NURS 201 PEDS Exam 2 Study Guide Complete Graded A.

NURS 201 PEDS Exam 2 Study Guide Major Stressors of Hospitalization and Illness 1.Separation, 2. Loss of Control, 3.Bodily Injury (or fear of bodily injury), 4.Pain 1. SEPARATION (Attachment and Separation Anxiety) 2. 864 Major stressors of hospitalization include separation, loss of control, bodily injury, and pain. Children's reactions to these crises are influenced by their developmental age; previous experience with illness, separation, or hospitalization; innate and acquired coping skills; seriousness of the diagnosis; and support systems available a. (Stages) Manifestations of Separation Anxiety in Young Children (b22-2p865) b. c. Nursing Care: Separation Anxiety- Be sensitive, understand that this is a normal response and prepare for a therapeutic response and interventions Stage 1 protest: Crying making a scene, lasts for days, older children may be aggressive or uncooperative, look and search for parents Stage 2 Despair: Separation anxiety Most intense for 16-24 months (toddlers), regress to earlier behavior (thumb sucking, bed-wetting, use of pacifier, use of bottle) Stage 3 detachment: adjusts may not want to go to parents when they return, interacts w/ strangers or familiar caregivers 3. LOSS OF CONTROL:May result from: 4. Doing exams on parents lap to reduce stress for infants and toddlers Increase immobilization if restriction is done e.g kept in crib for safety increases mobility by moving children in carriages, wagon , wheelchairs, carts. a. Common responses: i. Infants: Alteration in Trust Vs. Mistrust, restraints (crib or physical restraints for procedures) impede exploratory nature. Explain rationale to parent, try to maintain parent contact ii. Toddlers Feeling of loss of autonomy d/t loss of routine, being restrained in crib/equipment/elbow restraints. Loss of rituals, altered schedules, allow choices, explain schedule, maintain home routines. May make them a clock with pictures. 1. Negative 2. Uncooperative 3. temper tantrums 4. Regression 5. aggressive or passive 6. wants security objects iii. Preschool: Autonomy Vs. Shame and Doubt/ Initiative Vs. Guilt 1. Bring age appropriate toy 2. Allow toddler/preschool to help with task to promote autonomy 3. Don’t shame if they regress 4. Set and keep routine iv. School-age Common reason for hospitalization Illness or injury/MVA, loss of well-established autonomy: get homework/schoolwork, encourage self-care, more focused schedule, calendar 1. Loneliness/ boredom 2. withdrawal/depression 3. anger/frustration v. Adolescent Common Suicide/Homicide/MVA 1. Uncooperative 2. Withdrawal 3. Frustration 4. Depressed Promote independence, used medical terminology, explain what is going on, allow opportunities to express feelings, allow them to question, need responsibilities (measure urine output), allow peers to visit, pictures and notes from friends b. Nursing Care: Loss of Control Nursing Care i. Maintain rituals/routines of home ii. Joint planning of schedule iii. Minimize immobilization & restraints iv. Encourage self-care v. Give choices w/in limits vi. Provide security objects vii. Explain tests/ procedures. viii. Procedure do quickly and maintain parent- child contact ix. If child has an ouchy or if bleeding occurs put a band-aid helps child believe bleeding will stop. x. Equipment and positions, alleviate fear xi. Present info on their developmental level, e.g child having a CAT, will I turn into a cat or get scratches ? 5. BODILY INJURY (OR FEAR OF…) a. Common responses i. Toddler/Preschoolers… Infants: cry, have parents within sight, let parents comfort after shot 1. Anxiety/fear 2. Uncooperative 3. Aggressive: If you tell them not to move, are they going to listen? No. Usually on sedation for CT scan. Infants on crib, older ones on bed. Once awaken, they will try to take off C-collar and move around. What do you do? Give a little sedation. Educate parents on reason for sedation. Modify procedures to provide atraumatic care. ii. School age: Usually calm, fearful, cooperative: use basic medical terminology, be sure to explain using simple diagrams, explain why procedure is why procedure is necessary. iii. Adolescent: Peers are most important/ fear of losing status in school, body image, withdrawal, rejecting others 1. asks many questions 2. question whether care is adequate or correct 3. Withdrawal 4. reject others b. Nursing Care: Bodily Injury i. Meet physical needs promptly ii. Do procedures quickly iii. Restore body image iv. Prepare for procedures by development level (box p. 885 & 886) v. Infants: involve parent in procedure if possible, keep parent within sight and if parent can't be present provide a familiar toy. Limit the number of strangers entering the room, try to keep the same staff assigned if possible. Always approach slowly and in a non-threatening manner. Use sensory soothing measures, analgesics for pain control and cuddle with child after stressful procedure. Restrain adequately and keep harmful objects away from reach and view. Perform traumatic procedure in other areas besides crib. Model desired behavior or gestures. vi. Toddler: Same as infant plus; explain what child will see and hear and that it's ok to cry and express discomfort. Assign one person to talk to child during procedure to avoid confusion. Expect resistance, be firm and direct and ignore temper tantrums, use distraction techniques. Keep frightening objects out of view. Use simple terms, prepare parents separately, use play with doll and small equipment limit time to 5-10 minutes. Allow child choices and to participate in care whenever possible. vii. Preschoolers: explain procedure with neutral words and simple terms. Play out with dolls and miniature equipment. Use verbal explanation avoid overstimulation and encourage child to express feelings and ideas. Learning sessions of 10-15 minutes and multiple sessions if needed. Clarify why procedures are performed and that they are not a form of punishment. Keep equipment out of sight never show it to child. Point on drawing or doll where procedures will be performed and clarify that no other body parts will be harmed. Explain unfamiliar situations and noises. Allow choices and to participate in care when possible and praise for attempts to help never shame. viii. School Age: Explain procedure using medical terminology, photos, diagrams, dolls or other person and manipulate equipment. Allow time before and after for questions. Teaching sessions of about 20 minutes 1 day in advance. Explain what is expected and gain cooperation, teach ways to control self; like deep breathing, encourage participation, decision making and responsibility for simple tasks. Prepare two or more children for the same procedure to encourage them to prepare each other. Provide privacy ix. Adolescents: discuss why procedure is necessary or beneficial. Explain long term consequences, encourage questions, options and ideas. Provide privacy and explain what will be exposed, scars and emphasize benefits. Involve in decision making, plannin g and understanding that adolescents have difficulty accepting new authority figures. Impose as little restrictions as possible. Allow adolescents to communicate with other adolescents who have had the same procedure. 6. PAIN (PRESENTATION) a. Common responses: i. Infants: Infants 6 months: most consistent indicator of distress is facial expression of discomfort; ii. Toddlers: most reliable indicator of pain is irritability and increased frustration d/t lack of tolerance iii. Preschool: shows a localized body response with deliberate withdrawal from what is causing the pain, reveals expression of pain or anger, uses crying, reveals expression of pain or anger, demonstrates a physical struggle, especially pushing away from what is causing the pain. iv. School-age: Communicate about their pain in respect to its location, intensity, and description, try to waste time or distract from procedure, displays muscular rigidity, such as clenched fists, white knuckles, gritted teeth, contracted limbs, body stiffness, closed eyes, wrinkled forehead. v. Adolescent: Less vocal with physical resistance, more verbal in expressions, such as “it hurts”, displays increased muscle tension and body control. b. Nursing Care: Pain Non pharm. mang- distraction, cutaneous stimulation, relaxation, guided imagery Pharm. Pain mang- non-opiod for mild to mod (NSAIDS TY) Opiod for mod to severe (morphin, codeine, hydromorphine, fentanyl) Morphine gold standard for PCA 1mg/ml Assessment of Children’s Pain: Pediatric Assessment tools Children’s Responses To Pain @ Various Ages (box 5-1 p153) Ped. Pain Management Guidelines Non-pharmacologic Pain Management Techniques Know face and FLACC scale Tools of assessment MINOR STRESSORS OF HOSP/ILLNESS 1. Discomforts (hunger, nausea, wet, cold, itching) 2. Unfamiliar environment/food/ equipment 3. Fear of strangers 4. Sleep deprivation 5. Fever or hypothermia 6. Immobility Pediatric Variations in Nsg Care General hygiene- parents should gives baths, and the nurse will assist. The baby is at risk for hyperthermia, make sure to clean in the creases and folds, tell families of different cultures that we must clean parineal ares. i. Maintaining body temperature- LBW @ risk for hyperthermia because they don’t have sufficent brown fat, double wrap baby, place a cap, put crib in a draft free area of the room, or in a radiant warmer or isolet 1. Treatment of fever (rectal) for newborn patency, and severe sepsis Rectal= aux-1 (Auxiliary is 100.4 to treat) a. If 100-101.4 0 F ®: _Cooling measures (light clothing/blankets, monitor hourly)_ b. If 101.5-1030 F ®: _Antipyretic (ibuprofen {6 months or older } or tylenol) cooling measures, wait 40-50 min retake temp, monitor hourly until below 100 degrees_ c. If 1030 F ®: _Antipyretic, cooling measures, call the doctor, run lab test_CBC, culture and sensitivity Urine no bag for cultures, must straight cath. girls are more difficult. May use bag for urine analysis or drug test. 2. Restraining for Procedures/Safety a. Crib rails up- when they can stand and climb and procedures, may use a crib tent b. Mummy wrap or restraint boards- procedures such as IV’s, keep chest visible for breathing c. Hands and body- prevents pt. from rolling, crawling, falling off bed. Elbow restraints are used for cleft palate, ET, perph AC (anticubital) IV’s d. 3. Pediatric Medication Admin a. Adapt to developmental level (approach)- must change per devl. Stage as well as age. Give choices never ask yes or no questions. b. Only give safe meds, store/handle safely- know the expiration date, never mix it w/ a bottle or food because the patient may not want to eat that next time and the medication may not be fully consumed, . Give meds before eating then feed them. Infants use a nipple and then a syringe behind it and squirt as they suck. c. PO liquids: 3 m/o: _nipple_; 8 m/o: _syringe_; 18 m/o: _medicine cup_ d. Ear drops: 3 y/o: _pinna back and down_; 3 y/o _Pull pinna back and up_ e. Rectal suppositories: Lube tip of suppository only, side lying position, hold cheeks closed for 1 minute f. Injections: review sites vastus lateralis g. Trach suctioning- assess patient, hyper oxygenate w/ 100% o2 before Compliance: Organizational strategies involve the care setting and the therapeutic plan. i. Example: watches with alarms; charts to record completed therapy; messages on the refrigerator or morning coffee pot; and treatment schedules that incorporate the treatment plan into the daily routine, such as physical therapy after the evening bath. h. Treatment strategies relate to the child's refusal or inability to take the prescribed medication. i. Example: child may not be able to swallow pills. In this case, perhaps pills could be crushed or a liquid medication substituted i. Behavioral strategies are designed to modify behavior directly. i. Example: Positive reinforcement, earning stars or tokens, which can be exchanged for a special privilege or gift. Disciplinary techniques, such as a time-out for young children or withholding privileges for older children, may be needed to improve compliance. Emancipated minor: The nurse’s responsibility is to witnesses the patient's, parent's, or legal guardian's signature on the consent. Few states consider a mature minor to be 14 and older, as long as the information is understood they may sign a consent. An emancipated minor is one who is legally under age of 18 but can sign consent under certain circumstances such as pregnancy, high school graduation, independent living, marriage and military service. Based on state law. Informed Consent: Make sure it is signed, can reinforce what has been taught but can’t explain the procedure, refer to the Dr. if they don’t understand what is going on, have adolescents be a part of the informed consent documentation process. Mature minor: In some states a person as young as 14 who understand all elements of informed consent and can make decisions on their own. 1. For the following drug classifications commonly used in the management of childhood respiratory insufficiency, identify: action, side effects, contraindications, potential adverse effects, potential effect on development, and nursing considerations (refer to drug book) acute laryngotracheobroncitis LTB ● nebulized epinephrine - (beta adrenergic effect) vasoconstriction of mucosal lining and decreases subglottic edema. ● *corticosteroid for Inflammation helps to decrease subglottic edema p1186 ● Most common type of croup experienced by kids 5yrs ● Usually proceeded by an URI Asthma ● Corticosteroids are anti-inflammatory drugs used to treat reversible airflow obstruction and control symptoms and reduce bronchial hyperresponsiveness in chronic asthma, first line therapy in patients 5 year or older. P.1222 ● Asthma: inflammation, swelling, narrowing of the airways, production of excess mucous making it difficult to breath. Very common ● B- adrenergic agonists (short acting) primarily albuterol, levalbuterol{Xopenex}, & terbutaline ) used for treatment of acute exacerbation and for the prevention of EIB . the drugs bind to B-receptors on the smooth muscle of airways where they activate adenylate cyclase and convert adenosine monophosphate (AMP) to cyclic AMP (cAMP). The increased cAMP enhances binding of intracellular calcium to the cell membrane, reducing the availability of calcium and thus allowing smooth muscle to relax. So basically, does this Most β-adrenergic used in asthma therapy affect predominantly the β2-receptors, which help eliminate bronchospasm. ● Leukotrienes mediators of inflammation that cause increases in airway hyperresponsiveness. block inflammatory and bronchospasm effects. These drugs are not used to treat acute episodes but are given orally in combination with β-agonists and steroids to provide long-term control and prevent symptoms in mild persistent asthma. Montelukast is approved to treat asthma in children 12 months old and older, whereas zafirlukast is approved for children 5 years and older. Used as long-term control medications. ● cromolyn sodium is medication used as maintenance therapy for asthma in children over 2 years of age. It stabilizes mast cell membranes; inhibits activation and release of mediators from eosinophil and epithelial cells; and inhibits the acute airway narrowing after exposure to exercise; cold, dry air; and sulfur dioxide. It does not result in immediate relief of symptoms and has minimal side effects (d/.c in 2010 nedocromil sodium) used as long-term control medications ● Anticholinergics (atropine and ipratropium) help relieve acute bronchospasm. However, these drugs have adverse side effects that include drying of respiratory secretions, blurred vision, and cardiac and central nervous system stimulation. The primary anticholinergic drug used is ipratropium, which does not cross the blood-brain barrier and therefore elicits no central nervous system effects Ipratropium, when used in combination with albuterol, has been effective during acute severe asthma in significantly improving lung function and reducing hospitalizations in children coming to the emergency department.(rescue inhalers). ● Beta adrenergic agonists: i. Proventil (Albuterol) Treatment or prevention of bronchospasm due to reversible obstructive airway disease, prevention of exercise-induced bronchospasm. 1. Action: Stimulates beta2-adrenergic receptors in lungs, resulting in relaxation of bronchial smooth muscle. Therapeutic Effect: Relieves bronchospasm and reduces airway resistance. 2. Side effects: Frequent (27%–4%): Headache; restlessness, nervousness, tremors; nausea; dizziness; throat dryness and irritation, pharyngitis; B/P changes, including hypertension; heartburn, transient wheezing. Occasional (3%–2%): Insomnia, asthenia, altered taste. Inhalation: Dry, irritated mouth or throat; cough; bronchial irritation. Rare: Drowsiness, diarrhea, dry mouth, flushing, diaphoresis, anorexia. 3. Contraindications: Contraindications: Hypersensitivity to albuterol. Cautions: Hypertension, cardiovascular disease, hyperthyroidism, diabetes mellitus, HF, convulsive disorders, glaucoma, hypokalemia, arrhythmias. 4. Adverse effects: Excessive sympathomimetic stimulation may produce palpitations, exectopy, tachycardia, chest pain, slight increase in B/P followed by substantial decrease, chills, diaphoresis, blanching of skin. Too-frequent or excessive use may lead to decreased bronchodilating effectiveness and severe, paradoxical bronchoconstriction. 5. Potential effects on development: 6. Nursing considerations: BASELINE ASSESSMENT:Assess lung sounds, pulse, B/P, color, character