test 3 Flashcards
general difficulty or deficiency
cognitive impairment ot intellectual disability
how to dx cognitive impairments
must have 2 functional impairments
nursing care for impaired cognitive function
early intervention
teach child self care skills
promote optimal development
encourage play and exercise
establish discipline
strict sexual code of conduct in adolescents
down syndrome statistics
age 35: risk 1 in 350 births
age 40: risk 1 in 100 births
trisomy 21 in 95% cases
clinical manifestations of down syndrome
small head with upward slant eyes
flat nasal bridge
protruding tongue
hypotonia muscles
low set ears
physical problems with down syndrome
congenital heart disease
hypothyroidism
leukemia
therapeutic management for down syndrome
surgery to correct congenital anomalies
evaluation of hearing and sight
testing for thyroid function periodically
preventing of AAI- instability of cervical spine
ear infections common, greater risk for resp infections due to shorter tubes
Fragile X syndrome
second most common genetic cause of cognitive impairment
caused by abnormal gene on the lower end of the long arm of the X chromosome
fragile X manifestations
large head circumfence
long narrow face with prominent jaw
protrude ears
large testicles
cognitive impairment
hyperactivity
hypersensitivity to taste, sounds, touch
aggressive behaviors
autistic like behaviors
Fragile X ther management
tegretol/prozac for behaivoral control
stimulants for hyperactivity
early intervention
turner syndrome
only affects girls
missing a portion or all of the X chromosome
turner syndrome manifestations
short stature
difficulty with PO intake, reflux
webbed neck
low set hairline
heart defects (coartion of aorta)
renal and endocrine dysfunction
nonfunctional ovaries
nursing interventions for turner syndrome
baseline EKG
estrogen for puberty development
growth hormone for growth
nutrional guidance
common ototoxic drug
lasix
hearing impairment manifestations in infancy
lack of startle reflux
absence of reaction to auditory stimuli
absence of well formed syllables by age 11 months
general indifference to sounds
lack of response to spoken word
hearing impairment manifestation in childhood
deafness is likely to be dx in infancy but if not then when entry into school
abnormalities in speech development
learning disabilities
promoting communication for hearing impairments
lip reading - make sure you face them when speaking
cued speech
sign language
speech language therapy
socialization
hearing aids
cochlear implants
surgery
what hearing loss can cochlear implants be used in
sensory neural
common disorders causing visual impairments
sickle cell disease
juvenile rheumatoid arthritis
tay-sachs disease
myopia
nearsightedness
hyperopia
farsightedness
strabismus
Crossed eye or eye deviation
amblyopia
Lazy eye. One eye is worse than other
vision impairment management
provide a safe environment
orient child to surroundings
encourage independence
preventing visual impairments
rubella vaccine
prevent eye injuries
screen all children
autism spectrum disorders (ASDs)
complex neurodevelopment disorders accompanied by social and communication alterations
many different types
more common in boys
caused by not immunizing, and genetics
ASDs manifestations and dx
peculiar and bizarre characteristics primarily in specific areas:
socialization
communication
behavior
difficulty with eye and body contact
language delay
dx usually around 2-3 years
ASDs care management
no cure for autism
provide structured environment
use some improvements with language skills
decrease unacceptable behaivor
resource for family= autism society of america
common first sign of increased ICP
change in LOC
Pay attention to the early signs so you can intervene quickly and prevent any neurological compromise.
manifestations of increased ICP in babies
remember they cant tell you how they feel
setting sub sign- looks like the sun setting, bulging eyes
tense, bulging fontanelles
distended scalp veins
suture may be separated in skull
irritabiliy
poor feeding
difficult to soothe, cry
manifestations of increased ICP in children
headache
forceful vomiting
seizures
dizziness, lethargy
diminished physical activity
inability to follow simple commands
late signs of increasing ICP
vital sign changes- bradycardia
decreased motor response
decreased sensory response to painful stimuli
alterations in pupil size and reactivity
extension/flexion posture
decreased consciousness
coma
positions you may see after a head injury or infection that was not treated quickly
Decorticate posturing
Decerebrate posturing
glasgow coma
The Glascow Coma Assessment is a 3-part assessment focusing on eye opening, verbal response, and motor response.
The highest score attainable is 15.
A score of 8 usually signifies a coma, and a 3 is the worst possible score.
Decorticate posturing
arms flexed inwards, feet plantar flexed
Decerebrate posturing
wrist flexed outward
DX for increased ICP
cultures/lab test to find the issue
EEG to assess seizures
lumbar punctures for CSF
CT for concussions, MRI for bleeds/clots, Xray for skull fractures
evoked potentials
emergency management of unconscious child
- airway
- reduction of ICP
- treatment of shock
pain in comatose child
Pain is exhibited by agitation and rigidity in the comatose child, so we may give analgesics prn.
Remember that ICP can increase due to pain–this is why it’s important to keep pain under control.
vitals may change in response to pain. Pay attention to the vitals as part of your pain assessment.
- increase in HR, RR, BP
-decrease in o2
indications for ICP
glasgow coma scale score of less than 8
TBI with abnormal CT scan
deteriorating neuro condition
subjective judgement regarding clinical appearance and response
preventing ICP
prevent anything that would irritate a person
avoid neck vein compression
provide alternation pressure mattress
elevate HOB at 30 degrees
only suction if needed
meds for increased ICP
ABX for infections
corticosteroids for inflammation
sedatives, anti-seizures, paralytics
concussion
alteration in neuro or cognitive function with or without loss of consciousness
short lived and reversible. typically resolves in a week
generally followed by amnesia and confusion
dx with CT
contrecoup
bruising at a site far removed from point of impact in brain
basilar fracture
most concerning fracture
Some kind of fracture in base of skull. Worried about infection, meningitis. Give abx for prophylaxis
s/s
battle sign- bruising behind ears
raccoon eyes
CSF leak
head trauma for ER
severe injuries
loss of consciousness
prolonged/continues seizures
Nothing admin orally at first in case of surgery and aspiration risk
hematoma s/s can take 24 hours to develop. wake child up frequently to assess
assess vitals, pupils, nuero status, LOC
submersion injury (near drowning)
Typically hospitalize for 24 hours even if they seem fine
CPR at scene
hypoxia, aspiration, hypothermia common
frequent complication is aspiration pneumonia
prognosis <5 mins is best predictor
bacterial meningitis
more concerning than viral
acute inflammation of meninges and CSF
DROPLET PRECAUTIONS
decreased incidence of Hib and PCV vaccine. MCV vax at age 11/12 and before college
most commonly caused by: neisseria meningitis
symptoms, dx, tx of bacterial meningitis
fever, headache, nuchal rigidity
dx by lumbar puncture
treated by isolation IV ABX, isolation precuation, control temp and seizures, restrict hydration
aspetic/viral meningits
dx by CSF
onset may be abrupt or gradual
manifestations- headache, fever, malaise
tx is symptomatic
give ABX until we know for sure its not bacterial
what can cause seizures
underlying disease such as tumor, brain injury, etc
if unknown- epilepsy
partial seizure
local onset
small part of brain
general seizure
involves both hemispheres without local onset
full body jerking
absence seizures
abrupt onset
“day dreaming”
management of seizures
goal- control seizures or reduce frequency
correct the cause
management- drug therapy
ketogenic diet- no carbs
vagus nerve stimulation
surgery as last resort
time them
nothing in mouth
side laying position
5 mins or longer give meds
seizure precautions
padding, o2, suction, HOB raised
hydrocephalus
caused by imbalance in the production and absorption of CSF
treatment- ventriculoperitoneal shunt
this stays in forever
causes of hydrocephalus
result of developmental defects
often associated with myelomeningocele
other causes neoplasms, infection and trauma
shunt infection
greatest risk 1-2 months after shunt placement
treated by massive dose abx or shunt removal
can do external ventricular drain instead (EVD)
external ventricular drain (EVD)
External shunt needs monitored hourly and needs to be at ear level
Abx can be directly put in head if infection
reticulocytes
immature red blood cells. If retic count is increasing, we are increasing RBC, key marker in sickle cell, as well as hemolytic
how does RBC work in body
RBC carry oxygenated hemoglobin to body and deoxygenated blood back to lungs. Production of RBC stimulated by erythropoietin and tissue hypoxia
what is anemia defined by
low RBC/low hbg
this is a symptom, not a diagnosis on its own
three classifications of anemia
decreased RBC production
Increased RBC loss
Increased RBC destruction
what may cause decreased RBC production
nutritional deficiency
bone marrow failure
what may cause increased RBC loss
acute blood loss
what may cause increased RBC destruction
intracorpuscular
extracorpusclar
consequences of anemia
in mild cases, children usually adapt.
hemodilution
decreased peripheral resistance
increased cardiac circularion and turbulence
cyanosis
growth retardation
hemodilution
Occurs when there is less RBC when there should be. Body needs to work harder to ensure circulation, increasing cardiac workload can produce a murmur
iron deficiency anemia
caused by inadequate dietary supplement of iron
more prevalant in premies, milk babies/toddlers, or multi fetal babies
treated by increasing iron consumption
can use iron drops in between meals- but they could stain teeth
what drug can cause a drug induced anemia
cephalosporins
sickle cell anemia
abnormal hemoglobin S, making it difficult to hold on to oxygen. it is an autosomal recessive disorder, common in areas where malaria is common
there are multiple types. the worst is hbgSS
Sickled cells block blood flow, they are hard. They increase inflammation and cause Vaso inclusion, causing local hypoxia and tissue death over time
dx by newborn blood smear
complications of sickle cell
*acute chest syndrome
*Vaso inclusive crisis
*CVA
*Splenic sequestration
pain
abdominal pain
hematuria
hepatomegaly
avascular necrosis
retinopathy
death
acute chest syndrome
clustering in chest, pulmonary infiltrate. Similar to pneumonia symptoms. Pts will need O2, fluids. Use incentive spirometer. Treat with analgesics
vaso inclusive crisis
mild to severe pain from sickling. Most common in arms, legs, chest, or flank area. Most commonly occurs when dehydrated. Priority is bolus fluids and pain meds.
splenic sequestration
too many sickled cells get trapped in spleen causing splenomegaly. Damage is caused to spleen. This is a medical emergency. These patients typically get there spleen out by 6 if this constantly occurs
sickle cell management
prevent sickling, hydration, rest, analgesics, abx, blood replacement.
encourage vaccines.
penicillin used for prophylactic. monitor for bacterial infections
transcranial doppler yearly to assess stroke risk
if fever- treat asap, give abx
do not do blood transfusions unless hgb at 7 or 8
Why do we not want to constantly do blood transfusions in SCD
risk for reaction
exchange transfusions for SCD
replacing bad sickle cells with normal RBC
What is the only possible cure for SCD
stem cell trasnplant, but there are a ton of complications so its not done often
hydroxyurea for SCD
a chemotherapy that reduces bone marrow production but in recovery we found it increases production of hemoglobin F (fetal), which is less likely to sickle. This drug has caused a significant reduction in mortality, acute chest syndrome, vasoinclusive. Does come with a increase risk of leukemia and bone marrow suppression. Oral chemo, allows for much better quality of life overall
Hemophillia
a group of hereditary bleeding disorders that result from deficiencies of specific clotting factors. It could be type A or B
usually it is X linked recessive, so it is more common in boys.
treated by replacing missing clotting factors, using damopressin, and aminocaproic acid.
severe cases will have scheduled factor replacements
avoid NSAIDs in these kids
hemophillia dx
history of bleeding episodes
low levels of factor VIII or IX
prolonged PTT
platelet count is normal. This is not a platelet issue.
hemophillia management
Want kids to stay active and strengthen muscles around joints, but also prevent any bleeding
avoid contact sports
genetic counseling
immune thrombocytopenia
immune system mistakenly attacks the platelets.
this could be acute or chronic, but its typically acute
it typically follows upper resp infections or other infections
clinical manifestations of immune thrombocytopenia
platelets under 20,000
petechiae, ecchymoses, bleeding, hemathoris, hemataemesis
normal bone marrow with increased number of immature platelets or eosinophils
make sure to rule out other disorders where thrombocytopenia is preset, like leukemia, lymphoma
management of immune thrombocytopenia
primary supportive
Often started on prednisone and IVIG which helps recovery time
if becomes chronic and body doesn’t response well to treatment, spleen may need removed
IVIG vs anti D for immune thrombocytopenia
IVIG- liquid concentrate of antibodies from the plasma of healthy blood donors. Which will help overwhelm spleen and increase platelets. Premed them with Tylenol and Benadryl as we would with a normal blood product
Anti D antibody may be used instead of IVIG because it is cheaper. It does help increase platelet count by targeting RH factor on RBC, so the spleen focuses on RBC not platelets. We cant use this on RH- blood type
epistaxis
nose bleeds
common in childhood
could be due to underlying disease
bleeding usually stops within 10 minutes after nasal pressure. apply pressure to soft lower part of nose and lean forward.
keep child calm. agitation causes increased BP which could create more blood flow
HIV/AIDS transmission prevention
can be transmitted by risky behavior or from mother to child
HAART therapy prevents perinatal transmission
pediatric HIV/AIDS manifestations
lymphadenopathy, oral candidiasis, hepatosplenomegaly, diarrhea, FTT, developmental delay
severe combined immunodeficiency disease (SCID)
AKA bubble boy infection
absence of immunity. body is constantly ill
treated with donor bone marrow, IVIG, prophylaxis
key is to prevent infections.
Without a bone marrow or stem cell transplant, this is a poor prognosis
what to do for blood transfusions
Frequent vitals. Done before blood products, then 15 mins in.
Any reaction needs product to be stopped, or slowed down
Will be given in a pump on floor so its given safely
give tylenol and benadryl each time to prevent reactions
early signs of cancer
unusal mass/swelling
unexplained loss of energy and pallor
bruising
pain
fever prolonged
headaches with vomiting
vision changes
weight loss
what does lumbar puncture look at
looks for anything that metastasizes in CNS
cancer dx
labs- CBC, LFTs, coagulation, urinalysis
lumbar puncture, bone marrow aspiration/biopsy
CT, MRI, PET
surgery
how do children get chemo
thru central lines
We can not due it in peripheral lines because it will burn there tissues, peripheral IVs don’t last as long as central lines
3 phases of therapy (primarily for leukemia)
induction
intensification
maintence therapy
induction chemo
4-5 weeks, begins immediatly
We want to get them less than 5% of those bad cells, once they do, they are in remission and move to intensification
we want to see how chemo is responding before we proceed more
intensification therapy
chemo periodically over 6 months
high doses, lots of side effects
maintence therapy chemo
to perserve remission
weekly or monthly CBCs needed
treatment usually stops after 2-3 years
monitor for relapse
lower dose, less side effects
goal is for a 5 year remission for cure
biggest chemo concern
infection
Look at ANC count. We want it to be at least 500. if lower, use protective precautions. Use masks, hand washing, etc.
monitor for fevers, septic shock
what to do if chemo kid has fever
drawl blood cultures immediately, start broad spectrum Abx. One good one is vancomycin- but it has a lot of side effects
neutropenia precautions
avoid fresh fruits/veggies unless they can be pealed. No flowers in room
chemo side effects
hemorrhage due to low platelets
anemia
nausea and vomitting
altered nutrition
mouth ulceration
constipation
hemorrhagic cystitis
alopecia
foot drop
jaw pain
chemo side effect care
no platelet transfusion unless actively bleeding
no blood transfusion unless hgb under 7
zofran, benadryl or ativan for n/v
let them eat whatever they want- lots of calories, protein, fat
use stool softeners
keep shoes on to prevent foot drop
analgesics for any pain
increase fluids
dont give bladder toxic chemo at night
what NSAID do we not use in oncology kids
ibuprofen- bleed risk
graft vs host disease (GVHD)
most common complication of stem cell transplant
The new graft rejects the old host, presents as rash. We like to see a little of this as it means the graft can fight, but sometimes the graft gets too aggressive and attacks the GI tract. Monitor liver labs, it can cause severe liver damage. We have meds to treat and prevent this
cancer health promotion
still need basic health care aside from oncologist
no live vacccines, only inactivated
get varicella immune globulin instead of vax
leukemia
unrestrcited proliferation of immature WBC. these WBC dont fight anything.
ALL is most common
most common in toddler white boys
s/s- fever, pallor, fatigue, anorexia, hemorrhage, bone and joint pain.
leads to infection, anemia, bleeding
dx by peripheral blood smear, lumbar puncture, bone marrow aspiration/biospy
what to do if cancer is over blood brain barrier
Chemo does not pass blood brain barrier. If the cancer has, then they need intrathecal chemo
when is CNS prophylactic therapy used
in high risk children to reduce the risk of leukemic cells taking over the CNS
what leukemia can a bone marrow transplant help
ALL
AML
what male body part is resistant to chemo and could lead to relapse
testes
hodgkin disease
Nodules on lymph nodes. Found quicker, better success rates
presence of abnormal reed-sternberg lymphocyte cell
more prevalent in children age 15-19
typically painless
may have enlarged cervical or supraclavicular lymphadenopathy
cough, abdominal discomfort, anorexia may be present
accurate staging is basis for tx and prognosis
non hodgkin disease
reed sternburg cell not present
more prevalant in children under 14
Lower success rate as its harder to diagnose. No nodules, typically metastasizes.
Symptoms similar to those of TB: fever, anorexia, weight loss, night sweats
brain tumor
most common solid tumor in chlidren
s/s depends on location
may be headache, hydrocephalus, vomiting, nystagmus, ataxia, dysarthia, DI, growth failure
brain tumor management
We don’t know how bad the brain tumor is until we go to surgery. Imaging doesn’t show what its pressing on. We do surgery quickly then do chemo
Don’t lay the child on side of head where surgery is- brain damage could be caused
do frequent nuero checks
neuroblastoma
IN ADRENAL GLAND. develops from embroyonic nerual crest cells (these help in the womb)
commonly dx in infancy
most common extracranial solid tumor
diagnosis is often made after metastais occurs
surgery needed to remove as much as possible, chemo
younger age=better survival rate
neuroblastoma s/s
firm, non tender mass that goes across abdomen, resp obstruction, paralysis, periorbital edema, supraorbital ecchymosis, neuro impairment
osteosarcoma
most common bone tumor
common in lower extremites on growth plate
peak age: 15 year male
surgery to for biopsy and to save or amputate limb
chemo to decrease tumor size
osteosarcoma management
We don’t know how bad it is until we get in there. We must tell them prior to surgery about the potential of amputation
goal is to save bone
wilms tumor
kidney tumor.
s/s- painless nontender swelling/mass on one side, deep in flank area
common in toddler/preschool age
dx by ultrasound, CT, MRI, CBC, UA
wilms tumor management
1 nursing priority before surgery is to not palpate this mass
You can do ultrasound, but if you do firm palpation you could release the cancer cells throughout body
chemo is done for a year after surgery. this cancer has a great outcome and short treatment plan
surgery will be done soon after cancer found
rhabsomyosarcoma
cancer of soft tissue sarcoma.
can be in any soft tissue- muscle, organs, etc
s/s depends on site of tumor
dx by PET/CT, MRI, biopsies, LP
multimodal therapy demonstrates high survival in nonmetastatic disease
retinoblastoma
cancer arises in retina
s/s- white glow in pupil, strabismus, blindness
concern for secondary tumor
goal is to avoid loss of vision in eye
management- chemo, surgical implantation iodine for radiation, photocoagulation, cryotherapy
