NUR 2513 Maternal Child Nursing Exam 3

NUR 2513 Maternal Child Nursing Exam 3 NUR 2513 Maternal Child Nursing Exam 3 Hospitalization causes many issues - Stress is the Big one. This can be positive and negative 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. What are 3 things children are most afraid of? Answer- -losing control or independence -fear of pain or punishment -fear of bodily harm or change How can we minimize the stress of hospitalization? Answer- Parent rooming in w/ patient, bring an object/toy from home, draw pictures to hang in room, offer choices of watching movie or picking a game, therapeutic play, child life specialist, guided imagery How do we communicate with children? Answer- Children in general - Get to their level physically. Use simple words. Eye contact. Play to demonstrate. Be approachable. DO NOT LIE TO THEM! Communication: Hearing deficit Answer- 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 deficit Answer- 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 issues Answer- Be gentle and kind, very short directives. Praise. Hold boundaries. Separation comfort care Answer- -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 What is the benefit of play? Answer- ● Allows children to express feelings and fears. ● Facilitates mastery of developmental stages and assists in the development of problem solving abilities. ● Allows children to learn socially acceptable behaviors. ● Activities should be specific to each child's stage of development. ● Can be used to teach children. ● A means of protection from everyday stressors. Solitary play Answer- The child plays alone, without regard for those around him. Characteristic of infants. Onlooker play Answer- The child observes the other children around him as he plays alone; may alter own play activities based on what he sees the others doing or may be content to continue in his play while simply talking with the other children; play activities are different (e.g., one child may be bouncing a ball while another is playing with jacks). Characteristic of toddlers. **RED FLAG for continuing in this phase of play, which is usually indicative of autism Parallel play Answer- Children play independently among other children but they do not yet play together, which is characteristic of toddlers. Associative play Answer- Children playing together without organization, which is characteristic of preschoolers Cooperative play Answer- Organized playing in groups. Children assume designated roles in the games, have goals for the games, and rely on one another for the game to continue and progress. This is characteristic of school-age children and adolescents. 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. Toddlers: At risk for? Answer- Physiological anemia -Because of too much calcium in milk impedes iron absorption Physiological anorexia -Toddlers begin developing taste preferences and are generally picky eaters who repeatedly request their favorite foods. Physiologic anorexia occurs, resulting in toddlers becoming fussy eaters because of a decreased appetite. 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 needs Answer- -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] Adolescent nutrition requires Answer- Rapid growth and high metabolism require increases in quality nutrients, and make adolescents unable to tolerate caloric restrictions. **During times of rapid growth, additional calcium, iron, protein, folic acid, and zinc are needed. Rate of growth Answer- Greatest growth in infants, and then again in adolescents which puts them at risk for anemia due to menstruation and muscle mass increase. Restraints Answer- Are used for procedures to keep children safe!! *2 common types of restraints- mummy (papoose) and elbow restraints. • Elbow prevents elbow flex - can't reach things to pull/touch. • Mummy (papoose) is swaddling and whole body stabilization. Used for procedures and medication administration. **During a procedure you don't need an order for a restraint. If you want to KEEP THEM ON you need an order. **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 pre-op or post-op **Airway MUST BE MANAGED at all times. Child must be under direct surveillance at all times. Reasons for Restraints Answer- Restraining a child may be a necessary intervention to ensure a child's safety during a procedure or to prevent injury to an operative site. Consents - for invasive procedures Answer- *Need signature consent for invasive procedures; from parent, guardian or emancipated; pregnant, military, court order -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 Discipline strategies Answer- Distraction: Provide a toy to divert the child's attention. Time-Out: Move the child to a "cooling-off" place where the child can calm down. Removal of Privileges: Withhold a favorite toy until the child's behavior is appropriate. Verbal Reprimands: Give spoken warnings or disapprovals without berating the child or judging the child as "bad." Corporal Punishment (e.g., spanking, swatting, and grabbing): Not recommended. Harmful disciplines Answer- -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 discipline Answer- Time out [without isolation], redirection, distraction, positive reinforcement, modeling preferred /desired behavior, removal of privileges, natural consequences of actions. FLACC assessment tool Answer- Ages 2 months to 7 years Pain rated on a 0 to 10 scale by assessing the behaviors of the child FACES assessment tool (Wong-Baker) Answer- 3 years and older Pain rated on a scale of 0 to 5 using a diagram of six faces. Substitute 0, 2, 4, 6, 8, 10 for 0 to 5 to convert to the 0 to 10 scale. Explain each face to the child; ask the child to choose a face that best describes how they are feeling: 0: No hurt 1: Hurts a bit 2: Hurts a little more 3: Hurts even more 4: Hurts a whole lot 5: Hurts worst OUCHER assessment tool Answer- 3 to 13 years old Pain rated on a scale of 0 to 5 using six photographs. Substitute 0, 2, 4, 6, 8, 10 for 0 to 5 to convert to the 0 to 10 scale. Have the child organize the photographs in order of no pain to the worst pain; ask the child to choose a picture that best describes how they are feeling: 0: No hurt 1: Hurts a bit 2: Hurts a little more 3: Hurts even more 4: Hurts a whole lot 5: Hurts worst Numeric pain assessment tool Answer- 5 years and older Pain rated on a scale of 0 to 10. Explain to the child that 0 means "no pain" and 10 means "worst pain." Have the child verbally report a number or point to their level of pain on a visual scale. Non-communicating child's pain assessment tool Answer- 3 years and older Behaviors are observed for 10 min. Six subcategories are each scored on a scale 0 to 3. 0: Not at all 1: Just a little 2: Fairly often 3: Very often SUBCATEGORIES Vocal Social Facial Activity Body and limbs Physiological CUTOFF SCORES 11 or higher indicates moderate to severe pain. 6 to 10 indicates mild pain. Non-Pharm methods to allievate pain Answer- Distraction ● Use play, radio, a computer game, or a movie. ● Tell jokes or a story to the child. Relaxation ● Hold or rock the infant or young child. ● Assist older children into a comfortable position. ● Assist with breathing techniques. Guided imagery ● Assist the child in an imaginary experience. ● Have the child describe the details. Positive self talk: Have the child say positive things during a procedure or painful episode. Behavioral contracting ● Use stickers or tokens as rewards. ● Give time limits for the child to cooperate. ● Reinforce cooperation with a reward. Containment ● Swaddle the infant. ● Place rolled blankets around the child. ● Maintain proper positioning. Nonnutritive sucking ● Offer pacifier with sucrose before, during, and after painful procedures. ● Offer nonnutritive sucking during episodes of pain. Kangaroo care: skin to skin contact between infants and parents Myths about pain management in children Answer- • Children do not feel pain with the same intensity as adults. • Children cannot tell where they hurt. • Children will tell you if they are really having pain. • Children become accustomed to pain. • Narcotic analgesics are dangerous for children because they become addicted or go into respiratory distress. • If children can be distracted, they are not in pain. • If children say they are in pain, but do not look in pain, they do not need to be medicated. • Being in pain for only a little while is not that bad. • After children have undergone surgery, they should not be given analgesia until they can vocalize pain because they received enough anesthetic to "cover" their pain. • The best way to give analgesics is intramuscularly. • Children with neurological impairments do not feel pain as much as other children. • Children, especially boys, should learn to tolerate pain; they will make better, stronger adults. 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 is respiratory depression. • Titrate meds VERY carefully until 110 lbs (50 kg), at that point they will get the adult dose • When using adult dose you CANNOT continue to use age and weight for dosing (=OVERDOSE) • Be aware of possible respiratory depression, liver and kidney function, keep them well hydrated, possibility of addiction Infant reflexes - Stepping Answer- Birth to 4 weeks Elicited by holding an infant upright with his feet touching a flat surface, the infant will make stepping movements. Infant reflexes - Palmar grasp Answer- Birth to 3 months Elicited by placing an object in an infant's palm. The infant grasps the object. Infant reflexes - Sucking and rooting reflexes Answer- Birth to 4 months Elicited by stroking an infant's cheek or the edge of an infant's mouth. The infant turns her head toward the side that is touched and starts to suck. Infant reflexes - Moro reflex Answer- Birth to 4 months Elicited by allowing the head and trunk of an infant in a semi sitting position to fall backward to an angle of at least 30° The infant's arms and legs symmetrically extend, then abduct while fingers spread to form C shape. Infant reflexes - Startle reflex Answer- Birth to 4 months Elicited by clapping hands or by a loud noise The newborn abducts arms at the elbows, and the hands remain clenched. Infant reflexes - Tonic neck reflex (fencer position) Answer- Birth to 4 months Elicited by turning an infant's head to one side The infant extends the arm and leg on that side and flexes the arm and leg on the opposite side. Infant reflexes - Plantar grasp Answer- Birth to 8 months Elicited by touching the sole of an infant's foot The infant's toes curl downward Infant reflexes - Babinski reflex Answer- Birth to 1 year Elicited by stroking the outer edge of the sole of an infant's foot up toward the toes The infant's toes fan upward and out. Size milestones of infants to toddlers 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). *Posterior fontanelles close at 6-8 weeks old, anterior fontanelles close 12-18 months *Children; grow from head to tail, middle to distal, simple to complex, grow at the same steps but not the same rates. Motor skill milestones for the first year of life Answer- • Raises head and shoulders at 3 months • Babbling at 4 months • Roll tummy to back at 5 months • Roll back to tummy at 6 months • Picks up at bottle at 6 months • Bears weight on feet at 7 months • Sitting and uses pincer grasp at 8 months • Object permanence by 9-10 months • Walk at 11-12 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. -Developmental level drives the way we design and deliver their care. Erickson's theories focus on: Answer- The influence of social interaction. Mastery of each stage requires that the individual achieve a balance between two tasks (conflicting variables). Each stage represents a crisis that must be resolved to move on to the next stage in a healthy manner. Trust vs Mistrust (birth to 1 year) Answer- The task of this stage is for the infant to recognize that there are people, generally parents, who can be trusted to take care of basic needs. Through trust, the infant learns to have confidence in personal worth and well-being along with connectedness to others. Failure to master this stage leaves a sense of hopelessness and disconnectedness. Examples of this disconnect can be seen in infants with failure to thrive or with attachment disorders. Autonomy vs Shame and Doubt (1 to 3 years) Answer- The task of this stage is for the child to balance independence and self-sufficiency against the predictable sense of uncertainty and misgiving when placed in life's situations. It is the time for the child to establish willpower, determination, and a can-do attitude about self. The child must develop personal abilities while struggling with both fears and wishes. The child has self-doubt later in life if this stage is not successfully met. An example of this stage happens when the toddler wants to choose clothing and dress independently. Initiative vs Guilt (3 to 6 years) Answer- The child's task during this stage is to develop the resourcefulness to achieve and learn new things without receiving self-reproach. It is difficult for a young child to resolve the conflict between wanting to be independent and needing to stay attached to parents. The child's learning of new songs, games, or jokes are good examples of initiative. The child feels confident to try new ideas. It is important that parents and teachers encourage this initiative to help the child develop a sense of purpose. If initiative is discouraged or ignored, the child may feel guilt and lack of resourcefulness. Industry vs Inferiority (6 to 12 years) Answer- In this stage, the child develops a sense of confidence through mastery of tasks. This sense of accomplishment can be counterbalanced by a sense of inadequacy or inferiority that comes from not succeeding. The realization that the child is competent is one of the important building blocks in the development of self-esteem. Industry is evident when the child is able to do homework independently and regulate social behavior. Performing the prescribed tasks at school or home also shows industry. If the child cannot accomplish realistic expected tasks, the feeling of inferiority may result. Identity vs Role Confusion (12 to 18 years) Answer- During this stage, the adolescent wants to define "what to be when I grow up." The adolescent concentrates on goals and life plans separate from those of peers and family. At this point, the adolescent child has the ability to think about self as well as others and proceeds accordingly. An adolescent who is unable to make decisions about possible career choices, a personal belief and value system, and sexual orientation, for example, may develop a weak sense of self and be incapable of committing to an identity. This indecision leads to role confusion. Object permanence Answer- The process by which infants learn that an object still exists when it is out of view. This occurs at approximately 9 to 10 months of age. Separation anxiety Answer- 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. 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 death Answer- • 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 sharing Answer- -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 time Answer- Preschoolers begin to understand the sequence of daily events. Time is best explained to them in relation to an event. By the end of the preschool years, children have a better comprehension of time-oriented words. Cognitively impaired children Answer- -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 childhood Answer- *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 treatments Answer- ● Calculate the safe dosage for medication. ● Notify the provider if medication dosage is determined to be outside the safe dosage range, and for any questions about medication preparation or route. ● Double-check high-risk and facility-regulated medications with another nurse. ● Use two client identifiers prior to administration: client name and date of birth. Use parent(s) for verification of infants or nonverbal children. Two identifiers from the ID band must be confirmed: client name, date of birth, or hospital identification number. ● Determine parental involvement with administration. ● Allow the child to make appropriate choices regarding administration (choosing the left or right leg, whether the parent or nurse will administer the medication). ● Prepare the child according to age and developmental stage. Oral meds Answer- -measure correctly using only the the droppers that came with the medication, don't use a spoon or a cup. -NO aspirin for children under 18 (causes Reye's syndrome) EXCEPT for Kawasaki's disease. -if they are uncooperative use a syringe. -Do not mix in formula. Mix in food like applesauce or sherbet. Intramuscular (IM) meds Answer- ● Use a 22- to 25-gauge, ½- to 1-inch needle. ● Vastus lateralis is the recommended site in infants and small children, ventrogluteal for toddlers and up. ● Position the child supine, side-lying, or sitting. ● Vaccines in deltoid muscle, up to 1 mL at a time (preschool-school aged). ● Inject up to 0.5 mL for infants (in each site) ● Inject up to 2 mL for children (in each site) Sub-Q meds Answer- Give anywhere there is adequate subcutaneous tissue. Common sites are the lateral aspect of the upper arm, abdomen, and anterior thigh. ● Inject volumes of less than 0.5 mL. ● Use a 1 mL syringe with a 26- to 30-gauge needle. ● Insert at a 90° angle. Use a 45° angle for children who are thin. ● Check facility policy for aspiration practices. IV meds Answer- ● 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 infiltration Answer- Cool to touch, redness/blanching, paleness, edema (swelling), painful Otic meds (Ear drops) Answer- -pull pinna up and back older than age 3 -pull pinna down and straight back 3 years Trach for child Answer- -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- *Infants between 3 and 6 months of age are at increased risk of infection due to the decrease of maternal antibodies acquired at birth and the lack of antibody protection. *Shorter softer airway, short eustachian tubes, soft epiglottis & trachea, larger tonsils; exposed to more bugs (germs), don't have a very good immune systems, put everything in their 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 respiratory Answer- **ABC'S trump all!! Maintain the Airway first. -Children have Shorter airway, larger tonsils, epiglottis & trachea is longer, flaccid and floppy which is a greater risk to child's airway. -Upper Resp- Sinuses, airway, trachea, pharynx and larynx. -Lower Resp- involves bronchi, bronchioles, and alveoli Croup syndromes Answer- Croup is a generic term encompassing a group of illnesses affecting the larynx, trachea, and bronchi. The lateral walls of the trachea below the level of the vocal cords are marked by swelling and erythema. Croup is described according to the main anatomical area affected. Epiglottitis, supraglottitis, laryngitis, laryngotracheobronchitis and bacterial tracheitis encompass the croup syndrome. Commonly affects children between 3 months and 5 years of age, most often at around 2 years of age. Usually caused by Haemophilus influenza or Streptococcus pyogenes What are signs of Respiratory distress in babies? Answer- • Tachycardia (HR 160 bpm) • Tachypnea (RR 170 breaths per minute) • Rib or sternal retractions • Expiratory grunting • Flaring nostrils Respiratory distress in older children Answer- *6 years old and up -- wheezing, crackles, tripod position, drooling, adventitious breath sounds, nasal flaring, tachycardia, tachypnea, labored breathing Croup syndromes Answer- Croup is a generic term encompassing a group of illnesses affecting the larynx, trachea, and bronchi. The lateral walls of the trachea below the level of the vocal cords are marked by swelling and erythema. Croup is described according to the main anatomical area affected. Epiglottitis, supraglottitis, laryngitis, laryngotracheobronchitis and bacterial tracheitis encompass the croup syndrome. Commonly affects children between 3 months and 5 years of age, most often at around 2 years of age. Usually caused by Haemophilus influenza or Streptococcus pyogenes S/S of croup syndromes Answer- ● Predictive signs: Absence of cough, drooling, and agitation ● Sitting upright with chin pointing out, mouth opened, and tongue protruding (tripod position) ● Dysphonia (thick, muffled voice and froglike croaking sound) ● Dysphagia ● Inspiratory stridor ● Suprasternal and substernal retractions ● Sore throat, high fever, and restlessness Nursing management of croup syndromes Answer- ● Protect airway. ● DO NOT DO throat culture or use a tongue blade for exam (this may cause a laryngospasm leading to an immediate airway occlusion). ● Prepare for intubation. ● Provide HUMIDIFIED oxygen. ● Monitor continuous oximetry. ● Administer corticosteroids, and IV fluids as prescribed. ● Administer antibiotic therapy starting with IV, then transition to oral to complete a 10 day course, as prescribed. ● Droplet isolation precautions for first 24 hr after IV antibiotics initiated Cystic Fibrosis Answer- Respiratory disorder that results from inheriting a mutated gene. It is characterized by mucus glands that secrete an increase in the quantity of thick, tenacious mucus, which leads to mechanical obstruction of organs (pancreas, lungs, liver, small intestine, and reproductive system); an increase in organic and enzymatic constituents in the saliva; an increase in the sodium and chloride content of sweat; and autonomic nervous system abnormalities. Hallmark symptoms of CF Answer- -thick mucus secretions block the exocrine glands and other body systems as well as contribute to bacterial growth. -initially presents itself in the GI system, causing obstruction, bulky stools that are frothy and foul smelling (steatorrhea), malnutrition, anemia, growth failure, deficient of fat-soluble vitamins (A,D, and E) -In lungs; crackles, wheezes, diminished breath sounds with dry non-productive cough; pneumonia, bronchitis, clubbing of fingers and toes, barrel chest. -salty skin (sweat not reabsorbed) -don't typically live through teenage years without lung transplant -children are typically sterile due to viscous cervical mucus in females and decreased or absent sperm in males Manage symptoms of CF Answer- • 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 calorie, low-fat diet, don't strain with BM • Encourage oral fluid intake • Pancreatic enzymes with meals must be taken, daily vitamin supplements (optimizing nutrition) • Chest physiotherapy (percussion and vibrations) loosen and drain mucus. Avoid immediately before or after meals. • Manage airway using nebulizers and inhalers. Asthma - complex respiratory illness - how do we recognize? Answer- *Inspiratory and expiratory wheezing & dyspnea. -Give bronchodilators, 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. -Eliminate or reduce triggers! Management of Asthma Answer- • Use nebulized medication, corticosteroids, antibiotics where needed, bronchodilators. • Daily peak air flow meters to track airway function. -Implement asthma action plan (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 asthma Answer- -avoid triggers [dust, fear, anxiety] -use meds that are prescribed [steroids, bronchodilators] and always have them with you -have asthma action plan -education on peak air flow meter -teach how to recognize asthma exacerbation and interventions Congenital heart defects Answer- Anatomic defects of the heart prevent normal blood flow to the pulmonary and/or systemic system. Defects are categorized by blood flow patterns in the heart: ● Increased pulmonary blood flow (acyanotic): atrial septal defect (ASD), ventricular septal defect (VSD), patent ductus arteriosis (PDA) -- these defects present with symptoms of RT sided heart failure** ● Decreased pulmonary blood flow (cyanotic): Tetralogy of Fallot, tricuspid atresia -- these defects present with symptoms of LT sided heart failure** ● Obstruction to blood flow: Coarctation of the aorta, pulmonary stenosis, aortic stenosis ● Mixed blood flow: Transposition of the great arteries, truncus arteriosus, hypoplastic left heart syndrome Acquired heart defects Answer- Usually associated with an infectious process (*Streptococcus*) which also causes Rheumatic fever (scarlet fever) and also deposits scars on heart valves. -Valves may need to be replaced. RF is a complication of strep illnesses. Strep identification and finishing full treatment instructions are imperative. Kawasaki diease Answer- Also known as mucocutaneous lymph node syndrome, is a multisystem disease affecting the cardiovascular system. The cause is unknown, but a defective immune response to an infectious process is thought to be responsible. S/S of Kawasaki disease Answer- Onset of high fever that is unresponsive to antipyretics, with development of other manifestations: ● Fever greater than 38.9° C (102° F) lasting 5 days to 2 weeks and unresponsive to antipyretics ● Irritability ● Red eyes without drainage ● Bright red, chapped lips ● Strawberry tongue with white coating or red bumps on the posterior aspect ● Red oral mucous membranes with inflammation including the pharynx ● Swelling of hand and feet with red palms and soles ● Nonblistering rash ● Bilateral joint pain ● Enlarged lymph nodes ● Desquamation of the perineum ● Cervical lymphadenopathy. ● Cardiac manifestations: Myocarditis, decreased left ventricular function, pericardial effusion, and mitral regurgitation Order of care for cardiac defects Answer- Airway, fluid, intake, rest Cardiac catheterization Answer- An invasive test used for diagnosing, repairing some defects, and evaluating dysrhythmias. A radiopaque catheter is peripherally inserted and threaded into the heart with the use of fluoroscopy. A contrast medium (can be iodine based) is injected, and images of the blood vessels and heart are taken as the medium is diluted and circulated throughout the body. Pre Cath Procedure Answer- ● Perform a nursing history and physical exam. Evidence of infection, such as a severe diaper rash, can necessitate canceling the procedure if femoral access is required. ● Check for allergies to iodine and shellfish. ● Provide age appropriate teaching. ● Describe how long the procedure will take, how the child will feel, and what care will be required after the procedure. ● Provide for NPO status 4 to 6 hr prior to the procedure. (If the procedure is performed as outpatient, be sure the child and family are given instructions in advance.) ● Obtain baseline vital signs, including oxygen saturation. ● Locate and mark the dorsalis pedis and posterior tibial pulses on both extremities. ● Administer pre sedation as prescribed based on the child's age, height, weight, condition, and type of procedure being performed. Post Cath Procedure Answer- ● Lay child FLAT in bed for 6 hours ● Provide for continuous cardiac monitoring and oxygen saturation to assess for bradycardia, dysrhythmias, hypotension, and hypoxemia. ● Assess heart and respiratory rate for 1 full minute. ● Assess pulses for equality and symmetry. ● Assess temperature and color of affected extremity. A cool extremity with skin that blanches can indicate arterial obstruction. ● Assess insertion site (femoral or antecubital area) for bleeding or hematoma. ● Maintain clean dressing. ● Prevent bleeding by maintaining the affected extremity in a straight position for 4 to 8 hr. ● Monitor I&O for adequate urine output, hypovolemia, or dehydration. ● Monitor for hypoglycemia. IV fluids with dextrose can be necessary. ● Encourage oral intake, starting with clear liquids. ● Encourage the child to void to promote excretion of the contrast medium. 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. Hirchsprung's disease Answer- Hirschsprung's disease (congenital aganglionic megacolon) is a structural anomaly of the GI tract caused by lack of ganglionic cells in segments of the colon resulting in decreased motility and mechanical obstruction. EXPECTED FINDINGS Newborn ● Failure to pass meconium within 24 to 48 hr after birth ● Episodes of vomiting bile ● Refusal to eat ● Abdominal distention Infant ● Failure to thrive ● Constipation ● Vomiting ● Episodes of diarrhea and vomiting Child ● Undernourished, anemic appearance ● Abdominal distention ● Visible peristalsis ● Palpable fecal mass ● Constipation ● Foul smelling, ribbonlike stool Nursing management of Hirschprung's disease Answer- ● Prepare family and client for surgery (surgical removal of the aganglionic section of the bowel, temporary colostomy may be required). ● Assist family with improving nutritional status until surgery. --High protein, high calorie, low fiber diet --TPN in some cases ● Post-Op: Nurse to monitor patent NG, abdominal distention, assess for return of bowel sounds, I&O (including NG/colostomy output) ● Teach caregivers to care for colostomy, skin care, referral to community resources. Emotional support. Intussusception Answer- ● Proximal segment of the bowel telescopes into a more distal segment, resulting in lymphatic and venous obstruction causing edema in the area. With progression, ischemia and increased mucus into the intestine will occur. ● Common in infants and children ages 3 months to 6 years. EXPECTED FINDIN GS ● Sudden episodic abdominal pain ● Screaming with drawing knees to chest during episodes of pain ● Abdominal mass (sausage shaped) ● Stools mixed with blood and mucus that resemble the consistency of red currant jelly ● Vomiting ● Fever ● Tender, distended abdomen Diarrhea 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 Answer- -recognized by projectile vomiting -pea sized nodule at sternum -no weight gain -irritable -Failure to thrive -be alert to signs of dehydration, such as changes in skin turgor, appearance of the mucous membranes, depressed fontanelle, presence or absence of tears, urine output, and changes in vital signs as well as weight loss and evidence of discomfort. -Treatment for hypertrophic pyloric stenosis is surgery called a pyloromyotomy (incision and suture of the pyloric sphincter). It is performed by laparoscopy (abdominal exploration) with an endoscope. The pyloric mass is split without cutting the mucosa and the incision is closed. -Before surgery, the child is (NPO), and a NG tube is inserted to provide gastric decompression. Surgery may be performed without delay in infants without dehydration and electrolyte imbalances. If dehydration is present, the dehydration imbalance is corrected with IV fluids and administration of appropriate electrolyte therapy. Appendicitis Answer- ● Inflammation of the vermiform appendix caused froman obstruction of the lumen of the appendix. ● Average client age is 10 years. EXPECTED FINDINGS ● Abdominal pain in the right lower quadrant ● Rigid abdomen ● Decreased or absent bowel sounds ● Fever ● Diarrhea or constipation ● Lethargy ● Tachycardia ● Rapid, shallow breathing ● Anorexia ● Possible vomiting NURSING CARE ● Prepare the child and family for surgery using developmentally appropriate techniques. ● Avoid applying heat to the abdomen. ● Avoid enemas or laxatives. ● Care of a child who has undergone an appendectomy includes monitoring I&O, wound care, and pain control. The child will be NPO for 24 hours or until peristalsis returns. 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 disease Answer- This is SUPER important in an immunosuppressed child who is a surgical patient. Infant colic Answer- Colic is described as persistent, unexplained crying or fussing in infants younger than 3 months of age and spontaneously resolves by 4-6 months. May be related to formula. In addition, the infant has: • Episodes that usually occur at the same time each day • Episodes that often occur during the late afternoon or evening • Pulling-up both legs and arms into a flexed position • Frequent demand of feeding though fussy while feeding • Excessive gas • Difficulty in being consoled Crohn's Disease Answer- -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/S: 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 GERD Answer- -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 issues Answer- children get many bites, rashes, acne, and many can be treated with over the counter medications, goal is to avoid the itching 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) 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 3-7 days 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 or months 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 burns Answer- - 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. Fluid replacement is important during the first 24 hrs after major burns Answer- Isotonic crystalloid solutions, such as 0.9% sodium chloride or lactated Ringer's, are used during the early stage of burn recovery. Colloid solutions, such as albumin or plasma, may be used after the first 24 to 48 hr of burn recovery. Maintain urine output of 0.5 to 1 mL/kg/hr if the child weighs less than 30 kg (66 lb). Maintain urine output of 30 mL/hr if the child weighs more than 30 kg (66 lb). Be prepared to administer blood products as prescribed. Managing pain with major burns Answer- Establish ongoing monitoring of pain and effectiveness of pain management. Avoid IM or subcutaneous injections. Use IV opioid analgesics, such as MORPHINE, midazolam, and fentanyl. Monitor for respiratory depression when using opioid analgesics. Administer pain medications prior to dressing changes or procedures. Use nonpharmacologic methods for pain control (guided imagery, music therapy, therapeutic touch) to enhance the effects of analgesics and promote improved pain management. Prevent infection with major burns Answer- Follow standard precautions when performing wound care. Restrict plants and flowers due to the risk of contact with pseudomonas. Change position frequently to prevent contractures and prolonged pressure. Limit visitors. Use reverse isolation if prescribed. Monitor for manifestations of infection, and report to the provider. Use client-designated equipment, such as blood pressure cuffs and thermometers. Administer tetanus toxoid if indicated. Administer antibiotics if infection is present. Nutritional requirements when dealing with burns Answer- Increase caloric intake to meet increased metabolic demands and prevent hypoglycemia. Increase protein intake to prevent tissue breakdown and promote healing. Provide enteral therapy or total parenteral nutrition (TPN) if necessary due to decreased gastrointestinal motility and increased caloric needs. Administer vitamins A and C to facilitate cell growth, and zinc for wound healing. A very important aspect in the healing process with burns is restoring mobility Answer- Maintain correct body alignment, splint extremities, and facilitate position changes to prevent contractures. Maintain active and passive range of motion. Assist with ambulation as soon as the child is stable. Apply pressure dressings to prevent contractures and scarring. Closely monitor areas at high risk for pressure sores (heels, sacrum, back of head). Types of Burn: Answer- -Thermal [hot liquid/grease 80% of burns hospitalized] -Chemical -Radiation (sun) -Electrical Sprains versus Fractures Answer- -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. RICE: standards of care for sprains/strains/fractures Answer- R: Rest, allows to heal I: Ice for first 48 hours at 15 min. intervals to decrease swelling C: Compression (ace wraps) E: Elevation, early motion; helps keep full ROM More with cares for sprains & fractures Answer- *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 (except Kawasaki). -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? Answer- ● Maintain a position to provide a patent airway. ● Protect from injury (move furniture away, hold head in lap if on the floor). ● Be prepared to suction oral secretions. ● Turn child to a side-lying position (decreases risk of aspiration). ● Loosen restrictive clothing. ● Do not attempt to restrain the child. ● Do not attempt to open the jaw or insert an airway during seizure activity. (This can damage teeth, lips, or tongue). Do not put anything in the child's mouth. ● Remove the child's glasses. ● Administer oxygen. ● Remain with the child. ● Note onset, time, and characteristics of seizure. ● Allow the seizure to end spontaneously Types of seizures Answer- -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 medications Answer- -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- The pediatric GCS consists of three components of assessment: eye opening, motor, and auditory/visual responses. • Score of 9-15 (unaltered state of consciousness) • Score of 8-4 (state of coma) • Score of 3 or below (deep coma) 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 issues Answer- 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. S/S of UTI in infants: Answer- ● Increase in irritability ● Screaming with urination ● Poor feeding, vomiting, or failure to gain weight ● Increase in thirst ● Frequent urination ● Straining with urination ● Foul smelling urine ● Fever ● Diaper rash ● Dehydration ● Seizure ● Pallor S/S of UTI in children: Answer- ● Abdominal or back pain ● Pain with urination ● Poor appetite ● Vomiting ● Slowed growth ● Increase in thirst ● Enuresis, frequent urination ● Swelling of the face ● Seizures ● Pallor ● Fatigue ● Blood in the urine ● Edema ● Hypertension ●T etany Thyroid medications Answer- -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. Hypothyroidism Answer- -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' disease (hyperthyroidism) Answer- -overstimulation of thyroid w/ excess production of thyroid hormone [autoimmune] **S/S: enlarged thyroid gland, raised, thickened skin, palpitations, tachycardia, shakiness, increased perspirations, tremor, weight loss; low TSH, high T3 and T4 -Treatment w/ methimazole Diabetes Answer- -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 Caring for a child with a vision impairment Answer- ● Reassure the child and family. ● Orient the child to the surroundings and provide a safe environment. ● Promote independence and meeting developmental milestones while assisting with play and socialization. ● Refer to educational services for visual impairment (Braille, audio tapes, special computers). Caring for a child with a hearing impairment Answer- • Recognize behavioral cues suggestive of hearing loss. • Obtain the child's attention before speaking. • Face the child when talking. • Position yourself at the child's eye level. • Talk slowly and loudly. • Modify the environment; unnecessary noises are reduced. • Offer emotional support: A child with a hearing loss may face a potential stigma associated with the communication difficulty. 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 immunization Answer- -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 age Answer- -[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. *Ventrogluteal- 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 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 scale Answer- **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.