MCH Exam 3 Study Guide(graded A+)

Hospitalization causes many issues - Stress is the Big one. This can be positive and negative, please explain.Answer- Positive - Child begins to expand their world when parents are absent. Healthcare providers can see the child adapt. If parents are gone too long........abandonment can set in. **Stress helps them learn how to cope. -Negative - Long term stress (not good), however display itself in physical manifestation. Ways to interact friendly interchange with parents/address child:Answer- *No medical jargon -Get to their eye level, engage child and address child -Talk slowly & clearly (concrete words) assess child's cognitive ability -Utilize play, transitional objects, drawings, colors, pictures -Use a child life specialist to assist with communication & interactions -Allow child to make noise and be upset, give child something to do. [Make nice with parents] What is the child most afraid of - 3 things?Answer- 3 big stressors: -losing control or independence -their punishment/pain -change in body images. **[separation from parent and family, fear of unfamiliar, fear of pain and loss of control] How can we minimize the stress of hospitalization?Answer- **Alleviate stress and fears: ask parents stay participate, explain procedure, and provide distractions **Ways to min. stress - rooming in w/ patient [parent should be primary source for coping & comfort], bring an object from home, draw pic to hang in room, offer choices of watching movie or picking a game, therapeutic play, child life specialist, guided imagery, role modeling (decrease fear and anxiety and coping skills), move to procedure room [not in their own room] Separation anxietyAnswer- -Refers to severe distress that occurs when a child is separated from his or her primary caretaker-Begins 6 months of age and peaks in intensity at 14-18 months and then gradually declines;start to accept fact that parents will come back. How do we communicate with children?Answer- Children in general - Get to their level physically. Simple words. Eye contact. Play to demonstrate. Approachable. Communication: Hearing deficitAnswer- sign language, pictures, computerized electronics, eye contact, touch, turn light on. Gain their attention before speaking, face child when speaking, speak slowly and loudly. Communication:Visual deficitAnswer- announce yourself, let them know that you are there. Keep routine in the room the same. Make sure they have their glasses on. Bright lights. Communication: Cognitive issuesAnswer- Be gentle and kind, very short directives. Praise. Hold boundaries. Adapting to deficitsAnswer- **Child will learn to adapt to deficits quickly, better to recognize problem early on before they adapt, then harder to find the problems. May adapt to disabilities so that you may not notice them Basic fears of children are:Answer- separation, abandonment and fear of pain/unknown. [Infants from 6 mos. through toddler hood - fear of separation.] Separation comfort careAnswer- -with favorite items or activity, distraction, parents room in or go with child to procedures. -Child will protest separation due to anxiety, [prep with tours and explanation, use transitional objects] reinforce when they will see parent again. -Despair follows due to grief of separation, detachment due to ongoing anger/coping skills. Alleviate stress and fears:Answer- -explain procedure -distraction -ask parent to stay and participate in care -explain what's going on HOW they play in each of these stages? Note: primary school they tend to play in single sex groups.....and in high school they group by interest groups.Answer- *5 types of play • Solitary (0-2 Years) - infant/ toddlers. Adolescent. Child should be socialized. Can be at any stage, but do not want this type of play only • Parallel (2.5-3 Years) - toddlers. Two toddlers doing the same task, hasn't learned to play with each other. Egocentric. (two children playing together but oblivious to the fact, don't understand the concept of someone outside of themselves) • Associative (3-4 Years) - preschool, early child. Get together to something accomplished, but no rules. • Organized/cooperative (4-6 Years) - school aged/adolescents. Organized sports, rules. Concept of rules upholding. Need moderators. Sports w/Rules • Onlooker/Spectator (2-2.5 Years) - toddlers, young preschool. RED flag if it continues with this type of play; autism, cognitive development problems (can see in toddler or preschooler, but should want to participate) What is the benefit of play?Answer- - learn to socialize -learning society rules -communication; express thoughts -learning fine & gross motor skills -creativity & conceptualize -master skills -get stronger (muscles) -Enables child to explore, express, solve problems -Cognitive and Physical development, helps form independence over time. -provides psychosocial needs of child Nutrition is:Answer- the single most important factor in the growth and development of children. Are food fads that different children encounter harmful?Answer- -No, and are usually self- limiting. -Adolescents have many different needs for greater caloric intake and more concentrated iron, folic acid, and protein. Nutritional needs for baby's/infantsAnswer- -breast milk or formula for 1 full year. -Solids; at around 6 mo. when Surge of growth is the greatest. Toddlers: Food fads a problem?Answer- -No, food fads are not really a problem. -picky eaters, physiological anorexia "grazers". Introduce healthy snack foods. -They may incur physiological anorexia and physiological anemia due to the milk ingestion. Nutritional assessmentsAnswer- [In toddlers] **Too much calcium= Anemia because "calcium impedes iron absorption" -Adolescents (puberty)- surge of growth. Muscle mass. -Anorexia - Not eating; Control issues, body dysmorphia. -Bulimia - Binge and purge; Body dysmorphia. Risks with inadequate nutrition:Answer- • Cardiac and organic failure, electrolytic imbalance, cardiac dysrhythmia, tooth enamel erosion, esophageal damage. Kids are obsessive picky eaters. • Older kids become obsessive and restrictive. • Over-eaters think about meals before all else. • In little kids they can become constipated, unhealthy. • Anemia can be an issue. Food fads are not uncommon and if the child has a daily food intake that is overall balanced, the parent should be comforted and instructed to continue to track the intake. Nutritional needsAnswer- -Infant- breast feed up to 1 year, no milk prior -Solid foods - around 6 mo., slowly new food every 3-4 days -Toddlers - picky eaters, physiological anorexia, grazers; no food fads are detrimental unless purposely not eating. -Growth problems if not receiving proper amount of proteins: Ask what they like (if don't like milk find another option for calcium) **Too much milk can cause anemia [Ca impedes iron absorption] Rate of growthAnswer- Greatest growth in infants, and then again in adolescents which puts them at risk for anemia due to menstruation and muscle mass increase. RestraintsAnswer- - are used for procedures to keep children safe. *MUST BE ORDERED!* *2 common types of restraints- mummy and elbow restraints. • Elbow prevents elbow flex - can't reach things to pull/touch. • Mummy is swaddling and whole body stabilization. Used for procedures and medication administration. **Restraints 411:Answer- -Must be removed every 2 hours. -Parent teaching and return demonstrations must be validated. -Chemical restraints are sedation. Can be used to reduce anxiety. **Airway MUST BE MANAGED at all times. Child must be under direct surveillance at all times. Reasons for RestraintsAnswer- -Safety; keep patient safe, procedures **Restraints: used for procedures to keep safe and postoperatively (prevent pulling of IV or sutures) Consents - for invasive procedures [*Need signature consent for invasive procedures; from parent, guardian or emancipated; pregnant, military, court order]Answer- -If a child is of age, they don't need their parent's signature. -If emancipated they can sign as well. If not the parent must sign. -In emergencies physician can approve if parents are not available. -Religious beliefs can be overturned by courts in some cases. *Consents are Voluntary, understanding of procedure [cognitive/language barriers; interpreter if needed], attempt to contacts [document] telephone attempt; life or limb. Discipline is for:Answer- -Safety and education with positive reinforcement; to make good choices, aggressiveness with toddlers because they don't remember: -Withholding, time out, rationalizing, distractions Harmful disciplinesAnswer- -Corporal punishment [okay to hit, slap or harm] -Isolation (in some cases) -Demoralizing; screaming/verbal abuse -Neglect - passive aggression. Types: Authoritarian- dictator & Authoritative/democratic (is most effective) *Parent can go in and out of different style modes sometimes Beneficial disciplineAnswer- Time out [without isolation], redirection, distraction, positive reinforcement, modeling preferred /desired behavior, removal of privileges, natural consequences of actions. Pain is a frequent assessment done on all patients - what about pain assessments in children?Answer- *Manage as you would an adult. -Pain scales- Faces and FLACC are preferred. *For children 10-12 years old can use the numerical pain scale. -Believe the child's report. Non-Pharm methods to allievate painAnswer- -music and distraction -relaxation -holding hand -cuddling -reassurance -For baby use non-nutritive suckling, cuddling, sugar water -Play, toys, draw pictures What is different, and what are the myths and fallacies regarding "pain management in children"?Answer- Myth: children don't feel pain, neonates don't feel pain due to immature nervous system. They become accustomed to pain, pain doesn't last as long, and children should learn to tolerate pain for later in life. -Pain in children=*ALWAYS treat pain to validated level of response. Chart pain, intervention and response. What drug is most frequently used for severe or postoperative pain in children?Answer- **Most common medication used post-op pain is *morphine* - Biggest risk - Respiratory depression. • Titrate meds very carefully; until 110 lbs. or 50 kg use adult dose, cannot continue to use age and weight=overdose • When child is 50 kg they can go up to the adult dosing • Aware of Respiratory depression, liver and kidneys functional, hydrated well, addiction possibility What are the non-pharmacological measures used to enhance medication or change the pain perception?Answer- Non-pharm: guided imagery, distraction, play, music, massage, aromatherapy, pet therapy, hand holding, deep breathing, parental presence, play, non-nutritive sucking, playing with toys. Milestones of infants to toddlers - Be aware of these so if a child has not reached a milestone, what questions should you be asking and when do we alert the MD?Answer- *Infancy- greatest rate for growth at 6 mo. (7 lb.) Double birth weight @ 6 months (14), and triple weight by 1 year old (21lbs). *Children; grow from head to tail, middle to distal, simple to complex, grow at the same steps but not the same rates. * Anterior fontanelles close 12-18 months, 6-8 weeks posterior fontanelles close Investigate if not child is not meeting milestonesAnswer- • Babbling at 4 months • Roll front to back 5 months • Back to tummy at 6 months • Pick things up like food (handful) 4-6 months • Sitting by 8 months • Pick things up with Pincher 8-9 months • Object permanence by 9-10 months • Walk at 12 months Erikson's theories of Development - why?Answer- -Because if you do not recognize lags in developmental stages we as nurses cannot assist the family in helping this child become a social and productive person. -Object permanence is crucial, separation anxiety, concept of time, death, sharing. -Developmental level drives the way we design and deliver their care. *Erikson's theories show how children interact, when milestone is not met there is stagnation in steps moving:Answer- -Trust vs. mistrust (birth-1year) -Autonomy vs shame and doubt (1-3 years)- toddlers learning to be different, moving quickly away from parent, doing things themselves [balance independence and self- sufficiency] -Initiative vs guilt (3-6 years) exploring everything, mimic things you do. [wanting to be independent and needing to stay attached to parents] -Industry vs. inferiority (6-12 years)- mastery; star baseball player; frustrated [sense of confidence through mastery of tasks] -Identity vs. role confusion (12-18 years) - teenagers are struggling to find who you are, family is important if they are given positive reinforcement, if they don't get reaffirmation they look for it elsewhere. [struggling to find out who they are, biggest impact coming from parents or peers] object permanenceAnswer- the infant knows that an object still exists even if covered up or removed from sight (9-10 month) separation anxietyAnswer- -Normally occurs between 7 to 12 months and peaks between 9 to 18 months, but decreases for most children by age 2 ½. -If the anxiety is severe and excessively disruptive, & persists for longer than 4 weeks, the child should be evaluated by a mental health professional concept of deathAnswer- • Infant; undefined due to level of cognition. • Toddlers; unable to distinguish fact from fantasy inhibits true perception of death (death may mean separation from parents; respond with fear and sadness). • Preschoolers: can understand that something is wrong. Fear of death as early as 3 years. Magical thinkers; don't say death is like going to sleep (fear of sleeping). • School-age child: realistic understanding of death but is not precise until they understand the concept of time (ages 8-9). • Adolescents: can understand death, but difficulty in accepting it as reality. Thinks death can be defied. Emotional ability to face death is absent. concept of sharingAnswer- -preschooler looks to his peers for new ideas and information and begins to develop an understanding of what it means to be kind. -The preschooler is more social and is often more willing to share toys with others than when he was a toddler. (Ages 3-6 years) concept of timeAnswer- time entity, put with event for young children Erikson - What if stage is not completed?Answer- then may get stuck in that stage, recognize that chronological age has some impact in progressing through stages Cognitively impaired childrenAnswer- -Require more vigilance, more discussions, more education and we must help parents realize their true potential realistically, but the children need to socialize. -*Children need opportunity to play, grow and develop, and need to NOT be compared to able-bodied and non-delayed peers. -Guide parents to enable the kids to grow/learn/manage themselves. Injury prevention in each stage of childhoodAnswer- *Infants-[MVA, aspiration, suffocation, SIDs, choking], falls, baby-proof the house, drown in 1" of water, set the thermostat on the water heater low. Now a code for new homes. *Toddlers- MVA, drowning, suffocation, aspiration (choking), stranger danger, also diving, ATV or motorized bikes, tools and equipment, fire hazards, gates for confinement, stove top, outlet covers, doorknobs, lock up dangerous household items and medications. As they get older the risk taking behaviors need to be managed. *Adolescents - alcohol, drugs, MVA, guns. Medication administration and specific nursing treatmentsAnswer- Nurse has to understand the child's medications -*ALWAYS double check dosing and meds prepared to ensure accurate administration. -Small amounts, FlavorRX, gain the children's trust and involvement as soon as able. Oral medsAnswer- -measure correctly, don't use spoon or cup, no ASA for children except for Kawasaki's. -Uncooperative use syringe. -Do not mix in formula. Mix in food. - Make sure getting correct dose. IM/SubQAnswer- -know equipment and sites. -Best site vastus lateralis for babies and toddlers. -Vaccines in deltoids (preschool/school aged). -Ventral gluteal- choice, no major vessels, easy landmarks, less pain. PCN (oil based) I.V. medsAnswer- -24g IV (shorter catheter), 22g when older, 5/8 needle-1 in. -Check for infiltration frequently because of movement. -Use plastic domes (cups) over the site, tape, wrap in gauze, immobilizers, use tegaderm to view sites, use restraints if necessary and lots of tape Signs of infiltrationAnswer- Cool to touch, redness/blanching, paleness, edema (swelling), painful Otic Meds (Ear drops)Answer- -up and back at age 3 -otherwise down and back 3 years Trach for childAnswer- -less than 5 seconds on suction. -One pass. -Ensure Tubing is half the size of trach [prevent edema or trauma]. Why more infections in children?Answer- *Shorter softer airway, short Eustachian tubes, soft epiglottis & trachea, larger tonsils; exposed to more bugs (germs), doesn't have a very good immune system, puts everything in mouth. *Children are oral, poor at hygiene, and not fully developed tissues to manage the illness. Intercostal muscles weak, abdominal breathers when little. Infants are obligate nose breathers. Important stuff about respiratoryAnswer- **ABC'S trump all!! Maintain the Airway first. -Children have Shorter airway, larger tonsils, Epiglottis & trachea is longer and flaccid, floppy which is a greater risk to child's airway. -Upper Resp- Sinuses, airway, trachea, upper bronchioles. -Lower Resp- involves lower bronchus and lungs. What are signs of Respiratory distress in babies?Answer- -Retractions; use of accessory muscles -grasping, tachypnea (80-100 breaths per minute) -elevated respiratory rate -shallow labored breathing -head bobbing -Cyanosis -flaring nostrils -audible expiratory grunting -in infants color change, and as condition worsens flaccidity and apnea occurs. Respiratory distress in older childrenAnswer- *6 years old-wheezing, crackles, tripod position, drooling, adventitious breath sounds, nasal flaring, tachycardia, tachypnea, labored breathing Know the risks of Croup syndromesAnswer- **Viral, some is transient. -Larynx can become inflamed and swollen. -Narrow airway diameter so children more susceptible. -Poor tissue perfusion. Management of CroupAnswer- - Nebulization, oxygen tent, corticosteroids, if necessary use antibiotics, monitoring, artificial airway in emergency. -Use cool night air, cool air from the refrigerator or freezer, or a steamy bathroom (from running a hot shower) to assist in rearing the child's breathing. -With any respiratory compromise, elevate HOB to ease breathing. Croup signsAnswer- -Stridor; trachea get edematous because it's dry. -Sounds like a seal (seal bark) -stares into space [because of working hard on breathing], stridor, and seal barking cough Hallmarks of Cystic FibrosisAnswer- **Complex; exocrine disease; thick mucus that blocks exocrine glands that affect several body systems; Respiratory, GI, and reproductive. -thick mucus secretions block the exocrine glands and other body systems as well as contribute to bacterial growth. -CF is a multisystem disease (failure of two or more organs) mucous overproduction; initially presents itself in the GI system, causing obstruction, bulky stools, that are frothy and foul smelling, [Malnutrition, anemia, growth failure persists] - In lungs; impedes lungs [crackles, wheezes, diminished breath sounds with dry non- productive cough; pneumonia, bronchitis]. -salty skin [sweat not reabsorbed] -don't typically live through teenage years w/o transplant -Both parents have to have autosomal recessive gene (trait) to pass on. Children are typically sterile. Manage symptoms of CFAnswer- • Important that parents know how to manage the disease at home; teach about disease, proper techniques of portable suctioning at home, respiratory therapy prior to meals, teach family how to administer meds. • Needs well-balanced, high protein, high caloric food diet, don't strain with BM • Pancreatic enzymes with meals must be taken, daily vitamin supplements (optimizing nutrition), • Chest physiotherapy (percussion and vibrations) loosen and drain • Manage airway use nebulizers and inhalers. Asthma - complex respiratory illness - how do we recognize?Answer- *Inspiratory and expiratory wheezing, use meds that are prescribed. -Give steroids, IV access, infusers *Reactive airway symptoms; - non-productive cough, retractions, nasal flaring, tachypnea, wheezes, can get air in, but have trouble pushing it out, symptoms of respiratory distress. Management of AsthmaAnswer- • Use nebulized medication, corticosteroids, antibiotics where needed, bronchodilators. • Daily air flow meters to track airway function. -Implement green-yellow-red system and teach interventions at each level. • Increasing humidity in the environment will ease a compromised airway for the child with a reactive airway, whether viral, allergen, or bacterial trigger. **Signs of hypoxia include confusion, tripod position, and stridor. Education for asthmaAnswer- -avoid triggers [dust, fear, anxiety] -use meds that are prescribed [steroids, bronchodilators] and always have them with you Acquired defects are usually associated with an infectious process- what bacteria is the issue?Answer- *Acquired defects are related disease process [infection, autoimmune response, environmental factors, familial tendencies] (Acquired) ** Streptococcus* causes Rheumatic fever (scarlet fever) - also deposits scars on heart valves. -Valves may need to be replaced. RF is a complication of strep illnesses. Strep identification and full treatment instruction imperative. Kawasaki diseaseAnswer- **requires long term antibiotic therapy, ASA therapy -onset of high fever [up to 104f] and enlarged lymph nodes on the neck. -Bright red rash [more obvious on groin area]. -Conjuctivitis -dry cracked lips -"strawberry tongue" -swollen hands and feet after fever subsides -skin peels off hands and feet -treat with high dose aspirin and gamma globulin. -Most cases occur in children under the age of 5 years. Congenital defectsAnswer- • Tetralogy of fallot [become cyanotic when crying (right to left sided) because of overworking the heart], tricuspid atresia, CHF, & other mixed defects -Signs/symptoms: cyanotic (knees to chest); difficulty, turn blue when active: crying, eating or acyanotic (left to right; stress on lungs- pulmonary HTN edema, and other respiratory illnesses) children learn to adapt to limitations **Order of cares for cardiac defects: Airway, Fluid intake, Rest How do children with cardiac disease present to your ED, and how do you manage?Answer- -Child will present with SOB, irritability, edema, poor activity tolerance, puffy fontanels, delayed activity, poor nutrition, and altered vital signs. Pre Cath ProcedureAnswer- -teach child and family about the disease, its cause, and treatment. -NPO. -Answer questions child or family has, explain the risk of bleeding, infection, thrombus, arrhythmias, perforation, stroke, and even death. Post Cath ProcedureAnswer- **Lie flat. -Monitor vitals (HR, RR, BP); distal pulse -restrain -maintain IV therapy (dehydration) -Monitor bleeding of the site, and apply pressure above site if bleeding. *Note: place dressing on top to reinforce, do not remove dressing MD applied. -Monitor pain and administer pain meds as prescribed. -May need to add sedation if too rambunctious. -Vigilant surveillance of vital sign and bleeding. If bleeding is severe the patient must be attended with pressure held to the site while another nurse contacts the physician and calls for immediate assistance. GI issues - dehydration is huge.Answer- -Children that become dehydrated may suffer long term organ damage - so we must encourage fluids - PO or IV. -Watch the titration, it may cause problems if we run fluids too rapidly. -We do not restrict fluids, but should be mindful of what types of things they are drinking - milk may thicken secretions - fruit juice may induce diarrhea, soda/pop - may also induce diarrhea or cramping. Hirchsprungs- (GI problems)Answer- -congenital aganglionic megacolon, is caused by a congenital absence of Meissner's and Auerbach's autonomic plexus in the bowel wall. -This absence of ganglion cells results in lack of motility in the affected portion of the bowel Intussusception (GI problems)Answer- -telescoping of bowels [bowels slides into adjacent part of intestines]; causing obstructions, bowel perforation, infection, & death Diarrhea (GI problems)Answer- -rehydrate; if severely dehydrated - IV therapy, PO if possible -avoid soda, caffeine, sweet juices and milk -pedialyte or anything w/ electrolytes okay -Monitor I & O -do not stop diarrhea in order to get rid of the cause (if not long term) Do not use anti- diarrheal, do not restrict dieting. Pyloric stenosis (GI problems)Answer- -recognized by projectile vomiting -pea sized nodule at sternum -no weight gain -irritable -Failure to thrive Appendicitis (GI problems)Answer- S/Sx: RLQ pain or abdominal pain referred, vomiting, fever, difficult to identify **If perforated, the pain disappears [very dangerous] A child with nausea, vomiting and diarrhea should be given:Answer- -electrolytic replacement fluids -bland foods such as banana, rice, applesauce, dry toast and CLEAR liquids. -Sugars, fats and fiber should be avoided until all symptoms have subsided and stools return to normal. What are the nursing interventions that should be managed in most post-operative cases? [Repair of lacerations, tonsillectomy, and appendectomy]Answer- Post-surgical-**Pain management, checking incision, check for bleeding [excessive swallowing for tonsillectomy], and monitor vitals. Hand hygiene is paramount to prevent the spread of diseaseAnswer- This is SUPER important in an immunosuppressed child who is a surgical patient. infant colicAnswer- -Parent may be completely overwhelmed and exhausted. -Child has "fussy period" every day. -Car rides and walking the floor in cradled arms may help settle the baby. -This syndrome tends to resolve between 12 and 16 weeks spontaneously. -Sometimes a formula may aggravate the condition [dairy intolerance] and mom's diet may be implicated, but typically, it spontaneously resolves. Crohn's DiseaseAnswer- -chronic inflammatory disease characterized by periods of exacerbations and remissions in small bowels; terminal ileum; potential nutritional deficiencies (but can affect any portion) • Age of onset is between 10-20 years; condition occurs throughout life • S/Sx: Acute or insidious onset; abdominal pain, diarrhea, anorexia, & weight loss • Goal for treatment: controlling the disease, including remission & preventing relapse while maintaining adequate nutrition. Nurse can offer emotional support • Meds: Corticosteroids (reduction of inflammation) for acute exacerbations; Metronidazole (Flagyl) and ciprofloxacin (Cipro) treatment of perianal complications. Antibiotics; ampicillin (Marcillin), gentamicin (Garamycin), clindamycin (Cleocin), and metronidazole (Flagyl) are effective during acute exacerbations; Immunosuppressive medications are useful with corticosteroid-resistant disease HirschprungsAnswer- -peristalsis is impeded by obstruction and can become a perforation, no stools, need surgery to fix; Failure to pass meconium within the first 48 hours of life, failure to thrive, poor feeding, chronic constipation, & Down syndrome. • S/Sx: vomiting, abdominal obstruction, failure to pass stools, diarrhea, flatus, or explosive bowel movements (ribbon, pellet shaped, foul smelling) • Surgical correction- resect affected bowel w/ or w/o colostomy, excise agaglionic segment of bowel • Post-Op: Nurse to monitor patent NG, abdominal distention, assess for return of bowel sounds, I&O (including NG/colostomy output) • Nurse to teach caregivers to care for colostomy, skin care, referral to community resources. Emotional support GERDAnswer- -more common in *premature infants*, S/S: vomiting (may include undigested food or formula), fussy or irritated mood, refusal to feed because of discomfort, choking, wheezing, apnea, weight loss, frequent respiratory infections • May need to change volume of feeding, small amounts more often and burping frequently • Cereal added to bottle, position more upright (45 degree angle) • Meds: PPI (omeprazole), H2 inhibitors (cimetidine) • Surgical: Nissen fundoplication, feeding jejunostomy Constipation may also occur due to increase/decrease in activity, anxiety, or disease - so we must get some historical information - what would you be asking?Answer- **The nurse should ask the caregiver: to describe the color, consistency, frequency, and characteristics of stool. -Pain of constipation is typically left sided abdominal pain. -Some rectal pressure may be evident. -Focus on fluids, exercise and fibrous fruits are recommended. -Children with a sense of lack of control may hold their stools and develop mega-colon. -Education for the caregiver: dietary needs, toileting practices, and bowel cleansing. Skin issuesAnswer- children get many bites, rashes, acne, and many can be treated with over the counter medications and avoid the irritant. Burns care:Answer- Airway, shock, infection & fluid intake, Pain. 1st degree burn:Answer- -superficial -erythematous and painful -involve intact epidermis w/o blistering -no fluid loss -only outer epidermis layer -heals w/o scarring in 4-5 days [10% according to 9s] 2nd degree burn:Answer- -superficial partial thickness or deep partial thickness, -partial destruction of dermis -red painful w/ blister -weeping/moist appearance -heal w/ minimal scarring 7-10 days [10-20% according to 9s] • **2nd degree that involve 50% of dermis, destroy nerve fibers so less painful, white pale appearance 2-3 wks to heal, hard to distinguish between this and 3rd degree, at risk for fluid volume loss, skin grafting necessary [20% according to 9s] 3rd degree burns:Answer- -full thickness -white -waxy or leathery -no blanching or bleeding -may be black in color (eschar) -less painful from nerve damage -referred to burn center -skin grafting necessary -risk for infection and fluid loss **take several weeks to heal Rule of 9's for burn evaluation.Answer- Body surface is divided in area representing areas of 9% determined by Total Body Surface Area. - the face counts as 18%, chest 18%, back 18%, genitals 1%, each leg 13.5%, each arm is 9% Treatment for burns:Answer- -manage pain -cover to prevent infection -replace fluid loss -adequate nutrition. Management of burnsAnswer- is focused on pain control and infection prevention. -*In the immediate aftermath, the burn should be cooled with saline soaked cool cloths. -No oil/butter should be rubbed on the burn as it will continue to burn the skin. -Ice should never be used on a burn. Types of Burn:Answer- -Thermal [hot liquid/grease 80% of burns hospitalized] -Chemical -Radiation (sun) -Electrical Other Skin Issues:Answer- • Chicken pox would be deferred unless emergent with diagnosis being done preliminarily over the phone to prevent spread. - **Hallmark chicken pox- spots are the size of a pencil eraser (roughly) and pink, become vesicular, and crust over with scabs as they heal. • Measles are characterized by Koplik's spots in the oral cavity (hallmark signs) Sprains versus FracturesAnswer- -Sprains are soft tissue injuries [ligaments and tendon; occur after puberty after growth plates of epiphysis is closed]. -Fractures occur when the bone undergoes more stress than it can absorb [Open or closed]. Most common causes; falls, MVA, & bicycle accidents. Rest, Ice, Compression and Elevation are standards of care for sprains.Answer- R: Rest, allows to heal I: Ice for first 48 hours at 15 min. intervals to decrease swelling C: Compress, ace wraps E: Elevation, early motion; helps keep full ROM More with cares for sprains & fracturesAnswer- *Crutches or braces may be used as adjunctive therapy. If no weight bearing is ordered, patient should be fit for crutches. -Casts; don't stick anything down into cast, or make indents in casts. Complications; compartment syndrome, cast syndrome (compressing) -Nursing Considerations; skin, perfusion, sensation and movement, emotional affect of child, respiratory management, & pain management Reyes Syndrome - complicated how?Answer- **No aspirin to any child under the age of 18, with a viral illness. -Reye's syndrome thought to be driven by the use of aspirin in a child who has, or has recently had a febrile illness. **Aspirin used only when benefit outweighs risk [some rheumatologist's and cardiologist's will use aspirin in children if their condition warrants it]. How to protect immunocompromised children?Answer- Best possible infection control for all patients is excellent hand hygiene by patient, family and nursing personnel. **Handwashing super important!! Neuro - seizures - how do you manage seizures in children? ** Seizures- Airway, safety, documentationAnswer- Seizure management- (lecture says airway first then safety). -Maintain the airway, roll the child to their side, and stay with them during the seizure. -Anti-seizure medications should be given on a strict schedule. -Some children should wear helmets. -No child with seizure should be in or around water without continual observation. Types of seizuresAnswer- -Partial; focal localized in one area -Partial Complex; LOC with change in behavior. Confusion. Origin is temporal lobe. -Partial Simple; Last for 5 min, child only remembers aura. Sx only on one side of body. No LOC. -Generalized; starts in all parts of the brain. -Tonic/Clonic; muscle spasms, LOC, contraction of limbs. Confusion. Bladder incontinence. -Atonic; Sudden drop to the floor, no LOC, No convulsions, "stare". Several times per day "petit mal" -Tonic/myoclonic/clonic; "grand mal". Stiffness. Anti-seizure medicationsAnswer- -Dilantin; can cause significant overgrowth of oral gingiva. -Strict management of the gums should be discussed with the patient and family. Teach the child (seizures)Answer- -about seizure triggers and safety should be implemented as soon as the child is able to understand the information, as evidenced by repeat demonstration or conversation. The Glasgow coma scale allows the practitioners to use a numerical system to evaluate in a standardized way, the brain/neurological function. *Score of 1-15*Answer- • Score of 9-15 (unaltered state of consciousness) • Score of 8-4 (state of coma) • Score of 3 or below (deep coma) Glasgow Coma Scale assesses: 1. Eye opening- pupil dilation 2. Verbal Response- answer questions 3. Motor Response- move when asked Neuro exams include:Answer- -hand strength, limb strength -ability to follow commands -ability to move eyes in equal and uniform fashion -deep pain stimulus response -symmetrical and coordinated movement -clear, speech. Renal issuesAnswer- Renal disease causes: -chronic electrolyte imbalance -fluid retention -profound fatigue -foamy urine -low GFR -high creatinine. **In late stage: fluid sodium retention, poor color, poor decision making, brain fog. Why are children more prone to UTI?Answer- *Children have unique challenges avoiding UTI's due to their frequent interest in handling their genitals with unclean hands (hand hygiene), as well as having short urinary tracts in girls. Signs/Symptoms of UTI in children:Answer- *Neonate* -are failure to thrive, jaundice, fever or hypothermia, poor feeding, or vomiting. *Infant* -usually is a poor feeder, has fever, strong-smelling urine, vomiting, and diarrhea. *Preschooler* -often presents with anorexia and sleepiness along with vomiting, diarrhea, abdominal pain, fever, strong-smelling urine, enuresis, dysuria, urgency, or frequency. *School-age child*- has new enuresis, strong-smelling urine, urgency, or flank pain and some changes of personality. *Adolescents*-often experience fatigue and flank pain. Visual inspection of external genitalia for irritation, pinworms, sexual abuse, trauma, or vaginitis is important. Thyroid medicationsAnswer- -should be given on an empty stomach, at the same time every day. -Thyroiditis, Hashimoto's or thyroid storm can cause critical thyroid values and extreme hyperthyroid symptoms. -Endocrine issues require extensive testing for the family and the patient. -The stronger the education, the better the health of the patient, typically. HypothyroidismAnswer- -thyroid gland underactive -not enough thyroid hormone secreted -can lead to goiter if untreated -thyroid hormone controls *metabolism rate*. **S/Sx: bradycardia, tiredness, cold intolerance, low T3 and T4, high TSH -Treatment w/ levothyroxine Graves' (hyperthyroidism)Answer- -overstimulation of thyroid w/ excess production of thyroid hormone [autoimmune] **S/Sx: enlarged thyroid gland, raised, thickened skin, palpitations, tachycardia, shakiness, increased perspirations, tremor, weight loss; low TSH, high T3 and T4 -Treatment w/ methimazole DiabetesAnswer- -thorough education of disease -manage insulin and glucose -manage diet and activity -let the child self-medicate if able **Manage insulin, diet, & activities is the focus for DM1 -*Hyperglycemia* - polyuria, polyphagia, polydipsia, slurred speech, fatigue, blurred vision, ketones in blood and urine, fruity breath -*Hypoglycemia* - shakiness, pale, sweaty, hunger, palpitations, loss of consciousness Immunizations - What/when?Answer- -Hep B- [Hepatitis B] First @ 1-2 months, Next @ 6-18 months -DTap- [Diptheria, Tenus, Pertussis] @ 15-18 months -Hib- [Haemophilus influenza type b] @ 12-15 months -PCV- [Pneumoccoccal] @ 12-15 months -IPV- [Inactivated Polio Virus] @ 6-18 months -Influenza- yearly after 6 months -MMR- [Measles, Mumps, Rubella] @ 12-15 months -Varicella- @ 12-15 months -HepA- 2 doses @ 12-23 months DO NOT GIVE an immunizationAnswer- -to an ill child due to concerns about manipulating the immune system with a child who is ill or has a fever. -Fever above 100.4 or 101°F. -The nurse should also be prepared to intervene with epinephrine and diphenhydramine in the event of an anaphylactic reaction. Preferred site for injections by ageAnswer- -[vastus lateralis for infants, deltoid if arms are large enough to inject]. *BEST SITE is- vastus lateralis for babies and toddlers. *Deltoid site for Vaccines in for preschool/school aged children. *Ventral gluteal- choice place for IM, no major vessels, easy landmarks, less pain (safely give after the child is walking and build some muscle mass on glute). Sickle Cell Crisis - What is it? How do we treat it?Answer- Vaso-occlusive sickle cell crisis is caused atypical sickle-shaped morphology of the red blood cell in Sickle cell patients. • Symptoms of acute pain occur when the sickle cell shaped blood cells blocks the capillaries and vasculature becomes static. *Extreme pain in abdomen & joints* • Lack of circulation and perfusion cause anoxia to tissues, great pain, and anxiety. • Hydration and pain control are the focus of nursing intervention. **May need blood transfusion if severe What does the nurse look for in a child with hydrocephalus?Answer- -track the size of the infant head size at every visit allows the nurse to recognize changes in head diameter due to fluid building. Signs/symptoms (based on age): • Increased ICP • tapping on the skull (resonant sound) "Macewen's sign" or "cracked pot" due to cranial suture separation • child has difficulty holding head upright • face and cranial vault disproportionate • prominent forehead, dramatic head enlargement • optic chiasm, and compression of optic nerve if untreated. -A clogged shunt can cause headache, neurological changes, confusion, and vomiting. How would the nurse rule it out hydrocephalus?Answer- -Normal growth patterns and circumference in the head rules out concern for hydrocephalus. **If an increase in cranial size is noted on exam, hydrocephalus as well as brain tumor should be ruled out. Normal fluid intake and output in children. [Parenteral fluid volumes are based on this knowledge].Answer- Standard is 1ml to 2ml/kg/hr. This is normal urinary output. Normal oxygenation levels in children on pulse oximetry. When would you intervene?Answer- -Normal oxygenation levels is: 91-100% -Oxygen therapy should be implemented when a child's oxygen falls below 90% on room air. Normal ranges for pediatric Heart rateAnswer- -Infant: 80 to 150 -Toddler: 70 to 110 -Preschooler: 65 to 110 -School-aged: 60 to 95 -Adolescent: 55 to 85 Normal ranges for pediatric respirationsAnswer- -Infant: 25 to 55 -Toddler: 20 to 30 -Preschooler: 20 to 25 -School-aged: 14 to 22 -Adolescent: 12 to 18 Normal ranges for pediatric temperatureAnswer- -2 months: 99.4 (37.5) -4 month: 99.5 (37.5) -1 year: 99.7 (37.7) -2 years: 99.0 (37.2) -4 years: 98.6 (37.0) -6 years: 98.3 (36.8) -8 years: 98.1 (36.7) -10 years: 98.0 (36.7) -12 years: 97.8 (36.6) Normal ranges for pediatric blood pressureAnswer- -Infant: 65/45 to 100/65 -Toddler: 90/55 to 105/70 -Preschooler: 95/60 to 110/75 -School-aged: 100/60 to 120/75 -Adolescent: 110/65 to 125/85 What does the nurse look for when evaluating a child for possible child abuse?Answer- The nurse looks for repeated admissions or office visits for unexplained physical injury. • Spiral fractures is a main sign indicating child abuse • suspicious bruising, welts, or burns, new or healing lacerations • fear of going home • retinal hemorrhage (SIDS; babies) • hunger, clothing unsuited for weather (neglect) Other signs the nurse observes for abuseAnswer- -child signals fear of the adult care- giver -inability to answer questions without looking to the adult for approval -a child with little reaction to pain -poor eye contact -injury inconsistent with the story given for reason of injury. *To report child abuse the nurse can call local law enforcement agency and/or follow institution policy. Fever Management - How and why?Answer- -Fever is the primary reason for pediatric ED admission. -Fever management is imperative to prevent pediatric febrile seizure. -Temperature greater than 100.4 is considered fever and requires treatment. -If the fever does not respond to treatment, or lasts longer than 72 hours, the child should be evaluated to determine the cause of fever. -Any child under the age of 6 months requires evaluation. When a child is brought in by EMS for evaluation following an accident the nurse understands that the child is evaluated on the A-B-C-D scaleAnswer- **Airway, Breathing, Circulation and Deformity (& Exposure; signs of trauma bleeding, rash). -This is the standard trauma algorithm for emergency care: • Airway- Is the airway patent? • Breathing- Is the breathing sufficient? RR, cyanosis, lung auscultation • Circulation- Is the circulation sufficient? Cap refill, pulse, color changes • Disability- What is the level of consciousness? Alert, responds voice, responds to pain, unresponsive AKA Glasgow Coma Score.