-have not had an infusion in more than 8 weeks,
-have had a recent bacterial infection,
-have a history of serious infusion-related adverse reactions, or
-are diagnosed with agammaglobulinemia or hypogammaglobulinemia
Rate of IVIG
start infusion slowly and increase to the prescribed rate as tolerated
assessing vital signs and adverse effects when administering IVIG
Assess vital signs and check for adverse reactions every 15 minutes for the first hour, then every 30 minutes throughout the remainder of the infusion
signs of anaphylactic reaction
-headache,
-facial flushing,
-urticaria,(Urticaria – also known as hives, weals, welts or nettle rash – is a raised, itchy rash that appears on the skin.)
-dyspnea,
-shortness of breath,
-wheezing,
-chest pain,
-fever,
-chills,
-nausea, vomiting,
-increased anxiety, or -hypotension
What supplies/meds are needed for IVIG administration in case of emergency?
Have oxygen and emergency medications such as epinephrine, diphenhydramine, and intravenous corticosteroids available in case of anaphylactic reaction
What can you do if pt complains of discomfort at the IV site when administering IVIG?
cold compress might help
Therapeutic management for HIV
the use of a combination of antiretroviral medications
Types of medication therapy for HIV
Medication therapy ranges from single-drug therapy in the asymptomatic HIV-exposed newborn to highly active ART, consisting of a combination of antiretroviral drugs. Medications are prescribed based on the severity of the child’s illness.
Goal of ART- antiretroviral therapy
to prevent or arrest progressive HIV encephalopathy
Nursing management for HIV
-directed at avoiding infection, -promoting compliance with the medication regimen,
-promoting nutrition,
-providing pain management and comfort measures,
-educating the child and caregivers, and
-providing ongoing psychosocial support
signs of SLE
fatigue, fever, weight changes, pain or swelling in the joints, numbness, tingling or coolness of extremities, or prolonged bleeding, stomatitis, alopecia, anemia, seizure, Raynaud
-malar rash, discoid lesions on face or neck, pigmentation change of the skin
lab findings for SLE
wbc
platelet
hct/hbg
complement levels (c3 c4)
ANA
low hematocrit and hemoglobin
low platelet
low WBC
Complement levels (C3 and C4) are low
Antinuclear antibody (ANA) will be positive
What might be the first sign of juvenile idiopathic arthritis in young children/infants?
irritability/fussiness
Signs of juvenile idiopathic arthritis
doesn’t want to play/get out of bed
fever
evanescent, pale red, nonpruritic macular rash
mild to moderate anemia
elevated ESR
swollen, red, tender joints
Positive ANA (young children), positive rheumatoid factor in adolescents
flexed joints
gait is limp or pt is guarding of a joint
Signs of myasthenia gravis
fatigue
weakness
difficulty chewing
difficulty swallowing
difficulty keeping head up
pain with muscle fatigue
ptosis (eyelid drooping)
altered eye movements from partial paralysis
lab testing for myasthenia gravis
may involve the edrophonium (Tensilon) test, in which a short-acting cholinesterase inhibitor is used. Acetylcholine receptor (AchR) antibodies may be present in elevated quantities in the serum.
goals for nursing management of myasthenia gravis
include prevention of respiratory problems and providing adequate nutrition
Nursing management for myasthenia gravis
Administer meds (anticholinergic meds)-needs to be on time
see provider if chance of infection
manage stress
avoid extreme temps
notify provider if concerned about myasthenia crisis or cholinergic crisis
encourage child to wear a medical bracelet
Administering anticholinergic meds
should be given 30 to 45 minutes before meals, on time and exactly as ordered
signs of myasthenia crisis
severe muscle weakness, respiratory difficulty, tachycardia, and dysphagia
-increased muscle weakness with resultant respiratory distress
sign of cholinergic crisis
severe muscle weakness, sweating, increased salivation, bradycardia, and hypotension.
-increased muscle weakness with resultant respiratory distress
signs of food allergy reaction
hives, flushing, facial swelling, mouth and throat itching, and runny nose. Many children also have a gastrointestinal reaction, including vomiting, abdominal pain, and diarrhea. In extreme cases, swelling of the tongue, uvula, pharynx, or upper airway may occur. Wheezing can be an ominous sign that the airway is edematous.
risk factors for food allergy reactions
previous exposure to the food, history of poorly controlled asthma, or an increase in atopic dermatitis flare-ups in relation to food intake.
food allergy testing
Allergy skin-prick tests and radioallergosorbent blood tests (RASTs)
-food specific IGE test
-For an oral challenge, the child slowly eats a serving of the offending food over the period of 1 hour. Record vital signs and note the presence or absence of allergic symptoms.
Medications for food allergy reaction
histamine blockers and, in anaphylactic reactions, epinephrine.
pt education for food allergy
have written plan in case of emergency
teach how to administer meds
teach that it’s important to read food labels
teach about food substitutes
signs and symptoms of reaction
Refer families to Food Allergy and anaphylaxis network
Therapeutic management of anaphylaxis
focuses on assessment and support of the airway, breathing, and circulation
Nursing management for anaphylaxis
ABCs
oxygen through mask or bag mask
bronchodilator if pt is having bronchospasm
IV fluids
Observe child for 4 to 6 hours
Foods that cross react with latex
pear, peach, passion fruit, plum, pineapple, kiwi, fig, grape, cherry, melon, nectarine, papaya, apple, apricot, banana, chestnut, carrot, celery, avocado, tomato, or potato.
clinical manifestations of endocrine disorders occur as the result of?
as a result of the altered control of the bodily processes normally regulated by the gland or hormone.
Health history for endocrine disorders
look at growth and development
look at family trees
see how child is interacting with other kids
assess behavior or moods
assess if child is having excessive thirst, frequent urination, vomiting, inactivity, fatigue
GH deficiency pathophysiology
failure of pituitary and hypothalamus
Signs of GH deficiency
higher weight to height ratio
large face
higher subq fat deposits in abdomen
high pitch voice
delayed sexual maturation
decreased muscle mass
Ways to diagnose GH deficiency
x-rays of bones (bone age)
CT/MRI to rule out tumors
Pituitary function testing
pituitary function testing
This test consists of providing a GH stimulant such as glucagon, clonidine, insulin, arginine, or L-dopa to stimulate the pituitary to release a burst of GH
-confirms diagnosis
signs of diabetes insipidus
abrupt
signs of dehydration (irritability)
polyuria
polydipsia
intermittent fever
vomiting
constipation
frequent trips to the bathroom, enuresis, nocturia
nursing management for DI
Promoting hydration
promoting activity (bathroom breaks, have fluids by child)
education
Nursing assessment of SIADH
decreased urine output and weight gain, or GI symptoms such as anorexia, nausea, and vomiting. Assess neurologic status, noting lethargy, behavioral changes, headache, altered level of consciousness, seizure, or coma
-Neuro symptoms develop as sodium level decreases (lethargy)
complications of congenital hypothyroidism
intellectual disability
failure to thrive
Congenital Adrenal Hyperplasia (CAH)
management focuses on stopping the excessive adrenal secretion.
usually given hydrocortisone, fluticocortisone
will try to correct external genitalia
signs of acute adrenal crisis
persistent vomiting, dehydration, hyponatremia, hyperkalemia, hypotension, tachycardia, and shock
-IV steroids, fluids, dextrose
signs of shunt infection
elevated vital signs, poor feeding, vomiting, decreased responsiveness, seizure activity, and signs of local inflammation along the shunt tract
signs of shunt malfunction
vomiting, drowsiness, and headache
nml hct
36-52
nml creatinine
0.6-1.2
nml BUN
6-24
nml hbg
12-18
f: 12-16
M: 14-18
nml platelets
150,000-450,000
<40,000 be very concerned!
nml wbc
4.5-11
nml ca
9-11
nml phosphorus
2.5-4.5
nml cloride
95-105
mom –> son K(evin)
mom –> daughter Turner
low estrogen –> osteoporosis
get culture first –> give broad spectrum
ADHD - nonstimulants
ADD- stimulants
wilm’s tumour- don’t palpate abdomen
primitive: born with
moro-
suck
root
babinski
palmar grasp
plantar grasp
the step
protective: permanent
parashchute
riding
atypical trazadone- depression
hispanic- high risk for lymphoma
