Peds Exam 3 Flashcards
Production of what causes growth plates to fuse?
Androgens
What is the mildest form of Developmental Dysplasia of Hip (DDH)?
Dysplasia; femoral head remains in acetabulum (socket)
What are some assessment findings of DDH?
When baby on a flat surface:
Asymmetry of gluteal folds in prone position
Unequal number of skin folds on posterior thigh
Affected limb shorter, older kids walk with limp
Positive Ortolani and Barlow signs
What’s an Ortolani maneuver?
“clunk” when femoral head relocates back into the socket (with abduction)
What’s a Barlow maneuver?
“clunk” when femoral head slips out of the socket (dislocated with adduction)
What type of DDH is it when the femoral head does not have contact with the acetabulum and is displaced posteriorly?
Dislocation
What type of DDH is most common?
Subluxation; incomplete dislocation of the hip with intact femoral head
What are the priorities of care for DDH?
Neurovascular assessment (sensation, skin temp, color, cap refill, pulses, movement)
Skin care
Parent teaching
Why is neurovascular assessment and skin care important in DDH patients?
Because the management of this requires harness/cast/traction depending on their age and severity
What’s a Pavlik Harness?
Chest harness that abducts legs. Worn full-time for up to 12 weeks
DDH management for newborn - 6 months
What are some important parent teaching about Pavlik Harness?
Do not adjust straps
Harness must be used continuously until instructed by provider
Change diaper while in harness
Place baby on back for sleep
Check skin folds for redness, irritation or breakdown. Keep skin dry and clean
Baby may be bathed while harness is off but it requires provider permission
What are the big education points for Pavlik Harness?
Keep baby in it full time and not take it off unless instructed by provider
Keep skin clean and dry to prevent breakdown
When do parents need to contact provider regarding their baby in Pavlik Harness?
Baby’s feet are swollen or bluish
Harness appears too small
Skin raw or a rash develops
Baby unable to actively kick their legs
What is cerebral palsy?
Nonprogressive impairment of motor function, especially muscle control, coordination and posture
What abnormalities can cerebral palsy cause?
Abnormal perception and sensation, visual, hearing and speech impairments
Seizures and cognitive disabilities
What are some physical cues of cerebral palsy?
Failure to meet developmental milestones
Persistent primitive reflexes
Gagging or choking with feeding, poor suck reflex
Poor head control
Rigid posture & extremities
Arching back
Strabismus
What are the nursing priorities when caring for cerebral palsy patients?
Oxygenation/ventilation - positioning, suctioning, IS, aspiration precaution
Pain management - muscle spasms
Adequate nutrition
Skin care - reposition, monitor under splints/braces
Communication - picture boards, touch screen computers
Psychosocial - promote independence
Developmental - monitor developmental milestones, interact based on developmental age, not chronologic
Why are oxygenation and ventilation important in patients with CP?
It’s a motor/muscle-related disorder; they have difficulty breathing deeply.
They are prone to gagging and chocking due to poor suck reflex, which puts them at aspiration risk
What are some medications that are used to treat muscle spasms r/t CP?
Baclofen - centrally acting skeletal muscle relaxant
Botox - reduces spasticity in specific muscle groups
Carbidopa - dopaminergic that promotes relaxation of muscles
What are some complications of CP?
Seizures
Delayed growth and development
Hydrocephalus
Aspiration
Injury r/t limited mobility
What is muscular dystrophy?
Group of inherited disorders of progressive muscle weakness and wasting
What’s the most common form of muscular dystrophy?
Duchenne MD; onset 3-5 yrs of age with life expectancy into early adulthood
Absence of what causes progressive weakness of voluntary muscle in muscular dystrophy?
Dystrophin.
Fat tissue replace lower limb muscles
What are the labs/diagnostics used in muscular dystrophy?
Serum CK - levels high early before muscle wasting occurs
Electromyography (EMG) - reveals nerve/muscle dysfunction
Muscle BX - definitive dx showing absence of dystrophin
DNA testing - positive for dystrophin gene mutation
Which lab is used for definitive diagnosis of muscular dystrophy?
Muscle biopsy
What are some voluntary muscles affected by muscular dystrophy?
Hips, thighs, pelvis, and shoulders initially
Where does muscle weakness begin in muscular dystrophy?
In lower extremities
What’s the Gower’s sign for muscular dystrophy?
Observing child getting up from the floor. They will use all limbs to get up
What is the primary goal of muscular dystrophy?
Promote mobility, maintain cardiopulmonary function, prevent complications, and maximize QOL
What are the nursing priorities for muscular dystrophy?
Optimize physical function (ROM, strength/muscle training)
Oxygenation/Ventilation (breathing exercises, cough devices)
Adequate nutrition (lowe calorie, high protein & fiber)
Skin care (repositioning)
Psychosocial (respite/palliative, end-of-life)
Why is oxygenation and ventilation important in pt with muscular dystrophy?
Muscle atrophy is progressive; that includes muscles to breathe adequately and those smooth muscles to keep beating
What’s the nutritional need for pt with muscular dystrophy?
Low calorie, high protein and fiber
Because their mobility is limited
What are the complications of muscular dystrophy?
Respiratory compromise
Obesity
Contractures
Scoliosis
Infections
What are the physical findings for scoliosis?
Asymmetry in shoulder height
Prominence of one scapula
Uneven curve of waistline
Rib hump on one side
What is included in scoliosis post-op care?
Frequent neurovascular assessment of extremities
VS
Log rolling only to prevent damage to hardware
Pre-medicate before ambulation or moving
PCA pump
Wound care and assessment for any drainage around operation site and drainage tubes
When do girls need to be screened for scoliosis?
Age 10-12
When do boys need to be screened for scoliosis?
Age 13-14
What indicates surgical intervention for scoliosis?
For severe lateral curves (> 45 degrees), bracing not helping, cardiac or respiratory compromise
How long should scoliosis brace need to be worn?
18 hrs/day
What type of device will the scoliosis post-op patient have?
Hemovac
Why should we type and crossmatch scoliosis surgery patient?
Severe blood loss is anticipated with surgery
What is spina bifida?
Midline defect with failure of osseous body to close
What is spina bifida cystica?
Visible defect with saclike protrusion of meninges, spinal fluid, and nerves with varying degrees of neuromuscular, limb and sensory deficits
What is meningocele?
Meninges and spinal fluid herniate through defect in vertebrae
Usually minor or no neurological deficits
What is the less serious form of spinal bifida cystica?
Meningocele
What’s the most severe form of spina bifida?
Myelomeningocele
Lack of what causes spina bifida?
Prenatal care and folic acid
What’s the difference between meningocele and myelomeningocele?
Meningocele usually has minor or no neuro deficits, while myelomeningocele has varying degrees of neuromuscular, limb, and sensory deficits
What’s the priority of care for meningocele?
Sac care; Prevent rupture of sac, prone positioning before and after surgical repair
Monitor head circumference and monitor signs of increased ICP
Can surgery be delayed for meningocele patients?
Yes; as long as pt has normal neuro function and sac intact
What should the nurse do if there is a leakage from the sac in meningocele patient?
Immediately report to provider to prevent infection
Can surgery be delayed in pt with myelomeningocele?
No. surgical closure is needed as soon as possible after birth to prevent infection and trauma to the sac
While waiting on myelomeningocele surgery, the nurse should do what to prevent rupture of sac?
Frequent NS moistened dressings
Keep sac moist and prevent rupture
What is one big thing to monitor for when caring for post-op myelomeningocele patient?
Latex allergy
What position is recommended for both pre and post-op myelomeningocele pt?
Prone or supported on side
Why do we have to avoid swaddling and blankets on babies with myelomeningocele?
To monitor sac continuously for drying out
Instead of swaddling the myelomeningocele baby, what can you do to keep them warm and continue to monitor sac from drying out?
Keep in warmer or in isolette
In what position can we put baby into to prevent sac from being soiled by urine or stool?
Prone
May have to place plastic wrap below lesion to prevent contamination
After myelomeningocele surgery, can mom hold infant in normal position for breastfeeding/bottle feeding?
Yes. It is encouraged to keep parent-baby bond
What are the priorities of care for fractures?
Promote & monitor tissue perfusion (NV assessment on regular schedule)
Pain management
Infection prevention & monitoring
Promote mobility
Pt/family support & education (proper crutch use, signs to report. etc)
What are the components of Neurovascular assessment?
Sensation
Skin temp
Skin color
Spontaneous movement
Capillary refill
Pulses
What are the 2 complications of fracture?
Compartment syndrome
Osteomyelitis
What are the 5 P’s of compartment syndrome?
Pain (unrelieved with elevation of analgesics & increases with passive movement)
Paresthesia (early sign)
Pulselessness (distal to fx)
Paralysis
Pallor (cold skin, cyanotic nail beds, delayed cap refill)
What are the late signs of compartment syndrome?
Pallor, paralysis and pulselessness
What is the 2nd most common injury in child physical abuse?
Fractures
What disorder is caused by growth hormone deficiency?
Hypopituitarism
What is the pathophysiology behind hypopituitarism?
Pituitary not making enough GH -> impairs body’s ability to metabolize protein, fat, carbs -> hypoglycemia -> retarded bone age -> delayed maturation
What are the physical cues of hypopituitarism (GH deficiency)?
Large/prominent forehead
Underdeveloped jaw
High-pitched voice
Delayed sexual maturation
Delayed dentition/skeletal maturation
Decreased muscle mass
How is GH deficiency diagnosed?
Skeletal survey: 2+ SD<normal in bone age
CT/MRI: rule out tumors/other abnormalities
Pituitary Function Test to confirm
Growth Chart deviations
What medication is used to treat/manage GH deficiency?
Biosynthetic GH; Somatropin SubQ injection
What is the safe range of Somatropin?
0.18-0.3mg/kg/week
Divided in equal daily doses
How often should you check the height of the patient receiving Somatropin?
Q3-6 months
What time of day is Somatropin usually given?
At night (kids grow when they sleep)
When is Somatropin continued until?
Growth rate < 1in/yr
Bone age of > 16 yrs in boys or
age of > 14 yrs in girls
What are the physical cues of congenital hypothyroidism?
Macroglossia
Coarse facial features
Hypothermia
Constipation
Periorbital puffiness
Cool, dry, scaly skin
RR distress, bradycardia
Large fontanelles; delayed closure
What can happen if congenital hypothyroidism is untreated?
Intellectual disability, delayed physical maturation, short stature, growth failure
What is the goal of treatment for congenital hypothyroidism?
Prevent intellectual disability and restore normal growth and motor development
Why is newborn screening for thyroid function important?
Early detection is key for congenital hypothyroidism to prevent intellectual disabilities and growth problems
What is the expected lab value for a baby with congenital hypothyroidism?
Low FT4, high TSH
What medication is used to treat congenital hypothyroidism?
L-Thyroxine
How should you give L-thyroxine to babies?
Crush and place in small amount of formula or breastmilk; this med only comes in pill form
What is the education focus for congenital hypothyroidism?
Medication compliance, routine TFTs and developmental screens
Is thyroid hormone level monitoring a lifelong thing for congenital hypothyroidism patients?
Yes, because you can experience both hypo and hyperthyroidism symptoms depending on your body’s condition and stuff
Why should you not put meds into the whole bottle of feeding?
Baby may not finish the entire bottle. That leads to altered dosage of medications consumed
Missed dose of L-thyroxine can lead to
Developmental delay/poor growth
What type of formula/supplements do patients with congenital hypothyroidism avoid?
Soy-based formulas, fiber, calcium, iron preparations and antacids
Affect L-thyroxine absorption
What are the priorities of care for Trisomy 21?
Preventing complications
Promoting nutrition
Growth and development, support and education
What are some complications of Trisomy 21?
Aspiration - due to small mouth, large tongue, poor suck/tone, increased nasal stuffiness)
Hypothyroidism
Atlantoaxial instability
Cardiopulmonary issues
Hearing/vision impairments
What can you do to promote nutrition for Trisomy 21 patients?
Monitor GI conditions
Routine dental care Q6 months and daily teeth brushing
Regular diet and exercise
In Trisomy 21 patients, what symptoms require immediate attention?
Neck pain, unusual head/neck posturing, change in gait, loss of upper body strength, abnormal reflexes or changes in bowel/bladder function
Could be spinal cord injury due to atlantoaxial instability
How can DM cause dehydration?
Elevated glucose levels in blood -> cause osmotic fluid loss from cells -> intracellular dehydration
What is the overall goal of DM management?
Optimal serum glucose
Normal G&D
F/E balance
Prevent complications
Near normal A1C
What are the expected lab findings in DM 1?
BS >200
Fasting glucose > 126
HbgA1C > 6.5%
Glucosuria, ketones
Low C-peptide (this is the indicator of pancreatic insulin secretion)
Why is weight loss important in DM 1?
Because of breakdown of fat and protein due to not enough glucose available for body
What is DKA?
Acute, life-threatening condition characterized by BS >330, glucosuria and acidosis -> breakdown of fat for energy and accumulation of ketones in blood, urine and lungs
Can DKA patients stay at a regular unit?
No. If s/s of DKA, they need to be in PICU
What needs to be monitored in DKA patients to prevent cerebral edema?
Hourly BS checks; BS can’t fall more than 100/hr because it can cause cerebral edema
Why is IVF given to DKA patients?
To treat dehydration
Correct Na+ and K+
Improve peripheral perfusion
Which insulin cannot be mixed with other insulins?
Glargine (Long acting)
What are the generic & brand names of rapid acting insulin?
Aspart (NovoLog)
Lispro (Humalog)
Glulisine (Apidra)
What are some examples of short acting insulin?
Regular (Humulin R, Novolin R)
What are some examples of intermediate acting insulin?
NPH (Humulin N, Novolin N)
What are some examples of long acting insulin?
Glargine (Lantus)
Detemir (Levemir)
Degludec (Tresiba)
What are some s/s of hypoglycemia?
BS <60
Shakiness, lightheadedness, hunger
Headache, blurred vision
Pallor, cool, clammy skin
irritability, anxiety, decreased LOC
Tachycardia, palpitations
Normal - shallow respirations
How do you manage hypoglycemia if child is coherent?
Give glucose paste/tablets or 10-15g of simple carb (Ex. milk, OJ), followed by complex carb (peanut butter and crackers)
What do you need to do if a child is hypoglycemic and incoherent?
Glucagon subQ or IM
Under 20kg - 0.5mg
Over 2-kg - 1mg
D50 IV PRN
What is the main medication used in DKA?
IV regular insulin via titrated infusion based on protocol sliding scale
What are the 5 categories in pediatric LOC?
Full Consciousness
Confusion
Obtunded (limited responses to the environment and falls asleep unless stimulation provided)
Stupor (only responds to vigorous stimulation)
Coma (can’t be aroused even with painful stimuli)
What are the 3 categories of motor function assessment?
Decorticate posturing
Decerebrate posturing
Opisthotonic
What is the cause of decorticate posturing?
Damage to cerebral cortex or lesion to corticospinal tracts above brainstem
Rigid flexion of arms held tightly to body, flexed elbows/wrists/fingers, plantar flexed feet, legs extended and internally rotated, and possibly fine tremors or intense stiffness is an indicator of
Decorticate posturing
What is the cause of decerebrate posturing?
Damage to brainstem and extrapyramidal tracts
Rigid extension and pronation of arms/legs, flexed wrists and fingers, clenched jaw, extended neck, and possibly arched back is an indicator of
Decerebrate posturing
What is opisthotonic?
Abnormal posturing caused by severe muscle spasms primarily affecting infants and children due to an immature nervous system
What does pinpoint pupil indicate?
Commonly observed in poisonings, brainstem dysfunction and opiate use
Which pupil change is a sign of increased ICP and often associated with hydrocephalus?
Sunset eyes
Which pupil change can be associated with an intracranial mass?
Unilateral sudden dilation
What is anisocoria?
A benign condition where pupils are naturally different sizes
What do dilated but reactive pupils mean?
Usually seen after seizures
What do dilated and fixed pupils (Mydriasis) mean?
Associated with brainstem herniation due to increased ICP
What are the clinical manifestations of increased ICP?
Decreased pulse
Increased temperature
Decreased RR
Increased BP
Increased head circumference
Enlarged fontanelles
Separated suture line
Sunset eyes
Shrill cry
Hyperactive reflexes
Lethargy/irritability
What are the early signs of increased ICP?
Headache, vomiting (possibly projectile), blurred/double vision, dizziness, decrease pulse and RR
What are the late signs of increased ICP?
Lowered LOC, decreased motor and sensory responses, bradycardia, irrigular respirations, Cheyne-Stokes respirations, posturing, fixed and dilated pupils
What’s normal ICP?
5-15 mm Hg
What’s Cushing Triad?
Irregular breathing
Hypertension
Bradycardia
What are the measures to decrease ICP?
HOB at least 30, avoid suctioning, crying, decrease stimulation, no nose blowing, ICP monitoring, mannitol/hypertonic saline, seizure precautions, sedation and analgesia
How is ICP monitored?
Using EVD or bolt-like thing.
EVD can drain CSF, bolt cannot
In infants, poor suck/feeding, weak cry and lethargy, vomiting, inconsolable, opisthotonic posturing, fever, pin-prick rash, eyes turning away from lights, stiff neck, extreme sleepiness, bulging fontanel indicates
Bacterial meningitis
What are the s/s of bacterial meningitis?
Sudden onset of fever, chills, headache, vomiting, photophobia, stiff neck, rash, muscle rigidity, seizures, or history of URI or sore throat
What is positive Kernig sign?
Elicits pain or limited extension when prone, knee and hip flexed to 90 degrees, and trying to extend the knee in the air
What is Brudzinski sign?
Elicits hip and knee flexion when passive flexion of neck.
Pain response because menenges are being pulled when neck is flexed.
What are the expected lumbar puncture values in bacterial meningitis?
Elevated WBCs (infection)
Decreased glucose (bacteria eat glucose)
Increased protein (bacteria attracts protein)
Cloudy in color
Why do we do CBC, blood/urine/NP culture in bacterial meningitis patient?
To identify the source of infection, rule out sepsis
What’s the rule of bacterial meningitis management?
Managing and monitoring
What kind of precaution is required for bacterial meningitis?
Strict droplet
Until 24 hr of abx or order to discontinue isloation
What do we manage and monitor for bacterial meningitis?
ICP, s/s of shock, seizures, hyperthermia
What medication is used to treat bacterial meningitis?
IV broad-spectrum antibiotics after all cultures
What are the s/s of Reye syndrome?
Encephalopathy, cerebral edema, increased ICP, liver failure, hepatomegaly
What causes Reye syndrome?
Past viral infection + aspirin use
What are the expected lab values in Reye syndrome?
Elevated liver panel
Hyperammonemia
Hypoglycemia
Increased prothrombin time
What is the pathophysiology of hyperammonemia and encephalopathy?
Ammonia usually filtered by liver -> can’t due to liver failure -> hyperammonemia -> encephalopathy
Nursing management of Reye syndrome focuses on
Measures to decrease ICP and supportive care for the sequelae related to liver failure
We’re treating symptoms; not cure
A 16 year old is experiencing severe, persistent vomiting, lethargy, positive babinski, sluggish pupils and hepatomegaly. What condition is he likely to be experiencing?
Reye Syndrome
Hyperammonemia may be treated with
Lactulose (osmotic laxative)
But may need hemodialysis if >500
What 2 things can be used to treat coagulopathy r/t Reye syndrome?
Fresh frozen plasma (FFP)
Vitamin K
What is hydrocephalus?
Accumulation of excessive CSF within the cerebral ventricles and/or subarachnoid spaces, which leads to ventricular dilation and increased ICP
Why is early identification of hydrocephalus critical?
To prevent brain tissue damage from increase ICP
What are some physical cues of hydrocephalus?
Wide, open, bulging fontanels
Large head or recent change in head circumference
Thin, shiny scalp with prominent, visible scalp veins
Sunset eyes
Seizures
How is hydrocephalus managed?
Using ventriculoperitoneal (VP) shunt
What are some signs of VP shunt infection/obstruction?
Increased ICP
Poor feeding or vomiting
Drowsiness, headache
Local inflammation at shunt insertion site
Decreased responsiveness
Seizure
What is the most common complication of VP shunt?
Shunt tubing obstruction
When does shunt infection most commonly occur?
1-2 months after placement
But can occur any time as well
What is shunt infection treated with?
IV antibiotics
What happens if shunt infection is persistent?
Remove shunt and place EVD until CSF is sterile
What is a seizure?
Disrupted electrical activity in the brain that occurs from an imbalance between excitatory and inhibitory mechanisms
What is a generalized seizure?
Involves entire brain; absence, tonic, clonic, tonic-clonic, myoclonic, and atonic
What’s a febrile seizure?
Seizure caused by fever
Most common type of seizure in children
What should you do during a seizure?
Protect pt from injury; loosen restrictive clothing
Side lying position
Patent airway
Oral suction, O2
Do not attempt to open jaw or insert airway
Remove glasses
Remain with pt and calm, reassure caregiver
What should you do after a seizure?
Maintain side lying position
Monitor VS, breathing, head position, tongue
Assess for injuries
Neuro check
Rest/reorient/calm child
NPO until fully awake & swallowing reflex returns
How long does febrile seizures last?
15-20 seconds once in 24 hr period
Brief postictal period
Lab/diagnostics for seizure
Glucose, electrolytes, Ca2+
LP to rule out meningitis
Skull XR to rule out fx and trauma
CT/MRI for abnormality, bleeding, tumors
EEG to evaluate seizure type
Video EEG to evaluate behavior
What are some questions/things to know when seizure activity is observed?
Time of onset and length
Behaviors
Precipitating factors (fever, fall, activity, etc)
Description of movements and respiratory effort
Changes in color
Position of mouth
Loss of bowel/bladder control
State of LOC
Orientation
Duration of postictal state
Frequency of seizure
What are the 2 anticonvulsants used for seizures?
Phenytoin and Fosphenytoin
Which anticonvulsant do you need to monitor for serum levels to ensure therapeutic dosing?
Phenytoin
Which anticonvulsant has less common A/E and allow faster and easier administration?
Fosphenytoin
When using phenytoin, what do you need to watch for?
Gingival hyperplasia
If on prolonged phenytoin therapy, you need to make sure the patient takes adequate
Vitamin D containing food
What is the most common of all seizure types?
Tonic-clonic
What type of seizure starts with phase where body & limbs stiffen, piercing cry and loss of swallowing reflex to phase with violent jerking of body and incontinence?
Tonic-clonic
Tonic-clonic seizure has _______ postictal period
Long
What type of seizure is motionless, blank stare with minimal change in behavior; resembles daydreaming?
Absence seizure
Which seizure lasts 5-10 seconds and immediately resumes previous activities with no postictal period?
Absence seizure
