FINAL EXAM LIFESPAN

Mortality rates causes

1.Hemorrhage, 11.0%. 2.Infection or sepsis, 12.5%. 3.Amniotic fluid embolism, 5.6%. 4.Thrombotic pulmonary or other embolism, 9.0%. 5.Hypertensive disorders of pregnancy, 6.9%. 6.Anesthesia complications, 0.3%. 7.Cerebrovascular accidents, 7.7%. 8.Cardiomyopathy, 11.0%. 9.Other cardiovascular conditions, 15.7%. 10.Other noncardiovascular medical conditions, 13.9% 1.Birth defects 2.Preterm birth and low birth weight 3.Sudden Infant Death Syndrome (SIDS) 4.Pregnancy complications 5.Accidents

Feibrile seizure

oSeizure between 6 months and 5 years of age, associated with fever, without evidence of intracranial infection or defined cause.ooExact pathophysiology of febrile seizures is not known.ooSeizures with fever in children who have suffered a previous non-febrile seizure are excluded from this definition.Higher the fever higher the SEIZURE ACTIVITY: NOT TRUE

Review a febrile seizure worksheet on canvas

ok

3rd older adult nutrition malnutrition

Albumin is an indicator of nutrition a FEW WEEKS before - not an acute test Preablumin - short half life of 2 days - better indicator of deficiency Transferrin - iron transport protein - direct measurement or indirect by TIBC Anemia - low Iron, Low Energy TLC - Assess immune function - suppressed in malnutrition Know proper Lab levels - malnutrition lowers them ¨Albumin - Low ¤3.5-5.0 ¨Prealbumin ¨Transferrin ¤TIBC (Total Iron Binding Capacity) ¨Protein - low ¤6.0-8.3 ¨Hg/Hct - Low ¨Total Lymphocyte Count (TLC) ¨Low electrolytes

Epilepsy monitoring unit

Allow monitoring for seizures 24 hours per daycameras in the room, attempt to figure out where seizure activity is coming from

Rule out causes of seizures in its management

Breath Holding: temper tantrums hyperventilate hold breath and pass outSyncopeMyoclonus (facial or body twitching)Movement disorders including dystonia, chorea, ticsHyperventilationMovement related gastroesophageal reflux (Sandifer syndrome)Sleep disorders like Narcolepsy-cataplaxy, night terrorsMigrainePsychogenic non-epileptic events (i.e. pseudoseizure)Behavioral disorder

Age Appropriate Medication Administration:

DEVELOPMENTAL BEHAVIORS NURSING ACTIONS TO GIVE MEDICATION BIRTH TO THREE MONTHS Ø Reaches randomly towards mouth and exhibits strong palmar reflex to grasp objects Ø Must support head due to poor control Ø Sucks as a reflex with tactile stimulation Ø Tongue movement may force food out of mouth Ø Stops sucking when full Ø Infant becomes socially responsive and aware of environment Ø Infant's hands must be controlled to prevent spilling of medication Ø Support the infant's head while giving medication Ø Use the natural sucking behavior and place oral medication into a nipple via syringe or cup Ø A syringe or dropper should be placed to the side and back of the mouth Ø Give small volumes and when infant is hungry Ø Using feeding positions will increase the likelihood that medications will be taken successfully Ø Do not give medicine mixed with formula/juice in bottle 3 TO 12 MONTHS Ø Advances from sitting well with support (3-4 months) to crawling (6-9 months) Ø Begins to develop fine motor control Ø Advances from lying as placed (3 months) to standing with support (9-12 months) Ø Is able to smack and pout lips. Tongue may protrude when swallowing. Begins to drink from cup Ø Communication advances from random responses to specific gesturing (10-12 months) Ø Is very responsive to tactile stimulation Ø Recognizes familiar people. Exhibits early memory Ø Medications must be kept out of reach to avoid accidental ingestion Ø May mix medication with flavored syrups to administer to child Ø May resist medications with whole body Ø Medications may need to be retrieved and refed. A small med cup may now be appropriate Ø Be alert for infant indicating own needs (wants a drink after medicine) Ø Physical comfort/cuddling after a medication can by very helpful Ø The infant may recall negative experiences and respond negatively in similar situations 12 -30 MONTHS Ø Advances from independent walking (12-15 months) to running without falling (24 months) Ø Advances from messy self-feeding to proficiency with minimal spilling (24-30 months) Ø Develops voluntary tongue control (12-18 months) Ø Second molars erupt (20-30 months) and controls jaw well Ø Control of mouth has progressed; can clamp mouth tightly Ø Indicates needs by pointing; speaks 4-6 words (12-18 months) Ø Responds to sense of time and simple directions (20-30 months) Ø Responds to and participates in routines of daily living Ø Hospitalization threatens security and developing sense of autonomy Ø Exhibits independence and self assertiveness Ø Expresses feelings easily Ø Promote independence by allowing toddler to choose the position for taking a medication when possible Ø Allow child to take medication from a cup or spoon when possible Ø Can spit out disagreeable medicines. Many mix medications with syrups/puddings, etc when possible and refeed as necessary Ø Chewable tablets may be an alternative Ø Ask parents what words the toddler uses at home Ø The "bad taste will only last a minute" Ø "Open your mouth, drink this, swallow now" Ø Involve the parents; include the toddler in medicine taking routines Ø Allow as much freedom as possible Ø use games to gain cooperation Ø Use a consistent, firm approach Ø Give immediate tactile/verbal praise for cooperation Ø Allow for expression through dramatic play; accept behavior for what it is 30 MONTHS TO 6 YEARS Ø Knows full name Ø Little understanding of time (30-36 months) Ø Advanced understanding of time (4 years +) Ø Easily influenced by others in responding to new food experiences Ø Advances from little understanding of time (30-36 months) to a good sense of time (4 yrs +) Ø Enjoys making decisions Ø The young preschooler has many fantasies Ø The older preschooler exhibits general fear of mutilation Ø Sense of smell and taste become refined (4 yrs +) Ø Becomes very coordinated Ø Begins to lose temporary teeth (5 yrs +) Ø Shows variable response to parents Ø One bribe leads to a bigger bribe with next medication, avoid bribery Ø Do not refer to medicine as candy Ø Ask the child his name before giving the medicine Ø Approach the preschooler in a calm and positive fashion when giving new oral medicines Ø Use concrete and immediate rewards for the young preschooler and delayed gratification for the older preschooler Ø Give choices when possible Ø Give simple explanations; stress that the medicine is not being given because he child was bad Ø Give simple explanations for cause, illness and treatment Ø Child can distinguish mediation tastes. Nurses need to be honest in describing them Ø Can hold own medicine cup and master pill taking Ø Avoid chewable tablets if the preschooler has loose teeth Ø The nurse may have more success than the parent in giving medication 6-12 YEARS Ø Strives for independence but continues to be dependent on others at times Ø Able to tolerate some parental separation Ø Differentiates actions that are dangerous Ø Concern for body mutilation Ø Needs to know how things work Ø Tells time correctly Ø Advances in ability to understand future events Ø Honesty is important; begins to seek factual information yes or no questions Ø Increased need for privacy Ø Beginning concern for body image Ø Interaction with peers of great importance Ø Give acceptable choices when possible Ø Respect the need for some regression with hospitalization. Some children may find comfort in your doing more for them Ø Rreassurance that you will give injections safely Ø Include them in the daily schedule of medicines Ø Provides stickers for cooperation, use of calendar Ø Give careful explanations of how medications work and why they are given Ø Find out from child if he wants the parent present for injections, suppository, etc Ø Drape carefully when giving injections, etc Ø Make provision for peer interaction; allow child to share medication experiences with others 12 years + Ø Strives for independence Ø Is able to understand abstract ideas and theories Ø Is able to consider potential alternatives to situations Ø Decisions strongly influenced by peers Ø Questions authority figures Ø Strong need for privacy Ø Highly interested and concerned with sex and sexuality Ø Advances in logical decision making skills Ø Begins to participate in own health care decisions Ø Allow adolescent to make as many decisions as possible concerning his medications Ø Write a contract with the adolescent spelling out your expectations for self administered medicines Ø Explain how medications work and why they are given as the adolescent's level; telling him that "your ear will stop hurting" is not enough Ø Role play with adolescent any possible difficulties with peers as related to medications Ø Encourage adolescent to talk with peers in a support group Ø Work with adolescent to plan schedule of medicine Ø Differentiate "taking pills" and "taking drugs" Ø Be honest at all times; provide medication information written at the adolescent's level Ø Respect need for confidentiality regarding medication rationale, side effects, etc Ø Explain relationship between illness, medications, and sexuality; May need specific information: "This medicine will not affect your sexual interest or activities" or "This medicine will not prevent you from getting pregnant"

Sleep changes in the older adult

Decreased time in bed but with less sleep •70 year old average sleep time = 7 hours •Less stage 3 and 4, with more stage 1 •Less REM = Less restfulness •40% of older adults report sleep disturbance •Stage 1 •NREM - Lightest sleep, easily arousable, Decreased physiologic activity. •Stage 2 •NREM - Last 10-20 minutes, sound sleep, relaxation, still arousable •Stage 3 •NREM - Lasts 15-30 minutes, start of deep sleep, Muscles completely relaxed. •Stage 4 •NREM - Last 15-30 minutes, Deepest stage, difficult to arouse, sleepwalking •Stage 5 •REM - Starts 90 minutes after initial sleep, dreaming, very diffult to arose •Driving•Pain•Chronic Cardiac or Respiratory problems•Frequent Elimination - Nocturia•Involuntary movement in bed•Anxiety•Medication•Excessive environmental stimuli•Caffeine•Sedentary Lifestyletriage which are most concerning Medication Class Example Effects on Sleep Alpha Blockers Doxazosin, Tamsulosin - BPH Decrease REM, increased daytime sleepiness Beta-Blockers Metoprolol - Cardiac Inhibit Melatonin Nightmares Corticoid Steroids Cortisone Stimulates adrenal gland - increased awakening ACE Inhibitor Lisinopril Cough, leg cramps (Hyperkalemia) Dietary Supplements Glucosamine, Chondroitin Unknown why - nausea, insomnia SSRI Antidepressants Sertraline Unknown - but up to 20% Statin Atorvastatin Leg Cramps Set a regular bedtime and wake routine•Daily exercise - preferably outdoors (Decrease seasonal depression)•Increase overall light exposure•Limit nap to 30 minutes•Avoid caffeine, ETOH•Light snack - no BIG Meals•Warm bath or shower•Relaxation techniques•Identify factors affecting sleep•Bundle cares to decrease disruption•Change delivery of care to meet typical bedtime/wake time for the patient•Return to bedtime rituals ASAP•Make the environment friendly for sleep•Decrease noise•Lights low•Increase light during the day•Confort measures•Clean, wrinkle free linens•Lavender•Oral Hygiene•Nonrestrictive sleepwear•Decrease daytime napping•Review medications•Medications used to promote sleep can leave older adults with a lingering feeling of daytime sleepiness, hangover effects, confusion, and disorientation.•Some sedatives and hypnotics can actually exacerbate insomnia. Because they actually change the structure of sleep, they can cause more disturbances in sleep quality. These medications are usually long-acting drugs, and in older adults, they may be even longer acting because of their body's decreased ability to metabolize drugs.•In particular, sedatives and hypnotics that affect respiration should be used with extreme caution; correct dosages must be carefully calculated and monitored for each patient

Treatment of seizures includes

Do NOT restrain an actively seizing patient as this may lead to musculoskeletal injury. •Remove dangerous objects from the person's path • •Calmly direct the person to sit down and guide him or her from dangerous situations. • •Use force only in an emergency to protect the person from immediate harm, such as walking in front of an oncoming car • •Observe, but do not approach, a person who appears angry or combative • •Remain with the person until he or she is fully alert breathing, vomitting, only use soft tip catheter in the mouthMaintain a patent airway.¡Use a soft tip catheter for suction; avoid Yankaur suction catheters due to risk of mouth injuries.¡Apply oxygen therapy as needed to keep oxygen saturations above 90%.¡Place in recovery positionkeep 02 above 90%, only put oxygen on if under 90 Most seizures are self-limiting and will last less than 2-3 minutes.Once a seizure lasts longer than 5 minutes it is unlikely to stop without medications.¡Diastat: get prescription at home¡MidazolamDiastat: is like a suppositorygive meds at 5 minutes, push in the rectum than push the plungerbest practice in hospital IN (intranasal) midazolam After the seizure: Keep the patient in the side-lying recovery position until alert enough to handle secretionsMonitor vital signs (P, HR, BP)Monitor pulse oximetry until alert enough to handle secretions.Monitor for response to verbal stimuli, ability to follow directions, and ability to verbalize (if verbal at baseline) every 1-2 minutes until able to perform.If any residual weakness, monitor motor strength every 10-15 minutes until at baseline.Do not offer food or liquid until fully awake Long term treatments are: Medicines:¡Effective for about 2 in 3 people with epilepsy¡Often require routine labs¡Trial withdrawal after seizure free for 2 years or longerSurgical techniquesMost useful for focal seizures (especially in temporal lobe of brainSelf-management¡Take medicine¡Routine follow-up with specialists¡Recognize seizure triggers¡Keep record of seizures¡Get enough sleep¡Lower stress postictal patient will be tired, not fully with it, confusion, not able to handle secretions, make sure suction them good, put on oxygen, nothing to eat or drink until they are at their baseline Common meds given include: Carbamazepine (Tegretol or Carbatrol) Clonazepam (Klonopin) Ethosuximide (Zarontin) Lamotrigine (Lamictal) Levetiracetam (Keppra) Oxcarbazepine (Trileptal) Phenobarbital (Luminal) Phenytoin (Dilantin) Tiagabine (Gabitril) Topiramate (Topamax) Valproic Acid (Depakote or Depakene) effective in 2/3 people with epilepsy once person is seizure free for 2 years: can wean or take off medications not expected to know all the different types: tend to have a lot of side effects know the specific side effects Surgical interventions¡Vagus nerve stimulation¡Ketogenic diet (high fat, low carbohydrate with limited calories)÷Customized to each child÷High fat (80% of calories), adequate protein for growth, and very low carbohydrates÷Side effects:¢Constipation¢Kidney stones¢Slowed growth Seizures defined as Episode of neurologic dysfunction caused by abnormal cortical neuronal activity that results in a sudden change in behavior, sensory perception or motor activity. Status epilepticus is recurrent seizures without complete recovery of consciousness between attacks or virtually continuous seizure activity for more than 15 minutes with or without loss of consciousness.

Dying Children

Dying/ Actively Dying Ø The presence of stereotypical pattern of signs and symptoms in the last days of a patient's life, such as low appetite, irregular pulse, low body temperature, and slow respirations. (IAHPC, 2018) Ø Ø Children are often aware they are dying even if not told​

Neuro: Management of seizing patient and seizure classification

Epilepsy: Recurrent, unprovoked seizures from known or unknown causesA person is considered to have epilepsy if they meet the following condition:¡Had at least two seizures (or after one seizure with a high risk for more) that were not caused by some known medical conditionConsidered resolved for individuals who have remained seizure-free for the last 10 years, with no seizure medicines for the last 5 years Classification: ¡Partial/focal: Simple ¡Complex Generalized (All brain): ¡Tonic (stiffening/-clonic Rhythm (convulsions, grand mal) ¡Tonic seizures ¡Clonic seizures ¡Myoclonic seizures ¡Atonic seizures ¡Absence seizures ¡Infantile spasm

Dignifed Death

Facilitate a comfortable and dignified death​ Ø Ø Assess and carry out final wishes based on developmental levels of the child​ Ø Most children and families know where, how and with whom they wish to die Ø Ø Consider cultural influences​ Ø Affects how people view, talk about, and make decisions about death

·2nd Nutrition in older adults - 2 o Lab monitoring o Assessment/clinical manifestations

Malnutrition ¨16-30% of older adults are malnourished ¨Often have low protein stores ¨Vitamin deficient ¨PEM= Protein -energy malnutrition ( muscle wasting, low BMI) ¨Obesity = Proper Nutrition ¨Nursing Interventions: ¤Socialization ¤Ask about typical meal choices ¤Assist opening packages when needed

Munchausen syndrome by proxy (MSP)

Munchausen syndrome by proxy (MSP) -- or Munchausen by proxy -- is a psychological disorder marked by attention-seeking behavior by a caregiver through those who are in their care. MSP is a relatively rare behavioral disorder. It affects a primary caretaker, often the mother. The person with MSP gains attention by seeking medical help for exaggerated or made-up symptoms of a child in his or her care. As health care providers strive to identify what's causing the child's symptoms, the deliberate actions of the mother or caretaker can often make the symptoms worse. The person with MSP does not seem to be motivated by a desire for any type of material gain. While health care providers are often unable to identify the specific cause of the child's illness, they may not suspect the mother or caretaker of doing anything to harm the child. In fact the caregiver often appears to be very loving and caring and extremely distraught over her child's illness. People with MSP may create or exaggerate a child's symptoms in several ways. They may simply lie about symptoms, alter tests (such as contaminating a urine sample), falsify medical records, or they may actually induce symptoms through various means, such as poisoning, suffocating, starving, and causing infection

CHD (5) · Decreased pulmonary blood flow defects oTET spells · Mixed defects · Anticipatory guidance (post op education) · Fetal circulation Diabetes (4) · Treatment options · Insulin administration - patient education · Hypoglycemia Growth/Nutrition/GI (4) · Growth patterns; understanding of growth chart · Celiac disease · Cow's Milk protein allergy - management of Development / Family Caregiving (5) · Age appropriate medication administration · Family centered nursing care · Atraumatic care Elimination (3) · Diarrhea management · Hirschsprung disease · Dehydration assessment · Prioritizing nursing care Neuro (4) · Autism - diagnostic criteria · Autism - care of the hospitalized patient · Management of seizing patient · Classification of seizure Mobility (2) · Spina bifida post op care · Muscular dystrophy - nursing management Palliative care (2) · Age appropriate communication Violence (1) · Munchausen Syndrome by proxy Older adults 20 questions · Caregiver roles and caregiver strain 1 o Goals of Care o Factors that impact caregiver strain · Nutrition in older adults - 2 o Lab monitoring o Assessment/clinical manifestations · Diabetes - 1 o Patient interventions to prevent complications o Monitoring of labs - Labs that are affected by diabetes · Menopause - 1 o Treatment (pharmacological and non-pharmacological interventions) o Complications/Contraindications of treatment · Erectile Dysfunction - 1 o Clinical manifestations: Organic versus Functional, type of onset, triggers, etc. o Common causes (including but not limited to medications) o Treatment (pharmacological and non-pharmacological interventions) · Urinary Incontinence - 2 (Know the Comparison Slide for Incontinence) o Types of incontinence o Symptoms based on type o Interventions based on type § Medication § Nursing Intervention § Surgery · Constipation - 1 o Risk factors o Diet and lifestyle modifications · Heart Failure (2 questions) o Risk factors o Diagnostics o Left vs right clinical manifestations o Treatment § Medications § Diet § Lifestyle · Multiple Sclerosis (2 questions) o Types of MS (4) o Management of disease/Interdisciplinary Approach · Atypical Presentation of Illness (1 questions) o Types of diagnoses that present atypical and how they present · Sleep and Aging (1 question) o Age related changes to sleep · Anticholinergic Burden 1 (questions) o Central versus Peripheral Side Effects of Anticholinergic Burden · Dementia/Delirium/Competency - 2 o Common causes of Dementia/Delirium o Nursing Interventions · Palliative Care - 1 o Goals of Treatment · Violence/Elder Abuse (1 questions) o Risk factors for elder abuse o Assessment findings for suspected abuse Obstetrics (30 questions) · Preconceptual Care (1 question) o STI - genital herpes · Prenatal Care (12 questions) o Naegele's Rule o GTPAL o Warning signs in pregnancy o Nutrition in pregnancy including weight gain in pregnancy o Normal laboratory values in pregnancy - platelets, serum uric acid, serum creatinine, serum AST, prothrombin time, hemoglobin, leucocytes. o Preeclampsia and eclampsia § Management - magnesium sulfate management, side effects, assessment of toxicity, review calculation of medication and drop factor from pathopharm § Management of eclampsia o Leopold's maneuver - fundal height assessment o Medications used during management of preterm labor/premature birth (impact on maternal and infant labs/vital signs/assessment) o Evaluation of fetal well-being (prenatal testing) § NST, CST, Fetal heart rate monitoring o Gestational Diabetes ( § assessment, impact on fetal/infant development § prenatal goals § Complications o Maternal Prenatal Assessment normal vs abnormal physical exam, vital signs · Intrapartum Care (4 questions) o FHR monitoring - fetal heart rate patterns (their causes and priority management) o Pain Management - medications used for pain management during labor and their effects - focus on opioids o Labor induction Pitocin (oxytocin) o Fetal heartrate monitoring o Management in fourth stage of labor - including the 5-point check · Postpartum Care (11 questions) o Maternal Care § Normal vs Abnormal Postpartum Assessment (physical exam) § Breastfeeding support § General postpartum care and education o Care of Newborn § Hyperbilirubinemia (assessment, bilirubin values, normal vs abnormal) § Normal vs Abnormal Newborn Assessment (vital signs/physical exam) § Glycemic control (assessment, normal values, interventions) · Violence (1 question) o Therapeutic communication o Care management · Palliation and Bereavement o Considerations for care after loss. [1 question]

Overview

Erikson's Psychosocial Development

Pediatric stages: Infancy (1M-1year) Trust vs mistrust: •Nourishment, sucking, warmth, cleanliness and physical contact •Elements for trust are quality of •Parent/child relationship •Care the infant receives •Failure to learn delayed gratification leads to mistrust Early Childhood (2-3 years) toddlers (autonomy vs shame and doubt): •Learn to be self-sufficient in many activities: toileting, feeding, walking, talking •Behavior is own, has predictable, reliable effect on others •Don't want to relinquish dependence on others •Toddlers gain trust in the predictability of: •Parents, environment, interaction with others •Stage characterized by: •Tantrums •Exerting their autonomy •Participating in parallel play •Expanding their language skills (egotistical thought & limited language (although expanding) •Regression in behaviors if stressed • Preschool (3-6 years) Initiative vs guilt: •Want to undertake many adult-like activities, sometimes overstepping the limits set by parents and feeling guilty •Stage of energetic learning •Feels sense of accomplishment and satisfaction in activities •Uses imitation to model after parents •May rival or compete with the same sex parent •Preschoolers begin to develop a conscience •MAGICAL THINKGING - the idea that merely thinking about or wishing an interaction, person or event will cause it to occur -More fine motor development -Better ability to express themselves Middle childhood (school aged-6-11 years) Industry vs. inferiority •Learn to be competent and productive or feel inferior and unable to do anything well •Desires real achievement, able to complete tasks •Learns rules, how to compete with others, how to cooperate, achieve goals •Fears disability and being left behind due to illness •Fears loss of control Adolescence 12-18 years: Identift vs. role confusion •"Who am I?" •Establish sexual, ethnic and career identities or are confused about what future roles to play •Peer group is important •Rapid growth and physical development •Fears: •Relationships with opposite sex •Ability to assume adult roles

Phases of seizures

Pre-ictal phase: Occurs immediately before the seizure ÷May include an aura. ÷Auras include a headache, weakness, sense of fear, aphasia, unpleasant odor or visual or auditory hallucinations. ¡Ictal Phase: Seizure activity ÷Characterized by paroxysmal, uncontrolled, excessive discharge of electrical activity in the brain with corresponding EEG changes. ¡Post-ictal phase: Period immediately after the seizure ÷May include a change in the level of consciousness or behavior, numbness or weakness of the affected extremity or side of the face lasting from minutes to hours ÷With tonic-clonic seizures there may be amnesia, confusion, or fatigue.

feibrile seizures

Simple febrile seizures ¡Most common type of seizures - occurring in 2-5% of children. ¡Generalized tonic-clonic seizure that lasts less than 15 minutes and does not recur in a 24-hour period. ¡ Complex febrile seizures ¡Characterized by episodes that have a focal onset (i.e. shaking limited to one limb or one side of the body) ¡Lasts longer than 15 minutes OR ¡Occurs more than once in 24 hours

Recovery position side lying

Simple partial Patient is alert and oriented but is unable to control the symptoms. Divided into categories based on type of symptoms the person experiences: ¡Motor seizures (jerking of a finger) ¡Sensory seizures (smell something that isn't present) ¡Autonomic seizures (changes in heart rate) ¡Psychic seizures (suddenly feel emotions like fear)

things that signal treatment is needed for seizures

Symptoms: ¡Vomiting, decreased appetite ¡Fever ¡Irritability, headache ¡Seizures, lethargy, change in LOC ¡Nuchal rigidity, photophobia Nuchal rigidity: neck stiffness Nursing care: Need blood cx & CSF collected BEFORE starting antibiotics ¡Lumbar puncture is the definitive diagnostic test Droplet / contact precautions Isolation until minimum 24 hours on antibiotics Rest Low stimulation if child is moving around, probably not meningitis

Anticapatory guidance with feibrile seizures

gh rate of recurrence ¡<12 months with first seizure = > 50% chance of recurrent febrile seizure ¡>12 months with first seizure = 30% chance of recurrent febrile seizure ¡Of those who have a second seizure, 50% chance of having at least 1 additional recurrence ¡ No greater risk for developmental delays, learning disabilities or seizures without fever Antipyretics ineffective in preventing recurrent febrile seizure

Know that five stages are already stated earlier for pediatric loss and perinatal loss

got it

Pediatrics: Diabetes (4) · Treatment options · Insulin administration - patient education Hypoglycemia

Type 2 Treatment goals:§Increase promotion/support of breastfeeding §Increase consumption of fruits and vegetables §Reduce consumption of sweetened beverages §Increase awareness of portion control and portion sizes §Increase physical activity §Reduce amount of television/screen time////§Weight loss §Healthy eating §Physical activity Weight loss of 7% to 10% can substantially improve metabolic state §Medication §Metformin (biguanide) §Insulin hypoglycemia: §< 70 mg/dL §Error in insulin dosage §Injection into muscle §↑exercise without increase ↑calories §↑time between meals/snacks §Inadequate calories Exercise Therapy: §Increased insulin sensitivity and decrease insulin requirements §Improves insulin binding capacity to receptors in tissues §Cardiovascular benefits §Exercise 1 hour after meals or have 10-15 gram carbohydrate snack prior § §Avoid during peak of insulin or medication §Monitor BS before, during, after; risk for hypoglycemia up to several hours Nutrition Therapy: §50% Carbohydrates, 30% fat, 10-20% protein, adequate calories § §Carbohydrate counting §1 carb = 15 grams §Average: 1 unit of insulin covers 15 grams of carbs (determined by endocrine) § §Consistent intervals, adjust for exercise §Individualized to age, culture, food preferences § Nursing management/education with insulin: §Insulin dose §Basel vs. bolus §Insulin types §Storage, site rotation, absorption §Avoid lipohypertrophy Insulin dosing considerations: §Sliding Scale: Progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges. ___________________________________________________________ §Correction Dose: The dose of insulin needed if the blood sugar is not in the designated blood sugar range §Insulin to Carb Ratio: An individualized formula that means a unit of insulin will dispose of a specific amount (number of grams) of carbohydrates. §1 unit of insulin = 15 grams carbs (on average) Insulin Management Definitions: §BASAL insulin is the background insulin that is normally supplied by the pancreas and is present 24 hours a day, whether or not the person eats. §BOLUS insulin refers to the extra amounts of insulin the pancreas would naturally make in response to glucose taken in through food. Insulin function: §Insulin lowers blood glucose by transporting it into cell membranes of skeletal muscle, adipose tissue, liver where it can be used for energy or stored for later use. § §Normal glucose: 70-100 mg/dL Type 1: §Autoimmune destruction of insulin-producing pancreatic beta cells, deficiency Insulin treatment for life Treatment and Management Type 1 Diabetes: §Blood glucose monitoring §Urine ketone analysis §Insulin therapy §Diet §Exercise

jammed into there

Violence/Elder Abuse (2 questions) o Risk factors for elder abuse o Assessment findings for suspected abuse o Interventions for suspected abuse uElder abuse is an intentional act, or failure to act, by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult. (An older adult is defined as someone age 60 or older.)uTypes of AbuseuPhysicaluSexualuEmotionaluNeglectuFinancialcharacteristics of victimsuDecreased ability to complete ADLs and more physically frailuCognitive deficits such as dementiauHistory of childhood traumauDepression and other mental disorders, as well as an increased sense of hopelessnessuSocial isolation and lack of support systemsuHistory of substance abuseRISK FACTORS:•Individual Level•Current diagnosis of mental illness•Current abuse of alcohol•High levels of hostility•Poor or inadequate preparation or training for care giving responsibilities•Assumption of caregiving responsibilities at an early age•Inadequate coping skills•Exposure to abuse as a child•Relationship Level•High financial and emotional dependence upon a vulnerable elder•Past experience of disruptive behavior•Lack of social support•Lack of formal support•Community Level•Formal services, such as respite care for those providing care to elders, are limited, inaccessible, or unavailable•Societal Level•There is high tolerance and acceptance of aggressive behavior•Health care personnel, guardians, and other agents are given greater freedom in routine care and decision making•Family members are expected to care for elders without seeking help from others•Persons are encouraged to endure suffering or remain silent regarding their pains•There are negative beliefs about aging and eldersCaregiver stress leads to elder abuseCaregiver Role strain to assessNeed to have RN on LTC for 8 hours, every 48 hours Graitric IPV observations pyschological Assess cognition, mood, affect, and behavior.Assess for:Agitation, unusual behavior, level of responsiveness, and willingness to communicate.DeliriumDementiaDepressionNote any reports of being verbally or emotionally mistreated financial things to know Elederly abuse uChanges in money handling or banking practice,uunexplained withdrawals or transfers from patient's bank accounts,uunauthorized withdrawals using the patient's bank card, addition of names on bank accounts/cards,uSudden changes to any financial document/will, unpaid bills, forging of the patient's signature, appearance of previously uninvolved family members. Note any reports of financial exploitation. Caregiver neglect assessment uAssess for: Dehydration, malnutrition, untreated pressure ulcers, poor hygiene, inappropriate or inadequate clothing, unaddressed health problems, non-adherence to medication regimen, unsafe and/or unclean living conditions, animal/insect infestation, presence of lice and/or fecal/urine smell, soiled bedding.Note any reports of feeling mistreated Nursing care strategies/interventions for elerly abuse uA. Detailed screening to assess for risk factors for EM using a combination of physical assessment, subjective information, and data gathered from screening instrumentsuB. Strive to develop a trusting relationship with the older adult as well as the caregiver. Set aside time to meet with each individuallyuC. The use of interdisciplinary teams with a diversity of experience, knowledge, and skills can lead to improvements in the detection and management of cases of EM. Early intervention by interdisciplinary teams can help lower risk for worsening abuse and further deficits in health statusuD. Institutions should develop guidelines for responding to cases of EMuE. Educate victims about patterns of EM such that EM tends to worsen in severity overtimeuF. Provide older adults with emergency contact numbers and community resourcesuG. Referral to appropriate regulatory agencies.uContact Nurse supervisoruContact physicianuInform Adult Protective ServicesuDocument, document and document some more!!!uAssess options for patient & familyuAssist with removal/correction of abusive situation

findings in seizure patient

Vital signs including blood pressureSigns of head trauma/abuseSigns of systemic infection:¡Meningismus (Nuchal rigidity, photophobia, headache)¡Kernig's sign¡Brudzinski's signSkinNeuro examination

KNOW SLIDE ON FINAL EXAM: assessing deiciosonal capacity

if they have power of attorney, if there is still decisional capacity, the patient makes the decisions, communication should be the first line of therapy talk to patient on two separate occasions to see if patient understands

· Nutrition in older adults - 2 o Lab monitoring o Assessment/clinical manifestations

immediate post op npo renal diet for ESRD no added salt for heart disease or hypertension mechanical soft diet for ill fitting dentures pureed diet for dysphagia regular no diet restrictions no concentrated sweets for diet controlled diabetes sodium restricted for heart failure ADA diet for newly diagnosed diabetic high calorie high protein diet for when burns are over 40% of the body High fiber for constipation and diverticulosis

refer clients to

appropriate resources you can't say that people stop grieving, it can started again by triggers

Hospice vs palliative care

know the goals of each: Goal of hospice is meant to provide comfort through dying process: reassessed every 60-90 days

When a patient has meningitis and treating seizures

check blood cultures and CSF fluid

Views on death

curse, karma, test, blessing

Impact of Perinatal Loss

maternal death •Orphaned children •Economic impact at household, community, and national level with loss of productive years •Mental health - family grief Pregnancy loss or infant death •Majority of loses are 'hidden' or 'silent'. •Hard for them to grieve openly over a loss that is hidden: judgments like "you did not meet the baby yet", "you can always get pregnant again" •Contributes to mental health problems •Years of potential life lost (YPLL)

End of perinatal loss slides

end of perinatal loss slides powerpoint

Assessing decisional capacity

flip the screen down •Observe, document, and report the patient's ability to: •Articulate his or her needs and preferences •Follow directions •Make simple choices and decisions •Communicate consistent care wishes •Times of lucidity and confusion for trends

In class stuff about pediatric, geriatric end of life

from three powerpoints

· Caregiver roles and caregiver strain 1 o Goals of Care o Factors that impact caregiver strain

older than 50 are at risk population Assuming a caregiving role can be stressful and burdensome Patient's physical disabilities Cognitive impairment - Dementia Problem behaviors Type and intensity of care provided Caregiving has all the features of a chronic stress experience Family caregiving has high levels of unpredictability and uncontrollability, often requires high levels of vigilance Causes secondary stress in many areas such as work and family relationships, physical and emotional health •Psychological effects are more intense than physical effects • •Researchers have found impaired health behaviors, such as neglecting their own health care appointments and eating a poor-quality diet, among caregivers who provide assistance with basic activities of daily living (ADLs)

Absence seizure (staring into space)

orm of seizure consisting of momentary clouding of consciousness and loss of awareness of surroundings May be initially diagnosed with ADHD Simple absence seizures: stares into space for less than 10 seconds Confused with daydreaming or not paying attention ¡absence seizure video Complex absence seizures:movement in addition to staring into space (blinking, chewing, or hand gestures) ¡Can last up to 20 seconds

ways to have open communication that we open door for communication, respectful, allow children to explore feelings around deaht BreastMilk data as well

this is for the final exam You can store your breastmilk to keep it fresh for your baby in a number of ways: At room temperature (no more than 25 degrees C), for up to six hours. In a cool box, with ice packs, for up to 24 hours. In a fridge (at four degrees C or colder), for up to five days.

Nursing assessment in management of seizures

ubjective Data/History ¡Description of seizure activity including time of occurrence and duration ¡Onset, duration, characteristic, frequency of previous seizures ¡Presence or absence of fever, duration of fever if present, length of preceding illness ¡Previous history of seizure ¡Change in anti-epileptic medication (with previous history) ¡Neurologic abnormality, developmental delay, head trauma, history of headaches Past Medical History: ¡Birth and developmental: gestational age, perinatal complications ¡Maternal or neonatal infections ¡Family History: seizures, neurocutaneous disorders, developmental delays ¡Verify immunization status What happened before, during, and after the seizure is very important

wont be tested on

unusual circumstances

Types of MS and management

§Relapsing-remitting (RRMS) 85% (common) §Clearly defined exacerbations and remission §Return to previous state in remission §Symptoms resolve in a few weeks to months §Primary-progressive (PPMS) 10% §Slow but continuously worsening from onset of disease §No distinct remissions §Age 40-60 years §Secondary-progressive (SPMS) 50% of pts with RRMS originally §Develops within 10 years of diagnosis §Decreasing prevalence with the addition of disease modifying medications in RRMS §Over time: recovery diminishes, permanent disability occurs due to destruction of oligodendrocytes which prevents repair of myelin sheath §Progressive-relapsing (PRMS) rare 5% §Differs from RRMS §Has continued worsening between relapses rather than remission §Remission does not allow return to baseline. uBeta Interferons-β1a and β1bu1st line Rx; reduce relapse rates by one third vs. placebouSlow the progression of the diseaseGlatiramer Acetate, Natalizumab, Teriflunomide The priority collaborative problems for patients with multiple sclerosis includeu Potential for infection/decreased immunity secondary to disease and drug therapy for disease managementuDecreased mobility due to spasticity, tremors, and/or fatigueuDecreased visual acuity and COGNITION due to dysfunctional central system nerves •Dietary changes may include increased fluid intake and high fiber to reduce further complications•Prevent and manage relapses•Consider ways to help patients maximize daily function•Decrease Clutter in the home•Delay disease progression•Family Care

4th older adult nutrition dehydration

¨Older adults should drink at least 1500 ml of fluid per day to provide adequate fluid balance ¨Ideally 8-10 cups each day ¨Exceptions include CHF and renal failure, though they are usually on a fluid restriction of 1500 cc/day. ¨Dry mucous membranes ¨Concentrated urine ¨If an older adult states they are very thirsty, very serious warning sign (hypotension) ¤Sensation of thirst not a good indicator-will find out too late ¨Cardiovascular Assessment is a good indicator ¤Increased Pulse - Starlings Law ¤Caution with Position Changes - Orthostatic Hypotension ¨Neurologic Changes ¤Confusion/Seizures Draw your attention to skin turgor - assess on chest Remember: Ice cream, gelatin, ices, broth all considered liquids. Anything liquid at room temp 1 L of water equals 2.2lbs of weight - WEIGH YOUR PATIENT so for every pound of weight change that equates to about 500cc/ml of water shift. Cardiovascular Increased pulse to increase perfusion due to low BP. This is Starlings Law that states CO = HR x SV (dehydration) Neuro - Confusion from low perfusion or changes in Sodium Level provide good oral care LABS: ¨Hemoconcentration ¨Creatinine ¤Female 0.4-1.1 ¤Male 0.5-1.2 ¨BUN ¤3-20 ¨UA ¤Specific gravity ¤1.005-1.030 ¨Glucose - Hypoglycemia ¤70-100 ¨Sodium 136-145 mmol/L (normal range) ¤Hyponatremia or Hypernatremia - Seizures ¤ ¨Referenced from Medscape app Referenced from Medscape app - Reminder that lab normal can vary based on the laboratory Hemoconcentration - elevated Hg, HCT, serum osmolality, Creatinine and BUN will increase as the patient is "dry", be cautious of this number in renal patients Know - UA Spec Gravity - elevated but not always an accurate measurement of dehydration so be cautious. hypernatremia would show extreme thirst, flushed skin, and fever, whereas hyponatremia would show nausea and vomiting

Pediatric Death Experience

Ø Death is not standard it is unique to each child and involves cultural beliefs, values and relationships with others​ Ø Ø Developmental stages and a child's experience with grief and death affect their understanding​ Ø Ø Use an interdisciplinary approach ​ Ø Psychological professionals, Palliative Care, Chaplin, Therapists, Social workers, Physicians​ Ø Increases quality of care

Self care peds (last end of life pediatric slide powerpoint)

Ø Emotional burden Ø Grief Ø Support system ​

Nurses Role (peds)

Ø Increase support and provide reassurance of comfort​ Ø Parents often have concerns of decreased care if DNR (Do Not Resuscitate) ​ Ø Fear of increased pain and discomfort​ Ø Never provide false reassurance Ø Advocate for patient and family choices​ Ø Honor cultural beliefs, traditions, and rituals​ Ø Support families in decision making​ Ø Provide realistic information​ Ø Establish a plan in accordance with their beliefs, values, and goals​ Ø Important for families to feel they did their best with what they were given​ Ø Ø Provide education ​ Ø Ø Provide guidance​ ØProvide close collaboration with all disciplines​ Ø Ø Provide memory -making and keepsakes​ Ø Hand/foot prints, lock of hair, photos​ Ø Ø Promote visits with family and friends​ Ø May need to act as gate keeper for patients /families if there are to many visitors Honesty

Families of dying children

Ø Parents often don't disclose information to patients or others regarding a life limiting/ life threatening illness​ Ø Respect parents decision-making and choices​ Ø Help facilitate open communication between child and parents​ Ø Ø Parents often postpone grief to enjoy the remaining time​ Ø Ø Encourage providing care for the dying child by parents and siblings​ The more the family is involved the better their coping after death ØSiblings​ are Ø Often over looked​ Ø Encourage continuation of activities​ Ø Encourage verbalization of feelings​ Ø Maintain normal routines and care patterns​ Ø Child Life Specialist or other specialists can assist siblings and dying child​ Ø Ø Support extended family members​

Hospice Care

Ø The comfort care provided to patients who have a life expectancy of six months or less. (Vitas, 2018) Patients not receive curative treatments because their illness is terminal, and death is imminent.

five stages (Don't need to know the five stages)

ØDeveloped by Elizabeth Kubler-Ross (1969 - 2014) (Kubler-Ross, 2014) Ø Ø Five stages of grief Ø Denial Ø Anger Ø Bargaining Ø Depression Ø Acceptance

Communication

ØProvide information in a timely, simple, age appropriate manner​ Ø At appropriate educational level​ Ø Ø Answer questions honestly ​ Ø Ø Explore specific concerns and fears​ Ø Many families are fearful of the child learning they are dying​ Ø Children are often fearful of the dying process, pain, how they will look, of leaving their loved ones behind, and what happens after they die ​ not linear Ø Encourage honest and open communication between the patient and family​ Ø Ø Never destroy hope​ Ø Spirituality ØProvide active listening and presence​ Ø Provide opportunities for communication through collaboration ​ Ø Art, music, play, or dance therapy​ Ø Chaplin, social workers, psychology, palliative provider​

Pediatric death

ØSudden unexpected death (Accidents, SIDS-Sudden Infant Death Syndrome, and suicide)​ Ø Terminal illness, six months or less to live (Congenital defects or cancer)​ Ø Chronic diseases ​ Ø Soon after birth (SIDS, congenital defect)​ Ø Death in utero​

Dying children considerations

ØTalk to a child per their developmental level and level of understanding​ Ø Many children don't want to discuss their condition​ Ø Often want to know someone is available to listen even if not ready to talk​ Ø Don't force a child to talk and respect when they are finished sharing (don't push)​

Palliative Care (peds)

ØThe comfort care provided to the patient to relieve undesired symptoms (pain, nausea, shortness of breath etc.). (Vitas, 2018) Provided at the time of diagnosis, during curative treatment, and at EOL

EOLC (care) (peds)

ØThe emotional, social, physical, and spiritual support provided to dying individuals and their families. (NCA, 2018) The medical care and support provided to individuals around their time of death. (NI

Grief

ØThe natural emotional reaction or conflicted feelings caused by loss or change of any kind. (Friedman, 2013) Ø Pre and post death

EOL (end of life) (peds)

ØThe period when healthcare providers expect death within six months. (APA, 2018) Ø The time when a person becomes weak, but the mind remains alert, or when the cognition is lost, and the body remains strong. (NIH, 2017)

Discharge preparation

ØTransportation - they may need ride home ØParents may wish to plan funeral ØSocial workers assist in planning ØGrief support follow up ØCheck in phone call follow-up

legal definitions

•1. Consent: The informed consent process requires evidence of decisional capacity, disclosure of sufficient information, understanding of the information provided, voluntariness in choosing among the options, and, on those bases, consent to or refusal of the intervention. •2. LEGAL TERMS Competence: A legal presumption that an adult has the mental ability to negotiate various legal tasks (e.g., entering into a contract, making a will). •3. LEGAL TERMS Incompetence: A judicial determination that a person lacks the ability to negotiate legal tasks and should be prevented from doing so. •4. Decisional capacity: A clinical determination that an individual has the ability to understand and to make and take responsibility for the consequences of health decisions. Because capacity is not global but decision specific, patients may have the ability to make some decisions but not others. Capacity may fluctuate according to factors, including clinical condition, time of day, medications, and psychological and comfort status. • NEED TO KNOW FOR EXAM Someone who has a mental disability generally has a court appointed guardian: deemed incompetent legal term Gets interchanged with decisional capacity: DO YOU UNDERSTAND WHAT IS GOING ON WITH YOU, DO THEY UNDERSTAND WHAT HAPPENS IF THEY REFUSE, DO THEY UNDERSTAND DECISIONS can't use mini mental exam to decide on if they have decisional capacity

Decisional Capacity

•1. Decisional capacity reflects the ability to understand the facts, appreciate the implications, and assume responsibility for the consequences of a decision.2. The elements of decisional capacity: The ability to understand and process information; weigh the relative benefits, burdens, and risks of each option; apply personal values to the analysis; arrive at a consistent decision; and communicate the decision.3. Standards of decision making •a. Prior explicit articulation: A decision based on the previous expression of a capable person's wishes through oral or written comments or instructions. •b. Substituted judgment: A decision by others based on the formerly capable person's wishes that are known or can be inferred from prior behaviors or decisions.c. Best interests standard: A decision based on what others judge to be in the best interest of an individual who never had or made known health care wishes and whose preferences cannot be inferred. Decisional capacity can come and go through day, is situational how do we decide if they have decisional capacity. first what they think, 2nd conversation with someone, third what is there best interest

Nursing care after Perinatal Loss

•Assessment •Be nonjudgmental and sensitive •Make time, sit down and LISTEN •Ask open-ended questions •Avoid saying - "I know how you feel...." NO WE DON'T - grief is a personal experience •Possible nursing diagnosis •Anxiety related to - the loss, concerns about their partner, e.t.c •Ineffective family coping •Dysfunctional grieving •Fatigue

Emotional support for parents experiencing loss

•Be mentally present •Open posture •Silence when appropriate •Therapeutic touch •Avoid cliché phrases •Sincerity •Listen These actions should be present during labor, in presence of deceased infant, and during postpartum stay. Call baby by the name chosen by parents (when one has been chosen). Things to say: "I'm here for you, I'm sorry, what can I do for you, this must be so difficult for you" Things NOT to say: "your young you can have other children, you have an angel in heaven (they want their baby here), this happened for the best, there was something wrong with the baby, don't be sad, don't cry". Your body language can have a tremendous impact: sit with family, cry if you feel the need to (be careful not excessive), hand on shoulder, hug if patient is comfortable, and let parents talk about their baby and the pain that they are feeling.

Perinatal loss

•Fetal loss •Miscarriage - aka spontaneous abortion, is the loss of a pregnancy before viability (20 weeks) •Elective abortion - voluntary termination of pregnancy, whether fetus is viable or not •Ectopic pregnancy - condition where the embryo implants in the fallopian tube. This is an emergency and requires immediate action •Fetal death/demise - death of a fetus inutero •Molar pregnancy - condition where placenta and chorionic villi continue to grow rapidly despite fetal demise - it is cancer-like •Stillbirth - death of a fetus in utero after 20 weeks gestation and before •Perinatal Loss and Infertility -Assisted Reproduction •Infertility •Pre-implantation miscarriage •Preimplantation termination •Multifetal pregnancy reduction (MFR) / selective reduction •Miscarriages •Maternal mortality - aka maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes • •Neonatal death - infant death during the first 28 days of life after a live birth

Grief and Bereavement perinatal loss 10-15 percent of pregnancies end in miscarriage

•Involves painful emotions and related behavioral and physical responses to a major loss •Parental grief model: Grief responses •Acute distress - shock, crying, powerlessness, sadness devastation, an outburst of emotions. Some may be in a fog and be void of emotions •Intense grief - loneliness, emptiness, and yearning. They may also feel helpless, deep sadness and anxiety and fear may occur. Disorganization occurs •Reorganization - searching for meaning, bittersweet feelings

INFORMED CONSENT

•Joint Commision Goal •Consent Implies •Nature and reason for surgery •Who will be performing the surgery and whether others will be present during the procedure (vendors, students, fellows) •All available options and the benefits and risk associated with each option. •The risks associated with the surgical procedure and its potential outcomes. •The risks associated with the use of anesthesia •The risk, benefits, and alternatives to the use of blood or blood products during the procedure •Side, site should be on the consent. NURSING ROLE, look at the image: in wisconsin,not allowed to give any new information until the phsyican talks to them first

Wisconsin Maternal Mortality

•Leading causes of maternal mortality include cardiac complications, hemorrhage, clots, and embolic events •Pregnancy-related mortality for non-Hispanic black mothers is 5 times the rate for Hispanic white mothers •More that2 out of 3 maternal deaths occur in the postpartum period

Neuro (4) · Autism - diagnostic criteria · Autism - care of the hospitalized patient · Management of seizing patient · Classification of seizure

•Lifelong, brain-based, developmental disorder • •A developmental disability that involves impairment in socialization, communication and behavior. • •There is not one way that ASD might affect someone. •Neurodevelopmental disorder characterized by: • •Impaired social interaction / play • •Impaired communication / language • •Restricted interests • •Repetitive behaviors • VARYING LEVELS OF SEVERITY; FROM NONVERBAL TO HIGH-FUNCTIONING •When an individual is given an ASD diagnosis, the clinician must then specify if it is (circle) : -With or without accompanying intellectual impairment -With or without accompanying language impairment -Associated with a known medical condition or genetic condition or environmental factor -Associated with another neurodevelopmental, mental or behavioral disorder (e.g. learning disability, developmental coordination disorder, ADHD, anxiety disorder, self-injurious behavior, etc.) social and communication •Altered responses to social cues •Speech spectrum: no changes ßà nonverbal •Expressive and/or receptive language -Delay or regression •Use of atypical ways to communicate( i.e. Leading by the hand) •Poor eye contact repetitive •Unusual play •"Stimming" - repetitive movements & sounds - rocking, flapping, humming •Echolalia: meaningless repetition of another person's spoken words •Destructive - may be attempts to manage pain •Banging head •Biting hands •Posturing - pressing abdomen into hard objects cognitive and behavior •Uneven skill development •Emotional lability •Difficult transitions, prefer routine & familiar environments •Toe walking •Sensory processing problems -Sound sensitivity -Light sensitivity -Picky eating •challenging behavior may look like Communicating their fear or dislike of: -Loud, sudden noises or demands -Bright light, textures, odors -Multiple people speaking at the same time -Interruptions of their patterns or routines -Pain, discomfort -An unmet need such as, hunger, thirst, toileting diagnosis •Bright Futures/AAP recommend: -18 and 24 month screening •Modified Checklist for Autism in Toddlers (M-CHAT) -Validated developmental screening tool for toddlers between 16 and 30 months of age. •20 item questionnaire -Designed to identify children who may benefit from a more thorough developmental and autism evaluation. -Form can be downloaded for free second step is comprehensive diagnositc evaluation •Specialists who can do this type of evaluation include: •Developmental Pediatricians (doctors who have special training in child development and children with special needs) •Child Neurologists •Child Psychologists or Psychiatrists •Autism Diagnostic Interview (ADI-R) - interview with parents -Series of semi-structured talk or play activities -Requires training to administer absolute indications for referral and diagnosis: •No babbling by 12 months •No gesturing (pointing, etc.) by 12 months •No single words by 16 months •No 2-word spontaneous phrases by 24 months (no echolalia) •Any loss of any language or social skills at any age •diagnosis at 2 can be reliable, most aren't until 4, can be seen before 1st birthday diagnostics must rule out other causes with •CT or MRI •Lead screening •Metabolic Studies •DNA analysis •Electroencephalogram •Cognitive (IQ), behavioral, emotional and social psychological evaluations Hospital and home treatment final exam: •Speech therapy •Physical therapy for gross motor •Occupational therapy for sensory difficulties, feeding, fine motor, etc. •Individualized Education Plan (IEP) •Early intensive behavioral intervention •Applied Behavior Analysis (ABA) •Rapid Prompting Method (RPM) •Parent Training •Cognitive Behavior Therapy (CBT) •Video modeling, social scripting ABA is: •Individualized program •Positive reinforcement •ABCs of behavior -To help identify the reason for the child's behavior, think about what happened before and after the behavior. •Learner's day is structured to provide opportunities to acquire and practice skills •Intensive programs à less parental stress Sleep GI Anti-seizure Anxiety & OCD meds ADHD meds Antipsychotics for aggressiveness Risperidone & Aripiprazole - 1st meds w/ FDA approval for use in children with autism Complementary Alternative Medicine (CAM) medication problems for treatment in the hospital: •Sensory or oral aversions •Difficulty in assessing target symptoms & med effectiveness -Symptoms may be more upsetting to caregivers than the child •Chemical restraint concerns Do not interrupts self stimulatory behavior communication in treatment: •Do -Try distraction with a toy. -Try to extinguish behavior by ignoring it. -Speak in a calm voice and use short sentences. -Wait 11 seconds for child to answer. Listen when a child speaks about videos or asks random questions. You can simply answer "yes" other communication methods: •Slow down, focus on the child •Reduce the number of commands -Directive cycle (direct, wait 11 seconds, praise) •Tell them/show them what will happen before doing •Communication boards •Positive reinforcement, gentle praise other resources: •First, then", use a timer. •Provide distracters (squidgy balls, spinning toys) • •Coping Kit •Social Story •Safety -Seizures -Wandering •Comfort -Adjust environmental stimuli - ear buds or muffs -Maintain routines when possible, keep favorite objects -Allow non-dangerous repetitive activity -Pain relief •ADL assistance -Enhance communication - short, direct - •Family support • •Teaching -Anticipatory guidance -Community resources

Debriefing staff

•Loss of infants, children and young adults is out of the norm and often very traumatic for nurses •Depending on a nurse's own stage of life, may or may not be able to care for this type of patient at a given time •Nurses need support post care •Need to be able to talk, vent •Crying on part of nurse is ok postpartum depression might show up much earlier than the typical 2 weeks postpartum checkup should be done even though they lost the child

Factors that affect grief following perinatal loss

•Maternal age •Previous losses and infertility •Culture •Technology and media • Maternal/parental mental, physical, and social wellbeing •Religion •Family structure and social support system •Whether people knew of the pregnancy or not Remember people grieve differently and there are a multiple factors that may influence how one views and deals with perinatal loss grief may be several months or longer

Stillbirth care after delivery

•May or may not want to see baby •Prepare parents for seeing the baby •Special infant beds to keep body cool after birth •Infant may be kept with parents, in morgue, in nursery (depending on hospital) •Dress and swaddle infant •Allow them to take photos, handprints/footprints, and castings if desired •Spend as much time with baby as needed Some parents may wish to see and hold the infant, some would prefer not to. This may depend on the age of infant at delivery and condition/appearance of the body. Let parents decide, nurse can help to guide parents regarding preparing for visualization of the body. Some hospitals have special infant beds that keep the body cool so that parents can keep infant in room after birth as long as they wish to. Infant may be taken to morgue or special nursery depending on hospital policy. Some parents will wish to have the infant taken to morgue and back to room several times over the course of their stay. Parents may wish to dress the infant, take photos, and make special castings of hands/feet along with footprints/handprints. The nurse should assist in providing for the parents needs and wishes. Now I lay me down to sleep is an organization that provides for free photo shoots for parents who have experienced an infant loss. Photos are taken of the infant around the time of death or shortly there after, parents are then given the option to keep photos of so desired. Some parents don't decide immediately whether they want the photos but have them taken just in case they want them in the future.

(2) Development / Family Caregiving (5) · Age appropriate medication administration · Family centered nursing care · Atraumatic careGood Family Characteristics

•Members communicate well and listen to each other •Support for its members •Clear set of family rules, beliefs and values •Members teach respect for others •Sense of trust •Play and share humor together •Interact with one another •Shared sense of responsibility •Traditions and rituals •Adaptability and flexibility in roles •Members seek help for their problems Consist of Family: Structure (Who), Function (What), Process (How) •Nuclear family •Two parents and offspring •Extended family •Relatives of nuclear family •Extended-kin network family •Share social support network •Share chores, goods, services •Stepfamily •Biological parent with children, new spouse •Binuclear family •Post-divorce family with children members of two nuclear households •Intergenerational family •More than two generations of a family living together • Family Roles: •Provider •Housekeeper •Child care •Socialization •Sexual •Therapeutic •Recreational •Kinship •Authoritarian •"Just do what I say"; strict rules •Authoritative (IDEAL) •Rules, limits firm but more democratic •Permissive •Great deal of warmth; few controls •Indifferent •Not much interest in affection or rules, limits Family processes have greatest impact on nursing interventions Consider the family's boundaries: •Balance between engagement and autonomy •Cohesion •Balance between separateness (disengaged) and togetherness (enmeshed) Atraumatic Care: •The philosophy of providing therapeutic care through the use of interventions that eliminate or minimize the psychologic and physical distress experienced by children and families (Whaley & Wong, 1995) Includes: •Minimize separation of child from family •Identify child/family stressors •Minimize/prevent pain •Promote a sense of control •Promote parent-professional partnerships NURSING ASSESSMENT ATRAUMATIC CARE AND FAMILY CARE: •Detailed assessment in targeted areas •Provides insight into family's support system and needs •Consider family's interaction with the external environment •Establish trusting relationship •Collect data in a comfortable, private environment •Health History •Nurse focuses first on the family unit and then on the individuals PLAN OF CARE: •Who: Personnel responsible - APN, RN, SW, parents' role •When: Optimal time to present information • •What: Educational needs/other methods • •Where: Location for intervention • •Other considerations: language/cultural considerations and special needs family coping skills training include: •Coping skills training •Guided imagery •Positive self-talk •Muscle relaxation •Conscious breathing •Refocusing •Biofeedback during hospitlizations siblings can be ignored Stressors involved in atraumatic care in hospital: •Stressors for children undergoing hospitalization and/or invasive medical procedures: •Physical harm or bodily injury •Separation form parents and dealing with strangers (separation anxiety) •Fear of the unknown •Uncertainty about limits and acceptable behaviors •Loss of control, autonomy and competence • •Stressors for parents: •Concern about the possibility of physical harm or bodily injury •Alternation in the parenting role •Lack of information •The ICU environment •Postoperative changes in the child's behavior, appearance or emotional responses ways to support stressed family: •Support their sleeping patterns •Typically less sleep and poorer quality •Eating patterns •Not eating enough •Eating junk food/fast food more frequently •Often diminished appetite and more stomach upset than usual •Activity patterns •Spend a lot of time waiting •Less exercise •More stress release activities: biting nails, smoking, etc. additionally, these things may help: •Frank discussions •Validating feelings •Share emotional burden •Flexible visitation •Clear information and expected outcomes •Therapeutic Play •Allows child to express feelings & fears •More time with provider •Need for privacy •Reinforce Parenthood •Negotiate parents' role in hospital •Give positive feedback •Encourage parents to accept support resiliency allows families to overcome adversity

Development / Family Caregiving (5) · Age appropriate medication administration · Family centered nursing care · Atraumatic care

•Newborn: birth - 1 month •Infancy: 1 month - 1 year •Toddlerhood: 1-3 years •Preschool age: 3-6 years •School age: 6-12 years •Adolescence: 12 - 21 years

Hospital Unit Postpartum

•Parents may be offered a non-OB unit •Sign placed outside door to remind staff infant loss (falling leaf) •Sign placed by room when non-living infant is in the room (butterfly) •Discuss with parents wishes regarding visitors/privacy •Utilize social workers •Discuss risks for postpartum depression Some hospitals will have a policy of where patient can go after delivery (patient may have options). My hospital has two options depending on the infant loss situation. Mothers may go to the antepartum unit or the postpartum care unit depending on census and patient preference. Some hospitals would have an option to stay on a medical surgical floor however many of the other hospital units do not have the same specialization like the OB units. Nurse may be asked to come to other units for fundal assessment if non-OB. This photo is usually placed outside of the room on the patient's door to indicate the death of the infant, the butterfly may also be used in order to indicate that the deceased infant's body is present in the room or nursery. Both are meant to alert staff so that they may prepare to care for the client in an appropriate manner given the sensitivity of the situation.

REFUSAL of CARE

•Patient right •Can refuse even if it means death •Jehovah Witness •Intervention •COMMUNICATION - Be respectful of decision, but ASK and assess •Address Concerns •Ask the patient to describe what they think will happen? •What was the process for decision making? •Negotiate an acceptable solution use good communication, even if no decisional capacity, communication is key, situation can be resolved with good communication

Anticholinergic peripheral and central effects

•Peripheral side effects:•dry mouth•dry eyes•constipation•urinary retention•blurred vision•Increased heart rate• Central effects• dizziness,•sedation•confusion•delirium• Older adults are more at risk for anticholinergic side effects than young people because of increased permeability of the blood-brain barrier, decreased drug metabolism and elimination and age-related deficit in central cholinergic transmission

Care of a women after a miscarriage

•Physical loss of pregnancy •Occurs before 20 weeks gestation •Offer emotional support •Identify support persons for parents •If incomplete, may need D&C •Address physical pain •Explain what mother may witness during loss/bleeding etc. •Rh-? •Educate on when to call, abnormal findings •Future pregnancy recommendations A miscarriage occurs prior to 20 weeks gestation, after that time it's considered a stillbirth. Offer emotional support and help to identify coping mechanisms that parents utilize in difficult situations such as this (eg. Parents, close friends, therapists, etc.) A D&C is a dilation and curettage, this is the opening of the cervix and removal of contents and is generally done after an incomplete miscarriage. Other times women may be prescribed oral medications (misoprostol/cytotec) that can assist in the removal of the pregnancy contents after a miscarriage. Women may be prescribed pain medications for cramping (mild analgesic). Additionally women may be prescribed an antibiotic to reduce infection risk. Rh- women will need Rhogam within 72 hours to prevent future pregnancy rejection (sensitization). Mother should report heavy, bright red bleeding, fever, chills, foul-smelling discharge, and abdominal tenderness (after miscarriage is complete) Delay next pregnancy for at least 2 months after miscarriage. If third consecutive miscarriage, and if patient has not already done so, may want to consult OB in order to determine possible causes.

Infantile spasms

•Specific type of seizure seen in an epilepsy syndrome of infancy and childhood••Consists of a sudden bending forward of the body with stiffening of the arms and legs; some children arch their backs as they extend their arms and legs••Spasms tend to occur upon awakening or after feeding, and often occur in clusters of up to 100 spasms at a time••infantile spasms video

Generalized tonic clonic seizures grand mal

•Tonic seizure is associated with stiffening of the extremity •Clonic seizure is rhythmic limb jerking ¡Loss of consciousness, muscles stiffen, and jerking movements ¡ ¡Last 1 to 3 minutes ¡ ¡Longer for a person to recover ¡ ¡More than 5 minutes is a medical emergency

Care after a stllbirth or neonatal loss

•Traumatic Trauma care..... •Labor may need to be induced •Dedicated support by specially trained nurse •Limit staff to special team •Patient may want to be private patient status •Provide normal postpartum cares •Monitor for infection/complications •Women will still need education regarding postpartum care •Prepare mother for imminent lactation to start Stillbirth- Occurs after 20 weeks gestation in either the second or third trimester. Women will likely need to be induced, woman will not go directly to C-section unless medically indicated. Labor can be long and traumatic due to the nature of the delivery and non-living fetus. Limit staff to those providing for direct care. Patient may consider being private patient in order to limit visitors. Remind patient of caring for their own body's needs in postpartum period. Patients may want an early discharge. Monitor for S&S of infection, bleeding, and postpartum depression. Educate regarding these concerns and normal postpartum self care. The mother's milk will come in even if the infant never latches to the breast. Educate mother on reducing milk supply by using ice packs, supportive bra, and reducing stimulation to breasts during time of filling (day 3-5). Milk will subside unless mother chooses to pump and donate milk. Mother's Milk Alliance is an agency in Madison that takes donated breast milk from mothers who wish to donate. This can be healing for mothers who have suffered an infant loss.