Peds HESI Flashcards
Piaget 4 Stages of Cognitive Development
Sensorimotor
Preoperational
Concrete Operation
Formal Operation
Nursing Implications for the Infant (Birth to 1 Year)
Birth weight doubles by 6 months and triples by 12 months
Separation anxiety
Toys include mobiles, squeaking toys, picture books, balls, colored blocks, and activity boxes
Nursing Implications for the Toddler (1 to 3 Years)
Growth velocity slows
Give simple explanations immediately before procedures
Provide security objects
Expect regression
Toys include board and mallet, push-pull toys, toy telephones, stuffed animals, and storybooks with pictures
Autonomy should be supported by providing guided choices when appropriate
Nursing Implications for the Preschool Child (3 to 6 Years)
Child learns sexual identity
Therapeutic play or medical play allows the child to act out his/her experiences
Use simple words and give preparation for procedures
Nursing Implications for the School-Aged Child (6-12 Years)
Maintaining contact with peers is important
Explanation of all procedures is important
Privacy and modesty are important
Toys include board games, card games, and hobbies
Nursing Implications for the Adolescent (12-19 Years)
Illnesses, treatments, and procedures that alter body image can be devastating
Direct questions to the adolescent when parents are preset
Age of assent
Pain Assessment in the Pediatric Client
Verbal report from the child (as young as 3 years old)
Observe nonverbal signs of pain
Most often in response to acute pain rather than chronic pain
Nursing Interventions for Pain
CRIES can be used with infants 32-60 weeks of age
FACES can be used by children preschool aged and older
Numeric Pain Scale can be used by children 9 years and older
Oucher Pain Scale for children 3-12
FLACC pain assessment tool for the nonverbal child
Children as young as 5 can use a PCA pump
Rubeola
Highly contagious viral disease that can lead to neurologic problems or death
Direct contact with droplets
Fever and upper respiratory symptoms, photophobia, Koplik spots, confluent rash
Mumps (Paramyxovirus)
Fever, headache, malaise, parotid gland swelling and tenderness
Direct contact or droplet spread
Analgesics for pain and antiseptics for fever
Bed rest maintained until swelling subsides
Rubella (German Measles)
Teratogenic effects during first trimester of pregnancy
Droplet and direct contact
Discrete red maculopapular rash that starts on face and rapidly spreads to entire body–disappears within 3 days
Pertussis
Acute infectious respiratory disease occurring in infancy
Begins with upper respiratory symptoms; prolonged coughing and crowing/whooping upon inspiration
Lasts 4-6 weeks
Direct contact, droplet spread, or freshly contaminated objects
Varicella
Viral disease characterized by skin lesions that begin on the trunk and spread to the face and proximal extremities
Macular, papular, vesicular, and pustular
Direct contact, droplet spread, or freshly contaminated objects
Communicable prodromal period to time all lesions have crusted
Nursing Care for Children with Communicable Diseases
Treat fever with nonaspirin products
Administer Benadryl for itching
Isolate children during period of communicability
Teaching for Immunizations
Irritability, fever of 102 degrees, redness, and soreness at injection site for 2-3 days are normal side effects of DTaP and IPV administration
Call HCP if seizures, high fever, or high-pitched crying occurs
Tylenol administered orally every 4-6 hours
Pediatric Nutritional Assessment
Iron deficiency occurs most commonly
Typical vitamin deficiencies include A, C, B6, and B12
Recommended intake of vitamin D is 400 IU/day
Nutritional Nursing Interventions
Assess skin, hair, teeth, lips, tongue, and eyes
Hgb, Hct, albumin, creatinine, and nitrogen commonly used to determine nutritional status
Causes of Diarrhea
Infections
Malabsorption
Inflammatory diseases
Dietary factors
Conditions Associated with Diarrhea
Dehydration
Metabolic acidosis
Shock
Signs of Dehydration
Poor skin turgor
Absence of tears
Dry and sticky mucous membranes
Weight loss
Depressed fontanel
Decreased urinary output and increased spec. grav.
Acidotic status
Laboratory Signs of Acidosis
Loss of bicarbonate (pH < 7.35)
Loss of sodium and potassium through stools
Elevated hematocrit
Elevated BUN
Signs of Shock
Decreased blood pressure
Rapid, weak pulse
Skin mottled gray color, cool and clammy to touch
Delayed capillary refill
Changes in mental status
Nursing Interventions for Diarrhea
Monitor intake and output
Rehydrate as prescribed
Check stools for pH glucose, and blood
Assess hydration status and vital signs frequently
Scald Burns
Children younger than 5 are one of the two highest risk groups
Hot water heater temperature greater than 140 degrees can cause a third degree burn on a child
Nursing Assessment of Child Abuse
Bruises in unusual places, burns, whiplash injuries, fractures, bald patches
Failure to thrive
Lacerations of genitalia
Bedwetting or soiling
Child with STDs
Child appearing frightened and withdrawn
Nursing Interventions for Child Abuse
Legally required to report all cases of suspected child abuse
Take color photographs of injuries
Document
Establish trust
Nursing Assessment of Poisonings
GI disturbance: nausea, abdominal pain, diarrhea, vomiting
Burns of mouth, pharynx
Respiratory distress
Seizures, changes in LOC
Cyanosis
Shcok
Nursing Interventions for Poisonings
Assess child’s respiratory, cardiac, and neurological status
Determine child’s age and weight
Instruct parents to bring any emesis, stool, etc. to the emergency department
Gastric lavage, activated charcoal, N-acetylcysteine, naloxone HCl
Important Respiratory Signs in Children
Cardinal signs of respiratory distress: restlessness, increased respiratory rate, increased pulse rate, diaphoresis
Flaring nostrils, retractions, grunting, adventitious breath sounds, use of accessory muscles
Nursing Assessment of Asthma
Breath sounds typically coarse expiratory wheezing, rales, crackles
Chest diameter enlarges
Increased number of school days missed during past 6 months
Signs of respiratory distress
Nursing Assessment of Cystic Fibrosis
Meconium ileus at birth
Recurrent respiratory infections, pulmonary congestion, steatorrhea
Delayed growth and poor weight gain
End-stages: cyanosis, nail-bed clubbing, CHF
Nursing Interventions for Cystic Fibrosis
Monitor respiratory status
Assess for signs of respiratory infections
Administer pancreatic enzymes, fat-soluble vitamins, oxygen, IV antibiotics
High calorie, high protein, moderate to high in fat, and moderate to low in carbohydrates
150% of the usual calorie intake for normal growth and development
Nursing Assessment of Epiglottitis
Sudden onset
Restlessness
High fever
Sore throat, dysphagia
Drooling
Muffled voice
Child assuming upright sitting position with chin out and tongue protruding (tripod position)
Nursing Interventions for Epiglottitis
Encourage prevention with Hib vaccine B
Prepare for intubation or tracheostomy
Employ measures to decrease agitation and crying
Bronchiolitis
Viral infection of the bronchioles that is characterized by thick secretions
Caused by RSV and occurs primarily in young infants
Nursing Assessment of Bronchiolitis
Irritable, distressed infant
Paroxysmal coughing
Poor eating
Nasal congestion and flaring
Prolonged expiratory phase of expiration
Wheezing, rales can be auscultated
Deteriorating condition that is often indicated by shallow, rapid respirations
Nursing Interventions for Bronchiolitis
Isolate child
Monitor respiratory status and observe for hypoxia
Clear airway of secretions
Administer oxygen as prescribed, mist tent
Nursing Assessment of Otitis Media
Fever, pain; infant may pull at ear
Enlarged lymph nodes
Discharge from ear
Upper respiratory symptoms
Vomiting, diarrhea
Nursing Interventions for Otitis Media
Reduce body temperature
Position child on affected side
Warm compress on affected ear
Antibiotics if prescribed
Nursing Assessment of Tonsillitis
Sore throat and may have dysphagia
Fever
Enlarged tonsils, purulent discharge on tonsils
Breathing may be obstructed
Throat culture to determine viral or bacterial cause
Nursing Interventions for Tonsillitis
Encourage soft foods and oral fluids (avoid red fluids)
Do not use straws
Ice collar
Treatment very important if related to strep because it can cause acute glomerulonephritis or rheumatic heart disease
Acrocyanotic Congenital Heart Disorders
Left to right shunt
ASD, VSD, PDA, coarctation of the aorta
Increased pulmonary blood flow
Increased fatigue, murmur, increased risk of endocarditis, CHF, growth retardation
Cyanotic Congenital Heart Disorders
Right to left shunt
Tetralogy of Fallot, TGV, TA
Decreased pulmonary blood flow
Squatting, cyanosis, clubbing, syncope
Ventricular Septal Defect
Hole between the ventricles
Oxygenated blood from left ventricle is shunted to right ventricle and recirculated to the lungs
Small defects may close spontaneously
Large defects cause CHF and require surgical closures
Atrial Septal Defect
Hole between the atria
Oxygenated blood from left atrium is shunted to the right atrium and lungs
Most defects do not compromise children seriuosly
Can lead to CHF or atrial dysrhythmias later in life
Patent Ductus Arteriosus
Abnormal opening between aorta and pulmonary artery
Usually closes within 72 hours after birth
If patent, oxygenated blood from aorta returns to pulmonary artery
Increased blood flow to the lungs causes pulmonary hypertension
Characteristic machinelike murmur
Coarctation of the Aorta
Obstructive narrowing of the aorta
Most common sites are aortic valve and aorta near ductus arteriosus
Common finding is hypertension in upper extremities and decreased/absent pulses in lower extremities
Aortic Stenosis
Obstructive narrowing immediately before, at, or after the aortic valve
Oxygenated blood flow from the left ventricle into systemic circulation is diminished
Symptoms caused by low cardiac output
Tetralogy of Fallot
Cyanotic heart disease
Combination of VSD, aorta placed over and above the VSD, pulmonary stenosis, and right ventricular hypertrophy
“Tet” spells or hypoxic episodes relieved by child’s squatting or knee-chest position
Truncus Arteriosus
Cyanotic heart disease
Pulmonary artery and aorta do not separate
Blood mixes in right and left ventricles through a large VSD, resulting in cyanosis
Increased pulmonary resistance results in increased cyanosis
Transposition of the Great Vessels
Cyanotic heart disease
Great vessels are reversed
Pulmonary circulation arises from left ventricle, and systemic circulation arises from the right ventricle
Incompatible with life unless there is a VSD, ASD, or PDA present
Medical emergency
Nursing Assessment of Children with Congenital Heart Disease
Murmur, cyanosis, clubbing of digits
Poor feeding, poor weight gain, failure to thrive
Frequent regurgitation and respiratory infections
Heart rate, rhythm, and heart sounds, respiratory status, pulses, blood pressure
Nursing Interventions for Congenital Heart Disease
Maintain hydration due to polycythemia
Maintain neutral thermal environment
Monitor frequently for fever, plan frequent rest periods
Administer digoxin and diuretics as prescribed
Nursing Assessment for Congestive Heart Failure
Tachypnea, shortness of breath, tachycardia, difficulty feeding, cyanosis, grunting, wheezing, pulmonary congestion, edema, diaphoresis, hepatomegaly
Nursing Interventions for Congestive Heart Failure
Monitor vital signs frequently and report signs of increasing distress
Assess respiratory functioning frequently, elevate HOB
Administer oxygen, digoxin, diuretics
Maintain strict I&O
Low-sodium diet
Rheumatic Fever
Most common cause of acquired heart disease in children
Usually affects the aortic and mitral valves of the heart
Collagen disease that injures the heart, blood vessels, joints, and subcutaneous tissue
Managing Digoxin
Take child’s apical pulse for 1 minute to assess for bradycardia; hold if less than normal heart rate
Therapeutic levels are 0.8 to 2.0 ng.mL
Give 1 hour before or 2 hours after meals
Digoxin toxicity associated with vomiting, anorexia, diarrhea, abdominal pain, fatigue, muscle weakness, drowsiness
Nursing Assessment of Rheumatic Fever
Chest pain, SOB, tachycardia
Migratory large-joint pain
Chorea (irregular involuntary movements)
Rash, subcutaneous nodules over bony prominences
Fever
Elevated ESR and ASO
Nursing Interventions for Rheumatic Fever
Monitor vital signs, assess for increasing signs of cardiac distress
Assist with ambulation, encourage bed rest
Administer penicillin and aspirin
Nursing Assessment of Kawasaki Disease
Acute: high fever, conjunctival redness, swollen lymph nodes, red hands and feet
Subacute: peeling of hands and feet, cardiovascular manifestations, GI manifestations
Convalescent: all signs are gone
Nursing Interventions for Kawasaki Disease
Administer IVIG and aspirin
Monitor cardiac status by documenting child’s intake and output and daily weights
Monitor intake of clear liquids and soft foods
Down Syndrome
Most common chromosomal abnormality in children
Trisomy 21
Cardiac defects, respiratory infections, feeding difficulties, delayed developmental skills, mental retardation, skeletal defects, altered immune function, endocrine dysfunction
Nursing Interventions for Down Syndrome
Assess and monitor growth and development
Teach use of bulb syringe
Teach signs of respiratory infection
Feed to back and side of mouth
Monitor for signs of cardiac difficulty or respiratory infection
Cerebral Palsy
Nonprogressive injury to the motor centers of the brain causing neuromuscular problems of spasticity or dyskinesia
Causes include anoxic injury, maternal infections, kernicterus, low birth weight
Nursing Assessment of Cerebral Palsy
Persistent neonatal reflexes after 6 months
Delayed developmental milestones
Poor suck, tongue thrust
Spasticity, scissoring of legs
Seizures
Nursing Interventions for Cerebral Palsy
Administer anticonvulsant medications such as phenytoin
Administer diazepam for muscle spasms
Feed with child positioned upright and support the lower jaw
Spina Bifida
Malformation of the vertebrae and spinal cord resulting in varying degrees of disability and deformity
Caused by folic acid deficiency
Need to screen for latex allergies
Nursing Assessment of Spina Bifida
Presence of sac in myelomeningocoele is usually lumbar of lumbosacral
Flaccid paralysis and limited to no feeling below the defect
Associated with hydrocephalus, neurogenic bladder, poor anal sphincter tone, congenital dislocated hip, club feet, scoliosis
Nursing Interventions for Spina Bifida
Protect the sac; position child on abdomen with legs abducted
Monitor for signs of infection
Place infant in prone position after surgery
Develop a bowel program with high-fiber diet, increased fluids, regular fluids, suppositories as needed
Hydrocephalus
Abnormal accumulation of CSF within the ventricles that does not drain properly
Enlarged head circumference
Increased intracranial pressure
Nursing Assessment of Hydrocephalus
Children: Change in LOC, irritability vomiting, headache, motor dysfunction, seizures
Infants: irritability, lethargy, increased head circumference, sunset eyes, feeding difficulties
Nursing Interventions for Hydrocephalus
Monitor for signs of increased ICP
Seizure precautions, elevate HOB, assess for signs of shunt malfunction
Monitor for signs of infection
Tonic-Clonic Seizures (Grand Mal)
Consciousness is lost
Tonic: generalized stiffness
Clonic: spasm followed by relaxation
Aura, apnea, cyanosis, incontinence, disorientation
Phenytoin, carbamazepine, phenobarbital, and fosphenytoin
Absence Seizure (Petit Mal)
Momentary LOC, posture is maintained, has minor face-eye-hand movement
Last 5-10 seconds
Child appears to be inattentive; poor performance in school
Ethosuximide and valproic acid
Myoclonic Seizure
Sudden, brief contractures of a muscle or group of muscles
Nursing Interventions for Seizures
Maintain airway by turning client on their side
Do not restrain, support head
Maintain seizure precautions
Bacterial Meningitis
Exudate covers brain and cerebral edema
Lumbar puncture shows increased WBCs, decreased glucose, elevated protein, increased ICP, positive culture for meningitis
Nursing Assessment of Bacterial Meningitis
Classic signs of ICP, fever, chills, neck stiffness, photophobia, positive Kernic and Brudzinski
Poor feeding, vomiting, irritability, bulging fontanel, seizures
Nursing Interventions for Bacterial Meningitis
Administer antibiotics and antipyretics as prescribed
Isolate for at least 24 hours
Monitor vital signs and neurologic signs
Implement seizure precautions
HOB slightly elevated
Monitor hydration status and IV therapy
Reye Syndrome
Acute, rapidly progressing encephalopathy and hepatic dysfunction
Caused by viral infections, aspirin use
Nursing Assessment of Reye Syndrome
Lethargy, rapidly progressing to deep coma, vomiting
Elevated AST, ALT, lactate dehydrogenase, serum ammonia, decreased PT
Hypoglycemia
Nursing Interventions for Reye Syndrome
Monitor neurologic status
Maintain ventilation
Monitor cardiac parameters
Administer mannitol to increase blood osmolality
Brain Tumors
Third most common cancer in children
Infratentorial, making them difficult to excise surgically
Occur close to vital structures
Nursing Assessment of Brain Tumors
Headache, vomiting, loss of concentration
Change in behavior or personality
Vision problems
Widening sutures, increasing frontal occipital circumference
Nursing Interventions of Brain Tumors
Identify baseline neurologic functioning
Monitor IV fluids and output carefully–overhydration can cause cerebral edema and increased ICP
Suctioning, coughing, straining, and turning can cause increased ICP
Muscular Dystrophy
Inherited disease of the muscles, causing muscle atrophy and weakness
Nursing Assessment of Muscular Dystrophy
Waddling gait, lordosis, increasing clumsiness, muscle weakness
Gowers sign
Pseudohypertrophy of muscles
Muscle degeneration
Delayed cognitive development
Nursing Interventions for Muscular Dystrophy
Provide supportive care
Prevent exposure to respiratory infection
Encourage a balanced die
Acute Glomerulonephritis
Immune complex response to an antecedent beta-hemolytic streptococcal infection of kin or pharynx
Causes inflammation and decreased glomerular filtration
Nursing Assessment for Acute Glomerulonephritis
Recent streptococcal infections
Mild to moderate edema
Irritability, lethargy, hypertension, hematuria, proteinuria
Elevated ASO and BUN
Nursing Interventions for Acute Glomerulonephritis
Provide supportive care
Monitor vital signs and I&O
Weigh daily
Low-sodium diet with no added salt
Monitor for seizures, CHF, renal failure (decreased urinary output is the first sign)
Nephrotic Syndrome
A disorder in which the basement membrane of the glomeruli becomes permeable to plasma proteins; most often idiopathic in nature
Nursing Assessment of Nephrotic Syndrome
Edema that begins insidiously
Lethargy, anorexia, pallor, frothy urine, massive proteinuria, decreased serum protein, elevated serum lipids
Nursing Interventions for Nephrotic Syndrome
Monitor temperature and assess for signs of infection
Administer steroids such as prednisone and cholinergics such as bethanechol
Monitor intake and output
Small, frequent feedings of a normal protein, low-salt diet
Nursing Assessment of Urinary Tract Infections
Infants: vague symptoms, fever, irritability, poor food intake, diarrhea, vomiting, jaundice
Older children: urinary frequency, hematuria, enuresis, dysuria, fever
Nursing Interventions for Urinary Tract Infections
Collect clean voided or catheterized specimen
Suspect and assess for UTI in infants who are ill
Assess for recurrent UTI
Nursing Assessment for Vesicoureteral Reflex
Recurrent UTI
Reflux (common with neurogenic bladder)
Reflux noted on voiding cystourethrogram
Nursing Interventions for Vesicoureteral Reflex
Teach importance of medication compliance
Maintain hydration
Nursing Assessment for Hypospadias
Abnormal placement of meatus
Altered voiding stream
Presence of chordee
Undescended testes and inguinal hernia
Nursing Interventions for Hypospadias
Assess circulation to tip of penis postoperatively
Monitor urinary drainage after urethroplasty
Maintain hydration
Nursing Assessment of Cleft Lip or Palate
Failure of fusion of the lip, palate, or both
Difficulty sucking and swallowing
Nursing Interventions for Cleft Lip or Palate
Feed in upright position, slowly, with frequent burping
ESSR: Enlarge nipple opening, Stimulate the child to suck, Swallow normally, and Rest
Maintain patent airway and proper positioning (Cleft lip on side or upright, Clef palate on side or abdomen)
Nursing Assessment of Esophageal Atresia with Tracheoesophageal Fistula
Choking, Coughing, Cyanosis
Excess salivation
Respiratory distress
Aspiration pneumonia
Nursing Interventions for Esophageal Atresia, with Tracheoesophageal Fistula
Monitor respiratory status
Remove excess secretions
Elevate infant into antireflux position of 30 degrees
Maintain NPO
Monitor for postoperative stricture (poor feeding, dysphagia, drooling, regurgitation)
Nursing Assessment of Pyloric Stenosis
Vomiting usually begins around the 3rd-6th week of life
Projectile vomiting within minutes after eating
Hungry, fretful infant
Weight loss, failure to gain weight, dehydration, metabolic alkalosis
Nursing Interventions for Pyloric Stenosis
Assess for dehydration, provide small frequent feedings
Burp frequently to avoid stomach becoming distended
Weigh daily, monitor I&O
Intussusception
Telescoping of one part of the intestine into another part of the intestine, usually the ileum into the colon
Partial to complete bowel obstruction occurs
Blood vessels become trapped and necrotic
Nursing Assessment of Intussusception
Acute, intermittent abdominal pain
Screaming with legs drawn up to abdomen
Vomiting, currant jelly stools
Sausage shaped mass in upper right quadrant and lower right quadrant is empty
Nursing Interventions for Intussusception
Monitor carefully for shock and bowel perforation
Monitor intake and output
Prepare child for barium enema
Hirschsprung Disease
Congenital absence of autonomic parasympathetic ganglion cells in a distal portion of the colon and rectum
Lack of peristalsis in area of the colon
Nursing Assessment of Hirschsprung Disease
Suspicion in newborn who fails to pass meconium within 24 hours
Distended abdomen, chronic constipation, alternating with diarrhea
Nutritionally deficient child
Ribbonlike stools
Nursing Interventions for Hirschsprung Disease
Provide bowel-cleansing program as prescribed
Observe for symptoms of bowel perforation (abdominal distention, vomiting, increased abdominal tenderness, irritability, dyspnea and cyanosis)
Check axillary temperature
Nursing Assessment of Anemia
Pallor, tiredness, fatigue
Pica
Decreased Hgb, low serum iron level, elevated TIBC
Hemoglobin Normal Values
Newborns: 14 to 24 g/dL
Infant: 10 to 17 g/dL
Child: 9.5 to 15.5 g/dL
Nursing Interventions for Anemia
Support child’s need to limit activities
Provide rest periods
Refer family to a nutritionist
Nursing Assessment of Hemophilia
First red flag may be prolonged bleeding at the umbilical cord or injection site, or after circumcision
Prolonged bleeding with minor trauma
Hemarthrosis
Spontaneous bleeding into muscles and tissues
Loss of motion in joints
Nursing Interventions for Hemophilia
Administer fresh-frozen plasma, cryoprecipitate of fresh plasma, or lyophilized concentrate
Follow blood precautions risk for hepatitis
Nursing Assessment of Sickle Cell Disease
Children of African descent, usually over 6 months of age
Frequent infections, tiredness, delayed physical growth
Nursing Interventions for Sickle Cell Disease
Teach to avoid strenuous exercise, high altitudes, keep well hydrated, avoid infection
Administer IV fluids, monitor intake and output, administer blood products, administer analgesics and warm compress
Nursing Assessment of Phenylketonuria
Newborn screening using Guthrie test, serum phenylalanine level of 4 mg/dL
Frequent vomiting, failure to gain weight, irritability, musty odor of urine
Nursing Interventions for Phenylketonuria
Stress importance of strict adherence to low-phenylalanine diet
Screen infants as close to discharge as possible
