Peds Exam 4 Flashcards
What is amblyopia?
lazy eye, poor visual acuity in one eye caused by strabismus/ ptosis. can lead to blindness if uncorrected
What is the therapuetic treatment for amblyopia?
patches covering stronger eye/ atropine in the stronger eye
weakening the stronger eye forces the weaker eye to work harder
This sensory disorder is caused by the opacity of the optic lens. It is the leading cause of visual impairment and blindness in children.
Congenital cataracts
Your patient presents with opacity of the optic lens, cloudy cornea, and an absent red reflex. What do you suspect as the nurse?
Congenital cataracts
opacity of the optic lens can lead to amblyopia
What is the tx for congenital cataracts?
surgery, ideally before 3 months of age, as early as 2 weeks
How do you teach about the post op management of congential cataracts?
elbow restraints, ABX, steroids, eye patching, sunglasses to prevent UV ray exposure
patch the stronger eye after the operated eye has healed to strengthen the operated eye
What is infantile glaucoma?
patho
obstruction of aqeous humor flow, causing increased ICP, causing vision loss from retinal scarring and optic nerve damage
Your patient comes in with spasmodic winking, corneal clouding, enlargened eyeball with excessive tearing, frequent eye rubbing, keeping eyes closed, and a red reflex green/ grey in 1 eye. What do you suspect as the nurse?
Infantile glaucoma
What will be used to manage infantile glaucoma?
3-4 surgeries is 1st line tx
What will you teach post op to parents of a child with infantile glaucoma?
protect surgical site, elbow restraints, eye patch, bedrest, no rough housing, how to admin eye drops
What is proper nursing care of children with a vision impairment?
use child’s name to gain attention
identify presence before touching child
name and describe people/ objects/ activities so child is more aware of what is happening
use touch/ tone of voice appropriate to situation
use simple/ specific directions
use child’s body parts as reference
encourage exploration of objects through touch
Type of hearing loss where the transmission of sound through middle ear is disrupted, often caused by frequent OME or a ruptured TM
conductive
Type of hearing loss where there is damage to the hair cells in the cochlea, often caused by ototoxic meds (furosemide), meningitis, rubella
Sensorineural
Your patient comes in complaining of ears feeling full, hearing loss and balance disturbances and says “huh?” every time you ask a question. You also note during your assessment that the TM is dull, opaque, orange discolaration, visible fluid and air bubbles and decreased TM movement. What do you suspect?
Otitis Media with Effusion
How do you manage OME?
it should resolve on its own, check in 4 weeks. If it persists for three months, refer to ENT and assess for hearing loss/ speech delay
The parent of a patient with OME asks if she could give antihistamines, steroids, or decongestants to help with the symptoms. What do you teach her?
No! It does not help. Avoid bottle propping and feeding in a supine position
A patient presents with fever, ear pulling, irritability, poor feeding, lymphadenopahty, and a dull red bulging TM with decreased or no movement. The child also has had RSV recently. What do you suspect?
Acute otitis media
How do you manage acute otitis media?
Acetaminophen/ ibuprofen for pain and fever
Benzocaine drops if TM isnt ruptured
Warm/ cool compress
ABX (Amoxicillin, Azithromycin) PO 10-14days
What is a myringotomy and a tympanostomy?
small incision in TM, tubes to equalize pressure
What is the management for tubes?
General anesthesia, surgery, PACU, discharge in same day, post op pain uncommon
What are some post op teaching points for tubes?
Ear plugs when swimming, notify PCP if there is drainage from tubes, tubes remain in place for months and spontaneously fall out
What cues will you note for an infant with hearing loss?
wakes only to touch, doesnt babble around 6 mo
What cues will you note for a child with hearing loss?
doesnt speak by 2, communicates using gestures and relies on reading facial expression, doesnt respond to doorbell/ telephone
What cues will you note for an adolescent with hearing loss?
asks for things to be repeated, day dreams/ inattentive, poor school performance, monotone speech
What is the proper ear drop admin for a child under 3?
pull pinna back and down
What is the proper ear drop admin for a child over 3?
pull pinna back and up
What is a macule?
circular, flat discoloration < 1cm
What is a papule?
superficial solid elevated, less than 0.5cm
Plaque/ annular
ring with central clearing
vesicle
circulation collection of free fluid, less than 1cm
pustule
vesicle containing pus, pimple
What are the types of skin injuries?
abrasion, laceration, bites, bruises, burns
What are your risk factors for injuries?
poverty
prematurity <1yr
chronic illness
intellectual disability
parent w abuse/ substance abuse hx
extreme stressors
Be suspicious when…?
Injuries in uncommon locations
Bruises in infants < 9mo
Multiple injuries other than LEs
Frequent ED visits; delay in seeking care
Inconsistent stories
Usual caregiver – child interaction
injuries on butt, thigh, back
Sun safety in children
broadspectrum, oxybenzone free nonscented spf > 15
zinc oxide products for nose
hats, sunshirts
infants < 6mo out of direct sun
apply sunscreen 30 min prior, then q2hr or q60-80 min
What is the primary assessment for burns?
Airway
Breathing
Circulation
Airway patent, maintainable or unmaintainable
Assess for signs of airway injury or smoke inhalation
Respiratory effort, symmetry of breathing, breath sounds; Pulse oximetry, ABG, carboxyhemoglobin levels
Skin color, pulse strength, HR, perfusion status, edema; ECG if electrical burn
What is the secondary assessment for burns?
Burn depth
BSA
other injuries
What does a 1st degree burn look like?
(superficial thickness) epidermis, painful, pink- red, no blisters, blanches
What does a 2nd degree burn look like?
(partial thickness) damage to entire epidermis, painful, moist, red blisters, mild-mod edema, blanches
or
(intermediate thickness) entire epidermis and some dermis, painful, mottled, red-white with blisters and mod edema, blanches
What does a 3rd degree burn look like?
(full thickness) damage down to some subq, red, black, tan, waxy white, dry, leathery and no blanching
What does a 4th degree burn look like?
(deep- full thickness) all layers damaged, tendon and bone exposed, variable color, dry and dull, charring
What are the priorities of care with burns?
prevent hypothermia, wound care, manage pain, prevent infx, provide nutritional support, restore mobility, psychological support
review in notes, but yk this
What is atopic dermatits?
AKA eczema, inflammation caused by antigen response to environmental changes/ sweating. indicates secondary infx
What are the s/s of atopic dermatitis?
dry, scaly, purtitic skin with a rash/ erythema path on wrist, AC of arm, popliteal space. presence of wheezing is common (asthma)
What dx will you note for atopic dermatitis?
elevated IgE
What medications will you use to treat atopic dermatitis?
topical corticosteroids and immune modulators - tacrolimus
antihistamines @HS
What will you teach you patient who has atopic dermatitis?
avoid hot water, shower in warm water 2x/day
nonscented/ not dyed soap
pat skin dry, apply moisturizer often
cotton only clothes/ sheets/ etc
keep nails short
What are the phsyical cues of non-candida diaper dermatitis?
red shiny, within the diaper area
What are the physical cues of candida diaper dermatitis?
deep red lesions, scaly with satellite lesions (outside of diaper area), usually in creases & folds
How do you tx non candida diaper dermatitis? Candida?
Zinc oxide (skin barrier), Vitamin A/E/D ointment/ petroleum
Nystatin/ Antifungal/ Miconazole
What is the management for diaper dermatitis?
blow dry the area if candida
change diaper frequent
avoid rubber pants/ harsh soaps/ wipes
go diaperless to get some air to the area
What is the hx for acne?
fam hx, onset of acne, use of meds that exacerbate, hx of endocrine disorder, LMP
meds that exacerbate: steroids, androgens, lithium, phenytoin, isoniazid
What are the physical s/s of acne?
comedomes, pustules, hypertrophic scarring, oily skin/ hair
What are the meds that treat acne?
tretinion
benzyl peroxide
topical abx clindamycin
po abx tetracycline, erythromycin
isotretinion
oral contraceptives
How does tretinion affect acne?
interrupts abnormal keratinization that causes microcomedones
How does benzyl peroxide affect acne?
OTC, inhibits growth of P. Acnes
How does isotretinion affect acne?
for severe cases, teratogenic, inhibits sebaceous gland function
How does oral contraceptive effect acne?
decreases endogenous androgen production
What patient teaching will you give to a patient who has acne?
avoid oil based cosmetics and hair products
headbands/ helmets may exacerbate
balanced diet
clean skin with mild soap and water BID; shampoo hair regularly
avoid picking/ squeezing comedones
take topical meds as prescribed for 4-6 weeks
emotional counseling
monitor for infx/ cellulitis
What are some hx cues of immunodeficiency r/t frequency of certain infections?
4+ episodes of AOM in 1 yr
2+ episodes of severe sinusitis in 1 yr
2 episodes of PNA in 1 yr
2+ serious infx such as sepsis
If a child comes in with a hx of FTT as an infant, tx with abx for longer than 2 months with little/ no effect, requires IV abx to clear infx, has recurrent deep skin/ tissue abscesses and peristant oral thrush and skin candiasis at 1 year of age. Mom also has primary immunodeficiency. What do you suspect?
immunodeficiency
What are some lab cues of immunodeficiency?
ESR/ CRP, WBC differential
What does an increased ESR/ CRP detect?
presence of inflammatory response
What does an increased neutrophil detect?
ACUTE bacterial infx
neutrophils are the 1st line of defense against bacterial infx
What does an increased eosinophil detect?
allergic reaction
associated with antigen-antibody reactions
What does an increased T lymphocyte and B lymphocyte detect?
viral infx, or chronic bacterial infx
principle component of immune system
What are the different immunoglobulins?
IgG
IgA
IgM
IgE
GAME
What is IgG?
only one to cross placenta and trasnferred via breastmilk, protects against viruses, bacteria, toxins. lack of causes severe immunodeficiency
produced at 6mo -1 yr
What is IgA?
1st line defense against respiratory, GI, GU
pathogens produced at 3 mo
What is IgM?
most important in primary immune response, indicates active infx
produced before IgA
What is IgE?
increased in allergic states, parasitic infx, and hypersensitivity reactions
What is the patho behind severe combined immune deficiency? SCIDs
T and B cell function ABSENT
potentially fatal and requires emergency intervention
Your patient has a hx of persistent thrush, FTT, chronic diarrhea, and frequent infx. What do you suspect?
SCIDs
What levels will be low with SCIDs?
IgA and IgM, CMV is negative
What are some important interventions to provide to a patient with SCIDs?
prevent infx, admin IgG, bone marrow transplant desired
What are the physical findings of HIV?
HIV rapidly invades infants CNS, causing encephalopathy –> acquired microcephaly, motor deficits, and loss of previously achieved developmental milestones
A 19 mo old child presents to clinic with history of recurrent infections and fever of 102.4. HIV is suspected. What diagnostic tests would the nurse expect to be ordered for this child?
+ ELISA and Western Blot
9-month-old infant born to a mother with HIV presents to clinic with history of recurrent infections and fever of 102.4. What diagnostic tests would the nurse expect to be ordered for this child to check HIV status?
+ PCR and viral culture
What are the priorities of care for a child with HIV?
What is the patho behind Juvenille Idiopathic Arthritis?
autoimmune, body release antiinflammatory chemicals targetting synovium. may effect eyes/ other organs
Your patient presents with joint stiffness especially with inactivity or in the morning, irritable, withdraws from play, pain, swelling, severe anemia, poor weight gain, fever (103 for 2 weeks). What would you suspect as the nurse?
Joint Idiopathic Arthritis
What are the diagnostic labs for JIA?
elevated ESR/CRP and WBC
+ RA factor
+ ANA
CBC shows anemia
How do you manage JIA?
NSAIDs, Steroids, Antirheumatic (methotrexate, etanercept)
maintain and strengthen mobility (swimming), warm bath and compress @ HS, pain management, splints to prevent contractures
some antirheumatics are not approved for use in children
A patient has a reaction to peaches, but is not allergic to them. Why is that?
Patient must have an allergy to latex, 35% of these patients will have a cross reaction to kiwi, avocado, banana, peach, chestnut, fig, tomato, white potato
IgE response, forming and releasing cytokines
Patient is rushed into the ED, presenting with hvies, urticaria, angioedema, flushing, wheezing, mouth/ throat itching, and anaphylaxis? What do you suspect?
allergic reaction
What are the s/s of a severe, life threatening reactin? What is it called?
Anaphylaxis, respiratory compromise, low BP, Skin-mucosal tissue involvement, GI symptoms
How do you manage an allergic reaction in pediatric patients?
ABC’s, admin Histamine blocker and Epipen, airway, comfort
What do you teach the parents and patient about their allergic reaction?
have a written emergency plan
dietary consult
teach s/s of reaction and avoid triggers
plan for school/ daycare
A patient presents with a maculopapular rash that started on the face –> neck –> trunk –> arms -> legs –> feet, fever, and Koplik spots. The patient is coughing, has conjunctivits, malaise, and nasal inflammation. What do you suspect as the nurse?
rubeola (measles)
The nurse knows that these are complications of Rubeola?
PNA, diarrhea, encephalitis
What management techniques should the nurse plan for the patient who has Rubeola?
MMR vaccine (to prevent), antipyretics, supportive care, fluids, humidification, bedrest,
Post-exposure vaccination within 72 hours or immune globulin (IgG) within six days may reduce severity
What type of precautions will a patient with Rubeola have? How long will they be on these precautions?
airborn precautions until 4 days after the onset of rash
What will you give a hospitalized child who is 6mo-2 years old/ immunocompromised, who has Rubeola?
vitamin A
A mom brings her child in who has been experiencing a paryoxsymal cough (10-30x in a row) with a red face, cyanosis, protruding tongue when coughing, whooping cough, copious nasal/ oral secretions, with airway swelling and irritation. What do you suspect?
Pertussis
What medication class will you give to a patient with pertussis? What medication will you specifically give to a patient who is less than a month old?
Macrolides “-mycins”. Azithromycin if < 1 mo
What therapuetic management is used for patients with pertussis?
high humidity, droplet/ standard precautions, DTaP vaccine for all contacts less than 7 who are under/nonvaccinated
True or False: You should use a different site and a different device when assessing temperature.
FALSE, use same site and device
How do you assess temps in a patient with a fever?
assess temp q4-6hr when fever, and q30-60min after antipyretic med
keep linens dry and clean
admin ibuprofen and tylenol
use caution with ibuprofen in infants
What is lyme disease?
History of tick bite; Firm, discrete, pruritic nodule; Urticaria or localized edema
Your patient is experiencing erthema migrans @ bite site, chills, fever, HA, stiff neck, weakness. What stage of lyme disease are they at?
Stage 1; 3-30 days
Your patient is experiencing systemic involvement (neuro, cardiac, MS); paralysis/ weakness in the face; muscle pain; swelling in joints; fever, fatigue, splenomegaly. What stage of Lyme disease are they in?
Stage 2; 3-10 weeks
Your patient has advanced systemic involvement; MS pain, arthritis, deafness, cardiac complications, encephalopathy, speech issues. What stage of Lyme disease are they in?
Stage 3; 2-12 mo
What is the tx for Lyme disease for children over 8? Under 8? How long is their treatment regimen?
Doxycycline for over 8
Amoxicillin for under 8
(or Cefuroxime if there is an allergy)
14-28 days
What are the physical cues of pediculosis capitus?
extreme puritis, small red bumps on scalp, white specks attached to hair shaft, lice visible behind the ear or back of neck
What is the management of pediculosis capitus?
contact precautions
follow exact directions of pediculide, repeat if severe, lice comb hair q2-3 days, treat linens/ toys
Describe contact precautions.
diseases transmitted when in close proximity to patients or their environment (pediculosis capitus)
don gown and gloves before entering, dof before leaving room
Describe droplet precautions.
diseases caused by large droplets, generated by coughing, sneezing or talking, mask if within 3 feet (pertussis)
Describe airborn precautions.
used for infectious pathogens that remain suspended in the air & can travel great distances. N95 and negative pressure room (rubeola / measles)
Immunizations are what type of prevention for communicable diseases?
Primary
What is the patho behind acute lymphoblastic leukemia?
overproduction of immature WBC (leukoblasts) w/ neoplastic characteristics, leading to organ/ tissue infiltration
CASE STUDY
Your patient comes to the ED presenting with the following s/s:
low grade fever
s/s of infx
pallor
bruising/ petechia/ purpura
enlargened liver and lymph nodes
You just got their labs back, they are listed below:
CBC: low Hgb, low Hct, low RBC, low platelets, high WBC
bloor smear: + leukoblasts
LP: + leukoblasts
CXR: detects PNA and mediastinal tumor
Bone Marrow Aspirate: lymphoid and myeloid cell type, prolific quantities of blasts.
What do you suspect as the nurse?
Acute Lymphoblastic Leukemia
BMA is the most definitive way to test for leukemia
What is the patho behind lymphoma?
abnormal cell growth in lymphatic system, resulting in altered immune response nd increased r/f infx
A patient will have the following complaints in their history with lymphoma…
frequent night sweats, unintentional weight loss, Epstein Barr infx, frequent infx, immunodeficiency
CASE STUDY
A 16 year old patient comes in for a doctors appointment. They have an unexplained fever, cough, SOB, puritis, splenomegaly, hepatomegaly, painless enlarged supraclavicular/ cervical lymph nodes (sentinel nodes).
The doctor has a feeling they know what the patient has, so they order a lymph node biopsy. It comes back positive for reed sternberg cells.
What does the patient have?
puritis occurs d/t cytokine release
Lymphoma
The nurse prepares for a BMA by…?
prone position iliac crest (may use tibia in infants)
Local/topical anesthetic & Conscious sedation meds (Fentanyl/Versed)
Explain procedure/Comfort/Infx prevention
Hold pressure/pressure dressing & Monitor for bleeding & infection
What are the pre op nursing interventions for a brain tumor?
Monitor for ↑ ICP and manage accordingly
Steroids to decrease intracranial swelling
Pre-op teaching/Emotional support
What are the post op nursing interventions for a brain tumor?
I&Os, frequent V/S with pupil and LOC checks, monitor for increased ICP
treat hyperthermia with antipyretics, pain management, treat HA with analgesics
position on unaffected side at level ordered by provider, keep head midline
JP drain monitoring and care
What is Wilm’s tumor?
aka nephroblastoma, malignancy occuring in abdomen (kidneys) usially right sided unilateral and deep in flank
CASE STUDY
3-year-old presents to clinic with reported firm, nontender abdomen that was assymetrical, vomiting and weight loss. Other s/s include hematura, HTN , and dyspnea with cough. When asked about pain, the patient pointed to his chest.
Your team decided to get diagnostics and they are listed below:
ultrasound, CT, and MRI all show a renal mass
CBC: anemic
UA: + WBC + RBC
24 hour urine negative for HVA and VMA.
What do you suspect the child’s diagnosis will be?
Wilm’s Tumor
What key nursing intervention should be done for a patient with Wilm’s tumor?
do NOT palpate abdomen, hang a sign above the door and bed saying so as well, as palpation can rupture the tumor
What are some neutropenia precautions?
Hand hygeine
vitals q4hr and assess for signs of infection q8hr and PRN
Avoid rectal temps, enemas, suppositories, urinary catheters, and invasive procedures
No raw fruits, vegetables, fresh flowers, or live plants in room
Restrict visitors, mask on child when outside room
Soft toothbrush
What are some adverse effects of chemo?
Anemia- limit blood draws, iron rich food, Epoetin admin
Thrombocytopenia- avoid rectal temps and meds, IM, LPs, avoid ASA and NSAIDs, give acetominophen instead
Neutropenia- private room, hand hygeine, abx prophylactic
ANC < 1000
N/V/D- bland dry food, small frqnt meals, ice, carbonated drinks, popsicles, relaxation and guided imagery
What are some patient teaching points for radiation? Whats a common complication?
Wash skin with mild soap & water
Avoid lotions/powders/ointments, sun/heat exposure, use aloe vera
Diphenhydramine or hydrocortisone cream for itching, Antimicrobial cream to desquamation
Altered skin integrity
What are the s/s of iron deficient anemia?
pallor, MM, conjuctiva, spooning of nails, dizziness, SOB, Weakness, unstead gaist, difficulty feeding/ pica, HA, irritable
What are the labs for iron deficiency anema?
RBC, Hgb, Hct, MCV/ MCH, Ferritin decreased
RDW increased
What management should be used for treating anemia?
feed only formula fortified with Fe+
supplement Fe+ in breast fed infants by 4-5 mo, encourage moms to increase iron
> 1 yr old, less than 24 oz/cow milk/day
encourage Fe+ rich foods (beef, leafy greens, apricots)
place Fe supplements behind teeth to avoid staning, increase fiber and fluids d/t constipation, dark green stools normal
What are your physical cues of Hemophilia A?
(hemarthrosis) swollen/ stiff joints
multiple bruises
hematuria
bleeding gums/ sputum/ emesis
black tarry stool
chest/ abd pain (internal bleeding)
What is your only abnormal lab cue for hemophilia?
PTT, itll be greater than 35 seconds
What is the tx for hemophilia?
First, factor VIII admin (slow iV push)
Mild cases: Desmopressin
Desmo triggers the endothelium of blood vessels to release factor VIII
How do you manage a bleeding episode with hemophilia?
apply direct pressure to external bleeding, RICE to joint bleeding
What is sickle cell vaso occlusive crisis?
circulation of blood vessels is obstructed by abnormally shaped RBCs causing ischemia and infarction. RBC lysis occurs.
CASE STUDY
Your patient presents with extreme fatigue, irritability pain (abdomen, thorax, joints, digits) dactylitis (severe finger/ toe swelling) cough, increased WOB, fever, tachypnea, hypoxia
splenomegaly, jaundice (from hemolysis) or pale conjuctiva/ palms/ soles/ feet.
Her labs are presented below:
Hgb decreased
Hct decreased
Platelets increased
ESR decreased
Reticulocyte count increased
Bilirubin increased
What do you think she has? How should you manage it?
Sickle cell vaso occlusive crisis
Pain control on a regular schedule Hydration doubled (150ml/kg/day)
Hypoxia, O2 NC if SpO2 is < 92%
What are your risk fators for lead poisoning?
live in home built before 1956, live near busy road, toys/ imported products, poverty/ malnutrition, age, pica
What are the s/s of lead poisoning?
abd pain/ cramps, irritability, decreased appetite, V, ataxia, hematuria, new onset of seizures
What is chelation therapy?
tx for lead poisoning (blood lead levels > 45 ug/dL)- removes lead from soft tissue and bone then excreted via kidneys
What are the meds for chelation therapy? What do you need to monitor for as the nurse?
Succimer/ Dimercaprol/ Adetate calcium disodium
Adequate fluid intake, I&Os
