Peds exam 44444444 Flashcards
How far should the child stand away from the Snellen Chart?
10 ft
What’s amblyopia?
Lazy eye
What can happen if amblyopia is not corrected?
Reduced visual acuity in one eye & blindness in one or both eyes
How is amblyopia corrected?
Patching the stronger eye for several hours a day
Atropine drops in the stronger eye daily
Vision therapy
Eye muscle therapy
What’s the science behind the amblyopia treatment?
You weaken/restrict your stronger eye so the weaker eye can work and get stronger
What does the atropine drop do to the eye?
Blurs vision
What causes infantile glaucoma?
Obstruction of aqueous humor flow, leading to high intraocular pressure
What’s the patho behind infantile glaucoma?
Obstruction of aqueous humor flow -> high IOP -> optic nerve damage due to pressure & retinal scarring due to low aqueous humor
What’s one big assessment finding of infantile glaucoma?
Red reflex may appear gray or green
What are some general assessment findings of infantile glaucoma?
Keeping eyes closed
Frequent eye rubbing
Spasmodic winking
Excessive tearing or conjunctivitis
Corneal clouding
Enlargement of eyeball (pressure)
How is infantile glaucoma managed?
Surgery is the first line management. May need 3-4 surgeries
What are some post-op care for infantile glaucoma?
Protect surgical site: eye patch, elbow restraints, distractions
What discharge education is needed for parents with post-op infantile glaucoma patient?
How to administer eye medications
No rough-housing or contact sports for 2 weeks
How do you properly administer ear drops in kids age < 3 yrs?
Pull ear down & back
How do you properly administer ear drops in kids age > 3 yrs?
Pull ear up & back
What’s the patho behind congenital cataract?
Optic lens opacity, preventing light from entering into eye
Will lead to severe amblyopia if not treated
What are the 2 assessment findings of congenital cataract?
Cloudy cornea
Absent red reflex in affected area
Is cataract surgery earlier the better?
Yes. Best outcome if done within 3 months of life; can be done as early as 2 weeks old.
How is congenital cataract managed?
Surgical removal of cataract and placement of implantable lens
What are some cataract post-op care?
Site protection: eye patching, elbow restraints
Eye patching of good eye may be done after healing to strengthen vision of operated eye
What are some parent education needed for cataract post-op patients?
How to administer antibiotic and steroid drops
Wear sunglasses when going outside to protect from UV rays
What are some assessment findings of Acute Otitis Media (AOM)?
Decreased or no TM movement
Pain (ear rubbing and pulling)
Dull, red, bulging TM
Fever
Lymphadenopathy of head/neck
Purulent drainage may be visible behind TM, or canal if TM ruptured
Which Otitis Media is infectious?
Acute Otitis Media; this hurts more
What’s the main goal of Acute Otitis Media treatment?
Pain control and infection management
Can you administer ear drops if the TM is ruptured?
No
What medications are used to manage Acute Otitis Media?
Acetaminophen & ibuprofen for mild - moderate pain
Narcotic if severe pain
Benzocaine (Auralgan) drops for pain if TM not ruptured
Abx therapy - Amoxicillin, Augmentin, Azithromycin or 1 time ceftriaxone IM
How long is abx therapy for Acute Otitis Media?
Usually 10-14 days of PO Amoxicillin, Amoxicillin-clavulanate (Augmentin), or Azithromycin
What are some assessment findings of Otitis Media with effusion (OME)?
Feeling of fullness in the ear
TM dull, opaque, orange discoloration, visible fluid level, air bubbles
Vague findings including rhinitis, cough, diarrhea
Transient hearing loss and balance disturbances
How is Otitis media with effusion managed?
Usually spontaneously resolves; but needs to be rechecked every 4 weeks
Do not feed in a supine position and avoid bottle propping
What medications help resolve Otitis Media with Effusion?
None that we’re taught of; antihistamine, steroids, an decongestants do not help
Why is hearing important during development?
Hearing loss will lead to slow/no speech development
What are some effective communication techniques to use with child with hearing loss?
Turn off music/TV
Face child when talking
Use visual cues
Speak clearly, only slightly raised volume
What’s Tympanostomy (PE)/Myringotomy tube?
Plastic/metal tube placed into TM to equalized pressure, minimize fluid collection, and drain any fluid
Is post-op pain common after inserting tympanostomy (PE) tubes?
No
What’s the indication of Tympanostomy tubes?
Frequent OM
What should you do if you noticed drainage from Tympanostomy tube?
Report to the provider; drainage means there is an infection, and it needs to be treated
How is tympanostomy tubes removed?
It falls out spontaneously after several months with earwax
What are some discharge planning after the placement of tympanostomy tube?
How to administer ear drops if prescribed
Wear ear plugs when swimming/bathing, or going underwater
If water enters ear, allow it to drain out
What are the 3 types of hearing loss?
Conductive
Sensorineural
Mixed
What causes conductive hearing loss?
Transmission of sound through the middle ear is disrupted
What are some examples that cause conductive hearing loss?
Frequent OM
Foreign object
Allergies
Ruptured TM
Impacted earwax
Conductive hearing loss is all about
Middle ear (TM)
What causes sensorineural hearing loss?
Damage to the hair cells in the cochlea or along the auditory pathway
What are some examples that can cause sensorineural hearing loss?
Ototoxic medication
Meningitis
Excessive noise
Aging
Auditory tumors
What are some examples that can cause mixed hearing loss?
Genetic disorder
Infections
Head trauma
What are some tips for interacting with visually impaired child?
Gain child’s attention first before touching them
Name and describe people/objects to make child more aware of what is happening
Discuss upcoming activities
Use touch and tone of voice appropriate to the situation
Simple and specific directions
Use parts of the child’s body as reference points for location of items
Encourage exploration of objects through touch
What are some signs of hearing loss in infants?
Wakes only to touch, not room noise
Does not babble by 6 months
Does not startle at loud noise
What are some signs of hearing loss in young child?
Does not speak by age of 2
Communication needs through gesture
Focuses on facial expressions when communicating
Does not respond to doorbell or telephone
What are some signs of hearing loss in older child?
Often asks for statements to be repeated
Inattentive or daydreams
Poor school performance
Monotone speech
What is a macule?
Circular, flat discoloration that is < 1cm. Like a mole
What is a papule?
Superficial, solid, elevated that is < 0.5cm. Like a small pimple that’s just red, but no pus in it
What does plaque/annular look like?
Ring-like with central clearing
What is a vesicle?
Circular collection of free fluid <1cm. Like a small blister.
What’s a pustule?
Vesicle containing pus. Like acne that’s filled with nasty yellow stuff
What are the 3 types of inflammatory skin conditions?
Contact Dermatitis
Diaper Dermatitis
Atopic Dermatitis (Eczema)
What are the 2 kinds of diaper dermatitis?
Non-candida
Candida
What does non-candida diaper dermatitis look like?
Red, shiny
Usually affects skin on butt, thighs, abdomen, and waist
Usually not creases or folds
What does candida diaper dermatitis look like?
Deep red lesions, scaly with satellite lesions (outside of diaper area)
Usually in creases & folds
Which type of diaper dermatitis can you use standard diaper cream?
Non-candida
How do you manage diaper dermatitis?
Change diapers frequently
Avoid rubber pants, harsh soaps, and baby wipes with fragrance or preservatives
Topical cream
Keep area dry with warm dryer setting for 3-5 minutes
Have diaper-less period of time daily to allow healing
What kind of topical cream can be used to treat candida diaper dermatitis?
Skin barriers (zinc oxide)
Antifungal (nystatin)
Which type of diaper dermatitis can involve oral thrush?
Candida diaper dermatitis
What are some physical assessment findings of atopic dermatitis?
Inflammation, rash, and extreme itching
Dry, scaly, pruritic, erythematous patches on flexural surfaces
Presence of wheezing
What lab value is elevated in atopic dermatitis?
IgE
What causes atopic dermatitis?
Allergen or environmental factors like temperature change or sweating
It’s an antigen response
How is atopic dermatitis managed?
Avoid hot water
Bathe x2/day in warm water
Avoid soaps containing perfumes, dyes, or fragrances (use mild soap)
Pat dry skin and leave moist while apply moisturizers multiple times daily
What kind of clothing and bed linens should be used in kids with atopic dermatitis?
100% cotton
No synthetics and wool
What medications are used to manage atopic dermatitis?
Topical corticosteroids & immune modulators (tacrolimus)
Antihistamines at bedtime may assist with itching
How can you prevent kids with atopic dermatitis from itching too much while they are wake?
Behavior modification; clickers, distraction, reward
What can parents do to kids with atopic dermatitis to avoid bleeding and infection?
Keep fingernails short. Cut & file to not make it sharp
What are some hx that can cause acne vulgaris?
Family hx of onset
Hx of endocrine disorder
Use of medication (steroids, androgens, lithium, phenytoin, isoniazid, etc)
Date of LMP
What are some physical cues of acne vulgaris?
Onset of lesions
Presence of comedones
Oily skin/hair
What are some medications that are used to manage acne vulgaris?
Tretinion
Benzol peroxide (OTC)
Topical antibacterials
Isotretinoin
Oral contraceptives
How does tretinion work?
Interrupts abnormal keratinization that causes microcomedones
How does Benzol peroxide work when treating acne vulgaris?
It inhibits growth of P. acnes (Propionibacterium acnes)
What’s clindamycin’s drug class?
Topical antibacterial
What are the 2 oral antibacterial prescribed to manage acne vulgaris?
Tetracycline
Erythromycin
How does Isotretinoin help manage acne vulgaris?
By Inhibiting sebaceous gland function. This is a teratogenic drug
How does oral contraceptives work when treating acne vulgaris?
Decreases endogenous androgen production
What can we teach patients with acne vulgaris?
Avoid oil-based cosmetics and hair products
Headbands, helmets/hats may exacerbate
Eat balanced diet
Clean skin with mild soap and water BID
Shampoo hair regularly
Avoid picking/squeezing comedones
What are some types of skin injuries?
Abrasions
Lacerations
Bites
Bruises
Burns
What are some risk factors for nonaccidental skin injuries?
Poverty
Prematurity
Chronic illness
Intellectual disability
Parent with abuse hx; unrelated partner
Alcohol/substance abuse
Extreme stressors
What are some suspicious cues of nonaccidental skin injuries?
Injuries in uncommon locations
Bruises in infants < 9 months
Multiple injuries other than LEs
Frequent ED visits; delay in seeking care
Inconsistent stories
Unusual caregiver-child interaction
What are some common places of skin injuries when it’s nonaccidental?
Butt, back & thighs
Posterior side
What time frame should you not go outside to prevent sun damage?
10 am - 4 pm
What kind of sunscreen should you apply to your kids?
Broad spectrum (both UVA & UVB)
SPF 15 or higher
Fragrance and oxybenzone free
Zinc oxide products for nose, cheeks, ears, shoulders
True of false: You don’t have to wear sunscreen on overcast days
False
How often should you apply sunscreen?
30 minutes before sun activity
Reapply at least Q2H
If in water, Q 60-80 min
What age group should you use minimal sunscreen?
Infants < 6 months
Have them wear hats and sun shirts instead
How does 1st degree burn look like?
Damage to epidermis
Painful, pink to red with no blisters
Blanches
How does 2nd degree burn look like when there is damage to entire epidermis?
Painful, moist, red with blisters
Mild to moderate edema
Blanches
How does 2nd degree burn look like when there is damage to entire epidermis + some dermis?
Painful, mottled, red to white with blisters
Moderate edema
Blanches
How does 3rd degree burn look like?
Damage to entire epidermis, dermis, and some subQ
Red to tan, black, brown or waxy white
Dry, leathery
No blanching
What does 4th degree burn look like?
Damage to all layers of skin, muscle, fascia and bones
Color variable
Dull, dry
Charring
Possible visible bone, tendons
Primary assessment of burn consists of
ABCs, VS
Airway patency
Assess for signs of airway injury or smoke inhalation
Respiration effort, symmetry of breathing, breath sounds
Pulse ox, ABG, carboxyhemoglobin levels
Skin color, pulse strength, HR, perfusion status, edema
EKG if electrical burn
Secondary assessment of burn consists of
Burn depth
Body Surface Area (BSA)
Other traumatic injuries
What are some general nursing assessment done on burn patients?
Evaluate immediately for need of intensive management
Provide emergency care if respiratory compromised
Obtain brief hx of date, time and cause of burn
Determine if hx is consistent with injury
What intervention is important during first 24 hours of burn injury?
Fluid resuscitation
How is adequacy of fluid replacement determined?
By evaluating urinary output;
1-2mL/kg/hr
What kind of fluid is given during the early stage of burn recovery?
Isotonic crystalloid solutions (LR)
Dextrose added for small children
What is the most common complication of burn injury during the first 24 hours?
Hypovolemic shock
What are some nursing interventions for burn injuries?
Prevent hypothermia
Pain management
Wound care
Prevent infection
Provide nutritional support
Restore mobility
Psychological support
What are some ways of preventing hypothermia in burn patients?
Warmed IVF
Optimal room temperature
Frequent temp monitoring
Initial cleaning of burn consists of
Mild soap and water
How can you prevent infection in burn patients?
Tetanus shot if > 5 years or vaccine status unknown
Abx ointments with dressing change
How can you minimize/control pain during wound care in burn patients?
Premedicate 30-45 minutes before
Soak prior dressing with warm water before removal
What supplements can you expect to give to burn patients?
Vitamins A & C for cell growth
Zinc for wound healing
Do burn patients require more caloric and protein intake?
Yes, for healing
What kind of skin barriers are there for a non-candida diaper dermatitis?
Zinc oxide
A, D, & E ointments
Petroleum
The nurse is caring for an infant with a non-candidiasis diaper dermatitis. Which of the following should be included in the plan of care?
A) Apply Zinc Oxide to treat affected area
B) Apply Nystatin cream to treat affected area
C) Use alcohol based baby wipes to clean area
D) Apply hydrocortisone cream to reduce redness
A) Apply Zinc Oxide to treat affected area
Which WBC level is elevated with acute bacterial infection & severe stress?
Neutrophil
Which WBC level is elevated with allergic reactions, parasitic infestations, or some neoplasms?
Eosinophil
Which WBC level is elevated with viral infections or chronic bacterial infections?
Lymphocytes
Which immunoglobulins is the most important component in a primary immune response?
IgM
Which immunoglobulin presence indicates an active infection?
IgM
Which immunoglobulin starts producing in infants before IgA?
IgM
Which immunoglobulin is the 1st line of defense against respiratory, GI, GU pathogens?
IgA
At what age do infants begin to produce IgA?
~3 months of age
Which immunoglobulin protects against viruses, bacteria, and toxins?
IgG
What is the only immunoglobulin that crosses the placenta & transferred via breastmilk?
IgG
Lack of IgG causes
Severe immunodeficiency
When do infants start producing their own IgG?
~6 month - 1 year of age
Which immunoglobulin is referred as “passive immunity?”
IgG
Which immunoglobulin increases in allergic states, parasitic infections & hypersensitivity reactions?
IgE
Which immunoglobulin assist in the activation of B cells?
IgD
What are the history cues of immunodeficiency?
4+ new episodes of acute otitis media in 1 year
2+ episodes of severe sinusitis
Treatment with abx for 2 months or longer with little effect
2+ episodes of PNA in 1 year
Failure to thrive in infant
2+ serious infections like sepsis
Persistent oral thrush or skin candidiasis after 1 year of age
Hx of infections requiring IV antibiotics to clear
Family hx of primary immunodeficiency
What are some lab cues of infection/immunodeficiency?
CBC (WBC count; neutrophil, eosinophil, lymphocyte, etc)
ESR & CRP (inflammation markers)
CD4 (T-helper cells)
Immunoglobulins
Complement - C3
Is Severe Combined Immune Deficiency (SCID) a primary or secondary immune deficiency disorder?
Primary
Because it’s hereditary/congenital
How does secondary immune deficiency disorders occur?
As a result of chronic illness, malignancy, immunosuppressive meds, or HIV infection
What causes SCID?
Absent T and B cell function
What is the most important nursing intervention when caring for a SCID patient?
Infection prevention.
This patient has no immune system
How is SCID managed/treated?
IVIG (Exogenous IgG antibodies) to help decrease number of bacterial infections
Bone marrow transplant with HLA matched sibling or donor
IVIG can help but bone marrow transplant is desired
What are the functions of B & T cells?
B cells produce antibodies while T cells kill infected cells
How do infants acquire HIV?
Vertically via breastmilk or in utero
How do adolescents acquire HIV?
Horizontally via sexual activity and IV drug use
True or False: HIV is rarely acquired now via blood products
True
What is the patho behind HIV?
HIV infects CD4 (T-helper cells) -> they replicate itself in the CD4 cell then destroys it
If CD4 cells keeps getting infected and destroyed, there will not be enough normal CD4 in the body, resulting in altered T and B cell function = immune deficiency
What is the lab criteria for diagnosis of HIV in patients 18 months or older?
+ ELISA and + Western blot
What is the lab criteria for diagnosis of HIV in infants < 18 months and born to infected mother?
+ PCR and viral culture
Which lab tests for HIV genetic material (DNA, RNA)?
PCR test
Which lab tests for antibodies to HIV?
ELISA (enzyme-linked immunosorbent assay)
Which lab detects the specific HIV antibodies present in blood proteins?
Western blot
What determines stage of HIV infection?
CD4 counts
Which stage of HIV is considered AIDS?
Stage 3. Lower the CD4 count, lower the immune function
Why is HIV dangerous to children?
HIV rapidly invades the CNS in infants and children
Can also lead to HIV encephalopathy
19 month old presents to clinic with hx 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 & Western blot
9 month old infant born to a mother with HIV presents to clinic with hx 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 & Viral culture
What is the patho behind Juvenile Idiopathic Arthritis (JIA)?
An autoimmune disease that causes body to release inflammatory chemicals that attack the synovium
Causes unknown
Used to be called Juvenile Rheumatoid Arthritis
What are some assessment findings of JIA?
Hx of irritability or fussiness
Withdrawal from play or difficulty getting out of bed
Joint stiffness & pain usually after inactivity, especially in the AM after sleep
Fever
Pale red, nonpruritic, macular rash
Joint edema, warmth, erythema, tenderness
Joints flexed
May affect the eyes or other organs
What are the lab findings for JIA?
CBC (mild-moderate anemia, elevated WBC)
ESR, CRP elevated
+ antinuclear antibody (ANA)
+ rheumatoid factor (more serious case)
What is the goal of JIA management?
Inflammation control
Pain management
Promotion of remission
Maintaining mobility
Promoting normal life
What medications are used to manage JIA?
NSAIDs for pain
Steroids
Antirheumatic drugs like methotrexate but might not be approved for children
Why is regular eye exam important in patients with JIA?
JIA is systematic; it can affect eyes.
Regular screening is to prevent blindness
What exercise is best to maintain mobility?
Swimming
Decreases strain on joints while doing ROM and muscle strengthening
What are some physical cues of allergic reactions?
Hives
Flushing
Angioedema
Mouth/throat itching
Swelling of throat/pharynx/uvula
Runny nose
GI distress
Wheezing (sign of airway compromise)
What are some signs of anaphylaxis?
Respiratory compromise
Low BP
Skin-mucosal tissue involvement (hives, pruritus, swollen lips, etc)
GI symptoms
How are allergic & anaphylactic reactions managed?
Administer histamine blockers and Epi pen if anaphylaxis
Airway management
Comfort measures
What are some parent education we can do following an allergic/anaphylactic reaction?
How to recognize s/s of allergic reaction
Reading food labels and recognizing hidden sources of allergens
Have a written emergency plan for child’s allergy; Epi pen access
How is Epi pen administered?
Blue to the sky
Orange to the thigh
If a person is allergic to latex, they are likely to be allergic to
Kiwi, banana, peach, avocado, chestnut, fig, bell pepper, tomato, or white potato
What are some most common allergens in first year of life?
Eggs, peanuts, tree nuts, fish and shellfish, wheat and soy
What should nurse assess for if a person is having a latex allergy reaction?
ABCs
VS
Auscultate heart and lungs
Assess oropharynx and skin
What type of infection is pertussis?
Bacterial
Which type of infection is mononucleosis & measles?
Viral/exanthems
What type of infection is pediculosis capitus?
Parasitic
What type of infection is pinworms?
Helminthic (worm)
What’s viral exanthems?
A rash/skin eruption caused by a viral infection of the skin in childhood
Distinct rash patterns that assist with diagnosis of virus
How is viral exanthems managed?
Usually care at home with fever management and comfort measures
Precautions are an example of
Secondary prevention
What are the physical findings or pertussis?
Paroxysmal cough (coughing 10-30 times in a row)
Swelling & irritation of airways
Red face
Cyanosis
Protruding tongue
“whooping cough”
Tearing eyes, drooling copious secretions
Pertussis patients needs to be in what precaution?
Droplet
What medications are used to treat pertussis?
Macrolides (“mycins”) for infants > 1 mo
Azithromycin if < 1 mo
TMP-SMZ is alternative to macrolides
What kind of environment can help pertussis patients?
High humidity environment
What are the physical cues for Rubeola (Measles)?
Maculopapular rash (starts from top (face) to bottom)
Fever
Koplik spots
Cough
Nasal inflammation
Malaise
Conjunctivitis
What kind of precaution is required for Rubeola (Measles)?
Airborne until 4 days after the onset of rash
How is Rubeola managed?
Antipyretics, bedrest, fluids, humidification
Post-exposure vaccine within 72 hours or IgG within 6 days may reduce severity
What supplement/medication can be given to hospitalized Rubeola children 6 months to 2 years or immunocompromised?
Vitamin A
What are the physical findings of Lyme Disease?
Hx of tick bite
Firm, discrete, pruritic nodule
Urticaria or localized edema
Redness
Bulls eye rash
There are 3 stages; symptoms get more and more systemic as it progresses
How is Lyme Disease managed?
Abx as ordered; be sure to instruct to take the full regimen until completed
How long is the Lyme Disease treatment?
14-28 days
What abx is used to treat Lyme Disease in kids age >8?
Doxycycline
This can discolor teeth
What abx is used to treat Lyme Disease in kids age <8?
Amoxicillin
Cefuroxime if allergic to penicillins
When should you reassess temperature after antipyretic is given?
30 to 60 minutes after
Why is assessing fluid intake and encouraging oral intake or administering IVF per order important when managing fever in children?
They lose hydration with heat. It’s like boiling water.
We have to keep them hydrated
True or false: Acetaminophen & Ibuprofen is used to treat fevers in infants & children of all age
False
Ibuprofen is to be used > 6 months
How often should you assess temperature when a child is having a fever?
At least 4 - 6 hours
What are some assessment findings of pediculosis capitis (head lice)?
Nits or lice seen behind ears or at nape of neck
Extreme pruritus
Small red bumps on scalp
White specks attached to hair shaft
How is pediculosis capitis managed?
Follow directions exactly on pediculicide (Permethrin, Lindane)
Comb out hair every 2-3 days
Soak combs and hairbrushes in treatment solution, hot water, or shampoo
Treat all items in environment with hot water; dry cleaning may be needed or sealing in plastic bags
What kind of precaution is needed for pediculosis capitis?
Contact
Why is it important to follow directions exactly when using pediculicides (Permethrin, Lindane)?
To get rid of lice effectively
Those solutions are neurotoxic
What is the primary prevention for communicable diseases?
Immunizations
Contact precaution is used when
Diseases can be transmitted when in close proximity to patients or their environment
Droplet precaution is used for
Diseases caused by large droplets, generated by coughing, sneezing or talking
Airborne precautions is used for
Infectious pathogens that remain suspended in the air & can travel great distances
What are some pre-op nursing actions for brain tumor?
Monitor for increased ICP & manage
Steroids to decrease intracranial swelling
Emotional support
What are some post-op nursing actions for brain tumor?
Monitor for increased ICP & manage
I&Os
Frequent VS with pupil and LOC checks
Pain management
Position on unaffected side at level ordered by provider
JP drain monitoring & care
Keep head midline
Treat fever and headache
With brain tumor, why do we want to postpone/prolong radiation therapy as long as possible?
Because their little brain is still growing. Radiation will have a big impact & cause permanent damage
What history cues are found in Hodgkin lymphoma?
Hx of immunodeficiency, frequent infections, Epstein-Barr infection
Family hx of lymphoma
Unintentional weight loss, loss of appetite
Reports of night sweats
What are some physical signs of Hodgkin Lymphoma?
Painless, enlarged supraclavicular or cervical lymph nodes (“sentinel nodes”)
Unexplained fever
Pruritis
Splenomegaly/hepatomegaly
Cough, SOB
How is Hodgkin lymphoma diagnosed?
Lymph node biopsy + for Reed-Sternberg Cells
What is Wilm’s tumor?
Malignancy that occurs in the abdomen (kidneys), usually unilateral and deep in the flank
Most common on R side
What are some physical cues of Wilm’s tumor?
Firm, nontender abdominal swelling/mass
Hematuria
HTN
Abd asymmetry or visible mass
Abd pain, N/V, anorexia
Reported weight loss
Hx of UTIs
What lab test/diagnostics are done to diagnose Wilm’s tumor?
24 hour urine NEGATIVE for homovanillic acid (HVA) and vanillylmandelic acid (VMA)
This is to rule out other tumors
CT/MRI of abd
Abd ultrasound
What is the most important pre-op nursing intervention for Wilm’s tumor?
Do not palpate abd; can rupture tumor
Sign above the bed and outside the door
What is the most common childhood cancer?
Acute Lymphoblastic Leukemia (ALL)
What is the patho behind ALL?
Over production of immature WBC with neoplastic characteristics which leads to infiltration of organs and tissues
What are the history cues of ALL?
Persistent or intermittent fevers
Recurrent infections
Reports of join & bone pain, abd pain, N/V
What are the physical cues of ALL?
Low-grade fever
Signs of infection
Pallor
Bruising/petechiae/purpura
Hepatomegaly
Enlarged lymph nodes
Pancytopenia
What is the most definitive lab cue for ALL?
Bone marrow aspirate (BMA)
Will determine if lymphoid or myeloid and cell type
What other labs are used for ALL?
CBC (Low Hgb, Hct, RBCs, Platelets & low/normal/high WBC) -> since ALL attacks bone marrow
Blood smear
LP
Kidney function to help guide chemo dosage
CXR to detect PNA or mediastinal mass
What is the most common bone used for bone marrow aspirate?
Posterior or anterior iliac crest
Post op BMA
Apply pressure for 5-10 minutes then apply pressure dressing
Monitor for bleeding & infection
What position should the patient be in for BMA?
Prone
What kinds of medications are used for BMA?
Local/topical anesthetic & conscious sedation meds (fentanyl, versed)
Pre-op BMA
Explain procedure
Provide comfort
Infection prevention
Neutropenic precautions consists of
Private room
Meticulous hand hygiene before and after
VS Q4H
Assess s/s of infection Q8H
Nothing up the ass, foley or any invasive procedures
Restrict visitors
Mask on child when outside the room
No raw fruits, veggies, fresh flowers, or live plants
What is the focus of ALL treatment?
Pain management
Prevent infection, bleeding
Treat anemia
What is a major a/e of chemo?
Myelosuppression (bone marrow suppression) -> pancytopenia
What are some more common a/e of chemo?
Mucosal ulceration
Neuropathy
N/V/anorexia
Alopecia
Cognitive defects
What is a common complication of radiation therapy?
Altered skin integrity
What can be used to manage itching from radiation therapy?
Diphenhydramine or hydrocortisone cream
How do you calculate absolute neutrophil count (ANC)?
ANC = (Segs + bands) * WBC * 10
How can you manage N/V/anorexia caused by chemo?
Bland, dry foods
Small, frequent meals
Offer ice, carbonated drinks, popsicles throughout the day
What are some assessment findings of iron deficiency anemia?
Pallor
SOB (bc O2 not carried by hgb)
Spooning of nails
Splenomegaly
Irritability, headache
Unsteady gait, weakness, fatigue
Pica
What are the diagnostic findings for iron deficiency anemia?
Low RBC, Hgb, Hct, MCV, MCH, Rerritin
High RDW
How is iron deficiency anemia managed?
Feed only Fe+ fortified formula
Encourage breastfeeding moms to increase Fe+ in their diet
Limit cow’s milk in children > 1 yr
Fe+ supplements
Encourage Fe+ rich food
What are some s/e of Fe+ supplements?
Teeth staining (place behind teeth/rinse mouth after)
Constipation (increase fluid)
Dark, green stool
What are the risk factors of lead poisoning?
Age
Live in older home (paint, pipes, soil)
Live near busy road
Toys/imported products
Poverty/malnutrition
Pica
What are some physical assessment findings of lead poisoning?
Irritability
Abd pain/cramping
Poor appetite
Vomiting
Ataxia
hematuria
New onset seizures
What blood lead level should you start chelation therapy?
> 45 mcg/dL
What is chelation therapy?
Removes lead from soft tissue & bone then excreted via kidneys
What medications are used in chelation therapy?
PO or IV Succimer/Dimercaprol/Adetate calcium disodium
What nursing intervention is done during chelation therapy?
Ensure adequate fluid intake
Monitor I&Os
What is the patho behind sickle cell disease?
Cells sickle usually from a trigger -> blood become viscous from clumping and cause tissue hypoxia -> prevents normal blood flow to tissues through capillaries -> ischemia & infarction
What are some assessment findings of sickle cell disease?
Extreme fatigue or irritability
Pain
Cough, increased work of breathing, fever, tachypnea, hypoxia
Splenomegaly
Jaundice (from hemolysis) or pallor
Swollen joints
What are some lab findings in sickle cell disease?
Low Hgb, Hct, ESR
High Platelets, Reticulocyte count, bilirubin (from hemolysis)
What are 2 sickle cell disease complications?
Acute chest syndrome
Splenic sequestration
What’s acute chest syndrome?
Vaso-occlusion within the pulmonary microvasculature
What’s splenic sequestration?
Sickled cells obstruct spleen from draining & trapping RBCs, enlarging spleen
How is sickle cell vaso-occlusive episodes managed?
Pain control
Hydration to flush sickled cells out
Treat hypoxia but don’t over oxygenate
What is the patho behind hemophilia A?
Factor VIII is essential for platelets to clot; however, hemophilia A patients have deficiency of factor VIII
How much IVF is used in sickle cell vaso-occlusive episode?
Double maintenance fluid
150mL/kg/day
When is oxygen given during sickle cell vaso-occlusive episode?
When SpO2 <92%
What are some physical cues of hemophilia?
Swollen or stiff joints (hemarthrosis)
Multiple bruises
Hematuria
Bleeding gums
Bloody sputum or emesis
Black tarry stools
Chest/abd pain (internal bleeding)
What coagulability lab value is abnormal in hemophilia?
Only PTT is abnormal (prolonged); PT & platelets are normal
When a patient comes in with swollen joint & they are known to have hemophilia, what should you do first?
Factor VIII administration (slow IV push)
Both acute & prophylactic regimen
What medication can be used for mild cases of hemophilia?
Desmopressin (DDAVP)
Triggers the endothelium of blood vessels to release Factor VIII
What should you do when hemophilia patient is having a bleeding episode externally?
Apply direct pressure
What should you do when hemophilia patient has joint bleeding?
Apply ice or cold compress and elevate extremity unless contraindicated by causing further damage
