EXAM NURSP 433 #1 BLUEPRINT
rheumatic fever assessment
-auscultating the heart rate and heart sound characteristics especially when dx with rheumatic fever. assessment damage to the heart is a priority -jones criteria: child should should demonstrate the presence of two major criteria or the presence of one major and two minor criteria following an acute infection with GABHS infection.
Congenital heart defect that increase pulmonary flow assessment
-cardiac history: ask about poor weight gain, poor feeding habits, and fatigue during feeding, frequent respiratory tract infections and difficulties; and evidence of exercise intolerance -diagnostic tests: commonly used to assess cardiac function-radiography, ECG, echocardiogram, and cardiac catheterization labs
jones criteria major
-carditis -subcutaneous nodules -polyarthritis -rash -chorea
congenital heart defect diagnosis
-cause increase perfusion to the lungs -heart conditions that do not cause deoxygenation or low oxygen levels -the defects above cause blood to flow from the left side of the heart to the right side. left-sided blood is oxygenated so there it is red so there is no cyanosis noted
Bronchiolitis RSV treatment
-contact isolation -oxygen maintain sats>90% -humidified oxygen -fluids q4 oral or IV maintenance, I/O maintain airway possible antibiotics/steroids, CPT not recommended -cluster care to allow for rest -suctioning -synagis:used on preemies to prevent RSV under age 2
Respiratory Distress
-cystic fibrossis is the most common inherited disease -autosomal recessive trait -diagnostic confirmation of CF is made bt sweat chloride analysis (diagnostic if the level is above 60 mEq/L" -
Tet spell treatment
-decrease pulmonary resistance -knee chest position hips flexed knees brought up to chest -calm child 100% oxygen -morphine or propranolol
Acyanotic CHD (left to right shunt)
-defects that result in increased pulmonary blood flow -oxygenated blood circulates
Appendicitis risk factors
-diet low in fiber -diet high in sugar -family history -infection
jones criteria minor
-fever -arthralgia
6 month old reflexes
-gag, cough, blink, pupillary:protective reflexes -babinski:fanning of toes when sold of foot is stroked upward, disappears by 1-2 years
Kawasaki's Disease Assessment
-high fever for 5 days (unresponsive to antipyretics and antibiotics) -chills -headache -malaise -strawberry tongue -cracked lips -edema of the oral mucosa -vomiting -abdominal and joint pain
congenital heart defect medication does what?
-improve cardiac output decrease arrhythmias (irregular heart rhythm) -decrease risk of clotting
Digoxin
-improves contractility of the heart without increasing heart rate -improves cardiac output -improves perfusion and oxygenation
A nurse in the emergency department is assessing a toddler who has Kawasaki disease. Which of the following findings should the nurse expect?
-increased temperature -xerophthalmia -cervical lymphadenopathy
Hold digoxin if:
-infants and toddler heart rate less than 90, older children heart rate less than 70, and adult heart rate less than 60 -use a calibrated device that comes with medications to prevent overdose -brush teeth after giving to prevent tooth decay
appendicitis
-inflammation of the vermiform appendix -fatal if left untreated: gangrene, perforation and rupture develop. -average age 10 years
rheumatic fever
-is caused by an autoimmune reaction to throat infections due to streptococcus pyogenes. begins with a strep throat from a streptoccocal infection and can progress to rheumatic heart disease causing damage to heart valves -most common in age 5 to adolescence
Lasix
-monitor electrolytes especially potassium (3.5-5.0) -monitor for signs of dehydration -monitor intake and output (weigh diapers) -encourage consumption of foods with high potassium (orange juice, bananas) if doctor directs -watch for ototoxicity
Kawasaki disease intervention
-monitor vital signs -I/O daily weight IV to prevent dehydration -promote comfort -assess for heart failure respiratory distress -clear, non acidic foods
appendicitis obstruction causes:
-mucus outflow, increases pressure in the distended appendix -distention causes capillary and venous engorgement and increased intraluminal pressure -appendix contracts
Digoxin toxicity
-nausea, vomiting, anorexia, and fatigue -furesemide is a potassium wasting diuretic and can cause hypokalemia. hypokalemia increases the potential for digoxin toxicity -antidote digoxin:immune fab fragments
Appendicitis causes
-obstruction of the lumen of the appendix, usually with hardened fecal matter -swollen lymphoid tissue -rare cause of obstruction is enterobitus vermicularis -fecal mass -mucosal ulceration -stricture
TET spell is characterized by:
-period of uncontrollable crying -hyperpnoea (rapid, deep respirations) worsening hypoxia with cyanosis/pallor -limpness -loss of consciousness or convulsions -death
What are the earliest symptoms for appendicitis ?
-periumbilical pain -vomiting
rheumatic fever interventions
-prednisone to decrease inflammation -rest -penicillin long term to reduce risk of strep recurrence -encourage drug compliance
tet spell prevention
-quiet play -minimize stress -respond to crying quickly -treat fever -keep children calm -stool softeners -maintain hydration
acquired heart diseases:
-rheumatic fever -kawasaki's disease
What is it followed by that is the classic sign of appendicitis?
-right lower quadrant pain (McBurney's point)
appendicitis incidence
-the avaerage age of children with appendicitis is 10 years old; the disorder is rare under the age of 8
"TET" spells (hypercyanotic spells)
-transient periods when there is an increase in right to left shunting of blood; hypoxia, pallor, tachpnea -precipitated by crying, defecation, fever, dehydration, pain
8 common INJURIES incurred by infants
1. aspiration of foreign objects 2. bodily harm 3. burns - water no more that 120 degrees Fahrenheit 4. drowning 5. falls 6. poisoning 7. motor vehicle injuries - rear facing car seat until age 2 8. suffocation - crib slats should be no further apart than 6 cm
FLACC (Face, Legs, Activity, Cry, Consolability) scale used on what age range?
2 months to 7 years
Faces pain scale used on what age range?
3 years and older
A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child's appendix is perforated?
A sudden decrease in abdominal pain should indicate to the nurse that the appendix might be ruptured. If the appendix ruptures, the pain can disappear for a short period and the client might feel suddenly better. However, once peritonitis sets in, the pain returns and can spread into the whole abdomen.
The nurse should explain to the parents that their child is receiving furosemide (lasix) for severe congestive heart failure because of its effects as A. Diuretic B. Beta-blocker C. a form of digitalis
A. Diuretic
A nurse is caring for a client who has a heart failure and has a potassium level of 2.4 mg/dL. An adverse effect of which of the following medications is a possible cause of this potassium level? A. Furosemide (lasix) B. Nitroglycerin (Nitro-Bid) C. Metoprolol (lopressor) D. Spironolactone (aldactone)
A. Furosemide (Lasix)
Kawasaki's disease
-acute, self limiting vasculitis characterized by prolonged fever, mucosal lesion, skin rashes, and cervical lymphadenopathy that resolves in less than 8 weeks -also known as "mucocutaneous lymph node syndrome"
Bronchiolitis/RSV (lower respiratory)
-affects the bronchioles and bronchi/viral most often from respiratory syncytial virus (RSV) -winter and spring most common time, first 2 years of life -nasopharyngeal swab to diagnose for RSV antigen
Respiratory distress treatment
-aimed toward minimizing pulmonary comploications -maximizing lung function -preventing infection, facilitating growth -daily weights
Tonsillitis interventions
-antibiotics -tonsillectomy and adenoidectomy for chronic inflammation -minimize activities -prioritize:airway, breathing, circulation
Assessment after tonsillectomy
-assess for evidence of bleeding -assess airways and vitals -monitor for difficulty breathing form secretions, edema, or bleeding
congenital heart defect interventions
-assist in improving cardiac function -decrease cardiac demands:pharmacologic/nonpharmacologic -reduce respiratory distress: monitor activity level, provide periods of res, head of bed up (sit up) to prevent orthopnea -provide family support:we will see an increase pulmonary blood flow leading to signs of CHF
what medications are used for congenital heart defect?
-ACE inhibitors and angiotensin receptor blockers -antiarrhythmics -anticoagulants: warfarin (coumadin) -antiplatelets:aspirin or plavix -beta blockers: lopressor, carvedilol, inderal (caution) -digoxin -diuretic=lasix -bosentan and/or sildenafil:treat pulmonary arterial hypertension
Congenital heart diseases that result in increased pulmonary blood flow?
-Atrial Septal Defect (ASD) -Ventral Septal Defect (VSD) -Patenet Ductus Arteriosus (PDA) -TOF: Tetralogy of fallot (cyanotic heart defect)
A nurse is conducting a well-baby visit with a 6-month-old infant. Which immunizations should the 6-month-old have?
-Hepatitis B -DTAP(Diphtheria Tetanus acellular pertussis) -Rotavirus -HIB (haemophilus influenzae type B) -IPV(inactivated polio vaccine) -PCV (pneumococcal) -influenzae
Kawasaki disease treatment
-IV Immunoglobulin and high dose aspirin -monitor for cardiovascular changes due to inflammation of the arterioles, venules, and capillaries
Digoxin Nursing Considerations
-Monitor HR and BP Report symptoms of digoxin toxicity - must be double checked by 2 nurses as it has a very narrow therapeutic window with a high risk of overdose and toxicity -monitor for digoxin toxicity:vomiting, anorexia, abdominal pain, visual disturbance, bradycardia, and arrhythmias -take pulse for a full minute prior to giving: apical heart rate
acyanotic disorders (left to right)
-PDA -ASD -VSD
What three signs are associated with appendicitis?
-Psoas sign -Obturator sign -Rovsing sign
You are working with a family with a child who has a congenital heart defect. Future surgery is planned, and you are teaching the parent how to reduce cardiac demands. The parent needs more teaching when she says which of the following? A. I will wake my child for feeding every 2 hrs so he can get enough calories to gain weight. B. When I give digoxin, I will listen to the pulse for 1 full minutes. C. I should protect my child from people who have respiratory infections. D. I will count the number of wet diapers to be sure my child is not getting too much or too little fluid.
A. I will wake my child for feeding every 2 hours so he can get enough calories to gain weight
A nurse is caring for a client who receives furosemide (lasix) to treat heart failure. Which of the following laboratory values should the nurse be sure to monitor specifically for this client? A. potassium B. Albumin C. chloride D. Bicarbonate
A. Potassium
The nurse is preparing to give digoxin (lanoxin) to a 9-month-old infant. The nurse checks the dose; 4 ml of the drug is to be drawn up. Based on the nurse's knowledge of this medication and safe pediatric dosages, the most appropriate action by the nurse is A. do not draw-up dose, suspect error B. mix dose with juice to disguise its taste C. check heart rate; administer dose by placing it to the back and side of the mouth D. check the heart rate; administer dose by letting infant suck it through a nipple
A. do not draw-up dose *digoxin is most often prescribed in micrograms
A nurse is caring or a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse clarify?
Administer sodium biphosphate/sodium phosphate
A toddler who has Kawasaki disease is admitted to the pediatric unit. Which of the following findings should the nurse expect to observe during the physical assessment? A. vesicular rash B. dry, cracked lips C "strawberry" tongue D elevated temperature E. Edema of hands and feet
B, C, D, E
A nurse is assessing a school-age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect? A. purulent nasogastric drainage B. the absence of peristalsis C. passage of dark stool with mucus D. WBC count 6000mm^3
B. Absence of peristalsis
A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their pain as 7 on a 0-10 scale. Which of the following actions should the nurse take? A. instill a 500mL tap water enema B. Give morphine 0.005mg/kg IV C. administer polyethylene glycol 1g/kg PO D. Apply a heating pad to the child's abdomen
B. Give morphine 0.005 mg/kg IV
You are discharging a 5 week old infant with a congenital heart defect who will be going home on digoxin. Which of the following answers by the father indicate the need for more teaching? (select all that apply) A. I know I give the drug carefully by slowly directing it to the side and back of the mouth. B. I give the medication every 12 hrs, and I can place it in a bit of formula so that I know the baby will take it. C. If I miss a dose, I dont give an extra dose, but I give the next dose as ordered. D. If the baby vomits, I should give a second dose. E. If more than two doses have been missed, I should call the doctor
B. I give the medication every 12 hours and I can place it in a bit of formula so that I know the baby will take it D. if the baby vomits, I should give a second dose
A nurse is providing education about introducing new foods to the parents of a 4-month-old. To best supply needed nutrients, the nurse should recommend that the parents introduce which of the following foods first? A. strained yellow vegetable B. Iron-fortified cereals C. pureed fruits D. whole milk
B. Iron-fortified cereals
A nurse is assessing a 6-month-old infant. Which of the following reflexes should the infant exhibit? A. Moro B. Plantar Grasp C. Stepping D. Tonic Neck
B. Plantar Grasp The plantar grasp is exhibited by infants from birth to the age of 8 months.
A nurse is providing teaching to a mother of an infant who has a prescription for digoxin. Which of the following instruction should the nurse include? A. do not offer our baby fluids after giving the medication B. Digoxin increases your baby's heart rate C. give the correct dose of medication at regularly scheduled times D. if your baby vomits a dose, you should repeat the dose to ensure that he gets the correct amount
C. give the correct dose of the medication at regularly scheduled times
appendicitis labs
CBC and urinalysis
appendicitis diagnosis
CT shows enlarged appendix and thickening of appendiceal wall
A nurse is caring for a client who has a heart failure and is prescribed furosemide (lasix). For which of the following finding should the nurse withhold the medication? A. weight gain B. increased blood pressure C hematocrit of 33.4% D. potassium 2.8
D. potassium 2.8
A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse clarify?
Enemas and laxatives are contraindicated because they increase the volume in the bowel and can cause the inflamed appendix to rupture, increasing the risk for peritonitis.
A nurse in an emergency department is caring for a school-age child who has appendicitis and rates his abdominal pain at 7 on a 0-10 scale? What action should the nurse take?
Give morphine 0.05 mg/kg IV
Appendicitis Clinical Manifestations
Pain- Where? Anorexia & nausea Could have a low grade fever Localized tenderness-rebound tenderness Rovsing's sign S/S peritonitis: Assess for it!
What happens if appendix is perforated & intravenous antibiotics are given?
Pt is NPO with NG tube until bowel function returns
Bronchiolitis/RSV complications
RDS, Dehydration
PDA (patent ductus arteriosus)
a condition in which the normal fetal circulation conduit between the pulmonary artery and the aorta fails to close and results in increased pulmonary blood flow (left-to-right shunt)
ASD (atrial septal defect)
a hole in the septrum between the right and left atria that results in increased pulmonary blood flow (left to right shunt)
Infant safety
a. Parents must baby-proof the home. b. Guard the infant when on a bed or changing table. c. Use gates to protect the infant from stairs. d. Be sure that bath water is not hot; do not leave the infant unattended in the bath. e. Do not hold the infant while drinking or working near hot liquids or items such as a stove. f. Cool vaporizers should be used if needed, instead of steam, to prevent burn injuries. g. Avoid offering food that is round and similar to the size of the airway to prevent choking. h. Be sure toys have no small pieces. i. Toys or mobiles hanging over the crib should be well out of reach to prevent strangulation. j. Avoid placing large toys in the crib because an older infant may use them as steps to climb. k. Cribs should be positioned away from curtains and blind cords. l. Cover electrical outlets. m. Remove hazardous objects from low, reachable places. n. Remove chemicals such as cleaning or other household products, medications, poisons, and plants from the infant's reach. o. Keep the Poison Control Center number available.
tet spell caused by
an acute reduction in pulmonary blood flood associated with an increased in the magnitude of the right-left shunt
appendicitis pathophysiology
continued inflammation, pressure, and fluid collection can lead to perforation and spillage of the appendiceal contents into the peritoneal cavity, resulting in peritonitis and sepsis
A nurse is admitting a 4-month-old infant who has heart failure. Which of the following findings is the nurse's priority?
episodes of vomiting
What does FLACC stand for?
face, legs, activity, cry, consolability (0-10, 0 no pain)
Tonsillectomy complications
hemorrhage, dehydration, chronic infection. risk of rheumatic fever and kindey damage if beta hemolytic strep
VSD (ventricular septal defect)
hole in the septum between the left and right ventricle; flow is left to right, increasing pulmonary blood flow (left to right shunt)
A client with appendicitis begins to complain of increased pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. What is the appropriate nursing intervention?
notify the health care provider
A nurse in an emergency department suspects that a toddler has epiglottis. Which of the following actions should the nurse take?
prepare the toddler for a nasotracheal intubation
4 defects of congenital heart defects
pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect and overriding aorta
A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child's appendix is perforated?
sudden decrease in abdominal pain
How is appendicitis treated?
surgery