Peds Exam 2: Mobility Alterations, Prioritization, Delegation, & Emergency Care

for the emergency assessment we think *ABCNSP*:

*A*irway *B*reathing *C*irculation *N*euro *S*kin and extremities *P*ain

RNs can't delegate to UAPs what they can *EAT*:

*E*valuate *A*ssess *T*each -upon first assessing the patient's condition and evaluating if the UAP is competent to carry out the task, then the RN can then delegate a NON-COMPLEX task -key= pt is always the RN's ultimate responsibility

Pectus Carinatum aka pigeon chest:

-5-15% of chest wall deformities -biggest issue for these pts is body image!

bites in children

-9/10 are from dogs! -complications include infection, cellulitis, rabies -can be a penetrating and crush injury

Pectus excavatum aka funnel chest:

-90% of chest wall deformities -a depression that sinks INWARD at the xiphoid process -gets worse as the child grows (less room for the lungs/heart as child grows) -the more pronounced it is, the more CV/pulmonary symptoms occur -tx= surgical correction

What are some emergency care actions for fractures?

-ABCs -elevate limb -ice -analgesics (ofc watch respiratory status!) -stabilize the limb -NV status -pain -vitals

how do we manage a patient who is experiencing poisoning?

-ABCs -stabilize -give O2 -intubate if necessary -rinse or remove toxin -activated charcoal -NGT -antidotes!!! -CALL POISON CONTROL (1-800-222-1222)

What are some emergency labs or diagnostics we perform?

-ABGs -electrolyte levels -BG -CBC -C&S -UA -toxicology panel -blood type and crossmatch -CT/MRI/Xrays

What are some super important cardiac meds we can use if a peds patient is in cardiac arrest?

-Adenosine (this we push FAST and flush with NS immediately, low to patient, we give for paroxysmal SVT) -Atropine (anticholinergic to increase that HR in bradycardia or OD on cholinergic meds) -Epinephrine (vasopressor for bradycardia, severe asthma attacks, or anaphylaxis)

BP and temp in kids

-BP is not as accurate in kids so we watch trends mostly -temp is not as accurate in infants due to an immature regulatory system

Neuro

-LOC -activity level -are pupils ERRLA? -do they need a backboard or cervical collar?

LPN/LVN scope of practice vs RN:

-LPNs can evaluate or assess, but NOT for the initial assessments -they report findings to RN and the RN plans and implements -LPNs reinforce what the RN teaches

What are the first aid steps for an impaled object?

-NEVER remove an impaled object unless it penetrates the cheek or interferes with chest compressions -call EMS immediately -remove victim's clothing to expose wound if needed, cut it to avoid disturbing object -manually secure the object to prevent any motion -control bleeding with direct pressure (but not on the object or surrounding skin) -stabilize impaled object with bulky dressings and bandage it in place -calm and reassure victim -monitor for shock!!!

Osteogenesis Imperfecta (OI)

-OI means imperfect bone formation -brittle bone disease -this is an inherited disorder that is characterized by connective tissue and bone defects -complications: leads to osteoporosis, discolored teeth, deafness, transparent skin, shorter stature

muscular dystrophy:

-a group of inherited conditions that result in progressive muscle weakness over time -weakness in skeletal and voluntary muscles -7 types, but Duchenne's is the most common

What are some clinical manifestations of SCFE?

-a limp -altered gait -intermittent pain as the neck slips in and out

What is torticollis?

-aka wryneck -painless muscular condition in children due to tightening of the sternocleidomastoid muscle, resulting in a child's head being tilted to one side

Describe shock:

-an inadequate delivery of blood to the cells that is FATAL if left untreated -must be recognized and treated ASAP -can be gradual or rapid onset -2 main types: hemorrhagic and septic

Breathing

-assess their work of breathing -look for nasal flaring -O2 sat -look for retractions -look for spontaneous respirations

Septic shock:

-associated with sepsis (think in their blood or bones) -a severe infection causes dilation of blood vessels, blood pools in the vessels -poisonous substances accumulate in the bloodstream -BP plummets, blood flow to organs/tissues is compromised and those organs fail -think: full body inflammatory response

What are the first aid steps for a bleeding patient?

-biggest thing= INFECTION CONTROL (this means gloving up) -stop the bleeding *apply direct pressure to area *elevate above heart level *pressure bandage applied *use indirect pressure, like at a pressure point *air splint *use a tourniquet as a LAST resort bc it can result in amputation *blood pressure cuff is good for cutting off some of that blood flow -determine cause/source of bleeding and general condition of pt -place pt in position in which they will be least affected by the bleeding -maintain open airway -prevent or control shock

Airway

-check for airway patency -adjust their positioning to facilitate easier breathing -auscultate breath sounds

what are some examples of subjective data we might hear from kiddos in pain?

-complains of muscle spasms/muscle "pulling" -loss of function -refusing to walk or crawl (when they normally do it just fine) -kids are either overdramatic or under dramatic

what are some examples of objective data we might observe with kiddos in pain?

-crepitus (a grating sound of bone rubbing on bone) -deformity (shortened limb, the limb facing the wrong direction) -visible muscle spasms -edema/swelling -ecchymosis (indicative of bleeding into underlying tissues) -NV (5 P's) -X-rays

What are first aid measures for an abdominal injury?

-do not touch the organs or try to put them back in the abdomen -cover the protruding organs with a clean, moist, sterile dressing (nothing that will draw moisture away from wounds!) -never use absorbent cotton or material that clings or shreds -cover moist dressing with occlusive material to retain moisture and warmth -gently wrap dressing in place with bandage or clean sheet

What are some *behavioral* signs of cerebral palsy?

-extreme irritability or crying -failure to smile by 3 months -difficulty feeding, such as gagging or choking when being fed -persistence of extrusion reflex after 6 months (urge for babies to regurgitate their food when they eat/push it out with their tongue)

Assessing a patient after a near-drowning:

-focused on ABCs, respiratory system -we start CPR immediately -the key for kids is preventing it in the first place

what are some complications of myelomeningocele?

-hydrocephalus -chiari malformation -delayed developmental milestones

What are some things a nurse needs to remember about casts?

-ice and elevation will reduce swelling -watch or hot spots may indicate infection -watch the skin integrity (wounds, casts rubbing, skin breakdown) -compartment syndrome

What are some common medical treatments in emergencies?

-if airway or breathing is compromised, expect to do suctioning, give oxygen, Bag-valve-mask ventilation, intubate -if their circulation is compromised, anticipate IV fluids and blood products (FFP, PRBCs) -if neuro is compromised, expect cervical stabilization -defibrillation as a last ditch effort if they are circling the drain

What are the first aid steps for an amputation injury?

-if possible, rinse the amputated part with clean water but never scrub -wrap the limb in a dry sterile gauze dressing secured in place with Coban -placed wrapped part in a plastic bag -place bag in cooler on top of cold back or sealed bag of ice (Never dry ice) -we want to keep limb/part as cool as possible without freezing, so never cover with ice or immerse it in ice water -bag is given to EMS when they arrive

What are some other ways we treat fractures?

-immediate splinting and immobilization -reduction to line the bones back into normal placement

osteomyelitis

-infection in the bone secondary to an open fracture, break in skin, or a blood borne bacteria (usually Staph aureus) -key= SKELETAL TRACTION IS HIGH RISK FOR THIS

How do we treat SCFE?

-internal fixation surgery -pins, rods, wires -needs to be caught early -no weight bearing

What are some common s/s of osteomyelitis?

-limb feels warm and painful -erythema -edema -fever

What are some nursing considerations for traction?

-maintain comfort -repositioning -skin integrity -infection -the 6 P's -weights hang freely -clean pin site DAILY -trapeze to help pull up in bed -PACU assessment if they went to surgery

What are first aid steps for internal bleeding?

-maintain open airway -monitor ABCs -check for fractures and splint if needed -keep victim quiet -position them and treat for shock -elevate feet 8-12 inches -cover with blanket -monitor every 5 minutes until EMS arrives

How do we treat club foot/talipes equinovaris?

-management ultimately depends on severity -treatment needs to be EARLY on -usually exercise and stretching for mild for a few months -if severe, pt needs serial casting surgery if not corrected in 3-4 months (4-6 weeks of casting) -the outcome is not predictable -we watch for skin integrity, cast care

What are some nursing considerations we want to keep in mind for kids with cerebral palsy?

-many will have a need for increased caloric intake due to spasticity or increased motor functioning -seizure precautions!!!! -we want to provide them a safe environment, since they will have poor coordination (risk for injury) -the child may need to use a communication board or computer-assisted communication -self-care is a goal for all children, these kiddos need extensive collaboration with our OTs to assist with ADLs -adaptive feeding devices and upright positioning during feedings to prevent aspiration -collab with speech therapists, nutrition, OTs, PTs -the child and family form the CENTER of the team ^ key= adequate nutrition and rest is key

What is spina bifida?

-midline defect involving failure of the osseous spine to close -two main kinds: occulta and cystica

what are some *post-op* nursing considerations for myelomeningocele?

-monitor VS -assess pain -weight -I&Os -observe for infection -provide nourishment -support the family and teach them how to properly care for infant

What are *third-level* nursing problems/priorities?

-monitoring for med side effects -lack of patient knowledge -long term patient knowledge like D/C teaching -assistance with dressing or ADLs

Club Foot:

-most common is *talipes equinovaris* meaning inward and downward -deformity of the ankle and foot -occurs in every 1,000 births -can be caused by a number of reasons, such as intrauteral crowding (positional), syndromes such as cerebral palsy or spina bifida, or can be idiopathic/no known cause

Spina bifida *occulta*:

-not visible externally -common in the lumbosacral area (L5 and S1) -s/s: skin depression or dimple, hemangioma, dark tufts of hair, soft subq lipomas

How do we manage CP?

-often times these kids are diagnosed after 2 years -we give Baclofen, a skeletal muscle relaxant -Diazepam (Valium) is a bento given to relax that spasticity -botox -these meds can be on a pump or through a G tube if needed

Pain

-pain is usually the least important because it means they're ALIVE -we try to avoid opioids bc respiratory depression

How do we treat torticollis?

-passive stretching (90% effective) -physical therapy -Tubular Orthosis for Torticollis (TOT) collar

Who is most likely to experience fractures and why?

-pediatrics and geriatrics -they have softer/larger heads -children tend to be more active but less careful or safe -children play sports -plus side= kids' bones "bounce back" quicker and have less longterm effects r/t fractures than older adults

What are some *physical* signs of cerebral palsy?

-poor head control after 3 months of age -stiff or rigid arms or legs -pushing away or arching their back -floppy or limp body posture -cannot sit up without support after 8 months -uses only one side of their body or only the arms to crawl -clenched fists that don't disappear after 3 months

In what kids do we see SCFE most?

-pre-teens (growth spurts) -short and heavy kids -boys more often than girls -those that are in the 90th percentile for weight

mobility nursing considerations for OI:

-prevent fractures -maintain joint/muscle function -GENTLE turning -passive ROM exercises -daily skin care -avoid chest compressions

What are some nutrition considerations for kids with OI?

-prevent them from becoming overweight -diet HIGH in CALCIUM

What are some s/s of compartment syndrome?

-prolonged cap refill -paresthesia -pain unrelieved by meds -pallor

Nursing management for MD:

-promote mobility -maintain cardiopulmonary function -maximize QOL

What are some nursing considerations for a child with osteomyelitis?

-provide comfort measures and pain relief -IV abx (usually long-term, for 21 days +) -child life specialist -diversion therapy

Skin and extremities

-remove clothing -maintain body temp

what are the first aid steps for clamping injuries?

-remove the object that is clamping as quickly as possible -apply lubricant or soap and try to wiggle loose -elevate affected extremity -call EMS if unsuccessful

What are some s/s of internal bleeding?

-restlessness and anxiety -cool, clammy skin -weak, rapid pulse -rapid breathing -drop in BP -sometimes they won't show s/s until hours or days after bleeding starts -basically all signs point to hypovolemic shock

internal bleeding

-results from trauma, blunt injury, fractures, pelvis and femur injuries, injury to the spleen, liver, aorta, or kidneys -may see bleeding from ears, rectum -bleeding in emesis -hematuria -rigid abdomen

meningocele

-sac like protrusion (spina bifida) that encases the meninges and spinal fluid but no neural elements -is NOT associated with neuro defects -just a fluid sac protruding

What are closed injuries?

-soft tissues beneath the skin are damaged, but the skin is not damaged -examples: contusion, hematoma, crush injuries

ingestions and poisoning of kids:

-the kid has ingested or been in contact with something that produces a toxic effect -usually in the home, most commonly oral ingestion -children are at high risk because they are curious and may lack taste discrimination -adolescents may be suicidal -we want to evaluate their labs, do an H&P

Once the emergency is over, what do we focus on in our stable secondary assessment?

-the normal order: inspection, auscultation, palpation, percussion -we want to interact with the caregiver, give them update and keep them calm -establish the child's baseline prior to emergency -we get a full set of VS -provide comfort measures -full head-to-toe assessment -assess for child abuse possibility -get correct weight bc all meds are based on weight!

What are *second-level* nursing problems/priorities?

-these include mental status changes, changes in VS, acute pain, acute urinary elimination -untreated medical concerns requiring immediate attention like a diabetic needing their insulin, an abnormal pathology report -risks for infection, safety concerns, security

Why are kids a vulnerable population for emergency care?

-they have thinner skin, bigger/softer heads, they aren't always aware -harder to see in a moving car -we see a lot of drowning, poisoning, and traumatic injuries

spina bifida *cystica*:

-this is a VISIBLE defect externally -external sac-like protrusion -two forms: meningocele and myelomeningocele

Scoliosis

-this is an abnormal lateral curvature/spinal rotation with rib asymmetry and thoracic hypokyphosis -these kids will have uneven scapulas -clothes won't fit right -we test for scoliosis at schools now -we use a scale to determine how severe the scoliosis is -NO CURE but braces help stop the spine from continuing to curve

myelomeningocele

-this is the BAD one -involves the meninges, spinal fluid, and nerves -causes defect in spine and spinal cord -usually the sac is covered with a fine membrane which tears easily -the location and magnitude of the defect determine the nature and extent of neuro impairment -most commonly in the lumbar and sacral regions

Hemorrhagic aka hypovolemic shock:

-this type is associated with fluid/blood loss -this is the most common type for kids -caused by vomiting, diarrhea, diuretics, heat stroke, severe burns or guts, gunshot wounds, trauma, amputations, etc. -just think massive blood or fluid loss that causes the body/organs to shut down -the heart shuts down, failing to circulate the body -s/s: plummeting BP, massive drop in body temp, tachycardia, no UOP, weakness, confusion, pulses are weak, rapid/shallow breathing/dyspnea

What are *first-level* nursing problems/priorities?

-threats to a patient's IMMEDIATE survival or safety -these demand immediate nursing interventions -think ABCs

What is a spica cast?

-type of cast that covers the lower part of the body, usually from the waist down, and either one or both legs while leaving the feet open. -the cast maintains the legs in a frog-like position -usually, there is a bar placed between the legs to help support the cast.

what are some *pre-op* nursing considerations for myelomeningocele?

-use radiant warmer so that baby's body temp can be maintained without clothing -apply a sterile, moist dressing over the sac -change dressing q2-4h -keep the infant PRONE to reduce tension on the sac -leave diaper under the baby and do not fasten

what is *skin* traction?

-uses a pulling force with boots or straps -can be intermittent or continuous -bunch of types (bryant, russell, buck, cervical, side arm 90/90, etc.)

What do we need to remember about spinal cord injuries?

-we NEVER move their neck or spine, always immobilize -we watch for s/s of increasing ICP and internal bleeding, shock

Circulation

-what color is their skin? -check for cap refill -palpate pulses (remember jugular, brachial, or femoral tend to be easier in kiddos)

emergency bleeding

-when a pt bleeds, their body makes more RBCs and fluid is taken from cells into the bloodstream -platelets collect at wound site -WBCs collect at site of infection -we know that the severity of the bleeding depends on multiple factors such as how fast the blood is flowing, the size of the vessel, if its a vein or artery, if its internal or external, where the bleeding originated, etc. -the victim's age and weight plays a huge role, as well as their general physical condition -is the bleeding impacting airway/respirations?

Compartment Syndrome:

-when circulation is compromised due to too much pressure in the muscle compartment -causes ischemia and edema due to compromised NV status -external causes= too tight of cast, constrictive dressing -internal causes= accumulation of blood and fluid -tx= fasciotomy, cut cast, elevate and ice

Bryant Traction:

-where both legs extend vertically -used to reduce femur fractures in kids less than 2 or for developmental dysplasia of the hip

Scale for scoliosis:

10-20= slightly curved >40= surgery needed >80= severe, respiratory function compromised

air splint

A hollow, inflatable splint for immobilizing a part of the body.

What are some common poisonous substances?

Acetaminophen Salicylates Corrosives Hydrocarbons Lead Carbon Monoxide

What is the antidote for acetaminophen?

Acetylcysteine (Mucomyst)

What do we do if a kid comes in and he's crashing but we need to know his weight for meds?

Broselow emergency tape estimates weight based on height and is pretty accurate -color coded for equipment and meds

What is a classic sign of Duchenne muscular dystrophy (DMD)?

Gowers sign, which is the inability of the child to rise from the floor in the standard fashion because of weakness (puts hands on knees to help push up)

Can an LPN give an IV push?

NO!

Can an LPN hang blood?

NO!

What are the 5 P's of a neurovascular assessment?

Pain Pulselessness Pallor Paresthesia Paralysis Poikilothermia

What are peds nurses required to be certified in?

Pediatric Advanced Life Support aka PALS (instead of Advanced Cardiac Life Support or ACLS for adult pts) because we treat emergencies in kiddos differently

What do we give for salicylate poisoning?

Sodium bicarb

laceration

a break in the skin with a smooth or rough edge, varying in depth

Complicated Fracture:

a fracture that causes injury to other organs/tissues ex: rib fracture

Who would be the most likely person to be diagnosed with idiopathic scoliosis that requires treatment?

a young adolescent female

near-drowning

child survived longer than 24 hours after submerison

What is cerebral palsy?

chronic non-progressive disorder of posture and movement characterized by difficulty in controlling the muscles because of an abnormality in the extrapyramidal/pyramidal motor systems -this motor damage/abnormality can during the pre-natal, perinatal, or postnatal periods

hematoma

collection of blood under skin, lump with bluish discoloration -basically a really bad bruise

Buckle Fracture:

compression causes a raised area/bump at the fracture site

what are some signs of a brain bleed?

decreased LOC increased ICP

What do we give a pt who has ingested too much iron?

deferoxamine (DFOA)

Russell Traction:

for fracture of the hip, femur, or knee

Halo traction:

for fracture or dislocations of the cervical or high thoracic vertebrae -screws into skull

Cervical Skeletal Traction:

for fractures or dislocations of the cervical or high thoracic vertebrae

Buck Traction:

for hip and knee fractures or slipped capital femoral epiphysis (SCFE)

Spiral Fracture:

fracture from a twisting motion -key= POTENTIAL FOR ABUSE

How to manage or treat scoliosis?

greatly depends on the location, degree of curvature, and skeletal maturity of the child -if mild: child will wear a posture brace all day, will do extra exercising -if severe: surgery for internal fixation for surgery, expect to see chest tubes, NG tubes, catheters, PCA pumps, lots of PT visits, etc. because its their spine!!!

infant feet vs adult feet

infants have flatter and wider feet than adults, but their arches will present once they start walking for a few months

patients with myelomeningocele often develop what?

latex allergy

amputations

limb torn away from body -blood vessels spasm and retreat into surrounding tissues -common in kids= fingers (trampolines, car doors)

who do anterior chest wall deformities occur in most often?

males

penetrating or puncture wounds

penetration of sharp object through skin/underlying structures -this causes deep damage and internal bleeding -think gunshots, knife wounds

How do we treat *closed* fractures?

pressure and traction

The nurse is providing preoperative care for a newborn with myelomeningocele. Which action is the central nursing *priority*?

priority concern is to prevent rupture or leaking of CSF -we also keep them in prone to decrease pressure on the lesion -keep lesion free from fecal matter/urine

how often do we take VS on a bleeding patient?

q 5 minutes -repeat a victim assessment after 15 min -we need to stay alert for complications r/t blood loss (shock, death)

how often do we do NV assessments in kids with fractures?

q4h

Most pediatric codes are due to what?

respiratory failure or shock!

What type of fracture is commonly r/t abuse?

spiral (caused by wrenching force)

drowning

submersion that results in asphyxia and death within 24 hours

abrasion

superficial wound to the top most layer of the skin caused by rubbing, scraping, or shearing

How do we treat *open* fractures?

surgery -expect pain with movement and possibly drainage

how do we treat myelomeningocele?

surgery is the only option

the lower the region of the myelomeningocele...

the better!

contusion

the epidermis is intact, but the cells of the dermis are damaged -aka a bruise

avulsion

the tearing loose of a flap of skin or limb -may either remain hanging or be torn off altogether -causes scarring bc circulation is compromised

Open aka Compound Fracture:

this causes an open wound and the bone is sticking out of the skin -key= INFECTION RISK

Slipped Capital Femoral Epiphysis (SCFE) ("skiffy")

this is a relative displacement of the femoral neck from the femoral head that occurs during a period of rapid growth in adolescence

Closed aka Simple Fracture:

this occurs under the skin and does not cause a break in the skin

crush injuries

underlying layers of skin sustain severe damage -can cause few external signs, but may result in shock -results from sudden blow or blunt trauma

Side Arm 90/90:

used for humerus fracture or shoulder fracture

Cervical Skin Traction:

used for neck sprains, torticollis, or nerve trauma

90/90 Traction:

used when skin traction is inadequate

What is *skeletal* traction?

uses a continuous pulling force that is applied (via a pin) directly to the bone or skeletal structure -key= HIGH INFECTION RISK so we assess pin sites frequently -many types (dunlop side arm 90/90, 90/90 traction, cervical skeletal tongs) -remember that weights ALWAYS hang freely

Greenstick Fracture:

where the bone bends and cracks but doesn't break completely

What are open injuries?

where the skin is broken and pt is susceptible to external bleeding and contamination/infection -examples: abrasions, lacerations, avulsions, puncture wounds, amputations, bites