Test #5 Flashcards
what is the mature minors doctrine
a minor may consent to tx for certain procedures without informing legal guardian
what 2 categories fall under the mature minors docterine
- at any age a person can obtain treatment or prevention of pregnancy ( except sterilization)
- at age 12 and older- drug tx, HIV testing or tx, STI testing or tx, sexual assault diagnosis or tx does not have to have informed legal guardian
what qualifies a person to be an emancipated minor
a valid marriage
if you are in active duty in the armed services
if you have court ordered declaration of emancipation
(you have to prove you are a better support for yourself than your parents. )
what are the ethical consent considerations
- Assent
- dissent
what is assent
the children should participate in the decision making if they are capable.
the child should be taught in age appropriate ways and make sure the child agrees to the care if possible
what is dissent
-the childs refusal to assent
if the childs treatment is not time critical or essential it can be deferred.
can the parent refuse treatment for their child
yes- it is their fundamental right
it may be related to religious or cultural beliefs or the
childs quality of life.
if you suspect is is neglect - you are a mandated reporter and the situation needs to go through the judicial system.
what are things to focus on with a child with an illness
- they are a child -not the illness
- focus on what they can do not what they can’t
- pay attention to their developmental age not chronilogical age (they may be developmentally delayed.)
how should you handle the family with a sick child
- be honest with them
- relate to them in a therapeutic way
- awknowledge their expertise- they may have been dealing with their childs illness for a while and know what works and what doesn’t.
what is the goal of therapeutic play
to promote coping and minimize stress on the child
what is a child life specialist
a person in the hospital that designs interventions to reduce stress
they come up with things such as
injection play- the child gets to inject a teddy bear
using a kazoo for lung expansion rather than an IS
using a paper airplane for ROM
what are ways to promote normalization in sick kids
- include the child in decisions
- allow the family members to be apart of care
- apply same family rules to all children
- help the child focus on what they can do
how do you support parental coping
- model acceptance
- affirm the parents strengths. let them know they are doing a good job
- refer them to support groups
let the parent know you are there for their child and that if they want to go take a break thats ok.
build trust with the family
how do you support the siblings of a sick child
- try to explain age appropriately the illness
- encourage them to ask questions
- acknowledge their feelings
- find ways to involve them in their siblings care
what are the different stress points with a chronically ill child
- the diagnosis
- development/lack of development milestones
- start of schooling (worried if their child will be cared for appropriately/worry about leaving them in the care of someone else)
- adolescence- they are growing and going through puberty
- future placement- what will happen when they are grown
- death of a child
what is a primi’s respiratory system like
- compliant chest wall
- weak respiratory muscles
- intercostal muscles are less developed
- obligate nose breathers
retractions are more common in infants- their diaphragm is the major respiratory muscle
what is the child respiratory system like
-they have a small lower airway
-underdeveloped cartilage -
(these two predispose the child to infection)
- eustachian tube is short and horizontal- causing inadequate draining causing otitis media
- a higher respiratory rate
- use abdominal muscles to breath
qhow long does alveoli develop
until the age of 3
when does a child stop being a “belly breather”
children use their abdominal muscles to breathe until age 5
what is the most common illness in pediatrics
respiratory illness
when is the highest incidence of respiratory illness in a child
in winter and spring
what increases the risk for a child to get a respiratory illness
- 2nd hand smoke
- daycare
- fatigue/anemia
- malnutrition
- chronic disease
- air pollution
what are the upper respiratory tract infections
otitis media
croup
what are the lower respiratory tract infections
RSV (respiratory syncytial virus)
Inluenza
what are respiratory diseases
asthma
cystic fibrosis
why are pediatric patients at such a high risk for respiratory infections
because they have less developed immune system
what are the s/s of a respiratory illness
- fever 100.5 or higher (ages 6mo-3yrs)
- tachypnea
- stiff neck/HA (s/s resembling meningitis)
- anorexia
- vomitting/diarrhea
- dehydration (from vomiting/diarrhea- not necessarily the illness)
- abdominal pain
- nasal discharge (causing irritated skin/ulcerations)
- sore throat- causing dysphagia leading to anorexia
- cough
- adventitious lung sounds
what can a high fever do (what temp?)
a high fever can cause a febrile seizure in age 3-4
most occur greater than 102.2
what is acute otitis media
effusion (fluid) and inflammation of the middle ear
what causes AOM
pathogens such as s. pneumonia or h. influenza
virus’s do not cause AOM- they predispose the child for infection by altering the body immune response allowing these ear infections bacteria to grow and cause infection
who is at increased risk for otitis media
< age 3
pacifier use
bottle feeding d/t positioning and reflux of fluid
male
what are s/s of otitis media
-earache
-bulging, opaque, red tympanic membrane
-yellow/green purulent foul smelling ear drainage
fever
irritability
vomiting
anorexia
diarrhea
how do you diagnose AOM
s/s of AOM
pneumatic otoscopy- a puff of air observing the movement of the tympanic membrane
how do you manage non severe AOM
with abx or observation and follow up
what abx is used for AOM
amoxicillin if:
< or equal to 6 months AND severe sxs of AOM
or 6-23 months AND bilateral AOM without severe sxs
what can you do for recurring AOM
placement of tympanovstomy tubes
what is croup
the inflammation and edema of the larynx, trachea and bronchi.
what causes croup
usually a viral infection
however it can be bacterial
what does croup sound like
inspiratory stridor with a barking cough
what are the sxs of croup
-barking cough inspiratory stridor -retractions repsiratory distress AT NIGHT (usually lasts for a few hours and reside in the morning occurring again the next night)
how do you manage croup
diagnose via the s/s
-humid or cool air can help alleviate sxs. (go outside at night in the cool air or in the bathroom with a steaming shower)
when does a croup pt need to be hosptalized
if the pt has asthma.
what is the tx for severe croup
hospitalization
racemic (nebulized) epinephrine
oral dexamethazone
what does oral dexamethasone do
reduces inflammation and promotes broncho dilation
what is RSV
infected epithelial cells fuse and form syncita (giant cell)
edema and mucus obstruct the bronchioles causing hyperinflation, atelectasis and hypoxia
how is RSV trasmitted
via contact
can also be spread by droplet
what is the duration of RSV
10-14 days
the first 4-7 days the pt has mild URI sxs
the next 2-3 days the pt has tachypnea, tacky, wheezing, crackles, rhonchi, retractions, nasal flaring and cyanosis
temp up to 105.8
How is RSV CONFIRMED
A nasal wash
What is RSV management
Rest Humidified oxygen Fluids Elevate HOB Inhaled bronchodilator
How do you prevent RSV
Hand washing
Clean toys
No smoking
Who is a high risk RSV pt
Infants born between 35wks
Congenital heart disease or lung diseases
Is there to for RSV
No but there is prophylaxis for high risk infants
It is synagis-an immune globulin administered Iv monthly throughout RSV season
What is cystic fibrosis
A chronic multi system disorder that effects the exocrine glands of bronchioles, small intestines and pancreatic bike ducts
A thick mucus obstructs the passageway of organs
What is an autosomal recessive trait regarding cystic fibrosis
Meaning if both parents are carriers the child will have a 25% chance of getting cystic fibrosis
When one parent is a carrier and one has cystic fibrosis there is a 50 % chance the child will have it
What are the respiratory sxs of CF
Early stages leading to
Early- wheezing Dry cough Repeat pneumonia, bronchitis Purulent copious amounts of sputum LEADING TO: Adventitious lung sounds Dyspnea Tachypnea Retractions Hypoxia Cyanosis
What are the late stages of CF
Emphysema Atelectasis Cod pulmonale Chf Pneumothorax Hemotysis
Death from respiratory failure
What are the digestive sxs of CF
Blockage of the pancreatic duct prevents secretion of trypsin, amylase and lipase into sm intestine
(Therefore protein cho and fats are poorly absorbed)
Leading to steatorrhea and azotorrhea
Malnutrition d/t the decreased absorption causing underweight, protuberant abdomen, barrel chest, wasted butt , thin extremities
Deficiency in vit ADEK
Meconium ileus
Rectal prolapse
Intussusception
What may develop d/t the digestive complications of CF
Type one diabetes due to the damage to the pancreas
What is exocrine problems with CF
The movement of salt in and out of cells is impaired
Causing a risk for hyponatremia, hypochloremia and dehydration during hot weather
What is a sign of exocrine dysfunction related to CF
Very salty sweat
What happens to the reproductive system with CF
Thick cervical mucus can affect the reproductive organs blocking the Soren from entering the cervix
They cause sterility in 95%males
How is CF diagnosed
positive sweat chloride test on 2 occasions
DNA testing and positive newborn screens
what are the therapy goals for CF
Prevent and treat pulmonary infections
maintain nutritional balace
promote psychological adjustment
hospitalize during acute pulmonary infections for IV abx and vigorous chest physical therapy
how do you manage the respiratory problems with CF
percussion and postural drainage multiple times daily
forced exhalation and positive expiratory devices
inflatable best performing high frequency chest wall oscillation
what drugs are good for CF
mucolytic agents
bronchodilators
anti inflammatory
abx
why is oxygen therapy used with caution in CF pts
because the children are at risk for oxygen induced carbon dioxide narcosis
what type of diet should a CF pt have
A high caloric, high protein diet
with pancreatic enzymes with every meal or snack.
(fats are not restricted unless steatorrhea occurs)
obtain water miscible forms of vit ADEK
extra salt in hot weather or vigorous exercise
what other meds should a person take to protect the intestines in CF
H2 blockers or PPIs
in a normal heart which side has more pressure
the left side of the heart has more pressure
in a fetus where does oxygenation take place
in the placenta
where does the blood from the umbilical cord go to
describe blood flow through the fetal circulation
a small portion goes to perfuse the liver and the remainder goes through he DUCTUS VENOSUS to the inferior vena cava
into the R atrium
through the foramen oval to the left atrium
to the left ventricle to the body
a small amount goes from the rt atrium to the rt ventricle to the pulmonary arteries- off of the pulmonary arteries, blood flows through he ductus arteriosus to the aorta to the rest of the body.
a small amount of blood stays in the pulmonary arteries and goes to the lungs for perfusion.
explain the fetal transition to neonatal circulation
the lungs inflate with the first breath causing pulmonary resistance to fall
this increases pulmonary blood flow
the right side heart pressure falls
the increasing uptake of O2 by the lungs will cause the ductus arteriosus to constrict
as the pressure on the left side increases and the right side decreases the foramen oval will close
when does the ductus venosus close
when the cord is clamped
why is a pediatric heart have a fixed stroke volume
because the heart doesn’t have the ability to distend in the same way a mature heart does.
how does a pediatric heart keep up with cardiac output
it has to pump faster because it isn’t compliant to increase pressure to increase output.
what are early s/s of pediatric HF
tachypnea at rest
poor feeding
slow wt gain
lethargic
what does left sided HF produce?
RT sided?
LEFT: Pulmonary edema because the blood gets clogged up and pushed back in the lungs
RIGHT: systemic congestion because it backs up in the right side of the heart pushing back out to the rest of the body
right sided will produce JVD and periorbital edema
what med improves cardiac function and how
digoxin
it strenghtens the force of contractions
and
slows the heart rate to allow more time to fill
besides digoxin, what are managements of HF
remove fluids with diuretics
restrict fluids (Not in infants)
low Na+ diet
vasodilate with ace inhibitors
decrease cardiac demand by keeping them calm, HOB elevated, holding them up while feeding
monitor temp - cold or fever promotes tachycardia
improve perfusion with O2
optimize nutritional intake - give small amounts more frequently and allow them to burp
what is the cause of a murmur
defective valve or an abnormal heart passage
what are the classifications for congenital heart disease
increased pulmonary blood flow decreased pulmonary blood flow obstructive defect acyanotic cyanotic
what are the conditions of increased pulmonary blood flow
atrial septal defect
ventricular septal defect
patent ductus arteriosus
what are the conditions of decreased pulmonary blood flow
tetralogy of ballot
hypoplastic LT heart syndrome
transposition of great vessels
what are the conditions of obructive defects
coarctation of aorta
what CHD are acyanotic
atrial septal defect
ventricular septal defect
coarctation of aorta
what CHD are cyanotic
tetralogy of fall
hypoplastic lt heart syndrome
transposition of great vessels
what are the risk factors of CHD
the first 8 wks of life
maternal factors:
Rubella ETOH use
pregnant after age 40
type 1 diabetes
genetics:
chromosomal abnormalities
parents or siblings with CHD
down syndrome
what is atrial septal defect
and its classification
increased pulmonary blood flow
acyanotic
an abnormal opening between the atria such as:
patent foramen ovale
the blood in the left atrium flows to the right atrium and back up to the lungs.
the body is not getting enough blood flow and the lungs are getting too much
prognosis is good
possible s/s of atrial septal defect
systolic murmur
heart failure
what is the management of atrial septal defect
manage if HF is present
small may close without tx.
an occlusive device can be placed via cardiac catheterization
can be surgically closed with sutures or patch
what is a patent ductus arterioles and what calssification
increased pulmonary flow and acyonotic
it is the failure of the ductus arterioles to close and produces a LT to RT shunt
the blood comes into the RT atrium to the RT ventricle to the lungs to LT atrium to LT ventricle to aorta
from there the blood will flow back through the ductus arterioles back to the pulmonary artery
what is the management of patent ductus arteriosus
manage if HF is present
surgically: ligation
medical: indomethacin (prostaglandin inhibitor) to constrict ductus
what is coarctation of the aorta and what is the classification
it is an obstructive defect and an acyanotic defect
it is a narrowing of the aorta that restricts blood flow to the lower part of the body
causing blood to flow up the LT subclavian vein b/c it has less pressure
what are s/s of coarctation of the aorta
HA nosebleeds blurred vision Arms-High BP legs- Low BP leg pain/cramps-claudication LT sided HF stroke
*may present as pulmonary edema d/t the LT side of the heart not pumping properly
what is the management of coarctation of the aorta
manage HF if present
surgery: end to end anastomosis (cut out the stricted part and put the two ends together)
bypass- bypass the stricture with a graft
nonsurgical: ballon dilation with stent placement
what is tetralogy of Fallot and classification
decreased pulmonary blood flow- cyanotic defect
it is the combination of 4 cardiac abnormalities:
pulmonary valve stenosis-pulmonary valve makes it hard for blood to leave, RT heart has to work harder = increased pressure
ventricular septal defect: there is a hole in between the RT and LT ventricle pushing blood LT to RT
overriding aorta: aorta sitting over the ventricular septum getting blood from both sides
rt ventricular hypertrophy: rt side works so hard it hypertrophies and the rt will have higher pressure and move blood right to left ventricle
s/s of tetralogy of fallow
- cyanosis
- hyper cyanotic episodes (TET spells)- blue skin nails and lips after a sudden drop in O2 in the blood
-compensetory squatting- children may instinctively squat when they feel SOB, squatting improves pulmonary blood flow
fatigue
poor growth/weight gain
harsh systolic murmur
clubbing of the nails
polycythemia- increase in RBCs because the prolonged hypoxemia stimulates the kidneys to secrete erythropoietin causing production of more RBCs
what is the management of tetralogy of fallot
preop management of hypoxemia and polycythemia
surgery: successful in the 1st yr of life
- patch the ventricular septal defect
- replace the pulmonary valve
- widen the pulmonary artery
what can be done for a child with tetralogy of fallot who is not strong or big enough for surgery
a placement of a palliative shunt that copies the ductus arterioles that connects the subclavian to the pulmonary artery
what is central cyanosis
bluish coloration of the lips, skin, nails and mucus membranes
what does central cyanosis depend on
the absolute concentration of Desaturated hgb (3-5g.dL)
in a normal hgb cyanosis occurs around 85%
in an anemic pt cyanosis will occur at a lower O2 %
in a polycythemia pt they will appear cyanotic at a higher O2 sat
what are hypoxemia interventions
-calm the infant
-place in a knee chest position- this mimics squatting and promotes pulmonary blood flow
-administer O2
-administer morphine- to slow HR and RR- prevents hyperpnea and hyperventilation ultimately preventing metabolic alkalosis
IV hydration
why does a hypoxemic infant need IV hydration
because d/t the polycythemia
the IV fluids will help decrease the viscosity of the blood
increase the circulatory volume and reduce the risk of stroke
what is polycythemia and what is the cause
overproduction of RBCs
caused by chronic hypoxemia
there is an abnormal high H&H
blood viscosity is increased
what HCT is life threatenting
55%
what does polycythemia increase the risk for
thromboembolism or stroke
hypo perfusion- d/t the viscosity of the blood- it is moving slower throughout the body
what are the s/s of polycythemia
dyspnea
Ruddy (dusky or very red appearance)
lethargy
what is the treatment for polycythemia
exchange transfusion
take 10-20mLs of the infants blood and replace it with NS
what is hypo plastic LT heart syndrome and its classification
decreased pulmonary blood flow
cyanotic defect
when the left side of the heart does not develop completely, the LT side is unable to send blood to the body and the RT side is doing double duty.
there is LT to RT shunting via ASD
as the shunt begins to close the s/s become apparent
what are the s/s of hypo plastic LT heart syndrome
progressive cyanosis
HF
difficulty eating
lethargy
what is the management of hypo plastic LT heart syndrome
reconstructive sx - will give the pt a single ventricle
heart transplant
what is the transposition of the great vessels and what is the classification
decreased pulmonary blood flow
cyanotic defect
a condition in which the pulmonary artery and the aorta are reversed
the aorta is coming off of the RT ventricle and the pulmonary artery is coming off the LT
the oxygenated blood from the LT ventricle then enters the pulmonary artery and goes back to the lungs to the LT atria to LT ventricle and around again
the deoxygenated blood from the body enters the Rt atria to the RT ventricle out the aorta to the body back to the RT atria never going to the lungs to be oxygenated.
what are the signs and symptoms of the transposition of the great vessesl
cyanosis, acidosis, HF
what is the management of transposition of the great vessels
prostaglandins to maintain the ductus arterioles and foramen ovale
correct via arterial switch sx in the 1st month of life
what is Kawasaki disease
acute inflammation of the blood vessels
more often in boys than girls under the age of 5
it is the leading cause of acquired heart disease
what causes Kawasakis?
unknown
it is not contagious
how do you diagnose Kawasakies disease
based on the sxs- first 10days
need at least 4 to diagnose:
- high fever 4-5 days duration
- non purulent conjunctivitis
- cracked, dry, fissured mucus membranes
- red lips, strawberry tongue
- swollen hands/feet
- red palms/soles
- generalized erythematous rash
- enlarged cervical lymph nodes
- tachycardia
- *Extreme Irritability
what are complications of Kawasakis disease
Coronary artery aneurysm
Myocardial infarction
what happens in the sub acute phase of kawasakies disease
days 11-25- most of earlier sxs disappear
- desquamation of fingers and toes
- arthritis
- HF
- Arrythmias
- coronary artery aneurysm develops
how is Kawasakis disease managed
High dose IV gamma globulin (IVIG) - to prevent coronary artery damage High dose aspirin therapy promote hydration and comfort: -popsicles and ice -cool cloths -lubricate lips, -sponge bath, -lotion -quiet calm environment -support parent
what is the high dose aspirin for
anti-inflammatory: 80-100mg/kg/day until fever resolves
3-5 mg/kg/day up to 8 wks for antiplatelet aggregation
