PEDS exam 3 Flashcards
Congenital hypothyroidism
Failure of thyroid gland to migrate during fetal development
Low T3 and T4
If untreated=intellectual disability, delayed physical maturation, short stature and growth failure
Early identification=KEY
Physical cues-Congenital hypothyroidism
Poor sucking reflex, hypothermia, constipation, lethargy/hypotonia, preorbital puffiness, cool dry and scaly skin, bradycardia, RR distress, large fontnelles, delayed closure fontanelles, macroglossia, course facial features
Diagnostics (labs)-Congenital hypothyroidism
Low T3 and free T4(0.8-2.4ng/dL)
High TSH
Medications-Congenital hypothyroidism
L-thyroxine(Sythroid, Levothroid)
Medication management-Congenital hypothyroidism
Pill only- must be crushed and placed in 1-2 mL milk via bottle nipple or dropper
Missed doses may lead to developmental delay/poor growth
Teaching-Congenital hypothyroidism
Medication absorption affected by soy-based formulas, fiber, calcium, iron preparations, and antacids
Thyroid function tests to monitor
Growth hormone deficiency
Failure of anterior pituitary gland to produce sufficient GH or failure of hypothalamus to stimulate anterior pituitary gland. Impairs body’s metabolism of proteins, fat, carbs
-caused by injury to hypothalamus or pituitary gland
Cause of GH deficiency
Injury to pituitary gland or hypothalamus
-tumors, infection, infarction, CNS irradiation, congenital abnormalities, birth trauma, emotional depravation
Physical cues-Growth hormone deficiency
Large/prominent forehead, under developed jaw, high-pitched voice, delayed sexual maturation, delayed dentition/skeletal maturation, decreased muscle mass
Diagnostics-Growth hormone deficiency
Skeletal survey= 2+SD<normal in bone age
CT/MRI- tumors/rule out abnormalities
Pituitary function test to confirm
Medications-Growth hormone deficiency
Bio synthetic GH via Sub-Q injections
-0.18-0.3 mg/kg/week divided into equal daily doses
Medication management-Growth hormone deficiency
Monitor for s/e of meds
Monitor effectiveness of hormone replacement(measure height Q3-6 mo
-continued until growth rate of less than 1 in/yr or bone age >16(boys) or >14 (girls)
Type 1 DM
Deficient insulin secretion due to pancreatic beta cells damage
-quicker onset, autoimmune, Dx at younger age
Diagnostics-Type 1 DM
Blood sugar(and fasting glucose) and chemical panel, CBC, UA, oral GTT
Expected lab findings-Type 1 DM
BS>200mg/dL
Fasting glucose >126mg/dL
HbA1C:>6.5%
Chem panel: evaluate BUN/creatinine, Ca+, Mg+, PO4-, Na+
UA- presence of ketones and glucose
Oral GTT >200mg/dL at 2 hrs
Hypoglycemia s/s
Shakiness, lightheadedness, hunger, pallor, cool skin, diaphoresis, irritability, anxiety, slurred speech, tachycardia, palpitations, normal/shallow RR , seizures leading to coma, dec LOC
Hypoglycemia management
BS <60mg/mL
If child coherent- feels s/s hypo
-give glucose tab/15g of simple CHO (OJ/milk), followed by complex CHO(PB and crackers)
Incoherent:glucagon Sub-Q or IM
-under 20kg=give 0.5mg
-over 20kg= give 1 mg
-D50 IV PRN
Hyperglycemia S/S
Mental/behavior changes, weakness, fatigue, polyuria, polydipsia, polyphagia, HA, enuresis, blurred vision
Insulin types
Rapid acting,Short acting, intermediate acting, long acting
Rapid acting insulin
Novolog(aspart), Humalog(Lispro)
Short acting insulin
Regular (Humulin R, Novolin R)
Intermediate acting insulin
NPH(Humulin N, Novolin N)
Long acting insulin
Glargine(Lantus)DO NOT MIX, detemir(levemir), degludec (Tresiba)
Proper insulin administration
Sub-Q, self administer 2 times or more/day. rotating sites Q 4-6 injections. 2 in from Umbilicus=best absorption.
Draw up short acting (clear) first then longer-acting insulin (cloudy)
-90 degree angle, pinch up skin if thin
DKA
Diabetic ketoacidosis
Acute life threatening condition, untreated hyperglycemia- rapid onset
Untreated=coma which can progress to death, high mortality
Physical and lab cues-DKA
Dehydration N/V, fruity breath, BS>330mg/dL, dyspnea, confusion, ketonuria
Management-DKA
Priority=stabilize glucose, rehydration, electrolyte balance
Nursing actions-DKA
-BGL monitoring-prevent from falling <100mg/dL/hr(causes cerebral edema)
-IVFs for dehydration tx, correct Na+ and K+, improve peripheral perfusion
-IV regular insulin drip and sliding scale
Trisomy 21
-Extra copy of chromosome 21
-Most common chromosomal abnormality associated with generalized syndrome
-medical conditions accompany: congenital heart malformation, hypotonicity, immune system dysfunction, thyroid dysfunction, leukemia
Trisomy 21 features
-upslanting palpebral fissures
-low-set , small folded ears
-flattened nasal bridge
-epicanthal fold
-small, typically white, spots arranged in a ring of iris(brushfield spots)
-short neck
-single palmar crease
Complications-trisomy 21
Aspiration, FTT, hypothyroidism, atlantoaxial instability, cardiopulmonary issues, hearing/vision impairments, behavioral problems, anemia, leukemia, frequent OM, sleep apnea
Trisomy 21 risk factors
Advanced maternal age >35, paternal age greater than 55 years
Priorities of care-trisomy 21
Preventing complications, promoting nutrition, G&D support and education
Neuro assessment
LOC, motor function, pupils
LOC-Neuro assessment
Pediatric coma scale
Lower the score, less responsive the child
Motor function-Neuro assessment
Decorticate, decerebrate, opisthotonic posturing
Decorticate posturing
Damage to cerebral cortex/lesion to corticospinal tracts above brainstem
-rigid flexion of arms held tightly to body; flexed elbows and wrists/fingers, plantar flexed feet, legs extended and internally rotated
-fine tremors or intense stiffness
Decerebrate posturing
Damage to brainstem and extrapyramidal tracts
-rigid extension and pronation of arms/legs, flexed wrists and fingers, clenched jaw, extended neck, possibly arched back
Opisthotonic posturing
Abnormal posturing caused by severe muscle spasms
-primarily affects infants and children due to immature nervous system
Pupils-Neuro assessment
Pinpoint, sunset, unilateral sudden dilation, anisocoria, dilated and reactive, dilated and fixed(mydriasis)
Pinpoint pupils
Poisonings, brain stem dysfunction and opiate use
sunset eyes
Sign of increased ICP- often associated with hydrocephalus
Dilated and reactive pupil
Seen after seizures
Mydriasis
Fixed and dilate pupils- brain stem herniation due to increased ICP
unilateral sudden dilation-pupils
Associated with intracranial mass (tumor)
anisocoria
Benign condition- naturally different sized pupils
Hydrocephalus
Not a specific brain disorder, but caused by an underlying condition
-excessive CSF within cerebral ventricles/subarachnoid spaces= ventricular dilation and IICP
Physical findings/cues-Hydrocephalus
-Lethargy, irritability
-poor feeding, vomiting
-altered, diminshed, change in LOC
-wide open, bulging fontanelles(infants)
-c/o HA (older children)
Macewen sign: “cracked pot”, suture separation with percussion
Macewen sign
“Cracked pot”- suture separations with percussion
VP shunt
Tx for hydrocephalus
VP shunt placement
Infection most common 1-2 months after placement
VP shunt assessments
Monitor for s/s infection, shunt malfunction(vomiting, drowsiness, HA), increased ICP
VP shunt complications
Blockage and infection(1-2mo after placement):
- inc VS, poor feeding/vomiting, dec responsiveness, seizures, local inflammation at shunt insertion site
-vomiting, drowsiness, HA typically r/t shunt malfunction
VP shunt complication tx
Infection: IV abx
If persistent s/s, shunt removed and external ventricular drain (EVD) placed until CSF=sterile
Increased ICP
normal=15-20mmHg
Early Clinical manifestations-Increased ICP
Headache, vomiting (projectile), blurred vision, dizziness, tachycardia, irritability, changes in LOC
Infants: bulging tense fontanelle, wide sutures and inc HC, dilated scalp veins, high-pitched cry
Late increased ICP manifestations
Posturing, fixed and dilated pupils, Cushing’s triad(irregular breathing, HTN, bradycardia)
Cushing’s triad
Irregular breathing, bradycardia, HTN
Cushing’s triad-Increased ICP
Late sign of brain stem herniation warning
Nursing actions-Increased ICP
Normal 5-15 mmHg
-keep head midline with HOB at 30 degrees
-minimal oral sx,NO nasal sx
-avoid coughing, sneezing, blowing nose
-stool softener to prevent valsalva
-calm,quiet .limit visitors, seizure precautions
-I&O’s
Monitoring-Increased ICP
Sensing device inserted through cranium to detect ICP; monitored closely, alarms on at all times, measures to dec ICP
Seizures
Three types
Seizure precautions (pad bed rails, O2 and suction at bedside)
-phenytoin
-fosphenytoin
Seizure types
Tonic-clonic, absence, febrile
Generalized seizures
Tonic-clonic, absence
Tonic-clonic seizures
Stiffening of limbs and violent jerking
-loss of swallow reflex
-piercing cry with LOC
-incontinence
-apnea/cyanosis
Post-ictal period=30min-2hrs of deep sleep; sore muscles; no recollection
Absence seizures
LOC 5-10 sec, motionless blank stare’ resembles daydreaming; may lip smack or twitch eyes/face; immediately resume previous activities
Febrile seizures
Rapid rise in temp to 102.2 or higher, lasting 15-20 sec once in 24 hr period without CNS infection, brief post-ictal period
Labs/diagnostics-seizures
Glucose, electrolytes, Ca+=rule out dec BS and dec Ca+
LP=rule out meningitis or encephalitis
Skull XR= fracture or trauma
CT/MRI= ID abnormality, bleeds, tumors
EEG= evaluate seizure type
Video EEG= evaluate behavior and “catch a SZ”
Nursing actions during seizures
Seizure precautions (pad side rails, O2, suction at bedside) phenytoin and fosphenytoin
Nursing actions post seizure
Maintain side-laying position
Suction mouth as needed
Reorient/calm child
LOC assessment
Assess WOB,VS,head position and tongue, injuries?
DO NOT OFFER FOOD/FLUIDS UNTIL FULLY AWAKE AND SWALLOW REFLEX HAS RETURNED
Medication management- seizures
Primary treatment=med therapy with single-drug therapy at lowest dose possible, doses change as child grows
Do not stop medications-breakthrough seizures
Phenytoin
IV or PO, NO IM
Monitor levels to ensure therapeutic dosing, gingival hyperplasia. Monitor Ca, Mg, folate; IV form in NS ONLY
Fosphenytoin
IM,IV
Less adverse effects than phenytoin; more expensive
-water soluble, does not precipitate
Quicker administration
Bacterial meningitis
Infection of meninges surrounding brain and spinal cord; medical emergency- prompt ICU admission and tx
Physical cues older children- bacterial meningitis
Sudden onset of S/S
-fever, chills, HA, vomiting, photophobia, stiff neck (nuchal rigidity), rash, irritability, drowsiness, lethargy, muscle rigidity , seizures
Physical cues-infants- bacterial meningitis
Fever, extreme sleepiness, bulging fontanelle, crying, seizures, poor suck or feeding, weak cry and lethargy, vomiting, inconsolable, opisthotonic positioning
Pin-prick rash
Shivering
Turning away form lights
Stiff neck
Arching back
Cold hands and feet
Labs/diagnostics-bacterial meningitis
Lumbar puncture
CBC
Blood/urine/NP CX
Positive Kernig and brudzinski sign
Presence of rash/purpura or Petechiae
Lumbar puncture-bacterial meningitis
Increased WBCs, decreased glucose, high protein, cloudy in color
Nursing priorities-bacterial meningitis
Treat infection
Nursing actions-bacterial meningitis
Droplet isolation; IV abx, manage hyperthermia, reduce ICP, ventilator support
Reye syndrome
Encephalopathy and liver failure associated with previous illness (viral) and ASA ingestion
Physical and lab cues=reye syndrome
Stage 1-5 progression
Severe vomiting/lethargy/confusion—>stupor—> fixed and dilated pupils/decerebrate—>parallysis, no pupillary response, resp arrest, death
Lab cues=inc LFTs (AST/ALT)
Inc ammonia, bilirubin,amylase/lipase,inc PT
Nursing management-reye syndrome
Supportive care (dec ICP, Kayexalate, vit K, FFP)
Priority of care- reye syndrome
Decreasing ICP, bleeding precautions (Vit K and FFP)
Spina bifida cystica
Visible defect with saclike protrusion of meninges, spinal fluid, and nerves with varying degrees of neuromuscular,limb, and sensory deficits
Meningocele vs myelomeningocele-spina bifida cystica
Meningocele=less serious form of spina bifida cystica, meninges and spinal fluid herniate though defect in vertebrae
Myelomeningocele=most severe form, not visible sac protruding from spinal area
Priority of care-spina bifida cystica
Prevent repture of sac
Meningocele-spina bifida cystica
Myelomeningocele-spina bifida cystica
Fractures-neurovascular assessment
Priorities of care-fractures
Neurovascular assessment, pain
Complications-fractures
Compartment syndrome-5P’s
5 P’s-fractures
Pallor, pain, paresthesia, pulselessness,
Scoliosis
Lateral curvature of the spine
Scoliosis-physical findings
Post-op care: scoliosis
Scoliosis procedure
Developmental dysplasia of the hip (DDH)
Risk factors: family Hx, firstborn, female, breech position
DDH
Developmental dysplasia of the hip, three kinds: dysplasia, dislocation, subluxation
Priorities of care-DDH
Neurovascular assessment, skin care, parent teaching
Assessment findings:DDH
Asymmetry of gluteal folds in prone position ; unequal umber of skin folds on posterior thigh; shorter affected limb, walk with limp (older child)
Teaching guidelines-DDH
Pavlik harness: do not adjust straps, must wear
Muscular dystrophy
Nursing management-muscular dystrophy
Priority of care- muscular dystrophy
Labs and diagnostics-muscular dystrophy
Cerebral palsy
Nursing priorities- cerebral palsy
