Peds Unit 1 Slides/Practice Questions

hypoglucemia in children

kids have lower glycogen stores which increases the risk for hypoglycemia. Rapid metabolism can also cause this

Mandy, age 12, is brought to the clinic for evaluation for a suspected eating disorder. To best assess the effects of role and relationship patterns on the child's nutritional intake, the nurse should ask:

"Do you like yourself physically?"

Hyperthermia in peds

-Can be because of fever -Can be a result of a traumatic brain injury, brain tumor, or exposure to higher than acceptable external temperatures -Will lead to Hypoxia and Increased Intracranial Pressure -Can result in damage to the brain and/or death

•Respiratory System:

-Cartilage in airway of an infant is soft -The trachea of an infant is 1/3 that of an adult -At birth, there are 25-40 million alveoli and 300-400 million alveoli by age 8-10 -The size of alveoli does not change -Because of this, there is less lung volume -Tidal volume is proportional to weight -Heart rate and rhythm vary with age -Until puberty, percentage of cartilage in ribs is higher, making them more flexible and compliant -Short, narrow trachea in children under 5 makes them susceptible to foreign body obstruction -Until 4-5 years of age, the diaphragm is the primary breathing muscle -Carbon Dioxide is not effecting expired when child is distressed, making the child at risk for metabolic acidosis •Children have higher metabolic rates, higher oxygen needs, and higher caloric needs •Children generally have cardiac arrests secondary to primary respiratory arrests

Fever in peds patients

-Defined as: •Rectal 101.4 or above •Oral or tympanic 100.4 or above •Axillary 99.4 or above •Standing orders for fever reduction •ALWAYS recheck temps within ½ hour after treatment if elevated

Hypothermia in peds

-Exposure to temperatures that are less than those which promote a Neutral Thermal Environment -Can result in hypoxia and hypoglycemia -Can result in damage to the brain and/or death

Types of pain scales for specific ages

-Infants •Comfort scale (Alertness, /calmness/Agitation, Crying, Physical Movement, Muscle Tone, Facial Expression) •FLACC (Face, Legs, Activity, Cry, Consolability) -Toddlers to School-Age •Poker chip tool Hester and Barcus, 1986) •FACES (Wong and Baker, 1996) •Oucher Scale (Beyer et al., 1992) 'visual analog -Late School-Age and Adolescents (can understand incremental measurement) •0-10 scale

Output in peds

-Urine (1-2cc/kg/hr)

Pain in different ages....

0-12 months (infants) •Watch for non-verbal cues •Crying when held or picked up •Lethargy •Irritability •Poor feeding •Parent/caregiver reports and physical observations are critical 1-3 years (toddlers) •Listen for words that parents use to describe pain ("ouchie") •Watch behavior •Low frustration tolerance •Acting out can be a symptom of feelings of loss of control •Parent/caregiver reports and observations are critical; talk to the child in his/her language about he/she feels pain/discomfort 3-6 years (preschool) •Can tell you where the pain is located but have difficulty with describing intensity (cannot use 0-10 scale) •May only report pain to parents •Magical thinking-pain may be seen as punishment •Can use pictorial pain assessment scales 7-12 years (school age)• •Can tell you where and how intense but cannot describe characteristics of pain (i.e. "sharp") •May exaggerate by exhibiting a combination of reality and fantasy •May emotionally withdraw and show rigid body posturing •Want nurse to initiate pain assessment and treatment-give choices Adolescents •Behavior and affect often not a good indicator of pain (stoic or dramatic) •Most often use 0-10 scale •Trust their reports even if this seems out of line...this is essential for relationship development •Recognize pain may equate to onset of death

Cherry, the mother of an 11-month-old girl, Elizabeth, is in the clinic for her daughter's immunizations. She expresses concern to the nurse that Elizabeth cannot yet walk. The nurse correctly replies that, according to the Denver Developmental Screen, the median age for walking is:

12 months

When does the anterior fontanel close?

12-18 months

Nutritional deficit labs

A negative nitrogen balance may result from inadequate protein intake and is best detected by measuring the total protein level. Measuring total iron-binding capacity, hemoglobin, and serum transferrin levels would help detect iron-deficiency anemia, not a negative nitrogen balance.

Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse in charge detects dry mucous membranes and lethargy. What other findings suggests a fluid volume deficit?

A sunken fontanel In an infant, signs of fluid volume deficit (dehydration) include sunken fontanels, increased pulse rate, and decreased blood pressure. They occur when the body can no longer maintain sufficient intravascular fluid volume. When this happens, the kidneys conserve water to minimize fluid loss, which results in concentrated urine with a high specific gravity.

A 3 year old wants a bottle before naptime and bedtime. What would be apropriate?

A toddler should never be allowed to fall asleep with a bottle containing milk, juice, soda, or sweetened water because of the risk or nursing caries. If a bottle is allowed at naptime or bedtime, it should contain only water.

A maternity nurse is providing instruction to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse would instruct the mother to

Allow the infant to signal a need According to Erikson, the caregiver should not try to anticipate the newborn infant's needs at all times but must allow the newborn infant to signal needs. If a newborn is not allowed to signal a need, the newborn will not learn how to control the environment. Erikson believed that a delayed or prolonged response to a newborn's signal would inhibit the development of trust and lead to mistrust of others.

Sudden infant death syndrome (SIDS) is one of the most common causes of death in infants. At what age is the diagnosis of SIDS most likely?

At I week to 1 year of age, peaking at 2 to 4 months

A nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which of the following is the most appropriate activity for this child?

Crayons and a coloring book In the preschooler, play is simple and imaginative and includes activities such as crayons and coloring books, puppets, felt and magnetic boards, and Play-Doh. Large picture books are most appropriate for the infant. A radio and a sports video are most appropriate for the adolescent.

Nurse Kim is teaching a group of parents about otitis media. When discussing why children are predisposed to this disorder, the nurse should mention the significance of which anatomical feature?

Eustachian tubes In a child, Eustachian tubes are short and lie in a horizontal plane, promoting entry of nasopharyngeal secretions into the tubes and thus setting the stage for otitis media. The nasopharynx, tympanic membrane, external ear canal have no unusual features that would predispose a child to otitis media.

Lily , age 5, with intelligence quotient of 65 is admitted to the hospital for evaluation. When planning care, the nurse should keep in mind that this child is:

Mildly retarded but educable According to the American Association on Mental Deficiency, a person with an intelligence quotient (IQ) between 50 and 70 is classified as mildly mentally retarded but educable. One with an IQ between 35 and 50 is classified as moderately retarded but trainable. One with an IQ below 36 is severely and profoundly impaired, requiring custodial care.

A clinic nurse assesses the communication patterns of a 5-month-old infant. The nurse determines that the infant is demonstrating the highest level of developmental achievement expected if the infant:

Monosyllabic babbling Using monosyllabic babbling occurs between 3 and 6 months of age. Using simple words such as "mama" occurs between 9 and 12 months. Linking syllables together when communicating occurs between 6 and 9 months. Cooing begins at birth and continues until 2 months.

Expected vital signs in peds patients

Newborn HR 100-180 RR 30-60 T (ax) 97-99 BP 60/40 Infant 80-150 30-40 97-99 90/50 Toddler 70-110 25-35 97-99 94/56 School-Age 55-90 20-30 97.9-99 110/60 Adolescent 60-80 14-20 97-99 120/80

Hannah, age 12, is 7 months pregnant. When teaching parenting skills to an adolescent, the nurse knows that which teaching strategy is least effective?

Provide reading materials Because adolescents absorb less information through reading, providing age-appropriate reading materials is the least effective way to teach parenting skills to an adolescent. The other options engage more than one of the senses and therefore serve as effective teaching strategies.

When performing a physical examination on an infant, the nurse in charge notes abnormally low-set ears. This findings is associated with:

Renal anomalies Normally the top of the ear aligns with an imaginary line drawn across the inner and outer canthus of the eye. Ears set below this line are associated with renal anomalies or mental retardation. Low-set ears do not accompany otogenous tetanus, tracheoesophageal fistula, or congenital heart defects.

Nurse Walter should expect a 3-year-old child to be able to perform which action?

Ride a tricycle At age 3, gross motor development and refinement in eye-hand coordination enable a child to ride a tricycle. The fine motor skills required to tie shoelaces and the gross motor skills requires for roller-skating and jumping rope develop around age 5.

elimination in peds

Skin Turgor: Skin should not tent Capillary Refill: Under 3 Seconds, but best if under 1 ½ seconds Heart rate will increase with low fluid volume •Newborns/Infants: wet 6-10 times per day •Weigh diapers and record output -Zero out weight of diaper -1 gram=1ml -Document •Stooling patterns vary -Breastfed babies often have mustard stool with each diaper change -Usually stool at least once every 3 days -Significant findings: hard, pebble-like stools

A female child, age 2, is brought to the emergency department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. On entering the examination room, the child is crying and clinging to the mother. Which data should the nurse obtain first?

The most important data to obtain on a child's arrival in the emergency department are vital sign measurements. The nurse should gather the other data later.

Recomended injection site for an infant

The recommended injection site for an infant is the vastus lateralis or rectus femoris muscles. The deltoid is inappropriate. The dorsogluteal and ventrogluteal sites can be used only in toddlers who have been walking for about 1 year.

The parents of a 2-year-old arrive at a hospital to visit their child. The child is in the playroom when the parents arrive. When the parents enter the playroom, the child does not readily approach the parents. The nurse interprets this behavior as indicating that:

This is normal behavior The phases through which young children progress when separated from their parents include protest, despair, and denial or detachment. In the stage of protest, when the parents return, the child readily goes to them. In the stage of despair, the child may not approach them readily or may cling to a parent. In denial or detachment, when the parents return, the child becomes cheerful, interested in the environment and new persons (seemingly unaware of the lost parents), friendly with the staff, and interested in developing superficial relationships.

A nurse is evaluating the developmental level of a 2-year-old. Which of the following does the nurse expect to observe in this child?

Uses a cup to drink By age 2 years, the child can use a cup and can use a spoon correctly but with some spilling. By ages 3 to 4, the child begins to use a fork. By the end of the preschool period, the child should be able to pour milk into a cup and begin to use a knife for cutting.

Position of crib when child is standing

dome position

bowel sounds in the lungs

lot of water content causes those sounds to "bounce"

Fontanels

posterior 2-3 mo anterior 9-18

accordian chest

severe retractions, close to resp arrest

#1 indicator of fluid/electrolyte imbalances

wt

Play

•"The work of the child" •On unit, cupboards indicate typical toys for certain developmental stages •Things to consider: interest, gross and fine motor skills and safety •Goal of play is to promote development (learning about the world) •Goal of therapeutic play is to better understand a child's feelings and thoughts to reduce anxiety •See guidelines for therapeutic play in Wong •Talk with them as they play, note how they interact with the play materials (do they make careful shapes with the clay or pound it into a flat pancake?) •Energy release -Pounding, hitting, running, punching, shouting •Dramatic play -Preschool children, peak imagination, act out what has happened or what child fears may happen using puppets •Creative play -Drawing, using model clay Recomended play... •Reading child-focused books to a child is always appropriate •Infants: mobiles, busy boxes, toys with music/lights/color •Toddler: things that move and that they can manipulate (blocks, trucks, dolls, pull toys) •Preschool: Crayons/paper, imaginative play (dolls, kitchen set) •School age: games, puzzles

School Age

•6-11 years (Industry vs. inferiority) •Piaget: 6-11 years (Concrete operational) •Want basic explanations and reasons for everything •Big learners - interested in the functional aspects of all procedures, objects, and activities •Heightened concern about body integrity •Regression common in stressful situations •Use puppets, dolls, smiley faces on tongue blades, etc. •Explain briefly what you are doing, make comparisons when you can •Encourage participation in exam, allow child to safely touch equipment •Listen carefully to fears, avoid lying about or down-playing procedures •The child will not want to "act like a baby"

Newborn phsyical assessment

•Avoid rapid, startling movements •Cluster assessment to allow periods of uninterrupted rest •Start with least invasive first and those that are top priority (heart, lungs, bowel sounds) •Temperature taken per organization policy • BP may be difficult to obtain, but assessment done in an inpatient setting, while typically not done in an outpatient setting •Apical heart rate

Cardiac System

•Cardiac System -Heart is fully developed and pumping by week 7 -Blood volume is weight dependent: 80mL/k -Until late school age or adolescence, cardiac output is dependent on heart rate and not stroke volume -Because of this, heart rate is more rapid in a younger child

Preschool

•Erickson: 3-6 years (Initiative vs. guilt) •Piaget: : 2-6 years (Preoperational) -Everything is concrete and direct ("little stick in your arm", "coughing your head off", "two faced", etc) -Are magical thinkers •Everything that happens is because of this little person, whether it is good or bad •Assessment of a Preschooler -Regression common in stressful situations -Implement Play Therapy whenever possible -Time is concept the preschooler does not understand or comprehend -Explain briefly what you are doing, make comparisons when you can -Encourage participation in exam, allow child to safely touch equipment -Talk to the child in words he/she will understand

toddler development

•Erickson: Autonomy vs. Shame and doubt -Allow to "do it myself" whenever possible •Piaget: 2-6: Preoperational -Everything is concrete and direct ("little stick in your arm", "coughing your head off", "two faced", etc) •Egocentric, inability to delay gratification •Need consistent verbal and non-verbal communication and reinforcement of behaviors •The toddler will give inanimate objects human characteristics •Rapid development of receptive language •A time for physical independence •Stranger anxiety- peaks 7-8 months and 18-20 months •Strong emotional ties to parents/caregivers •Toilet training and Other means of gaining physical Independence •Mine, No, temper tantrums, food preferences •Approach with caution, allow handling of equipment when safe •Parents/caregivers nearby when appropriate, with ideally the toddler in the lap of the parent or caregiver •Clear, direct instructions •Distraction and play during assessment •Allow toddler to touch and become familiar with equipment if at all possible •Blow bubbles or blow out light for listening to airways •Secure limits, consistent discipline •Start with what is Most Vital first •Due to fear of large or unfamiliar object, do not bring these items in the room until needed, offer explanations

Adolescent development

•Erickson: Identity vs. Role Confusion •Piaget: Formal operational stage •Fluctuations between concrete and abstract thought •Regression can occur in stressful situations •Unpredictability in relation to emotions and how he/she will react to situations •"Personal Fable": "It will not happen to me." •Will quickly identify and dismiss individuals who have feigned interest are trying to impose values, or show a lack of respect •Highly modest •Often behaviors are masking other emotions •Confidentiality of great importance -Sexual activity -Pregnancy -STD -Alcohol and Drug use -Other risky behavior •Can progress head to toe •Do most invasive examination last •Keep teen covered as much as possible •Explain what you are doing and what you find •Reassure teen of normal findings when appropriate

Infant Development

•Erickson: Trust vs. Mistrust •Piaget: 0-2 Years of Age, Sensorimotor •Development of routines •Transitional items represent absent parents/caregivers •Huge developmental strides •Social skills-cooing, smiling, laughing, verbal •Primitive reflexes present -Rooting -Sucking -Tongue extrusion -Moro -Babinski -Stepping -Tonic neck -Blink -Palmar -Plantar •Stranger anxiety- peaks 7-8 months and 18-20 months •Prefer upright position vs. horizontal •Lack of object permanence - what I cannot see is not there •Gross motor: creeping by 4-5 months, sitting by 6-8 months, walking by 12-15 month (These are typical times, but there are individual variations)

•From birth until 22 (24) years of age, a person will go through 5 developmental stages:

•From birth until 22 (24) years of age, a person will go through 5 developmental stages: -Infant -Toddler -Preschool -School-aged -Adolescent

Children's heads

•Head size varies proportionally over time -One year of age: 19% of body surface -Five years of age: 15% of body surface -Adult: 9% of body surface •Because of this, the child is at an increased risk for head trauma

Water

•Higher Body Water Content -At birth: 90% -Within 24-48 hours: 70% -12 months of age (comparable to that of an adult): 61% -An increased amount of water in in extracellular spaces (through puberty) -Daily water exchange rate is much higher than in the adult population

Pain in peds patients

•If the assessment of pain is equal to or greater than 3 on a 0-10 scale a pain assessment must be done every 60 minutes until pain medication has reached an adequate level to provide pain relief with pain rating 3 or less. Take into consideration...•Age •Illness, Disease Process, and/or Surgical/Procedural Causes of Pain •Erickson's Stages of Development •Piaget's Cognitive Development •Family/Parental/Cultural Practices •Standards of Practice/Care •If the assessment of pain is equal to or greater than 3 on a 0-10 scale a pain assessment must be done every hour until pain medication has reached an adequate level to provide pain relief with pain rating 3 or less.

Caloric requirments in peds

•Infant 0-6 months -Body weight (kg) x 117 kcal per 24 hours -Formula is 20 kcal per ounce (typically) -IV calories •D5=170 kcals/1000ml •D10=340 kcals/1000ml •Child over 6 months (up to 7 years) -100 kcal per kg for first 10 kg -50 kcal per kg for second 10 kg -20 kcal per kg for each kg over 20 kg

IV therapy in peds

•Infant 0-6 months -Body weight (kg) x 165 ml per 24 hours •Child over 6 months of age -100 ml per kg for the first 10 kg -50 ml per kg for the second 10 kg -20 ml per kg for each kg over 20 kg •For infants 3.5 to 10 kg: - Daily fluid requirement is 100 mL/kg. •For children 11-20 kg - Daily fluid requirement is 1000 mL + 50 mL/kg for every kg over 10. • For children > 20 kg: -Daily fluid requirement is 1500 mL + 20 mL/kg for every kg over 20, up to a maximum of 2400 mL daily •The smaller the infant/child, the greater the risk for fluid overload •Check IV site for Phebilits, Infiltration and Infection: -Pallor -Cool skin -Swelling -Red line following vein •Bag changes every 24 hours •Tubing changes every 72 hours •Monitor hydration status closely •Monitor and verify rate every hour

Lab values

•Lower glycogen stores -Increasing risk for hypoglycemia •Rapid metabolism -Increasing risk for hypoglycemia and hypoxia

Musculoskelatal

•Musculoskeletal: -Until puberty bones are soft and are move easily bent and fractured -Muscles lack tone, power and coordination during infancy -Muscles are 25% of weight in infants and 40% weight in adults -Abdomen provide suboptimum protection for the liver and spleen, making the child at risk for trauma

Neuro

•Neurological System -Myelination of neurological system is greatest in the last trimester and the first two years of life -Posterior Fontanel closes between 2-3 months of age -Anterior Fontanel and open sutures palpable until 18-24 months of age

Renal function

•Renal Function: -Until 12-18 months of age kidneys do not concentrate urine effectively -The renal system does not exert optimal control over electrolyte secretion and/or absorption -Increasing risk for fluid imbalance, specifically dehydration which leads to hypovolemia

Piaget's Cognitive development

•Sensorimotor: Motor and Reflex 0-2 Years of Age •Pre-operational: Oriented to present time and representation of objects by symbols 2-7 Years of Age •Concrete Operational: Abstract thinking and accommodation 7-12 Years of Age •Formal Operational: Hypothetical and deductive reasoning 12 and Older

Thermoregulation

•Thermoregulation -The smaller the infant/child, the greater the disproportion of surface area to body mass ratio: There is a larger surface area in proportion to body mass -This increases the risk for heat loss, which can result in hypoglycemia and hypoxia -The goal is to keep the infant/child in a Neutral Thermal Environment

Erikson's Developmental Theory

•Trust versus Mistrust •Autonomy versus Shame and Doubt •Initiative versus Guilt •Industry versus Inferiority •Role Identification versus Role Confusion