Nurse 4 FINAL

Medical management for hypovolemic shock

-Fluid/blood replacement -STOP the bleeding apply direct pressure or surgical interventions -At least 2 large bore IVs or CVL or IO -Treat diarrhea and nausea with medications -0.9% NS or lactated Ringer's: 20 mL/kg 3mL of crystalloid for each 1mL estimated blood loss Hetastarch or Dextran avoided will interfere with platelet aggregation Massive blood transfusion - Type 0 negative -IV vasoactive medications constrict or dilate blood vessels given only when hypotension persists

What can trigger a headache?

-Foods -Intense activity -Food additives -Bright/flickering lights -Hormone fluctuations -Odors -Weather -Meal schedules -Season -Sleep patterns

Signs and symptoms of pyloric stenosis

-Forceful projectile vomiting hallmark sign -Palpable olive-shaped mass in abdomen just to the right of umbilicus -Visible peristaltic waves moving left to right -Acts hungry will eat after vomiting -Weight loss -No evidence of pain

What is the diagnosis of rubeola based on?

-Generalized rash lasting 3 or more days -Fever > 38.3 (100.9) -Cough, coryza, conjunctivitis (3 c's) -Koplik spots

Signs and symptoms of thalassemia

-Growth and development is delayed -Bronze colored skin -Splenomegaly -Skeletal deformities (frontal and maxillary bossing) -Pathologic fractures

Methods of Preventing Infectious Diseases

-Hand washing -Adequate immunization -Proper handling and preparation of food -Judicious antibiotic use -Transmission based isolation

Signs and symptoms of increased ICP in children

-Headache -Projectile vomiting with or without nausea -Seizures -Diplopia -Blurred vision

Imaginary playmates

-Helps enhance creativity and cognition -They become the kids friend in times of loneliness -They accomplish what the child is still attempting -They experience what the child wants to forget or remember -The friend is often blamed for wrongdoing -Helps the child differentiate between pretend and reality.

Signs and symptoms of epiglottitis

-High fever -Tripod position -Drooling -Dysphagia -Respiratory distress

Estrogen's Cardioprotective Effects

-Increase in high-density lipoprotein (HDL) that transports cholesterol out of arteries -Reduction in low-density lipoprotein (LDL) that deposits cholesterol in the artery -Dilation of the blood vessels, which enhance blood flow to the heart

Signs and symptoms of rubella

-Deep red blotchy rash on face and neck that descends down -Rash starts as discrete lesions then becomes confluent and salmon colored -When rash subsides a faint brown stain on skin remains and desquamation of skin begins.

Signs and symptoms of ALL

-Fatigue -Fever -Lethargy -Headache -Vomiting -Leukocytosis -Seizures -Bone or joint pain

Signs and symptoms of Acute Otitis Media

-Fever -Fussy -Diarrhea -Vomiting -Irritable -Pulling on ear -Crying a lot -Immobile or bulging tympanic membrane

S/S of Acute respiratory failure

-PaO2 < 60 mm Hg - hypoxemia -PaCO2 > 50 mm Hg - hypercapnia -pH < 7.35 -Restlessness -Fatigue -H/A -Dyspnea -Tachycardia -Tachypnea -Hypertension -Confusion -Lethargy -Cyanosis -Diaphoresis

S/S of Guillian-Barre Syndrome

-Paresthesias -Weakness/paralysis that starts in the lower extremities and spreads to your upper body, -Difficulty with eye or facial movements including speaking, chewing, or swallowing -Tachycardia -Difficulty breathing

Signs and symptoms of pulmonic stenosis

-Systolic ejection murmur heard over pulmonic valve -Right ventricular hypertrophy -Cardiomegaly

The nurse is talking with a teen and her parents about triggers for her frequent headaches. Which statements indicate understanding?

"I may experience headaches during certain periods in my menstrual cycle" "Change in weather can trigger my headaches" "Caffeine has an influence on my headaches" "Chocolate may trigger my headaches" Other food triggers: foods w/ tyramine, nitrates, alcohol Meds: Nitro, vasodilators

Normal appearance of a toddler

"pot bellied appearance" protruding abdomen results from undeveloped muscles. Bow legged appearance persists through toddlerhood since the legs must bear the weight of the relatively large trunk.

Atonic seizures

**Abrupt loss of muscle tone - no warning!! ** Commonly seen in infants and children AKA: drop attacks, astatic, akinetic seizures -Head drops -Loss of posture -Sudden collapse May result in injuries to head and face Tend to be resistant to drug therapy

Medical management for ventricular septal defect

-50% of cases close spontaneously -Open heart surgery by banding the pulmonary artery to decrease flow of blood from right ventricle to pulmonary artery leading to decreased pulmonary congestion.

Ischemic stroke MODIFIABLE risk factors

-asymptomatic carotid stenosis -A Fib -Diabetes -Dyslipidemia -excessive ETOH use -hypercoagulable states -HTN -Migraine -Obesity -Sedentary lifestyle -Sleep apnea -smoking

Types of burn accidents in toddlers

-hot water -grease -chewing cords -contact burns -chemical ingestion

A client with seizures presents for a f/u after being prescribed lamotrigine (Lamictal). Which finding assessment should the RN prioritize?

-lesions on the skin and mucous membranes -blisters on the face and neck -reports of muscle pain

When should kids receive hepatitis A vaccines?

1 year old and at least 6 months after first dose

Normal urine output for children

1-2 ml/kg/hr

When should head and chest circumference be equal?

1-2 years of age

What is a major cause of death in patients with spinal cord injuries?

1. septicemia 2. PE 3. pneumonia

When should kids receive varicella vaccines?

12-15 months and 4-6 years old

When should kids receive polio vaccines?

2 months, 4 months, 6-18 months, and 4-6 years old

Quality CPR

2" deep 100-120 bpm

When does the posterior fontanelle close?

2-3 months

Survival from shock increases if identified and treated within how many hours?

3 hours

Cushing's triad

3 signs: -increase in systolic pressure -widening pulse pressure -bradycardia This is when the ICP gets high and cerebral blood flow is significantly decreased Our bodies respond by trying to increase arterial flow and bring blood to cerebral tissues. This is a late sign requiring immediate intervention! If prompt treatment is not given - brain stem herniation will happen & patient will die

Normal toddler/preschool heart rate range

80-115 bpm

Normal infant heart rate range

90-160 BPM

What does an elevated CVP indicate?

A CVP greater than 6 mm Hg indicates an elevated right ventricular preload. hypervolemia (fluid overload) or Right-Sided Heart Failure

Huntington's Disease

A chronic degenerative hereditary neurologic disease characterized by uncontrollable body movements and degeneration of the nervous system caused by overactivity of the dopamine pathways. This is usually fatal 10 to 15 years after the onset of symptoms. symptoms do not appear until about the age of 30.

Roseola

A disease that starts with a persistent high fever for 3-4 days, then after fever subsides a rosy colored rash appears on the trunk then the face and extremities.

Food poisoning

A sudden illness caused by the ingestion of contaminated food/drink Management: ABCs, supportive measures, treat fluid & electrolyte imbalances, control N/V

Mean Arterial Pressure (MAP)

Average pressure at which blood moves through tissues should always be >65 mm Hg Calculate: (DBP X 2) + SBP/3

What items should be avoided at all times in someone with Glucose-6-phosphate dehydrogenase (G6PD) deficiency?

Avoid sulfa drugs, malaria-fighting drugs, methylene blue, naphthalene, and fava beans

tonic activity

A type of seizure movement involving the constant contraction of muscle groups. Stiffening of limbs

What drug is given to patients with chicken pox to help alleviate the course of the disease?

Acyclovir

Phosphodiesterase inhibitor contraindications

Allergy Severe aortic or pulmonic disease; MI; fluid volume deficit; and ventricular arrhythmias Caution: pregnancy, lactation; elderly

Burn pt - Acute Pain

Allow pt to verbalize pain experience - they may experience powerlessness

Hirschsprung's Disease (Megacolon)

Also known as megacolon (congenital aganglionic megacolon) it is a functional intestinal obstruction caused by the absence of parasympathetic ganglion cells in a portion of the colon usually the lower portion of the sigmoid colon just above the anus. This is more common in people with down syndrome (Trisomy 21) leads to intestinal obstruction and distention of the bowel. Nursing interventions/patient teaching: promote parent-infant bonding, prepare for surgery by educating about colostomy care, restore nutritional status, low-fiber, high protein, high calorie diet or TPN, daily enemas and stool softeners if ordered, antibiotics to decrease intestinal flora, and daily abdominal girth.

Seizures

An abnormal episode of motor, sensory, autonomic, or psychic activity resulting from a sudden, abnormal, uncontrolled electrical discharge from cerebral neurons.

Scabies

An infectious mite that burrows under the skin of school-aged children and leaves behind debris, feces, and eggs. Nursing interventions/patient teaching: Keep fingernails cut short to prevent scratching plus wear mittens or gloves to decrease the risk of a secondary bacterial infection, Loose clothing, mild perfume, wash with mild soap and water and dry thoroughly, avoid talcum powder, overheating, and hot baths, A&D ointment, and keep area open to air if possible.

Ventricular Septal Defect

An opening in the septum separating the ventricles causes oxygenated blood from the left ventricle to enter the right ventricle causing blood to become deoxygenated.

Adenosine

Antiarrhythmic Stops the heart (asystole) then hopefully comes back as NSR Like a heart reset Used with SVT rhythms

hemianopsia

Blindness in half of the visual field

Beta-adrenergic blockers

Block the stimulatory effects of the sympathetic nervous system Atenolol (Tenormin) Metoprolol (Toprol XL) Propranolol (Inderal) Nadolol (Corgard)

Dendrites

Branchlike parts of a neuron that are specialized to receive information.

Best indicators for VAP

CXR, fevers, (+) sputum culture

Prinzmetal's Angina

Caused by spasm of the blood vessels, not just by vessel narrowing

Medical management for acute otitis media

Children 6 and younger: 10-day course of Amoxicillin Children 6 and older: 5-7 day course of amoxicillin Teach parents that it is important to finish the whole bottle of antibiotics even if feeling better Myringotomy is a surgery with insertion of tympanostomy tubes that provide ventilation and drainage. Very important to avoid water in ear canal and tubes fall out on their own.

Treatment for acute otitis media

Children 6 and younger: 10-day course of Amoxicillin Children 6 and older: 5-7 day course of amoxicillin Teach parents that it is important to finish the whole bottle of antibiotics even if feeling better Myringotomy is a surgery with insertion of tympanostomy tubes that provide ventilation and drainage. Very important to avoid water in ear canal and tubes fall out on their own.

How can we supplement iron?

Dietary modifications and oral or IV iron supplementation.

Digoxin antidote

Digoxin immune Fab (Digibind)

What is the first sign of compartment syndrome?

Disproportionate pain for the injury

What happens if the child vomits after giving the digoxin?

Do not give a second dose of digoxin

When a doctor collects CSF from a lumbar puncture how should the test tubes be delivered?

Do not tube lumbar puncture CSF fluid. Hand carry it to the lab do not give it to your CNA to have them take it to the lab for you.

What allows blood flow between the pulmonary artery and the aorta shunting blood away from the pulmonary circulation?

Ductus arteriosus

Hyperkalemia & burns

Due to a decrease in cardiac contractility (cardiac dysrhythmias) - assess for hyperkalemia! Hyperkalemia can occur due to cell destruction

Nursing management for infective endocarditis

Complete IV antibiotic or antifungal treatment of the causative organism is necessary and treatment generally lasts 4 to 6 weeks Monitor vital signs especially temperature High-risk children who are undergoing dental procedures should receive prophylaxis 1 hour before and 1 hour after the procedure. Antibiotics typically used for prophylaxis may include ampicillin, amoxicillin, gentamicin, or vancomycin.

What are some side effects of taking the iron?

Constipation, black tarry stools, stained teeth

Management of cardiogenic shock

Correct underlying problem Reduce preload and afterload to decrease cardiac workload Improve oxygenation and restore tissue perfusion

Signs of acute coronary syndrome

Dyspnea, unusual fatigue, syncope

Tertiary care

Efforts focus on monitoring for and preventing recurrence of the primary cancer as well as screening for the development of secondary malignancies in cancer survivors.

Triage Categories

Emergent: highest priority Urgent: serious, but not life threatening Nonurgent: episodic illness

Separation anxiety

Emotional distress seen in many infants and toddlers when they are separated from people with whom they have formed an attachment. Often occurs when kids are hospitalized and kids will show regressive behavior during times of stress

RN intervention for autonomic dysreflexia

Empty bladder, empty rectum, look at skin Raise HOB or have pt seated Meds alone will NOT fix problem

Heart layers

Endocardium ( inner), myocardium ( middle), and epicardium ( outer)

unstable angina

Episodes of ischemia occur even when at rest

How often can digoxin be given to kids?

Every 12 hours

Language Development for toddlers

Expressive language milestones: 4-6 words at 12-18 months with 2 word combinations Toddler begins to use short sentences and has a vocabulary of about 300 words by age 2. Tends to ask many "what" questions Receptive language milestones: Points to 5 body parts and carries out 2 and 3 item commands.

Acute respiratory failure

Failure of the lungs to provide adequate oxygenation or ventilation for the blood

Atheromas

Fatty tumors in the intima of the heart vessels

Asystole

Flat line- always check two different leads to confirm rhythm. Make sure leads are attached. CODE button, CPR, Epinephrine!!

Medical management of celiac disease

Follow a gluten-free diet avoid foods that contain wheat, rye, oats, or barley. Milk, bread, cookies, cakes, crackers, cereals, spaghetti, beer, ale, and soups Supplemental vitamins (calcium, iron, and folate)

What is the opening between the atria called that allows blood flow from the right to left atrium?

Foramen ovale

Diarrhea

Frequent loose watery stools caused by poor hygiene, contaminated food, water, warm weather, food sensitivities, formula intolerance, celiac disease (gluten intolerance), inflammatory bowel disease, crohn's disease, crowded and substandard living, and toxins that invade the intestinal mucosa.

GERD

Gastroesophageal reflux disease effortless regurgitation of gastric contents into the esophagus that usually begins within the 1st week of life. This results from a incompetent lower esophageal sphincter causing regurgitation of gastric esophageal contents into the oropharynx. This occurs immediately after feeding or lying down. Commonly seen in premature infants,

Sickle cell anemia

Genetic disorder in which red blood cells have abnormal hemoglobin molecules (Hgb S) and take on an abnormal crescent shape. Commonly seen in African Americans. -Most severe form of sickle cell disease -It is a hemolytic anemia -Symptoms may appear within first 6 months of life -May be triggered by stress, cold temperatures, or physical exertion -Can lead to crisis, ischemia, necrosis, and infarction

What are the complications that can be caused due to scarlet fever?

Glomerulonephritis and rheumatic heart disease

Meningitis caused from what bacteria is most common in infants between the ages of 6 and 9 months?

H. influenzae type B

Cardiac output

Heart rate x stroke volume how much blood is pumped out of the heart with each beat.

hepatitis routes of transmission

Hepatitis A (HAV): Fecal-oral route usually by water and food contaminated with feces. It is the most common form today. Best protection is two dose vaccine. Hepatitis B (HBV): Body fluids, blood transfusions, contaminated needles, neddlesticks, and illicit IV drug use. All health care workers should get the vaccine and use needleless IV access devices if available Hepatitis C (HCV): needlesticks, blood transfusions before 1992, illicit IV drug use, and sharing contaminated straws used for snorting cocaine. Use needleless IV access devices if available

NIH Scale

Higher the number = the major the stroke

Other Signs of child abuse

History given not consistent with injury Conflicting stories of how injuries occurred Accident described and injury inconsistent w/ the child's developmental ability Physical signs, burns, or presence of physical injuries in various stages of healing Under nutrition or poor hygiene

HEADSS assessment

Home Education Activities Drugs/alcohol Sexuality Suicide/safety

medical management of ADHD

Includes the use of psychostimulants such as Dextroamphetamine (Dexedrine) or amphetamine and dextroamphetamine (Adderall). These medications are not a cure for ADHD but help to increase the child's ability to pay attention and decrease the level of impulsive behavior. Side Effects: Insomnia, Anorexia, weight loss, and HTN if used long term may suppress growth

Medical management of ADHD

Includes the use of psychostimulants, nonstimulant norepinephrine reuptake inhibitors, and/or α-agonist antihypertensive agents. These medications are not a cure for ADHD, but help to increase the child's ability to pay attention and decrease the level of impulsive behavior.

Erikson: Psychosocial Development

Infancy: basic trust vs. mistrust Toddlers: Autonomy vs. shame and doubt Preschool: initiative vs. guilt School age: industry vs. inferiority Adolescence: identity vs. role confusion

Acute otitis media

Infection of the middle ear that is usually associated with an upper respiratory tract infection and is most commonly seen in young children. 70% of infants have at least once case by a year old peaks during the first 2 years of life. Due to the horizontal position of the pediatric ear drum the middle ear has difficulty draining causing fever and pain.

Acute glomerulonephritis

Inflammation of the glomeruli of the kidney that most commonly occurs after a pneumococcal, streptococcal (often group A β-hemolytic streptococci, or viral infection. It affects primarily children of early school age typically around the age of 6 or 7. Assessment findings associated with acute poststreptococcal glomerulonephritis include fatigue, lethargy, abdominal pain, hypertension, crackles, and anorexia.

Conjunctivitis

Inflammation or infection of the conjunctiva. Causes can be chemical irritants or foreign bodies but the most common causes are bacteria, viruses (adenovirus), and allergies (seasonal allergens like pollen or grass)

Myocarditis

Inflammatory process involving the myocardium Most common pathogens tend to be viral complications: cardiomyopathy and heart failure s/s: fatigue, dyspnea, syncope, palpitations, chest pain

Thalassemia

Inherited blood disorder that causes a defect in the ability to produce hemoglobin.

quartenary blast injury

Injury results from preexisting conditions exacerbated by the force of the blast or by post blast injury complication Severe injuries w/ complex injury patterns - burns, crush injuries, head injuries. Common pre-existing conditions that become exacerbated - COPD, asthma, cardiac conditions, diabetes, HTN

tertiary blast injury

Injury that results from pressure wave that causes the victim to be thrown Head injuries. Fractures, traumatic amputations.

VCUG test for UTI preprocedural checks

It is important to double check whether the girl has any allergies. The test is contraindicated in children allergic to shellfish or iodine. Adequate hydration is also important but the check for allergies is a priority. Only females of reproductive age must be screened for pregnancy.

What if there is a S3 sound?

It's an abnormal heart sound heard early in diastole as resistance is met to blood entering either ventricle Most often due to volume overload associated with heart failure *Normal finding in children and adults up to 40 yrs old

What if there is a S4 sound?

It's an abnormal heart sound heard late in diastole as resistance is met to blood entering either ventricle during atria contraction most often caused by hypertrophy of the ventricle

What will you see on an EKG with a pacemaker?

Know the different types of pacemakers and where you will see the pacer spikes in the EKG

Cerebrum

Largest part of the brain; responsible for voluntary muscular activity, vision, speech, taste, hearing, thought, and memory. Lobes: frontal, parietal, temporal, occipital

ESI Emergency Severity Index

Level 1: most urgent to Level 5: least urgent

Shock

Life threatening condition in which tissue perfusion is inadequate to deliver oxygen and nutrients to support cellular function

Jones criteria for rheumatic fever

MAJOR (2 major symptoms OR 1 major and 2 minor) -Carditis -Migratory polyarthritis (multiple joints) -Erythema marginatum (clear rash thick margins) -Sydenham chorea (Worm-like movements) -Subcutaneous nodules Minor -Fever -Arthralgia -Prolonged PR interval -Elevated ESR -Positive C-reactive protein or ESR

What is the most common cause of severe injury and death in school-age children?

MVAs

Progressive Stage of Shock

Mechanisms that regulate BP can no longer compensate BP and MAP decrease. All organs suffer from hypoperfusion Vasoconstriction continues further compromising cellular perfusion. Myocardial depression leads to heart failure.

Primary headaches

Migraine Tension-type Cluster Chronic Daily

Ischemic strokes

Most common S/S: numbness/weakness of the face, arm, or leg - especially on one side of the body

Febrile Seizures

Most common in children younger than 5 yrs old Rare in babies younger than 6 mths or kids older than 5 yrs Higher risk with family history of febrile seizures Associated w/ a rapid rising fever over 102.2 Usually benign - related to viral illness or may be a sign of an underlying infection (meningitis or sepsis) Frightening Excellent prognosis Complications: status epilepticus, motor coordination deficits, intellectual disability, or behavioral problems

Osteosarcoma

Most common malignant bone cancer in children mostly adolescents at peak of growth spurts. Common sites include proximal humerus, proximal tibia, and distal femur.

Amyotrophic lateral sclerosis affects which area of the nervous system?

Motor nuclei of the brain steam Upper motor neurons of the cerebral cortex

Cardiac Biomarker Analysis

Myocardial cells that become necrotic from prolonged ischemia or trauma release specific enzymes - -creatine kinase (CK) -CK isoenzymes (CK-MB) -Proteins (myoglobin, troponin T, and troponin I) Substances leak into interstitial spaces of the myocardium and are carried by the lymph system into general circulation

What happens if MAP and ICP are equal?

NO cerebral circulation!!!

Mitral stenosis

Obstruction to blood flowing from the Left Atrium to the Left Ventricle due to NARROWING From Rheumatic Endocarditis Left atria has difficulty moving blood into LV resulting in decreased cardiac output Increased blood volume in LA causes it to dilate and hypertrophy Pulmonary circulation becomes congested resulting in Right Ventricular hypertrophy, dilation, and FAILURE

Aortic Stenosis

Obstruction to blood flowing from the Left Ventricle into the Aorta Caused by degenerative calcifications, congenital leaflet malformations, or an abnormal number of leaflets, rheumatic endocarditis

Medical management of Aortic Regurgitation

PREVENTION: treatment of bacterial infections Medical management: Avoid physical exertion, competitive sports, isometric exercise, restrict sodium intake SX: aortic valve replacement or valvuloplasty (treatment of choice)

Labs to monitor with aplastic anemia

Pancytopenia (low WBCs, RBCs, and platelets)

What type of play do toddlers develop?

Parallel play toddlers play side by side each other but not together. Push pull toys help enhance walking skills. Short attention spans cause toddlers to change toys often. Toys for toddlers: Play dough, blocks, containers, toy telephone, wooden puzzles, cloth books, and simple musical instruments

RN management of mitral valve prolapse

Patient education re: diet, activity, sleep Avoidance of OTC meds containing ETOH, caffeine, ephedrine, and epinephrine

The client in the ED has just had a diagnostic lumbar puncture. To reduce the incidence of a post-lumbar puncture headache, what is the nurse's most appropriate action?

Position the client PRONE

RN management SX valve repair

Post-surgical valvuloplasty or valve replacement: Focus is hemodynamic stability and recovery from anesthesia Frequent assessments w/ attention to neuro / resp / and cardiovascular systems

When is the fetal heart rate first present?

Postconception day 17

Decorticate posturing

Posturing characterized by adduction of the arms, flexion at the elbows with the arms held over the chest, and flexion of the wrists with both hands fisted and the lower extremities are adducted and extended. Occurs with damage of the cerebral cortex.

Decerebrate posturing

Posturing in which the neck is extended with jaw clenched, arms are pronated, extended, and close to the sides, and the legs are extended straight out. Occurs with damage at the level of the brain stem.

Reyes syndrome

Potentially serious or deadly disorder in children that has a potential association between the use of salicylates or salicylate containing products to treat a viral infection. Causes brain swelling, liver failure, and death in hours.

Droplet precautions

Precautions that would be used for children with streptococcal group A infections, rubella, and scarlet fever.

RN role in intubation

Prep: assure proper equipment is available

Multiple Organ Dysfunction Syndrome (MODS)

Presence of altered function of two or more organs in an acutely ill patient such that interventions are necessary to support continued organ function. Most common with severe sepsis due to inadequate tissue perfusion. -begins in the lungs → CV instability → liver → GI→ renal → immunologic → CNS

Wounds

Primary closure: sutures, staples Delayed primary closure: tissue loss, high potential for infection

Minimal triage category

Priority #3 - Green Color "Walking Wounded" -Injuries are minor and tx can be delayed hours to days. Individuals in this group should be moved away from the main triage area. Upper extremity fractures, minor burns, sprains, small lacs w/out significant bleeding, behavioral or psychological disturbances

What could an EKG show in kids with infective endocarditis?

Prolonged PR interval or dysrhythmias

Medical management for pyloric stenosis

Pyloromyotomy which cuts through muscle fibers of the enlarged pyloric muscle.

Myoclonic seizures

Rapid, brief muscular contractions of the body - usually involving one or more limbs, trunk Onset can be seen in children Usually occur simultaneously and bilaterally

Cardiac Glycoside Pharmacokinetics

Rapidly absorbed and widely distributed throughout the body Primarily excreted unchanged in the urine

Ventilator Acquired Pneumonia (VAP) Risk Reduction

Reposition side to side every 2 hours Oral care with chlorhexidine every 2 hours Head of bed elevated at least 30-45 degrees Maintain daily sedation and weaning protocols Hand hygiene No bolus feeds—risk for aspiration Monitor for GI ulcers- use PPI's, histamine blockers

RN process: Cardiomyopathy

Rest, dangle legs (decreased workload on heart, supplemental O2, medications, low sodium diet, avoid dehydration Cycle rest & activities, educate on symptoms that indicate need for rest

S/S of pulmonary edema

Restlessness, anxiety, dyspnea, cool/clammy skin, cyanosis, weak/rapid pulse, cough lung congestion (moist, noisy respirations), increased sputum production (sputum may be frothy & pink) decreased level of consciousness

Repolarization

Return of the cell to resting state, caused by reentry of potassium into the cell while sodium exits the cell.

Meningitis caused from what bacteria is most common in children older than 3 months and in adults?

S. pneumoniae & N. meningitides

P wave

SA node to atria Atrial depolarization Should be 0.11 seconds or less in duration

The nurse is caring for a client who is to have a lumbar puncture. What are the lowest vertebrae that contain the spinal cord?

Second lumbar vertebrae

Body fluids after burns

Systemically: Fluids move from intravascular to interstitial - which contributes to peripheral edema and hypovolemia At burn site: fluids shift to interstitial causing edema at burn site

__________________ refers to the events in the heart during contraction of the atria and the ventricles.

Systole (atrial systole occurs first, just at the end of diastole - followed by ventricular systole)

Object permeance

The awareness that toddlers have to know that objects continue to exist even when they cannot physically see them.

Why do we give aspirin to pts?

To prevent DVTs and blood clots Can be used as a prophylactic or maintenance

Beta blocker indications

Treats stable angina pectoris and HTN Prevents reinfarction in MI patients Treats stable CHF

Hypoplastic Left-Sided Heart Syndrome

Underdevelopment or absence of the left ventricle and hypoplasia of the ascending aorta form a univentricular heart. (ductus arteriosus remains patent providing systemic circulation).

Hypospadias

Urethral defect where the opening of the urethra is on the ventral surface of the penis (below it).

Management of pts with heat stroke

Use ABCs and reduce temp to 39.2 (102) as quickly as possible Cool sheets, towels, or sponging with cool water Ice to neck/groin/chest/armpits Cooling blankets Immersion in cold water bath IVs to replace fluid losses

What would someone have a Maze procedure?

Used for refractory atrial fibrillation - creates scar tissue so there is a nice pathway for the electrical conduction down to the ventricles

Preschool language development

Uses many words appropriately without a real knowledge of their meaning Vocabulary increases to more than 2100 words at the end of 5 years kids 3 to 4 years old use sentences of about 3-4 words with the most essential word to convey a meaning this is called telegraphic speech

Providing Atraumatic Care When Administering Medications

Using comforting positions Using topical anesthetic prior to injections (EMLA cream) Educating the child and parents Preventing medication errors

Croup tests/labs

Usually diagnosed by history and clinical symptoms (Barking cough at night, fever, and inspiratory stridor) Lateral neck X-ray shows steeple sign keep trach equipment near

Migraine headaches

Usually hereditary 4 Phases: prodrome, aura, headache, recovery (post-dromal phase) With or without aura Underlying cause: arterial vasodilation

1st degree AV block

Ventricular and atrial rate: Depends on the underlying rhythm. Ventricular and atrial rhythm: Depends on the underlying rhythm- but usually regular QRS shape and duration: Usually normal, but may be abnormal P wave: In front of every QRS complex; shows sinus rhythm, regular shape. PR interval: Greater than 0.20 seconds; PR interval measurement is constant. P: QRS ratio: 1:1 NO Beta Blockers - makes it worse

Nitrate pharmacokinetics

Very rapidly absorbed Metabolized in the liver Excreted in the urine

Smallpox (Variola)

Virus Incubation: 12 days Extremely contagious! Spread by direct contact w/ clothing or linens, or droplet person-to-person. High fever, malaise, headache, backache, a d prostration. After 1-2 days a maculopapular rash appears on face, mouth, pharynx, and forearms Contagious only after rash appears! Variola major (most common, 30% fatality rate) and Variola minor Supportive care treatment and abx for any additional infections

What is the treatment for pernicious anemia?

Vitamin B12 injections once a week or month for life or oral supplementation with thiamine.

Calcium Channel blockers pharmacokinetics

Well absorbed Metabolized in the liver Excreted in the urine

Continuous cardiac monitoring

The patient may NOT BE LEFT ALONE while they are off the monitor

A pt w/ Huntington disease has just been admitted to a long-term care facility. The charge nurse is creating a care plan for this pt. Nutritional management for a pt with Huntington disease should be informed by what principal?

The pt is likely to have an increased appetite

Intracerebral hemorrhage

bleeding into the brain tissue most common in pts w/ HTN and cerebral atherosclerosis - which can cause rupture of the blood vessels. can also result from brain tumors, and use of anticoags, or illicit drug use

Central nervous systme

brain and spinal cord

Peripheral nervous system

cranial nerves, spinal nerves, and autonomic nervous system

During assessment of a client admitted for cardiomyopathy, the RN notes the following symptoms: DOE, fatigue, fluid retention, and nausea. The initial appropriate nursing dx is what?

decreased cardiac output

abrasion

denuded skin

Pulse deficit

difference between the apical and radial pulse rates

dysarthria

difficulty speaking

Cardiotonic Agents

drugs used to increase the contractility of the heart muscle for patients experiencing heart failure Affect the intracellular calcium levels in the heart Cardiac glycosides: Digoxin (Lanoxin) Phosphodiesterase inhibitors: Milrinone

S/S of pulmonary congestion

dyspnea orthopnea paroxysmal nocturnal dyspnea cough pulmonary crackles that do not clear w/ cough rapid weight gain dependent edema abdominal bloating/discomfort ascites jugular vein distension sleep disturbance (anxiety or air hunger) fatigue

ACE inhibitors

"PRIL" Captopril, Enalapril, Benazepril, Ramipril, Lisinopril Antihypertensive Check BP before giving (hypotension) *Orthostatic Hypotension

Secondary Headache

**due to other medical condition Could be Benign...OR Could be meningitis, brain tumor, cerebral aneurysm

Signs and Symptoms of scarlet fever

-Abrupt high fever -Vomiting -H/A -Chills -Malaise Abdominal pain -Strawberry tongue -Sandpaper rash

Diagnostic tests for seizures

-EEG determines type and location of seizure -Labs (CBC, electrolytes, calcium, LFT, thyroid, and blood cultures) -Lumbar puncture to rule out meningitis -CT/MRI to r/o meningitis or encephalitis

Signs and symptoms of acute otitis media

-Fever -Fussy -Diarrhea -Vomiting -Irritable -Pulling on ear -Crying a lot -Immobile or bulging tympanic membrane

Tachycardia

faster than 100 bpm

A low pulse pressure indicates:

heart failure, shock, hypovolemia, mitral regurgitation, stenosis

aphasia

inability to express oneself or to understand language

Apraxia

inability to perform a previously learned action

stab

incision of the skin with well-defined edges, usually caused by a sharp instrument a stab wound is typically deeper than it is long

cut

incision of the skin with well-defined edges, usually longer than deep

Inotropes

increase contractility (increase the force of myocardial contraction)

Ocular trauma

leading cause of blindness among children and young adults (esp. males trauma victims) FLUSH chemical injuries (tap water or normal saline) Do not remove foreign objects Protect eye using metal shield or paper cup Potential for sympathetic ophthalmia causing blindness in uninjured eye in some injuries

Atherosclerosis

narrowing of the arteries

elevated triglycerides - lifestyle teaching points

nutrition

Rheumatic endocarditis

occurs most often in school-age kids after "group A beta-hemolytic streptococcal pharyngitis" Promptly recognize and treat strep throat s/s: Osler nodes, Janeway lesions, Roth spots, and splinter hemorrhages in nailbeds

Crush injuries

occurs when pt is caught between opposing forces Look for perfusion (hypovolemic shock), low BP, high heart rate Spinal cord injury Erythema and blistering Fractures Acute kidney injury (urine output, blood in urine)

nuchal rigidity

stiff neck

Hydrocephalus

Abnormal accumulation of cerebrospinal fluid (CSF) within the ventricles of the brain.

Disseminated Intravascular Coagulation (DIC)

Abnormal blood clotting in small vessels throughout the body that cuts off the supply of oxygen to distal tissues resulting in damage to body organs

brain death

-absence of brainstem reflexes -comatose (no response) -no breathing (apnea)

Disaster tags

-numbered Include triage priority, name, address, age, location and description of injuries, and treatments or medications given -Stay on the patient for the duration of the disaster

Atropine

0.5 - 1 mg given to INCREASE pulse Initial dose 0.5 mg Treats symptomatic bradycardia Can be given IV MAX of 3 doses

Normal urine output for infants

0.5 mL/kg/hr

Lifespan development age groups

1. Infancy: 1 month to a year old 2. Toddler: 1-3 years old 3. Preschool: 3-5 years old 4. School age: 6-12 years old 5. Adolescence: 13-19 years old

Normal urine output for adolescents

2 mL/kg/hr

A client arrives at the ED with an exacerbation of left-sided heart failure and c/o SOB. What is the priority nursing action?

Assess oxygen saturation

What type of play do preschoolers develop?

Associative play (play with other kids)

S/S of mitral regurgitation

Asymptomatic (chronic) Severe heart failure (acute) dyspnea, fatigue, weakness, palpitations, DOE, cough We will hear High-Pitched systolic murmur at the apex, regular/irregular pulse (extra systolic beats or a fib) DX by Echo

How long should you flush out an eye if exposed to chemical or irritant?

20 minutes Begin flushing process within 5 minutes of exposure for best outcome

Temporal lobe

Auditory plays a role in memory of sound and understanding of language and music

How do we know they are taking the iron supplement?

Black tarry stools are normal while taking iron supplements

subarachnoid hemorrhage

Bleeding into the subarachnoid space May result from an AVM, intracranial aneurysm, trauma, or HTN *most common causes are

Amiodarone

300 mg Q once 150 mg second dose Slows down the ventricles

What CPP would cause irreversible brain damage?

50 mmHg or less

Primary survery: ABCDE

A (airway): establish airway B (breathing): provide adequate ventilation C (circulation): evaluate and restore cardiac output; control hemorrhage, prevent and treat shock D (disability): determine neurologic status E (exposure): undress to assess wounds or areas of injury

Heart failure in kids

A condition in which the heart is unable to effectively pump the volume of blood, oxygen, and nutrients to the body organs and tissues that is presented to it. Blood and fluid backs up into lungs (LHF) or liver and veins (RHF).

Retinoblastoma

A congenital highly malignant tumor arising from a embryonic retinal cell.

chicken pox (varicella)

A diffuse vesicular rash usually with no fever. Three different types of rashes are present macules, papules, and a vesicular lesion on a erythematous base. Children are placed on airborne precautions and they can return to school once the lesions have crusted over. Prevent secondary skin infections from scratching by giving Benadryl to help alleviate scratching.

Acute alcohol intoxication

A multisystem toxin May result in death Maintain airway and observe for CNS depression and hypotension R/O other potential causes for behavior before assuming pt is intoxicated Be nonjudgmental, calm Pt may be noisy, belligerent - may need sedation

Alzheimer's Disease

A progressive and irreversible degenerative brain disorder characterized by gradual deterioration of memory, reasoning, language, and physical functioning. Brain changes include plaques in the cortex, neurofibrillary tangles, and the loss of connections between cells and cell death. Double lock doors and windows

Parkinson's Disease

A progressive disease caused by the degeneration of the dopamine producing neurons in the substantia nigra of the midbrain. This disease is more common in men and symptoms normally do not appear until you are 50 years old.

Troponin

A protein found in myocardial cells, regulated myocardial contractile process 3 different isomers - troponin I and T are specific for cardiac muscle. (reliable and critical markers of myocardial injury) Increased troponin can be detected within a few hours, during an acute MI. It remains elevated for a long period, as long as 3 wks. So it can be used to detect recent myocardial damage.

CRP (C-reactive protein)

A protein produced by the liver in response to systemic inflammation Plays a role in development & progression of atherosclerosis High-sensitivity CRP is used to predict CVD risk High = 3 mg/L or greater Moderate = 1 - 3 mg/L Low = less than 1 mg/L

Amylotrophic Lateral Sclerosis (ALS)

A rapidly degenerative neurological disease that attacks the nerve cells responsible for controlling voluntary muscles. Motor neurons in the brain stem and spinal cord gradually degenerate.

Exanthem

A rash or eruption on the skin. "Viral" means that the rash or eruption is a symptom of an infection due to a virus. Viral exanthems can be caused by many viruses, such as enteroviruses, adenovirus, chickenpox, measles, rubella, mononucleosis, and certain types of herpes infection.

Normal GI and GU system findings

A round abdomen, positive bowel sounds, dullness over the spleen, and descended testicles. Labial fusion, a distended abdomen, and undescended testicles are abnormal findings.

Mononucleosis

A self limiting illness caused by the Epstein-Barr virus. Important to check for a concurrent strep infection.

Cardiomyopathy

A series of progressive events that culminates in impaired cardiac output and can lead to heart failure, sudden death, or dysrhythmias

Acute chest syndrome

A symptom associated with sickle cell anemia where sickle cells get trapped in the lung and cause an infection.

rule of nines

A system that assigns percentages to sections of the body, allowing calculation of the amount of skin surface involved in the burn area.

Negativism

A typical behavior of toddlers saying "no", refusing to do what is asked, or doing the opposite.

Heat stroke manifestations

CNS dysfunction elevated temp (105 degrees or higher) hot, dry skin anhidrosis (inability to sweat) tachypnea hypotension tachycardia

Causes of seizures

Cerebrovascular disease Hypoxemia Fever (childhood) Head injury HTN Central nervous system infections Metabolic and toxic conditions Brain tumor Drug and alcohol withdrawal Allergies

Brain - 3 major areas

Cerebrum: two hemispheres, Thalamus, and Hypothalamus Brain Stem: Midbrain, Pons, and Medulla Cerebellum

Signs and Symptoms of cleft lip and palate

-Ineffective suck -Saliva and feeding leak into nasal cavity Gagging/choking/aspiration -Otitis media with effusion due to eustachian tube dysfunction

Gross and fine motor development of toddlers

-Locomotion -Improved coordination between ages 2 and 3 Fine motor development -Improved manual dexterity ages 12 to 15 months (holding spoon and feeding themselves) -Throws ball by age 18 months

What will we see during the toddler years?

-Locomotion and language -Bladder/bowel control -Explore and manipulate the environment -Temper tantrums -Sibling rivalry

Signs and symptoms of patent ductus arteriosus

-Machine like murmur audible at left upper sternal border -widened pulse pressure -Poor feeding -Bounding pulses

Signs and symptoms of influenza

-Profound malaise -Nonproductive cough -Fever and chills -Sore throat -Flush face -Nasal congestion -Rhinorrhea

Signs and symptoms of foreign body aspiration

-Sudden onset Cough, wheezing, or stridor -Decreased aeration on affected side -CXR will show if the foreign body is radiopaque

Medications of choice for heart failure

ACE inhibitors "prils": lisinopril, enalapril, etc.

Drug overdose

Clinical manifestations vary with substance Goals: support ABCs, enhance clearance of agent, safety for pt & staff IV drug users are at high risk for HIV, Hep B, Hep C, and Tetanus

Nephrotic syndrome

Clinical state characterized by edema, proteinuria, hypoproteinemia, hyperlipidemia, hypoalbuminemia, & anorexia.

What is the most common type of seizure in full term neonates?

Clonic seizures

Medical management for cleft lip and palate

Closure of lip defect precedes correction of the palate (12-18 months old). Z-plasty to minimize retraction of the scar and protect suture line with Logan bow or other methods.

What is the S1 heart sound?

Closure of the mitral and tricuspid valves (the atrioventricular valves)

A client reports "the worst headache" of her life with associated blurred vision. Subsequent diagnostic testing has resulted in a diagnosis of an intra-axial brain tumor. What other clinical manifestations would be consistent with this dx?

Cognitive and personality changes Seizure activity N&V

S/S of mitral stenosis

DOE (1st symptom) Progressive fatigue, decreased exercise tolerance, dry cough or wheezing Hemoptysis, palpitations, orthopnea, paroxysmal nocturnal dyspnea, respiratory infections, atrial dysrhythmias We will feel a weak, irregular pulse. Low pitched, rumbling diastolic murmur at the apex, s/s of HF

Appendicitis

Dangerous infection and inflammation of the appendix. It can rapidly lead to perforation and peritonitis. The lumen into the appendix becomes blocked by feces, foreign bodies or tumors. DO NOT put heat where it hurts it will cause the appendix to burst.

Blood agents

Decrease the function of Hgb in our blood - hydrogen cyanide and cyanogen chloride Direct effect on cellular metabolism, resulting in asphyxiation through alterations in Hgb Inhaled, ingested, or absorbed via skin or mucous membranes Leads to respiratory muscle failure, respiratory arrest, cardiac arrest, and death Rapid admin of amyl nitrate, sodium nitrate, and sodium thiosulfate is essential after pt is intubated and placed on ventilator

thromboembolism

Decreased mobility and decreased circulation increase the risk for clots in pts w/ cardiac disorders (including those pts with HF) S/S: dyspnea, pleuritic chest pain, tachypnea, cough Treatment: anti-coag therapy

Epispadias

Defect where the opening of the urethra is on the dorsal surface (on top) of the penis.

Legg-Calve-Perthes Disease

Degeneration of the femoral head due to avascular necrosis. Presents with pain, decreased ROM, antalgic gait, positive Trendelenburg sign. primary treatment focus is to relieve pain and maintain femoral head in proper position.

Diaper dermatitis

Diaper rash it Peaks at 9-12 months and is higher in formula fed infants. Caused by prolonged exposure to urine/feces, soaps, detergents, and inadequate cleaning while wearing disposable diapers. Medical management: Methylisothiazolinone (MI) preservative in diaper wipes. Nursing interventions/patient teaching: With diaper rash exposing the skin to air works well.

During the relaxation phase of the pumping action of the heart, all four chambers relax simultaneously, called ____________________.

Diastole (commonly referred to as the period of ventricular filling)

Dysphonia

Difficulty producing speech sounds or having an altered voice

Gower's sign

Difficulty rising to standing position has to walk up legs using hands occurs in Muscular dystrophy

Acute respiratory distress syndrome (ARDS)

Diffuse alveolar damage, sudden progressive pulmonary edema, increasing bilateral infiltrates on CXR, hypoxia unresponsive to O2 regardless of amount of PEEP, absence of ↑LAP

Trigeminy PVCs

every third beat is a PVC

Best way to increase HDL levels

exercise

Hypertrophic Cardiomyopathy (HCM)

heart muscle asymmetrically increases in size & mass, especially along the septum results in reduction in the size of the ventricular cavities and causes the ventricles to take longer to relax after systole Difficult for the ventricles to fill with blood during diastole Often detected after puberty Cells are weak due to defects in contractile proteins, the cells hypertrophy to do the same amount of work as normal cells. They require more oxygen and perform less efficiently = heart failure and sudden death during exertion Sudden Cardiac Arrest may be 1st Sign in young people! Systolic murmur

Beta 2 blockers affect

lungs (2 lungs)

Echo

measures ejection fraction confirms HF diagnosis

Diastole

period of ventricular relaxation resulting in ventricular filling All four chambers relax simultaneously - allowing the ventricles to fill in preparation for contraction tricuspid & mitral valves are open

Poisoning

poison is any substance that when ingested, inhaled, absorbed, applied to skin, or produced within the body in relatively small amounts - injures the body by its chemical action Treatment goals: remove or inactivate the poison before it is absorbed Provide supportive care in maintaining vital organ systems Administer specific antidotes Implement treatment to hasten the elimination of the poison

Nonexertional heat stroke

prolonged exposure to an environmental temp over 102.5 degrees F (39.2 degrees C)

hematoma

tumor-like mass of blood trapped under the skin

PPE level D

typical work uniform - scrubs

Coma

unconsciousness, unarousable unresponsiveness

Akinetic mutism

unresponsiveness to the environment, makes no movement or sound but sometimes opens eyes

Norepinephrine

vasopressor given to increase BP

Risk factors for septic shock

•Immunosuppression •Extremes of age (<1 yr and >65 yrs) •Malnourishment •Chronic illness •Invasive procedures •Emergent and/or multiple surgeries

Crystalloid fluid administration considerations

•Insufficient fluid replacement: ↑ Morbidity and mortality due to lack of tissue perfusion •Excessive fluid administration: Associated with systemic and pulmonary edema may progress to •ARDS •Abdominal hypertension •Abdominal compartment syndrome (ACS) •Multiple organ dysfunction syndrome (MODS)

Pediatric considerations for shock

•Pediatric septic shock presents as "COLD" shock (adults it's warm shock) •Hypotension is a LATE sign (CAB not ABCs)

Risk reduction for septic shock

•Strict infection control practices •Thorough hand hygiene techniques •Prevent central line infection •Early removal of invasive devices •VAP prevention measures •Early ambulation •Early debridement of wounds to remove necrotic tissue •Adhere to standard infection prevention/control policies •Meticulous aseptic technique •Proper cleaning of equipment and environment between patients

Who is at risk for the flu?

◦Young children <5 years old ◦Infants ◦People over 50 years old ◦Residents in LTC facilities ◦Pregnant ◦Immunocompromised ◦Health care providers

S/S of a Cardiac tamponade

Falling systolic BP Narrowing pulse pressure Rising venous pressure Distant heart sounds (because the sounds have trouble traveling through the fluid built up around the heart

A high pulse pressure indicates:

HTN, bradycardia, anxiety, exercise, fever, aging

Cardiac Glycoside Adverse Effects

Headache, weakness, drowsiness Vision changes (yellow halo around objects) GI upset and anorexia Arrhythmia development

Cardiac Glycosides

Increases force of myocardial contraction, Cardiac Output, and Renal Perfusion & Output Decreases blood volume to slow heartrate and conduction velocity through the AV node Ex: Digoxin (Lanoxin)

Epiglottitis

Inflammation of the epiglottis most often caused by Haemophilus influenzae type B. More rare now due to the HIB vaccine.

Hypothermia

Internal core temp is 35 degrees C or less Pt may also have frostbite - treatment for hypothermia takes precedence ETOH increases susceptibility

What to do when a pacemaker misfires

Lay down and call for help

What is the definitive diagnostic test for meningitis?

Lumbar puncture

Infectious diseases of the heart

Management for ALL infectious diseases is PREVENTION

Metoclorpramide (Reglan)

Medication that improves the motility of the esophagus and stomach and increases the lower esophageal sphincter (LES) pressure to help reduce reflux of gastric contents. They also accelerate gastric emptying.

Medical management of mitral regurgitation

Meds to decrease afterload (ACEIs, ARBs, Beta-Blockers) Activity restriction - HF symptoms Sx: mitral valvuloplasty or valve replacement

Warfarin therapy ranges

Mitral Valve Replacement: INR 2 - 3.5 Aortic Valve Replacement: INR 1.8 - 2.2 Bioprostheses: ASA and warfarin

heart failure classification system

NY Heart Association: I, II, III, and IV (higher = worse) American College of Cardio & American Heart Association: Stage A, B, C, D (higher letters = worse)

What is the earliest indicator of shock?

Narrowed or decreased pulse pressure (SBP-DBP)

Status Epilepticus

Neurological Emergency!! Prolonged or clustered seizures Consciousness does not return between seizures Can occur w/ any seizure activity Febrile seizures are the most common cause

Medical management for cellulitis

Obtain a CBC and wound and blood cultures to determine causative agent. Treatment is according to causative agent Streptococcus use cefazolin or nafcillin H. Influenzae use amoxicillin Staphylococcus use dicloxacillin MRSA use Bactrim, clindamycin, or Bactroban ointment

RN role - human trafficking victim

Offer opportunity for pt to speak alone (without companion) "Are you in control of your own money?" "Are you able to come and go as you please?" "Who is the person(s) accompanying you?"

Any precautions on administering the supplementation of iron?

Oral iron is best absorbed on an empty stomach and best taken with orange juice due to the vitamin C needed for absorption. Do NOT take with dairy products or antacids competes with same binding sites. -Give 1 hour before or 2 hours after meals -Liquid iron can stain your teeth use a straw when taking it and rinse your mouth after taking it.

Decreasing cerebral edema

Osmotic diuretics such as mannitol Hypertonic saline (3%) Steroids (dexamethasone) Fluid restriction Hypothermia (controversial)

Medical management of aortic stenosis

PREVENTION: controlling risk factors for proliferative and inflammatory responses Meds to treat dysrhythmia or left ventricular failure Surgical replacement of the aortic valve (definitive treatment) Non-SX candidates: one- or two-balloon percutaneous valvuloplasty procedures with or without transcatheter aortic valve implantation

Management of mitral stenosis

PREVENTION: treat strep throat!! Med management: treatment of heart failure, anti-coag therapy, cardioversion if a fib, beta blockers, (digoxin or calcium channel blockers if cardioversion fails) Avoid strenuous activities, competitive sports, pregnancy SX: valvuloplasty or valve replacement

Post-ictal phase after tonic-Clonic seizures

Patient will be lethargic, confused, sleepy and breathing may be irregular. Ultimately the patient may have no memory of the event.

Immediate triage category

Priority #1 - Red color -injuries are life threatening but survivable w/ minimal interventions. Could progress rapidly to BLACK if treatment is delayed Sucking chest wound, airway obstruction w/ mechanical cause, shock, hemothorax, pneumothorax, asphyxia, chest/abdominal wounds, incomplete amputations, open fractures of long bones, 2nd/3rd degree burns of 15%-40% total body surface

What can happen between a rapid test result and a send out test result?

Rapid test can come back as a false negative or positive but the send out test can come back positive or negative

Neuron

basic functional unit of the brain and nervous system

PR interval

beginning of P wave to beginning of QRS complex should be 0.12 - 0.20 seconds in duration (3 small boxes up to one large box)

Bradycardia

below 60 bpm

ecchymosis

blood trapped under the surface of the skin

contusion

bruise

When do we notify the MD when a patient is in the compensatory stage of shock?

SBP <90 mm Hg or a drop of 40 mm Hg from baseline -MAP <65 mm Hg -RR > 22/min -Altered mentation -Narrowed or decreased pulse pressure

STEMI vs NSTEMI

STEMI = ST elevation NSTEMI = ST depression, T-wave inversions

.....cardioversion

SVT a fib (used all other interventions)

Myelomeningocele

Sac that contains spinal fluid, meninges, and nerves. The spinal cord and meninges protrude through the spine.

Focal or partial seizures

Seizures that are limited to one part of the brain. May evolve into generalized seizures and affect the whole brain. Simple partial or "focal onset aware seizure" no loss of awareness or surroundings Complex partial seizures "Impaired awareness seizures" Not aware of surroundings, last 1 - 2 minutes, and may have an aura

Management of pts with chemical burns

Severity of the injury depends on: 1. the mechanism of action of the substance 2. the penetrating strength and concentration 3. the amount of skin exposed to the agent IMMEDIATELY flush the skin with running water (hose, shower, faucet)

Septic Shock

Shock caused by severe infection usually a gram negative bacterial infection.

Obstructive Shock

Shock that occurs when there is a Inability to produce adequate CO despite normal intravascular volume and myocardial function

What is the main electrolyte involved in cardiomyopathy?

Sodium

Foreign body aspiration

Solid or liquid substance becomes lodged in the respiratory tract and blocks the airway. Commonly seen in infants and young children. Toddlers biggest threat because they put everything in their mouth.

Sunburns

Superficial, partial thickness burned skin stays intact heals in 3-6 days w/ care

Post-operative positioning for cleft lip and palate

Supine and side-lying to promote digestion and prevent aspiration NO PRONE

Influenza

The flu a highly contagious viral respiratory disease. Can be spread through airborne, droplet, and direct contact with an infected person.

Scoliosis

The most common spinal deformity and it can be congenital or it can develop during childhood. Complex spinal deformity in three planes (lateral curvature, spinal rotation causing rib asymmetry, and thoracic hypokyphosis). Generally becomes noticeable after the preadolescent growth spurt may have complaints of ill-fitting clothes. Signs and symptoms: Unequal hip and shoulder heights, scapular and rib prominence, and a posterior rib hump that is visible when the child bends forward at the waist.

post ictal

The state of somnolence and decreased responsiveness after a seizure

Regurgitation

The valve will not close all the way It leaks when "closed" Will hear a murmur of blood leaking back through when the valve should be closed

Pediatric Glasgow Coma Scale

Three part assessment: Eyes Verbal response Motor response Score of 15: unaltered LOC Score of 3: extremely decreased LOC (worst possible score on the scale)

maze procedure

Treats symptomatic A. Fib surgical procedure to treat atrial fibrillation in which a new conduction pathway is created that eliminates the rapid firing of ectopic pacemaker sites in the atria Cut slices in atria to cause scar tissue so it cannot fire

Medical management for PUD

Triple Therapy: 2 antibiotics and a proton pump inhibitor Flagyl (metronidazole), clarithromycin, and a PPI (omeprazole or pantoprazole) Quadruple Therapy: 2 antibiotics, a proton pump inhibitor, and bismuth salts Flagyl, Tetracycline, PPI, and bismuth salts

Athetoid Cerebral Palsy

Type of cerebral palsy that is characterized by abnormal involuntary movement (chorea). It affects all four extremities with possible involvement of the face, neck, and tongue. The movements increase in periods of stress. Dysarthria and drooling may be present as well.

Spastic cerebral pulsy

Type of cerebral palsy that is characterized by poor control of posture, balance, and movement, exaggeration of deep tendon reflexes, and hypertonicity of affected extremities. Ataxic is characterized by poor coordination, unsteady gait, and wide-based gait.

Diazepam (Valium) rectal

Useful for home management of prolonged seizures and requires that the parents be educated on its proper administration. Monitoring the child's level of sedation is key when giving diazepam because it slows the central nervous system. When the use of an anticonvulsant is stopped, gradual reduction of the dosage is necessary to prevent seizures or status epilepticus. This is not done without a physician's order.

Sinus Arrhythmia characteristics

Ventricular and atrial rate: 60- 100 bmp in adult Ventricular and atrial rate: Irregular QRS shape and duration: Usually normal, but may be regularly abnormal P wave: Normal and consistent - One in front of every QRS PR interval: Consistent interval between 0.12 and 0.20 seconds P: QRS ratio: 1:1

PVC (Premature Ventricular Contraction)

Ventricular and atrial rate: Depends on the underlying rhythm Ventricular and atrial rhythm: Irregular due to early QRS, creating one RR interval that is shorter than the others. The PP interval may be regular, indicating that the PVC did not depolarize the sinus node. QRS shape and duration: Duration is 0.12 seconds or longer; shape is bizarre and abnormal. P wave: Visibility of the P waved depends on the timing of the PVC; may be absent (hidden in QRS or T wave) or in front of the QRS. If the P wave follows the QRS, the shape of P wave may be different.- there are no P waves associated with PVC'S PR interval: If the P wave is in front of the QRS, the PR interval is less than 0.12 seconds. P: QRS ratio: 0:1 , 1:1 **look for patterns of the PVC's

Sinus Tachycardia characteristics

Ventricular and atrial rate: Greater than 100 bmp in adult Ventricular and atrial rate: Regular QRS shape and duration: Usually normal, but may be regularly abnormal P wave: Normal and consistent - One in front of every QRS but may be buried in preceding T wave. PR interval: Consistent interval between 0.12 and 0.20 seconds P: QRS ratio: 1:1

Phosphodiesterase inhibitors pharmacokinetics

Widely distributed after injection Metabolized in the liver and excreted in the urine

What is the S2 heart sound?

closure of semilunar valves (pulmonary and aortic)

Center

cluster of cell bodies with the same function

Sodium Bicarbonate

corrects metabolic acidosis

Signs and symptoms of appendicitis

-Continuous mild upper abdominal pain that then radiates to RLQ -Rebound tenderness on palpation in RLQ -Rovsing's sign (LLQ pain that moves to RLQ) -Fever -Anorexia -N/V -Leukocytosis -Sudden stop of pain may indicate ruptured appendix

Signs and symptoms of aortic stenosis

-Cyanosis -Poor peripheral perfusion -Decreased or absent peripheral pulses -CHF from lung congestion -Tachypnea, crackles, rhonchi

Medical management for dehydration

-Daily weights -Monitor I&O closely -Restore fluid volume in small frequent amounts over 4-6 hours 50mL/kg -Continue breastfeeding along with oral solution -IV therapy for severe dehydration with evidence of circulatory compromise, persistent vomiting, or diarrhea.

S/S of anaphylactic shock

-Difficulty breathing (laryngeal edema) -Hypotension -GI distress -Skin and mucosal irritation -Cardiovascular compromise within minutes to hours after exposure -Headache -Lightheadedness -N/V -Acute abdominal pain/discomfort -Pruritus -Diffuse erythema and generalized flushing -Feeling of impending doom -Cardiac dysrhythmias

S/S of Myasthenia Gravis

-Diplopia -Ptosis (eyelid drooping) -Dysphagia -Dysarthria -Skeletal weakness improved by rest & worse by exercise -bladder & bowel incontinence -Ataxia

Nursing management of epiglottitis

-Do not attempt to visualize the throat can cause the airway to close completely -Do not leave the child unattended. -Do not place the child in a supine position. -Provide 100% oxygen in the least invasive manner. -If complete airway occlusion occurs tracheostomy may be necessary. -Ensure emergency equipment is available.

Signs and symptoms of PUD

-Dull, burning, or gnawing abdominal pain located in the umbilical region -Poor feedings -Vomiting -Irritability -Waking up at night -Hematemesis

Signs and Symptoms of pneumonia

-Dyspnea -Fever -Cough -Tachypnea -Chills -Headache -Lethargy -Wheezing -Crackles

Medical management for Septic Shock

-Early identification and elimination of cause of infection. Begin treatment within 3 hours for best prognosis -Collect blood, sputum, urine, wound drainage, and tips of invasive catheters for culture using aseptic technique -IV lines are removed and reinserted at alternate sites -If possible urinary catheters are removed or changed -Current guidelines suggest that antibiotics should be initiated within the first hour of treatment

Toddler Cognitive Development

-Egocentric thinking inability to view situations from perspectives of others (this is my toy all of the toys are mine) -Toddler likes to use active exploration and trial to explore the environment -Object permanence is developed at 12-18 months then is well developed at 18-24 months. -Imitation displays deeper meaning and understanding (such as imitating household activities) -Within second year increasingly uses language symbolically and is concerned with the "why" and "how" of things -Vocabulary (2 years old) over 20 words, 2 to 3 word sentences -Sense of time is exaggerated

Right-sided heart failure

-Elevated jugular venous pressure -Splenomegaly -Hepatomegaly -Decreased renal perfusion when upright -Increased renal perfusion when laying down (nocturia) -Pitting Edema -Weakness/fatigue

Medical management for rheumatic fever

-Encourage compliance with drug regimens -Penicillin remains the drug of choice. -Salicylates are used to control the inflammatory process and to reduce fever and discomfort. -Prednisone may be indicated in some patients with heart failure. -Bed rest or at least limited activity during the acute illness -Provide emotional support.

Medical management for the progressive stage of shock

-Enteral nutritional support -Targeted hyperglycemic control (maintain serum glucose < 180 mg/dL) -Reduce risk of GI ulceration: antacids, H2 blockers, or antipeptic medications

Signs and symptoms of scabies

-Erythematous papules appear in finger web spaces -Intensively pruritic -Burrows appear on skin as tiny light brown or grey lines.

S/S of DIC

-Excessive bleeding from mouth, rectum, urethra/bladder -Petechiae/Purpura -Hypotension -Multi-organ failure

Signs and symptoms of Tetralogy of Fallot

-Extreme cyanosis (unoxygenated blood enters systemic circulation) -Systolic ejection murmur -Clubbing of nail beds -Dyspnea -Child experiences "Tet" spells or hypoxic episodes relieved by child squatting or being placed in knee chest position.

Signs and symptoms of Hirschsprung's disease

-Failure to pass meconium stool within the first 48 hours of life -Abdominal distention -Vomiting -Poor feeding -History of constipation or failure to thrive

Signs and symptoms of croup

-Fever -Barking or seal-like cough -Inspiratory stridor -Hoarseness -Suprasternal retraction -Symptoms usually occur at night and are sudden

Signs and symptoms of UTIs in children

-Fever -Chills -Vomiting -Dysuria -Frequency -Urgency -Burning on urination -Suprapubic or lower back pain -Culture will be >100,000 units of offending organism

Signs and symptoms of UTIs in infants

-Fever -Irritability -Vomiting -FTT -Jaundice

Signs and symptoms of rubeola (measles)

-Fever -Malaise -Cough -Conjunctivitis -Coryza (runny nose) -Photophobia -Koplik spots 2 days before rash

Signs and Symptoms of RSV

-Fever -Rhinorrhea -Pharyngitis -Poor feedings -Cough 1-3 days into illness with wheezing

Signs and symptoms of infective endocarditis

-Fever (unexplained low-grade) -Roth spots (splinter hemorrhages with pale centers on the sclerae, palate, buccal mucosa, chest, fingers, or toes) -Osler's nodes (Small tender nodules on the pads of the toes or fingers) -New or changing murmur -Janeway lesions (Painless, flat, red or blue hemorrhagic lesions on the palms or the soles -Anemia -Nailbed splinter hemorrhages under the nails (Black lines)

Signs and symptoms of Kawasaki disease

-High fever >5 days unresponsive to antibiotics -Acute conjunctivitis -Strawberry tongue -Extreme irritability -Polymorphic rash -Swollen hands and feet

Medical management for patent ductus arteriosus

-IV Indomethacin (prostaglandin inhibitor) lowers prostaglandins and leads to ductus closure. -Interventional cardiac Cath via occluder device or coil -Surgical correction via ductal ligation (thoracotomy).

Signs and Symptoms of atrial septal defect

-In small defects they are normally asymptomatic -Dyspnea -Tachypnea -Tachycardia -Cough -SOB -A loud holistic systolic murmur

Children at risk for tuberculosis

-Infected with HIV -Incarcerated or institutionalized -Immigrants or recent travel to country with endemic disease -Exposed to an HIV infected person, homeless person, illicit drug user, recently incarcerated person, migrant farm workers, or nursing home residents

Nursing management for the irreversible stage of shock

-Inform family about the prognosis and likely outcome -provide comfort -Set-up conferences with all members of the health care team include palliative care specialists -Explain that the equipment and treatments being provided are intended for comfort and do not suggest that the patient will recover

Signs and symptoms of cellulitis

-Irregular shaped areas of skin with erythema & edema -Erythema, red, or lilac skin color -Warmth, tenderness around area -Regional lymphadenopathy -Fever, chills, and malaise indicates systemic involvement -Leukocytosis

Signs and symptoms of increased ICP in infants

-Irritability/poor feeding -High-pitched cry/difficult to soothe -Tense and bulging fontanels -Cranial sutures separated -Sunsetting sign in eyes -Distended neck veins -Increased head circumference

Nursing Interventions/PT for head lice

-Keep fingernails cut short to prevent scratching -Wear mittens or gloves this decreases risk of secondary bacterial infection -Loose clothing -Mild perfume free soaps or NO SOAP -Wash with mild soap and water and dry thoroughly -Avoid talcum powder, overheating, hot baths, and keep area open to air if possible.

Signs of Organ Dysfunction

-Lactic Acid > 2 mmol/L > 4 may be only sign of sepsis at first -Systolic BP < 90 -SBP decrease of > 40 mm Hg from baseline -Creatinine > 2 mg/dL -UOP < 0.5 mL/kg/hr > 2 hours -Bilirubin > 2 mg/dl -Platelet count < 100,000 -INR > 1.5 or aPTT > 60 -Altered mental status from baseline -Need for mechanical respiratory support Bipap or Ventilator

Psychosocial tasks of a preschooler

-Learns how to interact with other children -Learns socially acceptable behavior -Learns right from wrong and reward and punishments -Develops a conscience

Medical management for scabies

-Lindaine (kwell) lotion, cream, or shampoo. This is contraindicated for kids <2 years of age due to CNS toxicity -Petroleum jelly -Need to remove nits with a extra-fine tooth comb or tweezers -Hydroxyzine or Diphenhydramine for pruritus -Clean contaminated clothing and linens in hot soapy water -Discard or treat stuffed animals or fabric toys and inspect head of itching child.

Medical management for head lice

-Lindane (kwell) lotion, cream, or shampoo this is contraindicated for kids <2 years of age due to CNS toxicity -Petroleum jelly -Need to remove nits with a extra-fine tooth comb or tweezers -Hydroxyzine or Diphenhydramine for pruritus -clean contaminated clothing and linens in hot soapy water and inspect head of itching child

Ventilator Alarms -Low Pressure -High Pressure

-Low: disconnection, hole or crack in tubing, tube displacement -High: obstruction in tubing, biting, barotrauma, pulmonary edema (pink frothy secretions), suction for possible secretions, kinks.

Signs and symptoms of nephrotic syndrome

-Massive proteinuria -Hyperlipidemia -Decreased serum protein levels (hypoproteinemia) -Decreased serum albumin levels (hypoalbuminemia) -Elevated cholesterol level -BUN typically becomes elevated

S/S of Compensatory Stage of Shock

-Metabolic acidosis from anaerobic metabolism -Tachypnea due to acidosis may cause compensatory respiratory alkalosis -Anxiety -confusion -Pale, cool, clammy skin -Hypoactive bowel sounds -Decreased urine output

Risk factors for Acute Otitis Media

-More frequently among boys -Children in day care centers -Allergies -Exposed to tobacco smoke -Winter months -Breastfeeding seems to be protective -Sleeping with bottle places infant at risk

Signs and symptoms of brain tumors

-N/V -Unsteady gait -Blurred or double vision -Seizures -Motor abnormality or hemiparesis -Weakness -Swallowing difficulties -Irritability -failure to thrive -Developmental delay Location of the tumor helps to determine the extent to which it can be safely resected.

Nursing management during seizures

-Observe and record sequence of signs -Time of onset to time of end -Circumstances prior to seizure -Aura or not -Order of movements or stiffness, gaze, and head position -Type of movements -Pupil size open or closed -Automatisms

NURSING INTERVENTIONS DURING THE CHILD'S HOSPITALIZATION FOR FAILURE TO THRIVE

-Observe parent-child interactions especially during feedings. -Develop an appropriate feeding schedule -Provide feedings as prescribed (usually 120 kcal/kg/day is needed to demonstrate proper weight gain). -Weigh the child daily and maintain strict records of intake and output. -Educate parents about proper feeding techniques and volumes. -Provide extensive support to alleviate parental anxiety related to the child's inability to gain weight.

Surviving Sepsis Campaign Bundle: 3 hour Bundle

-Obtain serum lactate -Obtain blood culture prior to administration of antibiotics -Administer broad spectrum antibiotic -Initiate aggressive fluid resuscitation in hypotensive patients or elevated serum lactate of >4 mmol/L. -Minimum initial fluid bolus of 30 mL/kg using crystalloid solutions

Signs and symptoms of cystic fibrosis

-Pancreatic enzyme deficiency -Progressive chronic obstructive pulmonary disease (COPD) associated with infection -Failure to thrive -Increased weight loss despite increased appetite -Wheezing -Dry nonproductive cough -Patchy atelectasis -Cyanosis -Clubbing of fingers and toes -Repeated bronchitis and pneumonia -Delayed puberty in females -Sterility in males -Parents report kid tastes "salty'

Neutropenic precautions

-Place the child in a private room -Perform hand hygiene before and after contact with each child. -Monitor vital signs every 4 hours. -Avoid rectal suppositories, enemas, or examinations, urinary Catheterization, and invasive procedures. -Restrict visitors with fever, cough, or other signs/symptoms of infection. -Do not permit raw fruits or vegetables, fresh flowers, or live plants in the room. -Place a mask on the child when he or she is being transported outside of the room. -Perform dental care with a soft toothbrush if the platelet count is adequate.

What can kids who are at a high risk of developing infective endocarditis do to help decrease the risk?

-Practice good oral hygiene including regular tooth brushing and flossing. -Instruct parents or the older child to carry emergency medical identification at all times. The card may be presented to any physician or nurse practitioner and includes the recommended antibiotic prophylactic regimen. -Instruct the parents to notify the primary care provider or cardiologist if the child develops flu-like symptoms or a fever.

How do we prevent infection in someone receiving chemotherapy?

-Practice meticulous hand hygiene -Avoid known ill contacts especially people with chickenpox. -Immediately notify the physician or nurse practitioner if exposed to chickenpox. -Avoid crowded areas. -Do not let the child receive live vaccines till 3 months after infection. (MMR, varicella, and rotavirus) -Do not take the child's temperature rectally or give medications by the rectal route. -Administer twice daily trimethoprim-sulfamethoxazole (Bactrim) for 3 consecutive days each week as ordered for prevention of Pneumocystis pneumonia very important to prevent infections.

What will we see during the preschool years?

-Preparation for most significant lifestyle change going to school -Experience brief and prolonged separation -Use language for mental symbolization -Increased attention span and memory -Intrusive experiences are frightening there is fear that all their blood and insides can leak out

S/S of Amylotrophic Lateral Sclerosis (ALS)

-Progressive weakness and atrophy of the upper extremities -Dysarthria (slurred speech) -Dysphagia -Dyspnea -Spasticity deep tendon reflex brisk and overactive -Compromised respiratory function

Treatment for headaches

-Provide comfort measures -Quiet dark room (photophobia very common) -Massage -Local heat for tension

S/S of Duchenne Muscular Dystrophy

-Proximal muscle weakness -Causes waddling gait and toe-walking -Gower's maneuver pushing to a stand using the hands to climb up legs

Signs and symptoms of impetigo

-Pruritus -Pain -Malaise -Erythema -Honey-colored crust areas -Smooth red skin under the crust -low grade fever -leukocytosis

What findings are suggestive of a neuroblastoma?

-Swollen or asymmetric abdomen -Bowel/bladder dysfunction -Watery diarrhea -Severe edema in one leg -Bone pain -Anorexia -Vomiting or weight loss. -Hypertension

Why would a pt get a Pacemaker?

-Symptomatic bradycardia -3rd degree heart block -2nd degree, type 2 -Refractery A. Fib (symptomatic)

Indicators of cardiac dysfunction in kids

-Symptoms may appear 4 to 12 weeks after birth -Failure to thrive, poor weight gain, activity intolerance -Tachypnea/tachycardia first signs of respiratory or heart distress -Diaphoresis -Crackles -Hepatomegaly -Cyanosis -Heart murmurs -Sternal lift -Developmental delays -Positive prenatal history -Positive family history of cardiac disease

S/S of hypovolemic shock

-Tachycardia -Weak thready pulse -Thirst -Decreased UO -Hypotension -Cool clammy skin -Anxiety -Pallor/cyanosis -Dyspnea -Rapid deep breaths -Altered mental status -Increased lactate and pH levels

The RN is providing discharge instructions on the antiseizure med - valproic acid (Depakote) to a woman of childbearing age. Which teachings should the nurse include in the pt's education packet?

-The medication should be taken consistently -The medication may predispose her to osteoporosis -The medication may interact with oral contraceptives -The client should also take folic acid daily

Calcium Channel blocker adverse effects

*Adverse effects are related to their effects on cardiac output on smooth muscle cell CV: hypotension, bradycardia, heart block, arrhythmias GI: nausea, hepatic injury Skin: flushing, rash CNS: headache, dizziness, fatigue

Febrile seizures

- Commonly seen in kids 12-18 months old rare in kids <6months or >5 y/o -Caused by a rapid rise in temp (102.2 or higher) -Generalized seizure <15 minutes -Avoid tepid baths usually ineffective -Antipyretics ineffective as preventive -Call 911 if seizure > 5 minutes duration -Parents need reassurance that febrile seizures are benign in nature. Children who experience one or more febrile seizures are at no greater risk of developing epilepsy than the general population. No evidence exists that febrile seizures cause structural damage or cognitive declines.

Febrile seizures

-12-18 months old rare <6months or >5 y/o -Rapid rise in temp (102.2 or higher) -Generalized seizure <15 minutes -Avoid tepid baths usually ineffective -Antipyretics ineffective as preventive -Call 911 if seizure > 5 minutes duration -Parents need reassurance that febrile seizures are benign in nature. Children who experience one or more febrile seizures are at no greater risk of developing epilepsy than the general population. No evidence exists that febrile seizures cause structural damage or cognitive declines.

S/S of MODS

-1st Lungs: Progressive dyspnea and respiratory failure that is manifested as ALI or ARDS requires intubation & ventilation -2nd CV ↑ need for IVF or vasoactive drugs -3rd Hypermetabolic state BG, ↑LA, ↑BUN -4th Severe loss of skeletal muscle mass to meet high energy demands -5th 7 - 10 days hepatic dysfunction (↑ bili and LFTs) and renal dysfunction (↑Creatinine and anuria) -Worsening immunocompromise -Increased risk of bleeding

Signs and symptoms of celiac disease

-Abdominal distention or bloating -Diarrhea -Steatorrhea -Constipation -Malabsorption of foods containing gluten -Weight loss or FTT -Vitamin deficiencies -Poor muscle tone -Irritability and listlessness -Delayed onset of puberty or amenorrhea

Causes of pernicious anemia

-Absence of intrinsic factor leads to poor vitamin B12 absorption -Chronic PPI use greater than 2 years at risk for vitamin B12 deficiency -Patients on metformin

Medical management for Guillian-Barre Syndrome

-Adrenocortical Steroids -Immunosuppressant Plasmapheresis (Blood is cleansed for the removal of antibodies) -IVIG -Mechanical ventilation -Meticulous skin care -Range of motion exercises

Medical management for multiple sclerosis

-Adrenocorticotropic hormone (ACTH) -Steroids (IV methylprednisolone) -Spasticity treated with baclofen -Betaseron (interferon beta-1b) -Rebif or Avonex (interferon beta-1a) -Bactrim -Macrodantin

Signs and symptoms of asthma

-Airway edema -Tightness in chest -Dyspnea -SOB -Tachypnea -Restlessness -Cyanosis -Fatigue -Diaphoresis -Hypoxemia -Audible inspiratory and expiratory wheezes

When to refer to Burn Center

-All burns caused by electrical or inhalation -If pt has trauma as well as burn(s) -3rd degree burns -Partial thickness burns covering 10% of TBSA (Total Body Surface Area) -Burns to hands, face, feet, major joints, eyes, ears, or perineum

Peptic ulcer disease

A break or ulceration in the protective mucosal lining of the lower esophagus, stomach, or duodenum due to an increase in pepsin and hydrochloric acid. The most common causes include the presence of H. pylori bacteria in the stomach, regularly taking NSAIDS, and physical or emotional stress. Diagnosed with a EGD test.

Asthma

A chronic and episodic inflammatory disease that causes limited airflow or obstruction of the airway that reverses spontaneously or with treatment.

Triptans

A class of drugs commonly used to treat migraines they work by causing dilated blood vessels to constrict causing vasoconstriction. Can cause chest pain contraindicated in ischemic heart disease and crosses placenta Ex: sumatriptan (Imitrex) and almotriptan (Axert)

Rubella (German Measles)

A common viral disease that has an incubation period of 14-21 days and has teratogenic effects on a fetus during the first semester of pregnancy. It is transmitted by droplet and direct contact with infected person.

Transposition of the great vessels

A congenital abnormality where the aorta is attached to the right ventricle and the pulmonary artery is attached to the left ventricle (this is backwards and leads to two separate blood routes). THIS IS INCOMPATIBLE WITH LIFE AND HAS TO BE FIXED. Requires maintenance of PDA with prostaglandins until surgery is possible.

Tetralogy of Fallot

A congenital malformation of the heart involving decreased pulmonary blood flow that involves a combination of 4 heart defects: ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, and overriding aorta.

Multiple Sclerosis

A degenerative neurological disorder with demyelination of the brain stem, spinal cord, optic nerves, and cerebrum (Central nervous system). Frequently the disease is relapsing and remitting has exacerbations and recurrences of symptoms.

Cystic Fibrosis

A genetic autosomal recessive trait disorder that is present at birth and affects both the respiratory and digestive systems (pancreas). Thick tenacious mucous accumulates, dilates, and coagulates to form concretions in the glands and ducts. Stagnation of mucus and bacterial colonization result in destruction of lung tissue and tenacious secretions are difficult to expectorate leading to obstruction of the bronchi and bronchioles.

Down Syndrome (Trisomy 21)

A genetic disorder caused by the presence of all or part of a third copy of chromosome 21. Most common genetic cause of intellectual disability and congenital heart disease 80% have mothers who are older than 35 yrs old Feeding and breathing are common issues due to low muscle tone

Migraine headache

A headache characterized by throbbing pain on one side of the head often accompanied by disordered vision, nausea, or vomiting, lasting hours or days and caused by arterial vasodilation. 4 phases: prodrome, aura, headache, and recovery

Rubeola (Measles)

A highly contagious respiratory disease caused by a virus. One of the most contagious diseases it spreads when infected people cough or sneeze. People who are infected can spread measles 4 days before they get the rash through 5 days after it appears. Koplik spots appear 2 days before rash

Duchenne Muscular Dystrophy

A human genetic disease caused by a X-linked recessive allele characterized by progressive weakening and a loss of muscle tissue.

Duchenne muscular dystrophy

A human genetic disease caused by a X-linked recessive allele characterized by progressive weakening and a loss of muscle tissue.

Idiopathic thrombocytopenia Purpura

A immune response following a viral infection or MMR vaccine produces antiplatelet antibodies Parents will report the development of petechiae, purpura, excessive bruising, epistaxis, and bleeding gums. Avoid NSAIDs, aspirin, and antihistamines..

myelin sheath

A layer of fatty tissue segmentally encasing the fibers of many neurons; enables vastly greater transmission speed of neural impulses as the impulse hops from one node to the next.

What does a decreased CVP indicate?

A low CVP (less than 2 mm Hg) indicates reduced right ventricular preload Hypovolemia from dehydration, excessive blood loss, N/V/D, or overdiuresis

Astrocytoma

A malignant tumor of the brain or spinal cord composed of astrocytes

Doll's eyes

A maneuver that tests for symmetric eye movement to the opposite side when the head is turned in the other direction.

Lead poisoning

A medical condition caused by toxic levels of the metal lead in the blood. Check lead level at 1 year old and again at 18 months.

Infective endocarditis

A microbial infection and inflammation of the endothelial surfaces of the heart's chambers, septum, or valves. Children with congenital heart defects or prosthetic valves are at increased risk of acquiring this. Commonly caused from streptococcus or staphylococcus, bacteria, or fungi.

Eustachian tube

A narrow tube that connects the middle ear with the nasopharynx and helps to equalize pressure in the middle ear with atmospheric pressure.

Status Epilepticus

A neurologic emergency caused by prolonged or clustered seizures. Consciousness does not return between seizures. Treatment includes IV Ativan or valium and to monitor labs especially glucose (hypoglycemia can cause seizures) and electrolytes (arrhythmias can cause seizures)

Neuroleptic Malignant Syndrome

A potential Life-threatening adverse reaction to antipsychotics with severe muscle rigidity, fever temp of over 104, and rhabdomyolysis.

Tumor lysis syndrome

A potentially fatal complication that occurs spontaneously or more commonly following radiation or chemotherapy-induced cell destruction of large or rapidly growing cancers such as leukemia and small cell lung cancer. The release of tumor intracellular contents leads to rapidly induced electrolyte imbalances (hyperuricemia and hyperphosphatemia leads to renal stone formation and renal colic and hyperkalemia and hypocalemia can lead to life-threatening cardiac dysrhythmias, muscle cramps/weakness, confusion, seizures and end-organ effects on the myocardium, kidneys, and central nervous system.

Cellulitis

A potentially serious bacterial infection of skin cells that involves the underlying tissues of the skin. It occurs when bacteria enter the body through a break in the skin such as a cut, scratch, or insect bite that is not cleansed with soap and water. The most common causes in adults are group A streptococci and staphylococcus aureus. The risk is increased by venous insufficiency or stasis, diabetes mellitus, lymphedema, surgery, malnutrition, substance abuse, or the presence of another infection. This develops as an edematous erythematous area of skin that feels hot and tender.

Chelation therapy

A procedure in which excess metals such as lead is removed from the blood due to the chelation meds competing with binding sites.

Status Asthmaticus

A severe life-threatening asthma attack that is refractory to usual treatment and places the patient at risk for developing respiratory failure. Emergency treatment includes Epinephrine 0.01mg/kg SC

How do you obtain a stool sample?

A stool specimen for culture must be free of urine, water, and toilet paper. Therefore, the parent needs to understand how to collect the specimen so that it does not encounter any of these. In addition, the specimen should not be retrieved out of toilet water. Mineral oil, barium, and bismuth interfere with the detection of parasites. In such cases, specimen collection should be delayed for 7 to 10 days. Once the specimen is collected, it should be brought to the laboratory immediately.

Failure to Thrive (FTT)

A term used to describe inadequate growth in infants and children. The child fails to demonstrate appropriate weight gain over a prolonged period of time. Length or height velocity and head circumference growth may also be affected. Typical children may experience FTT but it is much more common in the child with special needs. Other organic causes of this include inability to suck and/or swallow correctly, malabsorption, diarrhea, vomiting, or alterations in metabolism and caloric/nutrient needs associated with a variety of chronic illnesses. Infants and children with cardiac or metabolic disease, chronic lung disease (bronchopulmonary dysplasia), cleft palate, or gastroesophageal reflux disease are at an increased risk. Poverty is the single greatest contributing risk factor. Screen all children for this to identify them early. In addition to poor growth the infant or child with this may present with a history of developmental delays or loss of acquired milestones. Infants or children with feeding problems may display nipple, spoon, or food refusal, difficulty sucking, disinterest in feeding, or difficulty progressing from liquid to puréed to textured food. Perform a detailed dietary history and instruct the parents to complete a 3-day food diary to identify what the child actually eats and drinks.

Tension headache

A type of headache in which pain is felt in all or part of the head. Pain is like a band squeezing the head. This type of headache occurs from long endured contraction of the skeletal muscles around the face, scalp, upper back, and neck.

Respiratory Syncytial Virus (RSV)

A viral infection that leads to acute inflammation of the bronchioles and small bronchi. Commonly seen in the winter and spring months and in infants/toddlers peaking at the age of 6 months.

autonomic dysreflexia

ACUTE EMERGENCY!! Occurs after spinal shock has resolved - possibly years after the injury Occurs in pts w/ spinal cord injuries above T6 Autonomic nervous system responses are EXAGGERATED S/S: Severe Pounding Headache, sudden increased BP, profuse diaphoresis, nausea, nasal congestion, and bradycardia Triggered by: 1. Distended bladder *most common cause* 2. Rectum distended with stool (constipation) 3. Stimulation of the skin (wrinkled sheets, tight clothes, etc)

2nd degree heart block type 1

AKA: Mobitz 1 or Wenckebach Ventricular and atrial rate: Depends on the underlying rhythm, but the ventricular rate is lower than the atrial rate. Ventricular and atrial rhythm: The PP interval is regular if the pt has an underlying NSR; the RR interval characteristically reflects a pattern of change. Starting from the RR that is the longest, the RR interval gradually shortens until there is another long RR interval. QRS shape and duration: usually normal, but may be abnormal P wave: In front of the QRS complex, shape depends on underlying rhythm. PR interval: The PR interval becomes longer with each succeeding ECG complex until there is a P wave not followed by a QRS. The changes in the PR interval are repeated between each "dropped" QRS, creating a pattern in the irregular PR interval measurement. P: QRS ratio: 3:2, 4:3, 5:4, and so forth Monitor, get VS, if symptomatic - may get pacemaker.

2nd degree heart block, type 2

AKA: Mobitz 2 Ventricular and atrial rate: Depends on the underlying rhythm, but the ventricular rate is lower than the atrial rate. Ventricular and atrial rhythm: The PP interval is regular if the pt has an underlying NSR. The RR interval is usually regular but may be irregular, depending on the P:QRS ratio. QRS shape and duration: Usually abnormal, but may be normal. "Dropped QRS's" P wave: In front of the QRS complex; shape depends on the underlying rhythm. P wave for EVERY QRS PR interval: The PR interval is constant for those P waves just before QRS complexes. P: QRS ratio: 2:1, 3:1, 4:1, 5:1, and so forth

Atonic seizures (drop seizures)

Abrupt loss of muscle tone no warning. Head drops, loss of posture, sudden collapse. May result in injuries to head and face.

What is the most reliable sign of cardiac arrest?

Absence of carotid pulse

Beta Blocker pharmacokinetics

Absorbed in the GI tract Undergoes hepatic metabolism Excreted in the urine

Tasks the adolescent must complete

Achieve more mature relations with friends (both sexes) and build meaningful relationships Accept one's physique and develop an identity

Nitrate Actions

Act directly on smooth muscle to cause relaxation and depress muscle tone

Types of rewarming (hypothermia)

Active core rewarming: Cardiopulmonary bypass, warm fluid administration, warm humidified O2, warm peritoneal lavage Passive external rewarming: warm blankets and over the bed heaters (bear hugger)

pulmonary edema

Acute - results from left ventricular failure As the left ventricle begins to fail, blood backs up into the pulmonary circulation - causing pulmonary interstitial edema Hypoxemia (often severe)

Acute Lung Injury

Acute inflammation that causes disruption of the lung endothelial and epithelial barriers. Acute onset of bilateral pulmonary infiltrates w/o pulmonary edema

A client is diagnosed with pericarditis. What symptoms will be the nurse's priority for treatment?

Acute pain

Acute Radiation Syndrome (ARS) Improbable Survivors

Acutely ill with N/V/D and shock!! Neuro symptoms suggest a lethal dose.

medical management for Kawasaki disease

Administer IV immunoglobin within the first 7-10 days to prevent aortic aneurysm or coronary artery damage -Give acetaminophen even though it doesn't work -In acute phase high doses of aspirin in four divided doses daily and a single infusion of IV immunoglobulin

What would you do first administer a bronchodilator or perform CPT?

Administer the medication before CPT to help the bronchi dilate and hopefully help the kid expectorate the mucus.

SVT classification

Adults: If the rate is greater than 150 bpm - we call it SVT (supraventricular tachycardia) Children: greater than 200 bpm

Pathophysiologic changes from a major burn

Affects all body systems!! -Respiratory function compromised -Dysrhythmia, circulatory failure -Massive infection -Fluid & electrolyte imbalance -Hypothermia

Post-Burn nutrition

Albumin level - indicates patient's nutrition level Total Protein

AVPU

Alert, Verbal, Pain, Unresponsive

Calcium Channel blockers contraindications

Allergy Heart block or sick sinus syndrome Renal or hepatic dysfunction Pregnancy or lactation

Nitrate contraindications

Allergy Severe anemia (less RBCs to move oxygen) Head trauma or cerebral hemorrhage Pregnancy and lactation CAUTION: hepatic or renal disease. Hypotension, Hypovolemia, and conditions that limit cardiac output

Cardiac Glycoside Contraindications

Allergy Ventricular tachycardia or fibrillation; heart block; or sick sinus syndrome Idiopathic hypertrophic subaortic stenosis Acute MI, renal insufficiency, and electrolyte abnormalities Caution: pregnancy & lactation; pediatric & geriatric patients

Wilms tumor

Also known as nephroblastoma. The most common malignant tumor of the kidneys. It affects the left kidney mostly (both kidneys in 10% of cases). It is a rapidly growing tumor and prognosis is dependent on staging at diagnosis and if any metastasis has occurred. Rapid changes in diaper sizes or feeling a mass in the abdomen are common signs in kids. Avoid palpating the kids abdomen at all costs can lead to a ruptured kidney.

Cholesterol meds safety

Always ask what their cholesterol level is Ask their kidney and liver function - check ALT, AST, BUN, Creatinine

Cardiac Med safety

Always ask when the pt's LMP was and if they are pregnant/breastfeeding!!

Homocysteine

Amino acid linked to development of atherosclerosis b/c it can damage endothelial lining of arteries and promote thrombus formation Elevated levels indicate high risk for CAD, stroke, and PVD Genetic factors and diets low in folate, B6, and B12 are associated w/ high levels Requires a 12-hour fast Optimal = less than 12 borderline = 12-15 high risk = greater than 15

Nitrate examples

Amyl nitrate Isosorbide dinitrate (Isordil) Isosorbide mononitrate (Monoket) Nitroglycerin (Nitro-Bid, Nitrostat)

Atrial Septal Defect

An abnormal opening between the left and right atrium that causes oxygenated blood from the left atrium to cross back to the right atrium. It causes deoxygenated blood to mix with oxygenated blood.

Pertussis (Whooping cough)

An acute infectious respiratory disease that has an incubation period of 6-20 days and usually occurs in infancy. Characterized by short rapid coughs followed by crowing or whooping sound upon inspiration. This is transmitted by direct contact or droplet spread and is treated with erythromycin and supportive care. Potential complications include pneumonia, hemorrhage, and seizures. DTAP vaccine given at 2,4,6,15 months helps prevent this

Guillian-Barre Syndrome

An acute rapidly progressing autoimmune condition that is the potentially fatal form of polyneuritis. It results in widespread inflammation and demyelination of the peripheral nervous system. It begins in the lower extremities and moves upwards. Possibly caused by a viral or autoimmune reaction.

Kawasaki Disease

An acute systemic vasculitis that can cause damage to heart vessels including the coronary arteries that supply blood flow to the heart. This disease can bring about permanent damage to the main arteries of the heart resulting in the formation of an aneurysm of the aorta.

Croup

An acute viral disease of infants and children that follows a upper respiratory tract viral infection that descends into the lower respiratory tract. This leads to inflammation of the larynx, trachea, and bronchi.

Myasthenia Gravis

An autoimmune disease characterized by the fluctuating weakness of certain skeletal muscle groups. Nerve impulses fail to pass at the neuromuscular junction resulting in muscle weakness.

Scarlet Fever

An infectious bacterial disease that is caused by group A beta hemolytic streptococci. It can be spread through direct contact with contaminated articles or by droplet spread.

Tuberculosis

An infectious disease that is caused by inhaling droplets of mycobacterium tuberculosis. People at high risk include homeless, impoverished, incarcerated, and children exposed to infected adults.

Rheumatic Fever

An inflammatory disease that peaks in school-age children normally 2-4 weeks after a streptococcal infection. It is the most common cause of acquired heart disease in children. It usually affects the aortic and mitral valves of the heart.

Celiac Disease

An inherited autoimmune disorder characterized by a severe reaction to foods containing gluten. It most common affects the small intestine but can affect any part of the GI system. When these proteins are ingested the immune system begins damaging the inner lining of the small intestine and destroying the villi. The function of the villi is to absorb nutrients into the bloodstream.

Pyloric Stenosis

An obstructive disorder in which the pyloric sphincter is obstructed and narrowed mechanically making it difficult for the stomach to empty properly.

Aortic stenosis

An obstructive narrowing that is present at the aortic valve. Oxygenated blood that flows from the left ventricle into systemic circulation is diminished.

Glucose-6-phosphate dehydrogenase (G6PD) deficiency

Anemia caused by a hereditary X-linked defect in RBC metabolism.

Pernicious anemia

Anemia caused by a lack of mature erythrocytes caused by the inability to absorb vitamin B12 into the bloodstream due to an absence of intrinsic factor.

Iron deficiency anemia

Anemia caused by inadequate iron intake

Aplastic anemia

Anemia characterized by an absence of all formed blood elements caused by the failure of blood cell production in the bone marrow.

When should kids receive influenza vaccines?

Annual vaccination starting at 6 months old. 1-2 doses each year up to age 7-10.

Digoxin toxicity

Anorexia, Nausea, vomiting, malaise, depression, irregular heart rhythms (heart block, atrial arrhythmias, and V-tach) *low potassium can cause dig toxicity

Nutrition in preschoolers

Appetite decreases because growth slows and they become picky eaters which leads to them needing a higher quality diet because calorie intake is reduced. By the age of 5 the child is more agreeable to trying new foods.

When does the anterior fontanelle usually close?

Around 12-18 months

S/S of aortic regurgitation

Asymptomatic Forceful heartbeat (head/neck), marked arterial pulsations, DOE, fatigue, s/s of Left Ventricular failure We will hear High-Pitched, blowing diastolic murmur at 3rd/4th intercostal space at the left sternal boarder Widened pulse pressure, water hammer Corrigan's pulse DX: Echo, TEE (Echo Q6Month if symptomatic; Q2-5 yrs if asymptomatic)

S/S Aortic Stenosis

Asymptomatic DOE, orthopnea, paroxysmal nocturnal dyspnea, pulmonary edema, dizziness, syncope, angina pectoris low to normal BP, low pulse pressure We will hear LOUD, harsh systolic murmur over the aortic area, S4, vibrations over the base of the heart Dx by Echo, ECG will show left ventricular hypertrophy

s/s of mitral valve prolapse

Asymptomatic, fatigue, SOB, lightheaded, dizzy, syncope, palpitations, chest pain, or anxiety We may hear mitral click (1st and only sign); murmur from regurgitation, and s/s of heart failure DX w/ Echo

When does the foramen ovale close?

At birth due to the pressure in the left atrium exceeding the pressure in the right atrium.

Risks after extubation

Atelectasis: alveoli collapse Turn cough and deep breath- to help mobilize secretions Incentive Spirometer - 2 times every hour Stridor—squeaky- due to very narrow opening (Stridor following extubation must be reported immediately.

Eczema

Atopic dermatitis Clinical manifestations: Pruritic allergic response, family history of asthma, allergic rhinitis, and dry skin. Medical management: Moisturize the skin and anti-itch creams Nursing interventions/patient teaching:Keep skin well hydrated, prevent scratching, and apply emollient after a bath.

EKG heart rate determination (six second strip)

Atrial rate: count every P wave and multiply by 10 Ventricular rate: count R wave and multiply by 10

Three physiologic characteristics of nodal cells & Purkinje cells are _____________, _______________, and ______________.

Automaticity: the ability to initiate an electrical impulse Excitability: the ability to respond to an electrical impulse Conductivity: the ability to transmit an electrical impulse from one cell to another

Erikson Psychosocial Development stage (Toddlers)

Autonomy vs. Shame and Doubt Ritualization provides sense of comfort (Daily routine is important).

Physical growth of a preschooler

Average growth of 2.5-3 inches/year Average weight gain of 4-5 lbs. a year loss of baby fat and growth of muscle gives the child a more mature appearance.

Status epilepticus treatment

BLS Meds: lorazepam, diazepam, fosphnytoin Labs: glucose, electrolytes

What lab levels should be monitored while on digoxin?

BUN/creatinine, digoxin level, and potassium levels

Pneumonia

Bacterial infection of the lungs that leads to inflammation of the lung parenchyma. Causes include viruses, bacteria, mycoplasma (needs a macrolide antibiotic), and fungi.

Medical management for conjunctivitis

Bacterial: topical ophthalmic antibiotics such as tobramycin, erythromycin, sulfacetamide, or polymyxin Gonococcal: Ceftriaxone Chlamydial: *Oral erythromycin or tetracycline HSV: Topical and systemic antivirals Allergens: Avoid known allergens, cold compresses, and Antihistamines

Medical management of coarctation of the aorta

Balloon dilation (angioplasty) with a catheter and stent where the aorta is narrowed. Surgical repair which removes the narrowed portion of the aorta with an end-to-end anastomosis or graft replacement.

Medical management for pulmonic stenosis

Balloon valvuloplasty via cardiac Cath to relieve stenosis Surgical repair via valvotomy

Burn pt - respiratory assessment

Be on the lookout for: -Stridor -Drooling -Dyspnea -Hoarseness **Means airway is COMPIRMISED!!

Surviving Sepsis Campaign Bundle: 6 hour Bundle

Begin vasopressor agents if hypotension is not improved (MAP < 65 mm Hg) after initial fluid resuscitation If hypotension persists after initial fluid administration (MAP <65 mm Hg) or initial lactate was ≥ 4 mmol/L reassess intravascular volume status and tissue perfusion using two of the following assessment parameters: -Measure CVP (goal 8-12 mm Hg) -Measure Scv¯O2 (goal > 70%) -Bedside cardiovascular ultrasound -Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge

Focal (partial) seizures

Begins or is Limited to one part of the brain May evolve into generalized seizures - affecting the whole brain Simple partial or "focal onset aware seizure": no loss of awareness of surroundings Complex partial seizures "Impaired awareness seizures": -Not aware of surroundings -lasts 1-2 minutes -May have aura -Include automatisms -May spread to both sides of the brain

Indicators of Pain in Infants

Behavioral -Facial expressions, body movements, and crying Physiologic -Changes in HR, RR, B/P, O2 Sat levels, vagal tone, palmar sweating, and plasma cortisol or catecholamine levels

Dobutamine

Beta 1 inotropic agonist (positive contractility) that stimulates myocardial beta receptors to increase the strength of contractility and improve cardiac output.

Developmental Hip Dysplasia

Birth defect of the hip joint in which the newborn's hips easily become dislocated also called congenital hip dysplasia (CHD).

When should kids receive hepatitis B vaccines?

Birth, 1-2 months, and 6-18 months

Head circumference measurements

Birth: 35cm 3 months: 40cm 9 months: 45cm 3 years: 50cm 9 years: 55cm

Beta Blocker Actions

Blocks beta-adrenergic receptors in the heart and kidneys Decreases the influence of the sympathetic nervous system on these tissues Decreases cardiac output and the release of renin

Atropine

Blocks parasympathetic action (rest and digest) increased SA node automaticity and AV conduction

Phosphodiesterase inhibitors Actions

Blocks the enzyme phosphodiesterase, leads to an increase in myocardial cell cyclic adenosine monophosphate (cAMP), which increases calcium levels in the cell, causing a stronger contraction and prolonged response to sympathetic stimulation Directly relaxes vascular smooth muscle

Vaso-occlusive crisis

Blood Cells start to sickle and can lead to increased destruction of RBCs, tissue ischemia, infarction, and necrosis. This is very painful. causes include dehydration, stress, and weather changes.

Labs and diagnostic tests for infective endocarditis

Blood culture: bacteria or fungus as causative agent CBC count: anemia or leukocytosis Urinalysis: microscopic hematuria Echocardiogram: cardiomegaly, abnormal valve function, area of vegetation, PR interval prolongation, dysrhythmias

Beta Blockers Contraindications

Bradycardia, heart block, cardiogenic shock, Asthma/COPD, pregnancy & lactation

When are the maternal stores of iron depleted from the infant?

By 4-6 months old

Things that can cause heart failure

CAD, HTN, Cardiomyopathy, valvular disorders, renal dysfunction w/ volume overload, and Diabetes

Creatine Kinase and its isoenzymes

CK-MM (skeletal muscle) CK-MB (heart muscle) CK-BB (brain tissue)

Carbon monoxide manifestations

CNS symptoms predominate Skin color is NOT a reliable sign - pulse ox is NOT valid!! Get fresh air immediately!! CPR as necessary Administer O2 (100% or oxygen under hyperbaric pressure Monitor continuously

No grapefruit with which meds?

Calcium channel blockers and statins

Medical management of cardiac failure uses similar methods whether it's left- or right-sided. Measures such as dietary modification, lifestyle changes, meds to reduce dyspnea and relieve anxiety, etc. are all used with one primary intention. The primary goal in the medical management of HF is to reduce _____________.

Cardiac workload

Cardioversion vs Defibrillation

Cardioversion: in sync with QRS, used in AFib, atrial flutter, VT w/ a pulse, SVT Defibrillation: not in sync with QRS, used in VFib and VT without a pulse

What is important to remember before starting antibiotics for someone with bacterial meningitis?

Check and make sure a blood culture has been drawn before starting antibiotics in order to not use up an antibiotic that won't work.

A client has been prescribed furosemide 80 mg BID. The asymptomatic client begins to have rare PVCs followed by runs of bigeminy with stable signs. What action will the nurse perform next?

Check potassium level

Therapeutic management for osteosarcoma

Chemo first to decrease size of tumor then surgical removal of the tumor is needed through a Radical amputation or limb salvage procedure

When a lumbar puncture is performed on a child how is the child positioned?

Child is placed on his or her side with their head flexed forward and knees flexed to the abdomen.

Child Abuse

Child maltreatment that includes physical abuse, sexual abuse, emotional abuse, and neglect. Physical abuse refers to injuries that are intentionally inflicted on a child and result in morbidity or mortality. Sexual abuse refers to involvement of the child in any activity meant to provide sexual gratification to an adult. Emotional abuse may be verbal denigration of the child or occur as a result of the child witnessing domestic violence. Neglect is defined as failure to provide a child with appropriate food, clothing, shelter, medical care, and schooling. Children usually do not want to admit that their parent or relative has hurt them partly from feelings of guilt and partly because they do not want to lose that parent. Abuse and violence occur across all socioeconomic levels but are more prevalent among the poor and the largest percentage of those affected are under 3 years of age. To protect children all states require by law that healthcare professionals report suspected cases of child abuse or neglect

diabetes insipidus

Complication of increased ICP *water deplete problem Decreased levels of ADH = increased urination. Decreased urine osmolality Serum hyperosmolarity Increased Sodium level

SIADH (increased ADH)

Complications of increased ICP *water retain problem Increased ADH causing retention Volume excess, decreased urine output, hyponatremia

Semilunar valves

Composed of three leaflets, shaped like half moons Pulmonic valve and Aortic valve As ventricles contract and intraventricular pressure rises - blood is pushed up against the semilunar valves - forcing them open. The semilunar valves are closed during diastole

Hemosiderosis

Condition of excess iron caused by the large breakdown of red blood cells. Treated with chelation therapy

Frostbite treatment

Controlled but rapid rewarming; 37-40 degrees C Circulating bath for 30-40-minute intervals

Medical management for cardiogenic shock

Coronary cardiogenic shock (Acute MI) Thrombolytic/fibrinolytic therapy -Percutaneous coronary intervention (PCI) -Coronary artery bypass graft (CABG) -Intra-aortic balloon pump (IABP) therapy -Ventricular assist device Oxygenation- NC 2-6 L/min goal 02 sat > 95% Pain control IV morphine also dilates coronary arteries Hemodynamic monitoring- Arterial line, CVP, PA Laboratory marker monitoring: BNP, cardiac enzymes (CK-MB, serial troponin levels), biomarkers lactate, CRP, procalcitonin Transthoracic echo, 12-lead EKG, ST segment monitoring, telemetry Fluid Therapy: Avoid rapid fluid boluses rapid infusion may cause pulmonary edema

What medication is given for muscular dystrophy?

Corticosteroids such as prednisone are given for this condition. -Corticosteroids can cause gastric upset so the medication should be given with food to reduce this risk. -They may mask the signs of infection so the parents need to monitor the child closely for any changes. -Treatment with this drug should not be stopped abruptly due to the risk for acute adrenal insufficiency. -Common side effects of this drug include weight gain, osteoporosis, and mood changes.

How would you prepare a pt for cardioversion?

Crash cart available at bedside Sedation (versed, ativan, etc) Pain management Oxygen Ambu bag w/ mask

What is the best type of fluid to give for a shock patient?

Crystalloid IV fluids (NS or LR) but in an emergency the best fluid is the one you have.

Diagnostic criteria for dehydration

Degree of dehydration is based on % of body weight lost *Mild <3% *Moderate 5-10% *Severe >10%

Beta blocker cautions

Diabetes Peripheral vascular disease Thyrotoxicosis

Safety measures during seizures

During a seizure the child should not be held down in a specific position. Protecting the child's head and body during the seizure is the priority. Ensuring a patent airway is the priority intervention but is not accomplished by loosening the child's clothing or hyperextending his head. The child should be placed on his side and nothing should be inserted into his mouth to forcibly open the jaw.

S/S of Alzheimer's Disease

Early stage you will have mild memory lapses and a decreased attention span. Second stage will have obvious memory lapses Third stage will have total disorientation to person, place, and time and apraxia. Terminal stage will have severe mental and physical deterioration.

Management of pulmonary edema

Easier Prevent than treat Early recognition: monitor lung sounds and for signs of decreased activity tolerance and increased fluid retention Minimize exertion and stress Oxygen (non-rebreather) Position: Upright w/ legs dangling (more blood in periphery = less stress (workload) on the heart IV Meds: Diuretics (furosemide), vasodilators (nitroglycerin)

Laboratory findings in someone who has tumor lysis syndrome

Electrolyte imbalances hyperuricemia and hyperphosphatemia leads to renal stone formation and renal colic. Hyperkalemia and hypocalcemia can lead to life-threatening cardiac dysrhythmias, muscle cramps/weakness, confusion, seizures and end-organ effects on the myocardium, kidneys, and central nervous system.

Medical management for neurogenic shock

Elevate and maintain HOB at least 30 degrees to prevent neurogenic shock when a patient receives spinal or epidural anesthesia. In suspected spinal cord injury neurogenic shock may be prevented by carefully immobilizing the patient to prevent further damage to the spinal cord Patients with neurogenic shock have a higher risk for venous thromboembolism (VTE) formation because of increased pooling of blood from vascular dilation. The nurse must check the patient daily for any lower extremity pain, redness, tenderness, and warmth. PROM of the immobile extremities helps promote circulation. Early interventions to prevent VTE include the application of pneumatic compression devices often combined with antithrombotic agents (low-molecular-weight heparin).

Assessment for child abuse

Elicit the health history noting the chief complaint and timing of onset. Assess for appropriateness of the parent-child attachment (often altered in the case of neglect). Pay particular attention to statements made by the child's parent or caretaker. Is the history given consistent with the child's injury? Identify abuse and violence by screening all children and families using these questions: Questions for children: Are you afraid of anyone at home? Who could you tell if someone hurt you or touched you in a way that made you uncomfortable? Has anyone hurt you or touched you in that way? Questions for parents: Are you afraid of anyone at home? Do you ever feel like you may hit or hurt your child when frustrated? Note nonspecific symptoms of emotional abuse such as low self-confidence, sleep disturbance, hypervigilance, headaches, or stomachaches.

Beta Blockers

Ends in -lol propranolol, atenolol, metoprolol, bisoprolol Side effects: hypotension, bradycardia (AV block), s/s of CHF, drowsiness, depression

Medical management for Transposition of the great vessels

Enlarging or making a atrial septal defect, a balloon septostomy, or a complete correction by switching the great vessels.

Cardiac Stress Test

Exercise stress test: fast for 4 hours, avoid stimulants Pharmacologic stress test: vasodilating agents - dipyridamole (persantine) and adenosine (adenocard) mimic the effects of exercise. Avoid stimulants prior to test - if they have chest pain - STOP test Helps determine: -Presence of CAD -cause of chest pain -functional capacity of the heart after MI or heart surgery -effectiveness of antianginal or antiarrhythmic meds occurrence of dysrhythmias -specific goals for physical fitness program

Cleft lip and palate

Facial malformations that occur during embryonic development. Cleft lip is caused by a failure of the medial nasal and maxillary processes to join. Abnormal development of external nose, nasal cartilages, nasal septum, medial nasal and maxillary processes result from this. Cleft palate is caused by a failure of the palatal shelves to fuse sometimes involving the soft and hard palates. Nursing interventions: Modify feeding techniques to facilitate growth (ESSR method) -ENLARGE the nipple to allow food to be delivered to back of throat without sucking -STIMULATE sucking by rubbing the nipple on the lower lip -SWALLOW\REST Use special feeding devices due to inability to generate suction, hold the child in an upright position introduce a soft nipple into the side and back of the mouth to prevent aspiration. Feed small amounts gradually and burp frequently.

Biological characteristics of sexual maturation during adolescense

Female: 1. Breasts become larger 1st visible sign of maturation 2. Rapid increase in height and weight 3. Menstrual cycle Male: 1. Testicular enlargement 2. Hair- pubic, axial, and facial

Aortic Regurgitation

Flow of blood BACK into the left ventricle from the Aorta during diastole Due to inflammatory lesions, infective or rheumatic endocarditis, congenital abnormalities, Syphilis, dissecting aneurysm, blunt chest trauma, or deterioration of a prior surgically replaced aortic valve

3 Primary Types of seizures

Focal: originated in one hemisphere Generalized: occurs and engage bilaterally Unknown: epilepsy spasms "Provoked": related to acute, reversible condition

headache assessment

Frequency Duration Location Time of day/Seasonal Any aggravating or alleviating factors Triggers Quality or intensity of pain

Antiepileptics

Group of medications that increase protein in the brain that turn off chemicals that lead to migraines. Black Box warning: life threatening liver toxicity and Fetal toxic Do not take during pregnancy (Cat D) Ex: Divalproex sodium (Depakote) and topiramate (Topamax)

Secondary survey

Health history Head-to-toe assessment: reassess airway, breathing, VS Diagnostic and lab testing Monitoring devices: ECG, arterial lines, urinary catheters Splinting of fractures Wound care Other interventions based on condition

Nitrates

Help restore the appropriate supply-and-demand ratio in oxygen delivery to the myocardium when rest is not enough Vasodilator: increases blood flow = more O2 to the area that is injured

Hepatitis Routes of Transmission

Hepatitis A (HAV): Fecal-oral route usually by water and food contaminated with feces. It is the most common form today. Best protection is two dose vaccine. Hepatitis B (HBV): Body fluids, blood transfusions, contaminated needles, neddlesticks, and illicit IV drug use. All health care workers should get the vaccine and use needleless IV access devices if available Hepatitis C (HCV): needlesticks, blood transfusions before 1992, illicit IV drug use, and sharing contaminated straws used for snorting cocaine. Use needleless IV access devices if available

Umbilical hernia

Hernia that occurs commonly in preterm infants and more frequently in African Americans. This is caused by an incomplete closure of the umbilical ring allowing intestinal contents to herniate through the opening of the umbilicus. These are not corrected surgically most children will have spontaneous closure by 4 years of age. Surgical correction is necessary only for the hernias that have failed to close by the time the child is 4 years old.

What can cause the T wave to be interuppted? (tall)

High Potassium or magnesium can cause elevated (tall) T waves

Food Poisoning assessment

How soon were s/s? Immediate onset suggests chemical, plant, or animal poisoning Any unusual taste or odor? Most foods causing bacterial poisoning do NOT have unusual taste or odor Did diarrhea occur? diarrhea is usually ABSENT w/ botulism and fish poisoning Fever? fever is characteristic in salmonella, ingestion of fava beans, and some fish poisoning

Antiepileptics (AEDs)

Hydantoins: phenytoin (Dilantin) and fosphenytoin (Cerebyx) Barbiturates: phenobarbital and primidone (Mysoline) Benzodiazepines: clonazepam (Klonopin) and diazepam (Valium) -Avoid alcohol and ginko can cause severe side effects

What route is commonly used to administer medications such as immunizations

IM

Nursing process (IPPA)

INSPECTION -Color -Respiratory effort -Cough/airway noises -Stridor or wheeze PERCUSSION PALPATION -Tenderness or enlargement of lymph node -fremitus Auscultation -Bilateral lung sounds

What medications are given to stop seizures immediately?

IV Ativan (Lorazepam) or diazepam (Valium)

What med is given to control the seizures?

IV benzodiazepines

Seizure meds

IV meds if you have access: IV Ativan, IV valium *IV is the best way to stop a seizure! * Rectal valium

Erikson Psychosocial Development stage (Adolescence)

Identity vs. Role confusion

acute myocardial infarction

If a coronary vessel becomes completely occluded and is unable to deliver blood to the cardiac muscle the area of muscle that depends on that vessel for oxygen becomes ischemic and then necrotic Resulting in excruciating pain, nausea and severe sympathetic stress reaction

What happens if you missed a dose of your child's digoxin?

If a dose has been missed and more than 4 hours have passed withhold the dose and give the next dose at the regular time. If less than 4 hours have passed give the missed dose.

Irreversible Stage of Shock

If patient reaches this organ damage is so severe that the patient does not respond to treatment and cannot survive. BP remains low despite treatment and the kidneys and liver fail. Respiratory system dysfunction prevents adequate oxygenation & ventilation despite mechanical ventilatory support and the CV system is ineffective in maintaining an adequate MAP for tissue perfusion.

What decreases Cardiac output?

If the heartrate is decreased, the cardiac output will be decreased. With decreased cardiac output - we will have decreased level of consciousness

Medical Management for Impetigo Contagiosa

-Topical antibacterial therapy (mupirocin) applied several times a day for 5-7 days -Soak or wash lesions first and bathe at least once a day with bactericidal soap -Systemic antibiotics may be needed if widespread infection or systemic involvement (amoxicillin, clindamycin, Bactrim, levaquin, or cipro) -Hand hygiene every time a lesion is touched and use separate towels/washcloths

DIC Treatment

-Treat the infection or other causative factor -Plasma replaces clotting factors, ↑ risk of transfusion-related acute lung injury (TRALI) -Platelets (goal 50,000) -RBC: goal 6 - 10 g/dL -IV Heparin thrombosis predominant problem

S/S of Parkinson's Disease

-Tremors -Bradykinesia (Slowed movement) -Rigid muscles (jerky cogwheel-type or ratchet like movements) -Postural instability -Shuffling gait -No arm swinging -Decreased blinking -Lean forward to maintain center of gravity -Pill rolling -Mask like face expression -Slow monotonous slurred speech

Signs and symptoms of aplastic anemia

-Unexplained bruising and bleeding -Pallor -Fatigue -SOB -Tachycardia

How do you relieve hypercyanotic (Tet) or blue spells?

-Use a calm comforting approach. -Place the infant or child in a knee-to-chest position -Provide supplemental oxygen -Administer morphine sulfate (0.1 mg/kg IV, IM, or SQ). -Supply IV fluids

What are some ways we can get a toddler to eat?

-Vary the time, texture, and temperature of the food -Limit sweets and empty calories -Avoid using food as a reward or punishment

Signs and symptoms of Transposition of the great vessels

-Venous blood returning from the right side exits thru the aorta without being oxygenated. Oxygenated blood from the lungs returns via the pulmonary artery to lungs again. -02 sats may be in the 60-70% range (often cyanotic at birth)

What are the four heart defects in Tetralogy of Fallot?

-Ventricular septal defect -Pulmonary stenosis -Right ventricular hypertrophy -Overriding aorta

S/S of multiple sclerosis

-Visual problems -Short term memory loss -Confusion -urinary incontinence -Fatigue (most disabling) -Weakness -Tremors -Loss of balance -Pain and numbness -Swallowing difficulties

Signs and symptoms of GERD

-Vomiting or spitting up in 1st week of life -Aspiration which causes apnea, choking, and gagging -Chronic cough -Wheezing (mistaken for asthma) -Recurrent pneumonia -Poor weight gain and growth -Esophageal ulceration and bleeding -Hematemesis -Melena

Toilet training readiness signals

-Walks well (myelin sheath must be developed well) -Has the ability to communicate the urge to go -Has awareness of a wet or soiled diaper -Can hold urine for 2 hours -Is interested in pleasing parents Bowel control is accomplished first then bladder control

S/S of neurogenic shock

-Warm dry skin -Hypotension -Bradycardia

Determining Children's Doses by Body Weight

-Weigh the child (kids are weighed everyday) -If the child's weight is in pounds, convert it to kilograms (divide the child's weight in pounds by 2.2). -Check a drug reference for the safe dose range (such as 10 to 20 mg/kg of body weight). -Calculate the low safe dose. -Calculate the high safe dose. -Determine if the dose ordered is within this range.

Risk factors for influenza

-Young children <5 years old -Infants -People over 50 years old -Residents in LTC facilities -Pregnant -Immunocompromised -Health care providers

Complications of lead poisoning

-behavioral problems -learning difficulties -encephalopathy -seizures -brain damage

Age related changes of the cardiac system

-loss of function of the cells throughout the conduction system leads to a slower heartrate -Heart size increases due to hypertrophy (thickening of the heart walls), which reduces the volume of blood the chambers can hold -Hypertrophy changes the myocardium - reducing the strength of contraction -Valves stiffen and no longer close properly, resulting in backflow creating murmurs. -CV system takes longer to compensate from increased metabolic demands due to stress, exercise, or illness. Older adults may be symptomatic w/ fatigue, SOB, or palpitations.

Phosphodiesterase Inhibitors adverse effects

-ventricular arrhythmias -hypotension -GI: N/V, anorexia, abdominal pain -Thrombocytopenia -Pericarditis -Pleuritis -Fever -Chest pain -Burning at injection site Drug-to-Drug: Furosemide (precipitates form)

DIC Laboratory studies

-↑ PT (11 - 13 ) -↑ aPTT (21 - 35) -↓ Fibrinogen (150-400) -↓ Platelets (140-450) -↑ D-dimer - Reference range < 0.5µ/mL

Normal digoxin level range

0.8-2.0 mg/L

Epinephrine dose

1 mg Q 3-5 minutes

Burn pt - hourly urine output

1 ml/kg/hour for peds pts

U-bag collection procedure

1. Cleanse the perineal area well and pat dry. If a culture is to be obtained cleanse the genital area with povidone-iodine (Betadine) or per institutional protocol. 2. Apply benzoin around the scrotum or the vulvar area to aid with urine bag adhesion. 3. Allow the benzoin to dry. 4. Apply the urine bag For boys: Ensure that the penis is fully inside the bag a portion of the scrotum may or may not be inside the bag depending on scrotal size. For girls: Apply the narrow portion of the bag on the perineal space between the anal and vulvar areas first for best adhesion and then spread the remaining adhesive section 5. Tuck the bag downward inside the diaper to discourage leaking. 6. Check the bag frequently for urine

In a 10 year old child who weighs 78 pounds how much urine output would be expected in 12 hours?

1. Convert 78 pounds to kg =35 kg 2. Normal urine output for kids is 1-2mL/kg/hr (multiply 1x35 and 2x35) 3. Answers are 35 mL/hr and 70 ml/hr (normal urine output for this child per hour should be between 35-70 mL/hr) 4. Then you take the mL/hr and multiply it by the number of hours asked in the question. (35x12 and 70x12) 5. Answers are 420mL and 840mL. This child should have a urine output between 420-840mL in 12 hours.

A client brought to the ED by a friend who states that the client recently ran out of lorazepam and has been having a grand mal seizure for the last 10 mins. The RN observes that the client is still seizing. What should the nurse do in order of priority - first to last.

1. Page the ED doc and prepare to give diazepam IV 2. Monitor the client's safety and ask the UAP to get the oxygen mask 3. Ask the friend about the pt's medical history and currents medications 4. Document the time, duration, and nature of the seizure's events

IV fluid calculation

100 mL per kg of body weight for the first 10 kg 50 mL per kg of body weight for the next 10 kg 20 mL per kg of body weight for the remainder of body weight in kg

When should kids receive TDAP vaccine?

11-12 years old

When should kids receive meningococcal vaccine?

11-12 years old and 16 years old

When should kids receive MMR vaccines?

12-15 months and 4-6 years old

When should kids receive Rotavirus vaccines?

2 months and 4 months old

When should kids receive Hib vaccines?

2 months, 4 months, 12-15 months

When should kids receive pneumococcal vaccines?

2 months, 4 months, 6 months, 12-15 months

When should kids receive DTAP vaccines?

2 months, 4 months, 6 months, 15 months, and 4-6 years old

Epilepsy

2 or more Unprovoked recurring seizures 1 unprovoked or reflex seizure, plus chance of further seizures of at least 60% after 2 unprovoked seizures, happening over next 10 years Diagnosis of an epilepsy syndrome

Epilepsy diagnosis criteria

2 or more unprovoked, recurring seizures 1 unprovoked or reflex seizure, plus at least 60% chance of further seizures happening in the next 10 years

Physical growth during adolescense

20-25% of total height achieved during puberty. Usually occurs within 24-36 month period Tanner Staging (Give pictures of breasts and penises to show level of development)

A child in status epilepticus has been prescribed phenobarbital 15 mg/kg IV to be administered over 15 minutes. The child weighs 24 kg and the drug is added to a 50-mL minibag. At what rate, in mL/hour, should the nurse administer the drug?

200 ml/hour 1 hour divided by 15 minutes = 4 So multiply 50ml by 4 = 200 ml per hour

Room air oxygen percentage

21%

Gross motor skills (preschool)

3 years old -Rides tricycle -Goes up stairs using alternate feet but may still come down using both feet on step 4 years old -Skips/hops on one foot -Catches ball reliably -Throws ball overhand -Walks downstairs using alternate footing 5 years old -Skips and hops on alternate feet -Throws and catches ball well -Jumps rope -Balances on alternate feet with eyes closed

Fine motor skills (preschool)

3 years old: Builds tower of nine or ten cubes 4 years old: Can lace shoes, use scissors, and successfully cut out pictures 5 years old: Can tie shoelaces (Velcro shoes have put this skill behind)

What CPP would cause irreversible brain damage?

50 mmHg or more

Normal Heart Rate

60-100 bpm

Normal school age/adolescent heart rate

60-100 bpm

At what heartrate does the heart best perfuse at?

60-100 bpm Faster HR shorten diastole, which decreases cardiac perfusion. (this can result in myocardial ischemia)

Preschooler fears

The dark, being left alone, animals, ghosts, and objects/or persons associated with pain. Ways to overcome fear is by actively involving the child in practical method to deal with the frightening experience (nightlight at night)

Patent Ductus Arteriosus

The ductus arteriosus that connects the pulmonary artery to the aorta fails to close within the 1st weeks of life which allows oxygenated blood to shunt from the high-pressure aorta to the low-pressure Pulmonary artery leading to increased blood flow going to the lungs.

Generalized Tonic Clonic/Grand Mal seizures

The most common type of seizures. Usually starts with tonic activity (stiffening of limbs) followed by Clonic activity (jerking). Usually will have an aura before the seizure begins During the seizure breathing may decrease, cease, or be noisy and labored causing cyanosis of lips and nail beds. Bowel and bladder Incontinence may occur.

What should we do as nurses when we suspect compartment syndrome?

The nurse should notify the doctor immediately because Immediate treatment is required to prevent excessive swelling and to detect neurovascular compromise as quickly as possible.

Patient teaching after insertion of baclofen pump

The parents should discourage any twisting at the waist, reaching high overhead, stretching, or bending forward or backward for 4 weeks. The child would avoid tub baths for about 2 weeks Avoid sleeping on his stomach for 4 weeks. The parents should notify the physician or nurse practitioner if the child's temperature is greater than 101.5°F.

A patient w/ restrictive cardiomyopathy taking digoxin presents with symptoms of anorexia, nausea, vomiting, headache, and malaise. What should the nurse expect to be included in the plan of care?

The patient's digoxin dose will be decreased

FiO2 (fraction of inspired oxygen)

The percent of O2 a client receives The ventilator can go up to 100% - before you suction a pt, up them up to 100% at least 20 seconds before you suction them.

period of communicability

The period of time when you are infectious and can spread your germs (whether bacteria, viruses, or parasites) to an uninfected person.

apical impulse or point of maximal impulse (PMI)

The point of maximal impulse is located at the intersection of the midclavicular line of the left chest wall and the 5th intercostal space

Transmission

The way a microbial organism moves from one host to another. (Droplet, airborne, or direct contact)

Cystic fibrosis effects on GI tract

Thick secretions block the cystic ducts leading to cystic dilation, degeneration, and diffuse fibrosis. Prevents the pancreatic enzymes from reaching the duodenum leading to impaired digestion and absorption of fat. Leads to steatorrhea (frothy, bulky, foul smelling stools) and impaired protein digestion and absorption leads to azotorrhea.

Advancing liquid diet

Thin liquids > nectar > honey > pudding-like

Magical thinking

Thinking is egocentric preschoolers believe that thoughts or behaviors are all powerful and that they have control over specific situations. Preschoolers cannot logically reason the cause and effect of an event.

Impetigo

This is caused by S. aureus, streptococci, or a mixed bacterial invasion of the skin. It is a highly contagious inflammatory disorder seen at all ages but particularly in children. The lesions start as macules then they develop into pustulant vesicles and then rupture and form a dried exudate. This is spread by touching personal articles, linens, and clothing of the infected person.

Graft versus host disease

This reaction occurs when the donor lymphocytes initiate an immune response against the recipient's tissues during the beginning of engraftment. This is a major cause of morbidity and mortality in the allogenic transplant population. To prevent this from happening patients receive immunosuppressant drugs such as cyclosporine before their transplant.

Two toddlers are in a sandbox playing and one of them wants the other ones toy. What will happen when the toddler takes the toy?

Toddler will cry because they have egocentric thinking and in his mind the other toddler took his toy.

Physiologic anorexia

Toddlers do not grow as much as they did in infancy so they will become picky with their food choices and not eat very much.

nursing bottle caries

Tooth decay that is the result of prolonged nursing after the infant has been put to bed (when milk, juice, or other fluid is allowed to sit on the teeth).

cholesterol levels

Total Chol <200 mg/dL Trigs: 100-200 mg/dL (stored in adipose tissue and used as energy) LDL < 160 mg/dL (transports cholesterol and trigs INTO cells) HDL: men 35-70 mg/dL HDL: women 35-85 mg/dL (transports cholesterol AWAY from tissue to the liver for excretion)

Medical management of cardiomyopathies

Treat HF: low-sodium diet; exercise/rest regimen; fluid restriction (2 L/day) Control dysrhythmias: antiarrhythmic meds, implanted electronic device (ICD) Anti-coags to prevent thromboembolisms HCM: Avoid dehydration; beta blockers; pacemaker; alcohol septal ablation HCM or RCM: limit physical activity, avoid excessive weight gain DCM & HCM: biventricular pacing may increase ejection fraction and reverses some of the structural changes

What is the therapeutic management for DIC?

Treat underlying cause and Heparin is used at lower dose to counteract the deficiency in the coagulation/anticoagulation pathway.

Cardiac Glycoside Indications

Treatment of Heart Failure A. Fib Atrial flutter Paroxysmal atrial tachycardia

Treatment for fever

Treatments such as sponging the child with alcohol or cold water are not appropriate interventions for fever management. Rather, the nurse would use tepid sponge baths and cool compresses. Administering antipyretics, keeping the child's fingernails short, and monitoring intake and output are appropriate.

Neurogenic Shock

Type of shock that causes vasodilation as a result of a loss of balance between the parasympathetic and sympathetic stimulation. The patient experiences a predominant parasympathetic stimulation that causes vasodilation lasting for an extended period leading to a relative hypovolemic state despite adequate blood flow.

Anaphylactic Shock

Type of shock that is caused by a severe allergic reaction when patients who have already produced antibodies to a foreign substance (antigen) develop a systemic antigen-antibody reaction specifically an immunoglobulin E (IgE)-mediated response. This antigen-antibody reaction provokes mast cells to release potent vasoactive substances such as histamine or bradykinin and activates inflammatory cytokines causing widespread vasodilation and capillary permeability. Most common triggers are foods (especially peanuts), medications, insects, and latex

Cardiogenic Shock

Type of shock that occurs when the heart's ability to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and the tissues. Coronary cardiogenic shock is seen most often in patients with acute MI resulting in damage to a significant portion of the left ventricular myocardium

Temper tantrums in toddlers

Typical until they learn how to deal with frustration by engaging in different actions and verbalizing their feelings -Discipline for a toddler consists of consistency, timing, commitment, and age-appropriate approach -Structured firmness for meeting reasonable expectations, ignoring temper tantrums, praising accomplishments, and a brief explanation as to why a behavior is unacceptable. you cannot reason with a toddler

What would be best post-surgical positioning for astrocytoma?

Unaffected side with the head of the bed flat or at the level prescribed by neurosurgeon. Side lying preferred so child can manage secretions.

Pericardiotomy

Under general anesthesia - a portion of the pericardium is excised to permit the exudative pericardial fluid to drain into the lymph system

Management of hypothermia

Use ABCs; remove wet clothing, rewarm, supportive care Cold blood returning fro the extremities has high levels of lactic acid and can cause potential cardiac dysrhythmias and electrolyte disturbances

Pavlik harness

Used for children with hip dysplasia. It is a abduction harness that is worn for 24 hours a day even when you shower. Needs to be adjusted by doctor ever 1-2 weeks due to rapid growth of child.

Vasoactive medications

Used when fluid therapy alone doesn't maintain MAP. Therapeutic Actions: Increased strength of heart contractility, regulates HR, reduces myocardial resistance, and initiates vasoconstriction Norepinephrine is first choice of vasopressor for sepsis and septic shock. Vasopressin should be adjunct to first line drug causes vasoconstriction and antidiuresis Best administered via a CVL but do not delay if you only have a peripheral line (monitor site closely) and monitor VS at least q15min until stable Titrated based on prescribed dose and parameters and patient's response (keep MAP > 65 mm Hg). DO NOT stop abruptly may worsen shock state

Infectious endocarditis

Usually develops in people with prosthetic heart valves or structural cardiac defects Also occurs in pts who are IV drug abusers and in pts with debilitating diseases, indwelling caths, or prolonged IV therapy Usually bacterial - Staph, streptococci, fungi, and Rickettsiae

what types of rhythms would you defribulate?

V fib V tach pulseless V tach

Who is prone to iron deficiency anemia?

Vegetarians, vegans, premature infants, infants 6-12 months old, toddlers 12-24 months old, and kids going through puberty

normal sinus rhythm (NSR) characteristics

Ventricular and atrial rate: 60- 100 bmp in adult Ventricular and atrial rate: Regular QRS shape and duration: Usually normal, but may be regularly abnormal P wave: Normal and consistent - One in front of every QRS PR interval: Consistent interval between 0.12 and 0.20 seconds P: QRS ratio: 1:1

Atrial Fibrillation

Ventricular and atrial rate: Atrial rate is 300-600 bpm; ventricular rate is usually 120-200 bpm in untreated atrial fibrillation RVR: When rate is greater than 100 bpm Ventricular and atrial rhythm: Highly irregular QRS shape and duration: Usually normal, but may be abnormal P wave: no discernible P waves; irregular undulating waves that vary in amplitude and shape are seen and referred to as fibrillatory or F waves PR interval: Unable to determine P: QRS ratio: Many:1

Atrial flutter

Ventricular and atrial rate: Atrial rate ranges from 250-400 bpm; ventricular rate usually ranges between 75-150 bpm. Ventricular and atrial rhythm: Atrial rhythm is regular; The ventricular rhythm is usually regular but may be irregular because of change in the AV conduction QRS shape and duration: Usually normal but may be regularly abnormal or may be absent. P wave: Saw-toothed; these waves are referred to as F waves. PR interval: Unable to determine P: QRS ratio: 2:1, 3:1, 4:1

3rd degree AV block (complete heart block)

Ventricular and atrial rate: Depends on the escape rhythm and underlying atrial rhythm, but the ventricular rate is lower than the atrial rate. Ventricular and atrial rhythm: The PP interval is regular and the RR interval is regular, but the PP interval is not equal to the RR interval. QRS shape and duration: Depends on the escape rhythm; with junctional rhythm, QRS shape and duration are usually normal; with idioventricular rhythm, QRS shape and duration are usually abnormal P wave: Depends on the underlying rhythm PR interval: Very irregular P: QRS ratio: More P waves than QRS complexes. QRS is regular = 3rd degree block!! Pt will get pacemaker!

Premature Atrial Complex

Ventricular and atrial rate: Depends on the underlying rhythm Ventricular and atrial rate: Irregular due to early P waves, creating a PP interval that is shorter than the others. QRS shape and duration: The QRS that follows the early P wave is usually normal but may be abnormal. It may even be absent. P wave: The early P wave may be seen or may be hidden in the T wave; other P waves consistent PR interval: The early P wave has a shorter-than-normal PR interval, but still between 0.12 and 0.20 seconds P: QRS ratio: usually 1:1 Caused by: caffeine/nicotine overuse, stress, hiccups

ventricular tachycardia

Ventricular and atrial rate: Ventricular rate 100 to 200 bpm; atrial rate depends on the underlying rhythm Ventricular and atrial rhythm: Usually regular; atrial rhythm may also be regular QRS shape and duration: Duration is 0.12 seconds or more; bizarre, abnormal shape P wave: Very difficult to detect, so the atrial rate and rhythm may be undeterminable. PR interval: Very irregular, if P waves are seen P: QRS ratio: Difficult to determine, but if P waves are apparent, there are usually more QRS complexes than P waves Call a CODE - shockable rhythm Check for pulse - you can have pulseless V Tach!! Epinephrine - 1 mg Q3-5 minutes

Sinus Bradycardia characteristics

Ventricular and atrial rate: less than 60 bmp in adult Ventricular and atrial rate: Regular QRS shape and duration: Usually normal, but may be regularly abnormal P wave: Normal and consistent - One in front of every QRS PR interval: Consistent interval between 0.12 and 0.20 seconds P: QRS ratio: 1:1

Idioventricular Rhythm (IVR)

Ventricular rate: Between 20 and 40 bmp; if the rate exceeds 40 bpm, the rhythm is known as accelerated idioventricular rhythm. Ventricular rhythm: Regular QRS shape and duration: Bizarre, abnormal shape; duration is 0.12 seconds or more.

Ventricular fibrillation (V-fib)

Ventricular rate: Greater than 300 bpm Ventricular rhythm: Extremely irregular, without a specific pattern QRS shape and duration: Irregular, undulating waves without recognizable QRS complexes MAKE sure pt is on MONITOR!! Shockable rhythm - Call CODE!!

Growth of the toddler

Weight gain slows to 4-6 pounds/year Height increases by 3 inches/year Elongation of the legs rather than trunk and growth is step like rather than linear.

angina pectoris (chest pain)

When the supply of oxygen and nutrients in the blood is insufficient to meet the demands of the heart, the heart muscle "aches" The heart requires a large supply of oxygen to meet the demands placed on it

How do you know the pt is ready for exubation?

When vent settings are close to breathing over vent, more purposeful When pt tolerates weaning down ABG normalizing -PO2 greater than 80%

Pacemakers

Why? heart block, perfusion interrupted. 3 types: internal, external, and internal that works as defibrillator too Internal: permanent (atrial, ventricle, or both *dual paced) External: awaiting surgery, usually not permanent Internal w/ Defibrillator: AICD pt has had a lethal arrhythmia in the past Post-Op Risk for dislodgement, Infection risk, malfunctioning post-op. No lotions or creams on the site - do not stimmulate. DO NOT RAISE arms above shoulders for 2 wks!! No heavy lifting!! Wear loose, baggy clothing. Nothing restrictive. No MRI's, magnetic fields, microwave ovens!! Educate patients!! Carry card or bracelet for pacemaker!! No "wanding" over the site - go through walk-through at airport security.

Is it normal to see a fontanel pulsate or briefly bulge when a baby cries?

Yes however overhydration or increased ICP would cause persistent bulging

Spina Bifida

a congenital defect that occurs during early pregnancy when the spinal canal fails to close completely around the spinal cord to protect it.

A RN teaching a client who has facial muscle weakness and has recently been diagnosed with myasthenia gravis. The RN should teach the client that myasthenia gravis is caused by:

a lower motor neuron lesion

Double diapering

a method used to protect a child's urethra and stent or catheter after surgery and additionally helps to keep the area clean and free from infection.

Spinal shock

a sudden depression of reflex activity BELOW the level of spinal injury -muscular flaccidity, lack of sensation and reflexes

neurogenic bladder

a urinary problem caused by interference with the normal nerve pathways associated with urination

Cardizem (diltiazem)

calcium channel blocker Decreases heart rate

What affects prefusion?

cardiac output affects perfusion -blood pressure -heart rate (too fast - not effectively perfusing)

CK-MB

cardiac specific isoenzyme - found mainly in cardiac cells Increases when there has been damage to the cardiac cells Indicator of acute MI Levels begin to increase within a few hours and peaks within 24 hours of an infarct.

Anthrax

caused by replicating bacteria that release a toxin Incubation: 1-6 days Skin contact: lesions GI ingestion: fever, N/V/D, ab pain Inhalation: 1st stage - respiratory s/s that mimics influenza 2nd stage - severe respiratory distress, hypotension, shock, meningitis, death Treatment: Penicillin V, erythromycin, or doxycycline Mass casualty event: Cipro or doxycycline PO (easy to give)

Exertional heat stroke

caused by strenuous activity that occurs in hot environments

Neurogenic shock

caused by the loss of function of the autonomic nervous system -BP, heart rate, and cardiac output decrease Venous pooling occurs because of peripheral vasodilation Paralyzed portions of the body do not perspire

myocardial infarction

cells in the myocardium become necrotic and die

Reduce risk of burns in toddlers

check water heater - lower temp setting of hot water

Pulmonary agents

chemicals that primarily cause injury to the lungs - Phosgene and Chlorine (both vaporize rapidly causing pulmonary injury) Destroys the pulmonary membrane that separates the alveolus from the capillary bed, disrupting alveolar-capillary O2 transport mechanisms. Capillary leakage results in fluid-filled alveoli. Causes pulmonary edema w/ SOB, especially w/ exertion. Initially hacking cough is followed by frothy sputum production. PPE: particulate air filter mask

Meningitis symptoms

classic triad of headache, neck stiffness and fever -photophobia, vomiting, altered mental status, rash seizure precautions

Ganglia

clusters of cell bodies

neurotransmitters

communicate messages from one neuron to another OR from a neuron to a target cell Includes amino acids, peptides, and monoamines Can either excite or inhibit activity of the target cell Synthesized in the cytoplasm of the axon terminal

Endocardium (inner layer)

consists of endothelial tissue and lines the inside of the heart and valves

S/S poor perfusion/low cardiac output

decreased exercise tolerance muscle wasting or weakness anorexia or nausea unexplained weight loss lightheadedness or dizziness altered mental status resting tachycardia daytime oliguria cool or vasoconstricted extremities pallor or cyanosis

BNP (brain natriuretic peptide)

diagnostic indicator of HF less than 100 = normal Higher the value, the more acute the disease

pulse pressure

difference between systolic and diastolic pressure

Intracranial (Cerebral) Aneurysm

dilatation of the walls of a cerebral artery due to weakness in the arterial wall Exact cause is unknown - could be due to atherosclerosis, congenital defects, HTN, head trauma, or advanced age

ST segment

early ventricular repolarization end of QRS complex to beginning of T wave

Depolarization

electrical activation of a cell caused by the influx of sodium into the cell while potassium exits the cell

Bigeminy PVC

every other beat is a PVC

Epicardium (outer covering of the heart)

exterior layer of the heart

SIADH treatment

fluid restriction (usually less than 800 ml/day) possibly hypertonic saline to pull fluids out

diabetes insipidus treatment

fluids, electrolytes, vasopressors (vasoconstriction to increase pressure)

Frostbite manifestations

hard, cold, and insensitive to touch May appear white or mottled May turn red and painful as rewarmed DO NOT massage or handle; if feet are involved, do not walk

Cephalgia

headache one of the most common physical complaints Many reasons/triggers for pts to get headaches - inflammation, hormones, intracranial regulation, perfusion, genetics, environmental factors, psychological

Beta 1 blockers affect

heart (1 heart) Goal of therapy = decrease heartrate

Restrictive Cardiomyopathy (RCM)

heart walls become stiff Diastolic dysfunction caused by rigid ventricular walls that impair diastolic filling and ventricular stretch. Systolic function is usually normal. Cause unknown, may be associated with amyloidosis & other infiltrative diseases S/S: dyspnea, nonproductive cough, chest pain, s/s of heart failure DX: Echo

G6PD deficiency is an _____________ disorder that effects the functioning of the red blood cells.

hereditary X-linked

PPE level B

high level of respiratory protection (SCBA) but lesser skin and eye protection; chemical resistant suit

What physiologic responses are common to all types of shock?

hypoperfusion of tissues, hypermetabolism, and activation of the inflammatory response

mitral valve prolapse

improper closure of the mitral valve; one or both leaflets' balloons back into the atrium during systole blood regurgitates from the left ventricle BACK into the left atrium

Normal age-related changes

increased systolic blood pressure, increased ventricular wall thickness, increased myocardial fibrosis May have atypical s/s such as fatigue, weakness, and somnolence Decreased renal function can make them resistant to diuretics and more sensitive

Vasopressin

increases systemic vascular resistance and BP

ventriculostomy complications

infection (meningitis) ventricular collapse cath occlusion

Complications of pacemaker

infection, dislodgement, misfires

Chain of infection

infectious agent: Any agent capable of causing infection reservoir: A place where the pathogen can thrive and reproduce portal of exit: A way for the pathogen to exit the reservoir mode of transmission: Direct transmission: Body-to-body contact Indirect transmission: Transferred by fomite or vector or spread by droplet or airborne transmission portal of entry: A way for the pathogen to enter the host susceptible host: Any person who cannot resist the pathogen

carbon monoxide poisoning

inhaled carbon monoxide binds to hemoglobin as carboxyhemoglobin. Carboxyhemoglobin DOES NOT transport oxygen!!

primary blast injury

injuries due to the pressure wave of the blast Pulmonary barotraumas, including pulmonary contusions. Head injuries, including concussion, other severe brain injuries. Tympanic membrane rupture, middle ear injury. Abdominal hollow organ perforation, hemorrhage.

Preload is commonly referred to as:

left ventricular end diastolic pressure

how to diagnose meningitis

lumbar puncture, spinal tap CT head to r/o brain bleed

Myocardium (middle layer)

made up of muscle fibers and is responsible for the pumping action

Preventing heat-induced illness

maintain adequate fluid intake, wear loose clothes, reduce activity in hot weather Replace fluids & electrolytes Plan outdoor activities to avoid hottest part of the day (between 10-2)

Maintain cerebral perfusion

maintain fluid volume Inotropic meds (maintain CPP over 70 mmHg) Hemicraniectomy

CVP (central venous pressure)

measurement of the pressure in the vena cava or right atrium Normal CVP is 2-6 mm Hg

The RN providing d/c teaching to a patient diagnosed with heart failure. What should the nurse teach this patient to do to monitor fluid balance?

monitor weight daily

Thermal (scald) burns

most common burn injury in infants!

PPE level A

most hazardous Self-contained breathing apparatus (SCBA) and vapor-tight chemical resistant suit, gloves, and boots

Axon

moves electrical impulses from the cell body

Stenosis

narrowing; the valve will not open all the way -harder to force blood through it -will hear murmur of blood shooting through the narrow opening when the valve is open

Transient Ischemic Attack (TIA)

neurologic deficit lasting 1-2 hours sudden loss of motor, sensory, or visual function s/s result from temporary ischemia to a specific region of the brain - but no evidence on CT scan **may serve as a warning sign of a stroke (about 15% of the time)

What is the difference between triage during a disaster and during non-disaster situations?

non-disaster: Heathcare workers assign highest priority and allocate most resources to the most critically ill pt (acuity) disaster situations: decisions are based on the likelihood of pt survival and he consumption of resources We want to go the greatest good for the greatest number of people

Systemic Inflammatory Response Syndrome (SIRS)

overwhelming inflammatory response may be a protective inflammatory response or response to infection which may lead to sepsis. •Clinical criteria -Temp > 38.3 °C (> 101 °F) or < 36 °C (< 96.8 °F) -Tachycardia -Tachypnea -WBC > 12,000 cells/mm³ or < 4000 cells/mm³ -Bands (immature WBCs) > 10% -Clot formation caused by activated coagulation system

hemiplegia

paralysis of one side of the body

hemiplegia

paralysis of one side of the body The most common motor dysfunction

The heart is encased in a thin, fibrous sac called the ____________?

pericardium (which is composed of two layers)

What laboratory findings assist to confirm DIC?

prolonged prothrombin time (PT), partial thromboplastin (PTT), and activated partial thromboplastin time (aPTT) Increased levels of fibrinogen, fibrin split products, platelets, clotting factors II, V, VIII, X, and antithrombin III.

Magnesium Sulfate

promotes adequate functioning of cellular sodium-potassium pump

Regression

psychoanalytic defense mechanism in which an individual faced with anxiety retreats to a younger stage of development. Example: 10 year old wetting the bed or sucking their thumb

pericardiocentesis

puncture of the pericardial sac to aspirate the pericardial fluid Treatment for pericardial effusion

AV node

rate of 40-60 bpm

SA node (sinus node)

rate of 60-100 bpm

systole

refers to the events in the heart during contraction of the atria and the ventricles semi lunar valves are forced open as blood is ejected from the ventricles

mechanical debridement

removes dead tissue by applying a mechanical force such as whirlpool, scrubbing or wet to moist dressing

automatisms

repeated purposeless behaviors

What does the U wave represent?

repolarization of the purkinje fibers

HF lifestyle modifications

restriction of dietary sodium Cessation of smoking Avoid excessive fluid & ETOH intake Weight reduction Regular exercise

Gyri

ridges on the brain. The "rounded up" part Increases the surface area of the brain

Nitroglycerin

side effects: hypotension, headaches Routes: sublingual, dermal patches, paste, IV sublingual safety: sore in brown bottle, away from light, expires in 6 mths, .....

Multiple trauma

single catastrophic event that causes life-threatening injuries to at least two distinct organs or organ systems Requires a team approach Assume C-spine injury

What is the primary pacemaker of the heart?

sinoatrial node (SA) inherent firing rate of 60-100 impulses per minute

laceration

skin tear w/ irregular edges and vein bridging

Epinephrine

start w/ epi Increases BP (vasopressor) Improves perfusion and myocardial contractility

Preload vs Afterload

stretch vs resistance

transesophageal echocardiography (TEE)

study of the heart via a probe placed in the esophagus NPO 6 hours Informed consent, IV access Monitor VS during procedure Bedrest post-procedure

avulsion

tearing away of tissue from supporting structures

Pericardial effusion

the accumulation of fluid in the pericardial sac

Cardiac Output

the amount of blood pumped by each ventricle in liters per minute -Assess vital signs, skin color, CRT, heart sounds, listen to aorta. Aorta heave/lift: inflammation

Afterload

the amount of resistance to ejection of blood from the ventricle

Who is at an increased risk for abusing a child?

the caretaker or someone who has access to the child

Agnosia

the inability to recognize familiar objects.

Frontal lobe

the largest lob of the cerebral hemispheres located in the front of the brain major functions: concentration, abstract thought, information storage (memory), motor function, judgement, personality, inhibitions, and affect Broca's area - left hemisphere; motor control of speech

The ________________________ supply arterial blood to the heart.

the left and right coronary arteries and their branches

ADHD

the most common neurodevelopmental psychological disorder marked by the appearance by age 7 of one or more of three key symptoms: extreme inattention, hyperactivity, and impulsivity. This is characterized by inattention, impulsivity, distractibility, and hyperactivity.

LOC

the most important indicator of the pt's condition

cardiac tamponade

the restriction of heart function (pumping) because of fluid build up in the pericardial sac Results in decreased venous return and decreased Cardiac Ouput

Clonic activity

the spasmodic jerking of muscles during a seizure

Valve prolapse

the stretching of an AV valve leaflet into the atrium during diastole

Carotid Endarterectomy (CEA)

the surgical removal of the lining of a portion of a clogged carotid artery leading to the brain

Frostbite

trauma from exposure to freezing temps and freezing of the intracellular & intercellular spaces

What is the most sensitive indicator of a myocardial injury?

troponin

What is better tube feedings or gavage feedings?

tube feeding - less likely to aspirate

Dopamine

vasopressor given to increase BP and contractility

What does the QRS complex represent?

ventricular depolarization

QRS complex

ventricular depolarization 0.12 seconds or less in duration (one small box and up to 3 small boxes)

QT interval

ventricular depolarization and repolarization beginning of QRS to end of T wave 0.32 - .0.40 seconds in duration (less than 0.4 seconds)

T wave

ventricular repolarization

What does the T wave represent?

ventricular repolarization

Calcium Antagonists (Calcium Channel Blockers)

verapamil, diltiazem, nifedipine, amlodipine

Occipital lobe

visual interpretation and memory

hemiparesis

weakness on one side of the body

When does the ductus arteriosus close?

within 10-15 hours after birth in the presenece of increased oxygen

patterned wound

wound representing the outline of the object (ex. steering wheel) causing the wound

Concepts for celllulitis

Impaired Skin Integrity -Warm compresses as ordered -Elevation of affected limb -Document wound size, drainage, shape, color, and location distribution -Medicate as ordered prior to dressing change Infection -Administer antibiotics as prescribed -Assess VS every 4H -Assess lab values -Assess wound -Keep fingernails short -Avoid school/day care for 24 - 48 hours *Trace outer edges of wound and monitor progression

Vesicants

blister agents - Lewisite sulfur mustard, nitrogen mustard, phosgene Causes blistering and burning; respiratory effects can be serious and cause death Decontaminate w/ soap & water; do not scrub or use hypochlorite solutions Eye exposure requires copious irrigation Respiratory exposure requires intubation and bronchoscopy to remove necrotic tissue Treatment for Lewisite exposure: dimercaprol IV or topically

Cardiac Glycoside Actions

Increases intracellular calcium, allows more calcium to enter the myocardial cell during repolarization Increases renal perfusion with a diuretic effect Decrease in renin release and slowed conduction through the AV node

Stages of infectious disease

Incubation period: The time from entrance of the pathogen into the body to appearance of first symptoms. During this time pathogens grow and multiply Prodromal period: The time from onset of nonspecific symptoms such as fever, malaise, and fatigue to more specific symptoms. Illness: Time during which child demonstrates signs and symptoms specific to an infection type. Convalescence: Time when acute symptoms of illness disappear

Erikson Psychosocial Development stage (School-age)

Industry vs. Inferiority -Movement from egocentric to objective thinking seeing other's points of view, seeking validation, and asking questions -Difficulty dealing with remote, future or hypothetical matters, learns alphabet, reading, tells time, and relates to timing of events of history -Development of various mental classifying and ordering activities

Common types of burns

Infants: thermal burns from flames or hot water Toddlers: Hot water - check hot water heater setting, grease, chewing cords, contact burns, or chemical ingestion Preschool: Contact w/ hot appliances School-age: Playing w/ matches, fireworks, climbing high-voltage towers

Acute Otitis Media

Infection of the middle ear that is usually associated with an upper respiratory tract infection and is most commonly seen in young children. 70% of infants have at least once case by a year old peaks during the first 2 years of life. Due to the horizontal position of the pediatric ear drum the middle ear has difficulty draining causing fever and pain.

Pericarditis

Inflammation of the pericardium Many causes! Potential complications: pericardial effusion and cardiac tamponade Usually viral: HIV virus, coxsackievirus, influenza s/s: new heart murmur, friction rub at left lower sternal border

Calcium Channel Blockers Actions

Inhibit the movement of calcium ions across the membranes of myocardial and arterial muscle cells, altering the action potential and blocking muscle cell contraction

Calcium Channel Blockers

Inhibit the movement of calcium ions across the membranes of myocardial and arterial muscles Amlodipine (Norvasc) Diltiazem (Cardizem) Nicardipine (Cardene) Nifedipine (Procardia) Verapamil (Calan)

Erikson Psychosocial Development stage (Preschool)

Initiative vs. Guilt -Feelings of guilt, anxiety, and fear may result from thoughts that differ from expected behavior. Preschooler shifts from egocentric thinking to social awareness and is able to consider other viewpoints.

secondary blast injury

Injury results from debris from the scene or shrapnel from the bomb Penetrating trunk, skin, and soft tissues injuries. Fractures, traumatic amputations.

Types of pacemakers

Internal, external, AICD

Intrathecal catheter with baclofen

Intrathecal administration of baclofen has been shown to decrease tone, but it must be infused continuously due to its short half-life. Surgical placement of a baclofen pump will be considered in children with general spasticity that is limiting function, comfort, activities of daily living, and endurance. To test whether it is a suitable option an intrathecal test dose of baclofen will be administered. If the trial is successful, a baclofen pump will be implanted. Once inserted, delivery of the drug can be individualized to meet the child's unique needs. The pump needs to be replaced every 5 to 7 years and must be refilled with medication approximately every 3 months depending on the type of pump. Complications with baclofen pump placement include infection, rupture, dislodgement, or blockage of the catheter.

Nystagmus

Involuntary, rapid, rhythmic, jerking movements of the eyes

Mitral Regurgitation

Involves blood flowing BACK from the left ventricle into the left atrium during systole Caused by degenerative changes of the mitral valve, ischemia of the LV; rheumatic heart disease Could be problems with one or more leaflets, chordae tendineae, annulus, or papillary muscles

Secondary care

Involves screening and early detection activities that seek to identify precancerous lesions and early-stage cancer in individuals who lack S/S of cancer.

Pediculosis Capitis (Head Lice)

It is a scalp infection that is severely itchy and it commonly affects preschool and school-aged children. Clinical manifestations: Intense pruritis the adult louse attaches to the skin and feeds on blood then attaches to the hair shaft and lay eggs that hatch in 7-10 days.

What teaching should be included with a patient receiving cyclophosphamide?

It is important that you have adequate hydration and drink lots of fluids. Also empty your bladder frequently including at least once during the night. This will help prevent kidney and bladder problems and keep your kidneys working well. Complication that could arise is called hemorrhagic cystitis. Antidote for Mesna

Absence seizures (petit mal)

Lapses of awareness, Staring spells, vacant stare Usually occurs in children Start and end abruptly, lasting only a few seconds They do not speak or respond to voice when it is occurring It may not be noticed, or it can be mistaken for inattentiveness No warning or Aura. Once ended the child will return to previous activity as though nothing happened. May occur for several months to years before medical attention Often provoked by hyperventilation

Absence or petit mal seizures

Lapses of awareness, staring spells, vacant stare. These seizures start and end abruptly lasting only a few seconds. Kids do not speak or respond to voice when it is occurring. It may not be noticed or it can be mistaken for inattentiveness can go month to years without diagnosis. No warning or aura. Once ended the child will return to previous activity as though nothing happened. Often provoked by hyperventilation

Heart chamber presssures

Left ventricle has the most pressure (closest to our BP) Atrial lines monitor pressure Central lines go in the right atrium and measure VOLUME.

Why is leucovorin given with methotrexate as part of the chemotherapy regimen?

Leucovorin is the antidote for methotrexate. It works by protecting healthy cells from the effects of methotrexate or similar medications while allowing methotrexate to enter and kill cancer cells.

Acute Lymphoblastic Leukemia

Leukemia which arises during childhood and is commonly seen in kids with trisomy 21. Prognosis is based on WBC count at time of diagnosis, age of the child at diagnosis, and the extent of extramedullary involvement. EMLA cream prior to venipunctures, port access, LP, and bone marrow aspiration is important.

Medical Management for Parkinson's Disease

Levodopa /Carbidopa (Sinemet) -Levodopa is most effect agent primary treatment converted to dopamine in basal ganglia -Carbidopa added to avoid metabolism of levodopa before it can reach the brain -Most beneficial in first couple years. Effectiveness decreases and adverse effects increase after a couple of years develop dyskinesia (bizarre wriggling and writhing movements that involve the face, mouth, jaw, tongue) •Do not hold Parkinson medications prior to surgery -On-off syndrome periods of no effect then periods of return of good effect

Cardiogenic shock

Life-Threatening w/ high mortality rate Decreased Cardiac Output = inadequate tissue perfusion and initiation of shock syndrome S/S: symptoms of HF, shock state, and hypoxia The heart is in shock!!

Dopamine

Low dose 0.5-3 mcg/kg/min does not improve renal blood flow. No longer recommended for this purpose -2-8 mcg/kg/min Improves contractility (inotropic), slightly increases HR (chronotropic) and may increase CO

Nephrotic syndrome diet and medical management

Low to moderate protein with sodium restrictions when large amounts of edema are present Steroids: 2 mg/kg divided into BID doses Prednisone drug of choice.

Generalized Tonic-Clonic Seizures (grand mal)

MOST COMMON -occurs in all age groups Usually starts w/ tonic activity (stiffening of limbs) followed by clonic activity (jerking) Breathing may decrease, cease, or be noisy and labored - therefore, the pt may have cyanosis of lips and nail beds May bite tongue or have episode of bladder & bowel incontinence Post-ictal phase: lethargic, confused, sleepy, and breathing may be irregular. Pt may not remember event.

Neuroblastoma

Malignant tumor composed mainly of cells resembling neuroblasts that occurs most commonly in infants and children. Usually metastasized by the time of diagnosis. Mainly occurs in the abdomen in the adrenal glands. Must be removed surgically then radiation and chemo if it is stage 2 or higher.

How do we manage bleeding and prevent bleeding due to hemophilia?

Manage bleeding by applying direct pressure, applying ice or cold compresses, and elevating extremity. Protect toddlers with soft helmets, padding on the knees, carpets in the home, and softened or covered corners. Children should stay active: swimming, baseball, basketball, and bicycling (wearing a helmet) are good physical activities. Avoid intense contact sports such as football, wrestling, soccer, and high diving. Avoid trampoline use and riding all-terrain vehicles (ATVs). Arrange premedication with Amicar if oral surgery is indicated.

Radiation exposure

May occur d/t nuclear weapon, nuclear reactor incidents, or exposure to radioactive samples Exposure is affected by duration (time), distance, and shielding External irradiation: all of part of the body is exposed to radiation. Decon is not necessary. Not a medical emergency. Contamination: exposure to radioactive gases, liquids, or solids. Requires immediate medical management to prevent incorporation!! Incorporation: uptake of the radioactive material into the cells, tissues, and susceptible organs (kidneys, bones, liver, thyroid) BAD!!! Sequelae of contamination and incorporation can occur days to years later

Victims of Human Trafficking

May present to ED w/ injury, accompanied by boyfriend or travel partner H/O running away, homelessness, self-mutilation Cowering, frightened, agitated, deferring to person accompanying them May c/o injuries, poor healing, abdominal pain, dizziness, headaches, rashes or sores Behaviors: addiction, panic attacks, impulse control, hostility, suicide ideations

Reticulocyte count

Measures the ability of your body to make RBCs. Extremely high in anemia except for aplastic anemia.

Management of ingested poisons

Measures to remove the toxin or decrease absorption - Emetics, gastric lavage, activated charcoal, cathartic, administration of antagonist asap Corrosive agents (acids, alkaline) cause destruction of tissues by contact. DO NOT induce vomiting with corrosive agents!!

Hydroxyurea

Medication that increases fetal Hgb production in the bone marrow and dilutes the formation of abnormal Hgb S.

Medical management for Alzheimer's Disease

Memantine (Namenda) This drug works in another brain cell communication network and slows the progression of symptoms with moderate to severe Alzheimer's disease. For agitation Lorazepam and Haldol. For dementia Cognex and Aricept. Nutrition includes finger foods, frequent feedings, and encourage fluids.

Left sided valve disorders

Mitral valve disorders: -Mitral valve prolapse -Mitral regurgitation -Mitral stenosis Aortic valve disorders: -Aortic regurgitation -Aortic stenosis

What position do you put a patient in hypovolemic shock in to help redistribute fluids?

Modified Trendelenburg with legs elevated to increase venous return to the heart

RN management Balloon Valvuloplasty

Monitor for HF and emboli Assess heart sounds Q4 hours Same care as post cardiac cath

Dilated Cardiomyopathy (DCM)

Most common cardiomyopathy Diminished contractile elements and diffuse myocyte necrosis. Results in poor systolic function Significant dilation of the ventricles without simultaneous hypertrophy & systolic dysfunction DOE, fatigue, s/s of heart failure Diastolic & Systolic murmurs, extra heart sounds (S3, S4) MANY diseases/conditions can cause this (pregnancy, ETOH, viral infection, flu, chemo drugs) Idiopathic DCM: cause unknown, could be familial genetics Treatment: Biventricular pacing

Intussusception

Most common cause of intestinal obstruction in children between 3 months and 3 years of age. The most common site is the ileocecal valve. This disease results in telescoping of one portion of the intestine into another part. Nursing interventions: Observe patient for at least 24 hours for recurrence, NPO (NG tube) to low intermittent wall suction, IVF until bowel sounds return then a gradual intro to oral feeding, and post-op monitoring for return of bowel sounds and stool.

Post pacemaker placement

NO raising your arm x 2 wks Wear a sling to remind them NOT to lift their arms No microwaves, no MRIs, no magnents No restrictive clothing monitor for s/s of infection

Coarctation of the aorta

Narrowing of the lumen of the aorta where the ductus arteriosus inserts. Results in increased pressure proximal to the defect which causes oxygenated blood from the left ventricle to enter the right ventricle causing blood to become deoxygenated.

Pulmonic stenosis

Narrowing of the opening and valvular area between the pulmonary artery and right ventricle. Increased pressure in right ventricle leads to hypertrophy of the right ventricle and decreased cardiac output.

BNP (brain natriuretic peptide)

Neurohormone that helps regulate BP and fluid volume Secreted by ventricles in response to increase preload w/ resulting elevated ventricular pressure Useful in dx Heart Failure Other dx that will elevate BNP = PE, MI, and ventricular hypertrophy BNP greater than 100 = heart failure

How often do you suction pts who are intubated?

ONLY when they need it!

Signs of child abuse

Observe the parent-child interaction noting fear or an excessive desire to please. Note the infant's level of consciousness. Vigorous shaking in the infant leads to intracranial hemorrhage and shaken baby syndrome. Inspect the skin for bruises, burns, cuts, abrasions, contusions, scars, and any other unusual or suspicious marks. Current or healed scratches or cuts may be found on parts of the body ordinarily covered by clothing in the child who self-mutilates. Burns that occur in a stocking or glove pattern or only to the soles or palms are highly suspicious for inflicted burns. Injuries in various stages of healing are also indicative of abuse. Bruises on the chest, head, neck, or abdomen are suspicious for abuse. Nonambulatory children infrequently experience bruises or fractures.

Medical management for scarlet fever

Penicillin V is the antibiotic of choice for the treatment of scarlet fever. -Respiratory precautions until 24 hrs after antibiotics initiated -Quiet activities -Encourage fluids

Sunsetting sign

Performed by rapidly lowering the infant from upright to supine and looking for the sclera of the eyes to be above the iris

Hydrocele

Peritoneal fluid in the scrotal sac that is a benign finding. This usually resolves spontaneously around 1 year old and is not associated with the development of infertility.

Medical management for Huntington's Disease

Pharmacological therapy the aim is to reduce the chaotic movement, subdue the behavioral issues, and drug therapy for supportive and symptomatic treatment. - Xenazine the only drug approved to treat the symptoms of chorea -Antiparkinsonian medication-may be helpful in treating some of the rigidity Antipsychotics to control behavior and help to decrease anxiety

What are the common treatments used for cerebral palsy?

Physical therapy, orthotics and braces, and occupational therapy

Airborne precautions

Precautions that are designed to reduce the risk of infectious agents transmitted by airborne droplet nuclei or dust particles such as for children with measles, varicella, or tuberculosis.

Diagnosis of ADHD

Presence of six or more of the following in the child 17 years of age and younger: -Failure to pay close attention -Careless mistakes on schoolwork -Difficulty paying attention to tasks or play -Doesn't listen -Doesn't follow through -Doesn't complete tasks -Doesn't understand instructions -Poorly organized -Avoids, dislikes, or fails to engage in activities requiring mental effort -Loses things needed for task completion -Easily distracted -Forgetful -Fidgety or squirmy -Often out of seat -Activity inappropriate to the situation -Cannot engage in quiet play -Always on the go -Talks excessively -Blurts out answers -Has difficulty waiting his or her turn -Often interrupts or intrudes on others

Acute Radiation Syndrome (ARS) Possible Survivors

Present with N/V that persists for 24 hours to 48 hours

What is the primary goal for somebody with hemophilia?

Prevent excessive bleeding factor administration is prescribed- once replaced - clotting factors return to fairly normal levels for a period of time.

Nitrate Indications

Prevention and treatment of attacks of angina pectoris

Calcium Channel Blockers indications

Prinzmental's angina

delayed triage category

Priority #2 - Yellow Color -injuries are significant and require medical care but can wait hours w/out threat to life or limb. Pts get treatment only after all RED pts are treated Stable abdominal wounds w/out evidence of significant hemorrhage, soft tissue injuries, facial wounds w/out airway compromise, vascular injuries w/ adequate circulation, GU tract disruption, fractures requiring open reduction & external fixation, most eye and CNS injuries

Expectant triage category

Priority #4 - Color Black -Injuries are extensive and chances of survival are unlikely even w/ definitive care. Persons in this group should be separated from other casualties, but not abandoned. Comfort measures should be provided when possible. Unresponsive w/ head wounds, high spinal cord injuries, wounds involving multiple anatomic sites and organs, 2nd-3rd degree burns in excess of 60% of total body surface, seizures or vomiting within 24 hours of radiation exposure, profound shock w/ multiple injuries, agonal respirations, no pulse, no BP, pupils fixed and dilated

Seizure Precautions

Priority: Prevent Injury -Protect head and DO NOT PUT ANYTHING IN PATIENTS MOUTH!!! -Place on side with head flexed forward -Bed in lowest position or ease patient to floor -Side rails up and padded -Do not restrain patient -Loosen restrictive clothing -Have oxygen and suction available and hooked up -Oral airway may be needed. Do not attempt to place finger or tongue blade into mouth during seizure. -Provide privacy -Support patient and family physically and psychologically

Management of Sexual Assault victims

Provide support Reduce emotional trauma Gather available evidence for possible legal proceedings Specimen collection, treatment of STIs or pregnancy

AICD (automatic implantable cardioverter defibrillator)

Pts who have HAD a lethal arrhythmia

When caring for a patient in hypovolemic shock who is receiving large volumes of IV isotonic fluids, the nurse should monitor for symptoms of:

Pulmonary edema

Laboratory and Diagnostic Tests Ordered for Pneumonia

Pulse oximetry: oxygen saturation might be decreased significantly or within normal range Chest x-ray: varies according to child age and causative agent Sputum culture: may be useful in determining causative bacteria in older children and adolescents White blood cell count: might be elevated in the case of bacterial pneumonia

Thalassemia Major (Cooley's Anemia)

RBCs become rigid and hemolyze easily Leads to severe hemolytic anemia and to survive the child requires ongoing medical attention, blood transfusions, and iron removal (chelation therapy).

A client with a h/o epilepsy is brought to the ED due to seizure activity. What information about the client is most important for the RN to collect?

Recent medication history

primary care

Reduces the risk of disease through health promotion and risk reduction strategies.

Preload

Refers to the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole. The end of diastole is the period when filling volume in the ventricles is highest and the degree of stretch on the muscle fibers is greatest. The volume of blood within the ventricle at the end of diastole determines preload.

Nitrate adverse effects

Related to the vasodilatation and decreased in blood flow CNS - Headache, dizziness, and weakness GI - Nausea, vomiting CV - Hypotension Misc. - Flushing, pallor increased perspiration

Beta blocker adverse effects

Related to their blockage of sympathetic nervous system CNS: dizziness, fatigue, emotional depression GI: N/V, colitis CV: CHF, decreased cardiac output, and arrhythmias Respiratory: bronchospasm, dyspnea, and cough Drug-to-Drug: Clonidine

What laboratory tests would you most likely see in someone with a wilms tumor?

Renal and abdominal ultrasounds CT scan or MRI of abdomen CBC, BUN, Creatinine all usually WNL U/A may reveal hematuria or leukocytes 24 hour urine collection for urine catecholamine levels will not be elevated with Wilms

Heart Failure

Resulting from structural or functional cardiac disorders that impair the ability of the ventricles to fill or eject blood Characterized by s/s of fluid overload or inadequate tissue perfusion Indicates myocardial disease - either a problem with contraction (systolic) or filling of the heart (diastolic) **most HF is chronic, progressive condition managed with lifestyle changes and meds

Risk factors for child abuse

Risk factors for abuse in children include poverty, prematurity, cerebral palsy, chronic illness, or intellectual disability. Risk factors for being abusers in parents or caretakers include a history of being abused themselves, alcohol or substance abuse, or extreme stress.

Growth of school age child

School-age kids tend to gain 2-3 kg (4.4-6.6 lbs) and grow in length about 2 inches yearly Girls often grow faster than boys and commonly surpass them in height and weight Eager to develop skills and participate in meaningful and socially useful work. Peer approval is strong motivator

Phosphodiesterase Inhibitors

Second class of drugs that act as cardiotonic (inotropic) agents Types- Inamrinone (Inocor): approved only for use in pts w/ HF that have not responded to digoxin, diuretics, or vasodilators Milrinone (Primacor): short-term management of HF in pts who are receiving dig and diuretics

Piaget stages of cognitive development

Sensorimotor: (Birth-2 years) kids use sense and motor abilities to understand the world and coordinates sensorimotor skills that begins with reflexes, develops schema, begins to interact with environment, learns object permanence, and develops thinking and goal-directed behavior. Preoperational: (2-7 years) kids develop egocentric thinking conceptualizes time in present terms only, uses symbols to respect objects, develops more logical intuitive thinking, and gains an imaginative ability. Concrete operational: (7-11 years) understands and applies logical operations to interpret specific experiences or perceptions, more realistic views, improves use of memory, focused on more than one task, develops logical thoughts, understands basic ideas of conversation, and number classification. Formal operational: (12+ years) uses a systemic scientific problem solving approach, recognizes past, present, and future, think about abstractions and hypothetical concepts, an ability to take a broader and more theoretic approach to experience increases.

Parietal lobe

Sensory lobe Analyzes sensory info and relays the interpretation to other cortical areas Essential to a person's awareness of body position in space, size and shape discrimination, and right-left orientation

Hemophilia

Serious life long bleeding disease inherited as an X-linked recessive disorder transmitted by female carriers and is caused by a deficiency in factor VIII which is a necessary component of blood coagulation Classic is type A.

Signs and symptoms of graft versus host disease

Severe diarrhea, mucositis, and a maculopapular rash on the hands and feet

Hypovolemic Shock

Shock state resulting from decreased intravascular volume due to fluid or blood loss. 15-30% decrease in fluid volume causes symptoms. Decompensation: CO drops, BP drops, tissues not perfused

Phosphodiesterase inhibitors indications

Short-term treatment of HF in pts unresponsive to digitalis, diuretics, or vasodilators

Dehydration

Significant loss of water and electrolytes from decreased fluid intake, vomiting, or diarrhea. Fluid output is greater than fluid intake. This is expressed as a % of body weight lost. This can cause electrolyte abnormalities that must be replaced with Pedialyte (ORS) over 4-6 hours 50mL/kg. Do not give Pedialyte with milk or broth. Nursing interventions: Daily weights, monitor I&O closely, monitor VS, thorough assessments, appropriate nutrition, and teach appropriate hygiene and infection control.

A basic and widely used triage system has several categories. What does an emergent category for a patient mean?

Signifying potentially life-threatening injuries or illnesses requiring immediate treatment

Tet spells or blue spells

Spells related to an increased need for oxygen in face of limited pulmonary blood flow. Results from a transient increase in resistance to blood flow to the lungs with increased flow of deoxygenated blood to the body.

Spinal vs. Neurogenic Shock

Spinal: loss of reflex, motor, and sensory function below level of injury. Neurogenic shock: damage to sympathetic nerve that runs along spinal cord bradycardia instead of tachycardia

Sympathetic nervous system effect on the heart

Stimulates Beta 1 receptors - causing: -Increased HR in SA node -Increased atrial contractility -Increased conduction & automaticity of AV node -Increased conduction & automaticity of ventricles

Meningitis caused from what bacteria is most common in newborns and infants?

Streptococcus group B along with Escherichia coli (E.coli)

Nerve agents

Substances that interfere w/ the CNS Sarin, soman, tabun, organophosphates, and VX Inhaled or absorbed percutaneously or sub-Q They inhibit acetylcholinesterase so that acetylcholine is not inactivated - results in hyperstimulation of nerve endings Cholinergic symptoms progressing to LOC, seizures, copious secretions, apnea, and death Treatment: supportive care, atropine, benzodiazepine, and pralidoxime Decontaminate w/ copious amounts of soap & water or saline for at least 20 mins. Blot water - do not wipe off! Plastic equipment will absorb sarin gas

Suctioning rules

Suction OUT never in no longer than 10 seconds at a time 100% oxygen for 30 seconds prior to suctioning avoid suctioning for 20 mins before ABG drawn Assess pt before and after - did it help? Suction ONLY when needed

Medical management for Hirschsprung's disease

Surgical excision of affected portion of bowel in 2 stages: First stage: Temporary colostomy in portion of normal innervated colon just proximal to defect. This allows for a period of rest so normal bowel will regain tone. Second stage: Excise affected segment and pulling normal innervated segment down through the anus when the child is around 20 poiunds.

What is the most reliable diagnostic test for cystic fibrosis?

Sweat chloride test sodium and chloride will be 2-5x greater than the controls

Laboratory and Diagnostic Tests Ordered for Cystic Fibrosis

Sweat chloride test: considered suspicious if the level of chloride in collected sweat is above 50 mEq/L and diagnostic if the level is above 60 mEq/L Pulse oximetry: oxygen saturation might be decreased, particularly during a pulmonary exacerbation. Chest radiograph: might reveal hyperinflation, bronchial wall thickening, atelectasis, or infiltration Pulmonary function tests: might reveal a decrease in forced vital capacity and forced expiratory volume, with increases in residual volume

Cardioverson

Sync w/ R wave

Sub-Q Nitro

Take once every 5 minutes Can repeat up to 3 times Call 911 if you have to take a second dose If pt complaining of headache - let MD know

Patient teaching for fever

Teaching the mother to ensure fluid intake is important because fever can cause dehydration. The child should be dressed lightly. There is no need to call the doctor unless the child's fever lasts more than 3 to 5 days or the fever is greater than 101.5ºF. A rapid rise to a high fever can cause a febrile convulsion but it does not lead to brain damage.

atrioventricular valves

The AV valves separate the atria from the ventricles Tricuspid valve and Bicuspid (mitral) valve (Try before you Buy) Blood returning to the heart fills the atria - putting pressure on the AV valves - so the AV valves are forced open.

Cholinergic Crisis

•Caused by overmedication with cholinesterase inhibitors •Severe muscle weakness with respiratory and bulbar weakness •Patient may develop respiratory compromise and failure

Causes of delirium

•Drugs •Epilepsy/electrolyte imbalance •Liver failure/low oxygen (MI, PE) •Infection •Retention (urine, fecal) •Intracranial •Uremia •Metabolism

Disseminated Intravascular Coagulation (DIC)

•Endothelial tissue inflammation caused by microorganism activating macrophages that stimulate the extrinsic coagulation cascade that produces fibrin. Causes small blood clots to form in vessels and cutting off the supply of oxygen to distal tissues

Risk factors for anaphylactic shock

•History of medication sensitivity •Transfusion reaction •History of reaction to insect bites/stings •Food allergies •Latex sensitivity

When is the diagnosis of Parkinson's disease made?

•Presence of 2 of the 4 cardinal manifestations tremors, rigidity, bradykinesia, postural changes •Positive response to administration of levodopa

Why is enteral nutrition preferred over TPN in shock?

•Promotes GI function through direct exposure to nutrients •Limits infections (IV) & complications associated with total parenteral nutrition (TPN)

Medical management for anaphylactic shock

•Remove causative antigen (d/c antibiotic or scrape stinger out) •Emergency BLS support •Fluid resuscitation massive fluid shifts can occur w/in minutes •IM epinephrine for vasoconstrictive action •Diphenhydramine (Benadryl) IV to reverse histamine effects decreases capillary permeability •Albuterol for histamine-induced bronchospasm •CPR and intubation if cardiac and pulmonary arrest occur

Myasthenic Crisis

•Result of disease exacerbation or precipitating event most commonly a respiratory infection •Severe generalized muscle weakness with respiratory and bulbar weakness •Patient may develop respiratory compromise failure

Risk Factors for neurogenic shock

•Spinal cord injury •Spinal anesthesia •Depressant action of medications

Passive Leg Raise (PLR) Challenge

•Start with patient in recumbent position of 30-45° •Measure CO or SV via monitor (not BP) •Without touching patient use bed controls raise legs 30-45° •Wait 60 seconds and re-measure CO or SV •Return patient to semi recumbent position and reassess CO or SV •If CO or SV increase is at least > 10% the patient is fluid responsive

Laboratory and Diagnostic Testing for kawasaki disease

-CBC count may reveal mild to moderate anemia -Elevated white blood cell count during the acute phase -Significant thrombocytosis (elevated platelet count 500,000 to 1 million) in the later phase. -The erythrocyte sedimentation rate (ESR) and the C-reactive protein (CRP) level are elevated. -Echocardiogram is performed as soon as possible after the diagnosis is confirmed to provide a baseline of a healthy heart or to evaluate for coronary artery or aortic involvement.

S/S of obstructive shock

-CHF but lungs are clear -Pulsus paradoxus: exaggerated blood pressure variation with respiratory cycle -Narrow pulse pressure -Pericardial rub -JVD -Tamponade due to hemorrhage may be rapid > EMD

Respiratory management of cystic fibrosis

-CPT -Bronchodilators -Forced expiration -Aerosolized antibiotics -Home IV antibiotic therapy -Give bronchodilators before CPT to allow the lungs to dilate and allow the kid to expectorate secretions.

ALI/ARDS Diagnostics

-CXR: Bilateral pulmonary infiltrates -Respiratory alkalosis unless due to sepsis then metabolic acidosis -PaO2 low PaCO2 elevated -BNP<100 in ARDS/ALI >100 r/o cardiogenic pulmonary edema -Echocardiography: LV ejection fraction, wall motion, valve abnormalities -Pulmonary artery catheterization: Check PA pressures

Clinical manifestations of increased ICP

-Changes in LOC / AMS -Irregular respirations -Restlessness -Increased drowsiness -Vasomotor responses -Coma (decorticate/deceb/flaccid) = brain dead

Signs and symptoms of rheumatic fever

-Chest pain -SOB -Tachycardia -Fever -Migratory large joint pain -Chorea (Irregular involuntary movements) -Subcutaneous nodules over bony prominences

Signs and symptoms of acute chest syndrome

-Chest pain -Fever -SOB -Tachycardia -Tachypnea -Chest X-ray with a new infiltrate needed to diagnose

Risk Factors for conjunctivitis

-Children who attend school or day care -upper respiratory infection or otitis media -Those that wear contacts

S/S of Huntington's Disease

-Chorea (Abnormal and excessive involuntary movements -Cognitive impairment -Apathy and blunted affect -Ataxia to immobility

Comfort measures for conjunctivitis

-Clean drainage with warm clean cloth- inner canthus outward -Avoid bright lights -Avoid reading -Frequent eye irrigations -Soaking eyelids with cool compresses

Interventions for neurogenic bladder

-Clean intermittent catheterization to promote bladder emptying -Medications such as oxybutynin chloride (Ditropan) to improve bladder capacity -Prompt recognition and treatment of infections -Surgical interventions such as a continent urinary reservoir or vesicostomy to facilitate urinary elimination

Medical management for atrial septal defect

-Spontaneous closure (60% of cases) -Open heart surgery (pericardial patch) at risk for endocarditis -Cardiac Cath to close defect

Intra-abdominal injuries

abdominal trauma can cause massive life-threatening blood loss into abdominal cavity Also ask - "when was the last time you ate?" Ensure airway, breathing, circulation Immobilize c-spine

conductivity

ability to transmit an electrical impulse from one cell to another

arteriovenous malformation (AVM)

abnormal embryonic development that leads to a tangle of arteries & veins in the brain. Common cause of hemorrhagic strokes in young people

Hemorrhagic stoke

about17% of strokes S/S: "exploding headache", decreased LOC

Amiodarone

acts on sodium-potassium and calcium channels to prolong action potential and refractory period

PPE level C

air-purified respirator, coverall w/ splash hood, chemical-resistant gloves and boots

What increases afterload?

arterial vasoconstriction

What decreases afterload?

arterial vasodilation (because there is less resistance to ejection)

What does the P wave represent?

atrial depolarization

Nursing implications while on digoxin

-Check apical pulse for one full minute hold meds if pulse is below 90-110 in infants and young children and 60-70 in older children -Obtain EKG strip and assess fir prolonged PR interval and dysrhythmias -Monitor BUN/creatinine, digoxin level, and potassium levels throughout therapy

Cardiac catheter postprocedural care

-Check the pulses distal to the site -Monitor the temperature and color of extremities -Take vital signs every 15 minutes -Monitor the dressing for bleeding or hematoma -Monitor intake and output -Must lay supine in bed for 6-8 hours after the procedure (NPO and no sitting up) -Another RN only person we can delegate assessments too

automaticity

ability to initiate an electrical impulse

Excitability

ability to respond to an electrical impulse

What is the secondary pacemaker of the heart?

atrioventricular node (AV node)

S/S of cardiogenic shock

-Anginal pain -Dysrhythmias -Tachycardia -Fatigue -Express "feelings of doom" -Anxiety -Hypotension -Narrow pulse pressure -Increased preload ( ↑ CVP) -Pulmonary congestion -Dyspnea -Crackles -↓ CO -↓ UO (oliguria)

Can digoxin be given with food

No - taking digoxin with meals can alter its absorption

Signs and symptoms of iron deficiency anemia

-Angular cheilosis -Pica -chest pain -Pallor -SOB -Tachycardia -Brittle spoon shaped nails

Signs and symptoms of digoxin toxicity

-Anorexia -Bradycardia -Headache -Dysrhythmias -Confusion -N/V -Visual disturbances (blurred vision, yellow vision, and/or halo vision)

Medical management for UTIs

-Antibiotics -Fever management -Increase fluid intake -Cranberry juice -Cotton underwear -Wipe front to back in females -Avoid caffeine it is an irritant to the bladder

Medical management for myasthenia gravis

-Anticholinesterase drugs such as Neostigmine (Prostigmin) and pyridostigmine (Mestinon) -IVIG -Plasmapheresis

Medical management for Amylotrophic Lateral Sclerosis (ALS)

-Antidepressants -Anxiolytics such as lorazepam and midazolam hydrochloride -Mucolytic such as guaifenesin nebulizer with saline or an anticholinergic bronchodilator to thin secretions -Atropine sulfate for drooling and excessive salivation -Muscle relaxers for spasms or cramps -Morphine sulfate for intermittent dyspnea -Riluzole to slow progression and extend survival time -Analgesics -Oxygen -Tracheostomy -PEG tube

Left-sided heart failure

-Anxiety -Tachypnea, Dyspnea, Orthopnea, Hemoptysis, Rales -Cardiomegaly, audible S3, Increased heartrate -GI upset, nausea, abdominal pain -Decreased peripheral pulses -Hypoxia

Risk Factors for ARDS

-Aspiration (gastric secretions, drowning, hydrocarbons) -Drug ingestion and overdose -Hematologic disorders (disseminated intravascular coagulopathy, massive transfusions, cardiopulmonary bypass) -Prolonged inhalation of high concentrations of oxygen, smoke, or corrosive substances -Localized infection (bacterial, fungal, viral pneumonia) -Metabolic disorders (pancreatitis, uremia) -Shock (any cause) -Trauma (pulmonary contusion, multiple fractures, head injury) -Major surgery -Fat or air embolism -Sepsis

Goals of Asthma Management

-Avoid exacerbations (extreme hot or cold temperatures) -Avoid allergens -Relieve asthmatic episodes promptly -Relieve bronchospasm -Monitor function with peak flow meter -Self-management of inhalers, devices, and activity regulation

S/S of Septic Shock

-B/P may remain normal in early stage OR hypotensive -Tachycardia -Hypothermia -Cool pale skin -Bounding pulses -Tachypnea -UO decreased -N/V -Diarrhea -↓ gastric motility - ↑ bilirubin -Thrombocytopenia -Confusion/agitation -Elevated Lactate (lactic acid) •Elevated WBC, C-reactive protein (CRP), procalcitonin

Medical management for intussusception

-Barium enema or water-soluble enema if there is no free air or potential for perforation. Most cases are corrected without surgery via a nonoperative reduction successful in 80% of cases. -Some will have to have a manual reduction and possible resection of nonviable bowel with end-to-end anastomosis.

What labs do we want to monitor in the compensatory stage of shock?

-Bicarbonate -Lactic acid -Sodium -Glucose -BUN and creatinine -Blood cultures

Signs and symptoms of DIC

-Bleeding from venipuncture sites -Bleeding from arterial lines -Purpura, petechiae, and hematomas -Symmetric cyanosis of the fingers and toes

Medical management for aplastic anemia

-Bone marrow transplant (very expensive but can cure) -blood transfusions

Late signs of increasing ICP

-Bradycardia -Decreased motor response to command -Decreased sensory response to painful stimuli -Alterations in pupil size and reactivity -Extension or flexion posturing -Decreased consciousness -Cheyne-Stokes respirations

Causes of seizures

-Cerebrovascular disease -Hypoxemia -Fever (childhood) -Head injury -Hypertension -Central nervous system infections -Metabolic and toxic conditions -Brain tumor -Drug and alcohol withdrawal -Allergies

S&S of the progressive stage of shock

-Rapid shallow respirations -Crackles -Pulmonary edema -Alveoli stop producing surfactant which leads to ALI then ARDS -Dysrhythmias and ischemia -Tachycardia (>150) -Elevated troponins -Agitated/confused -Lethargic -GFR decreases (<125) -Elevated BUN and creatinine -UO < 0.5mL/kg/hr or < 30mL/hr -Elevated ammonia and lactic acid levels -GI bleeding/bloody diarrhea -Increased infections -Widespread ecchymoses, petechiae, and mottled skin -Prolonged coagulation times (PT and aPTT) -Decreased clotting factors and platelets

Risk factors for acute glomerulonephritis

-Recent episode of pharyngitis or other streptococcal infection -Older than 2 years old -Male gender

Signs and symptoms of conjunctivitis

-Red itchy eyes -Severe photophobia -Excessive tearing -Watery, purulent, or white mucoid drainage -Cobblestone appearance to upper inner conjunctiva -Glued eyelids (stuck together after sleeping)

Preventative measures for headaches

-Regular eating and sleeping habits -Avoid MSG, chocolate, sulfites, alcohol, vasodilators, and histamines -Control stress -Low dose beta blockers, antidepressants, antiseizure meds, HRT, and magnesium

GI management of cystic fibrosis

-Replacement of pancreatic enzymes -High protein high calorie diet

S/S of irreversible stage of shock

-Requires mechanical or pharmacological support to maintain a good BP -Erratic HR -Requires Intubation and mechanical ventilation for breathing -Jaundice -Anuria -Unconscious -Profound acidosis

Medical management for diarrhea

-Restore fluid and electrolyte balance -Treat underlying cause -Continue breastfeeding -Teach personal hygiene, ensure a clean water supply, careful food preparation, and proper hand washing

Compensatory Stage of Shock

-SNS causes vasoconstriction, increased HR, and increased heart contractility (maintains normal BP and CO) -Body shunts blood from less vital organs such as the skin, kidneys, & GI tract to the brain, heart, and lungs.

Signs and symptoms of coarctation of the aorta

-Severe CHF -Epistaxis -Cardiomegaly -Bounding pulses in upper extremities -Weak or absent pulses in lower extremities -Blood pressure in upper extremities is 20 mm Hg higher than lower extremities (reverse of normal).

Signs and symptoms of intussusception

-Severe abdominal pain/cramping -Child in fetal position -Vomiting -Lethargy -Palpable sausage-like mass in RUQ of abdomen -Passing a currant jelly stool hallmark sign (feces with blood and mucus).

Contraindications for stress tests

-Severe aortic stenosis -Acute myocarditis or pericarditis -Severe HTN -Unsuspected unstable angina

Most common side effects from antiepileptics

-Severe dermatologic reactions (hydantoins, barbiturates (Dilantin), Succinimides) -Bone marrow suppression -Cardiac arrhythmias

Signs and symptoms of developmental hip dysplasia

-Shortened limb on affected side -Restricted abduction of hip on the affected side -Unequal gluteal folds when the infant is lying prone -Positive ortolani test and a positive Barlow test.

Signs and symptoms of dehydration

-Skin (cool, dry, gray, decreased turgor) -Eyes are sunken -Sunken fontanels -Dry mucous membranes -Decreased LOC -Tachycardia -Prolonged CRT

Signs and Symptoms of ventricular septal defect

-Small defects may be asymptomatic -Fatigue -Poor feedings -A loud holistic systolic murmur -Palpable thrill at point of maximal impulse (PMI).

Medical management for GERD

-Small frequent feedings H2 receptor antagonists Pepcid or PPIs Prilosec, Nexium, prevacid -Thickened formula -Elevate HOB to upright position -Avoid foods that exacerbate acid reflux such as citrus, tomatoes, peppermint, caffeine, and spicy or fried foods -Patients may need to have a surgery that wraps the fundus of the stomach around the esophagus to prevent reflux of stomach contents into the esophagus (Nissen fundoplication)

signs and symptoms of down syndrome

-Small square head -Upward slanted eyes -Flat nasal bridge -protruding tongue -Mottled skin -Hypotonia (low muscle tone)

Risk Factors for multiple sclerosis

-Smoking -Vitamin D deficiency -Epstein-Barr virus infection -HLAS (human leukocyte antigens) on cell wall

Signs and symptoms of mononucleosis

-Sore throat -Fever -Malaise -Lymphadenopathy -Increased lymphocytes & monocytes

Signs and symptoms of hydrocephalus

-Spasticity of lower extremities -Bulging fontanels -Brisk reflexes -Skull asymmetry

Physical Assessment Techniques

Newborn Place to perform Exam: May lie on examination table or in caregiver's lap. Examination Direction: Keep up a running dialog with the caregiver explaining each step as you do it. Infant Place to perform exam: In caregiver's lap or on examination table with caregiver right beside infant. Examination Direction: Continue to explain each step to the caregiver, address child by name, and Perform most invasive parts last. Toddler Place to perform exam: Allow some freedom of movement when possible. Child may stand between seated caregiver's legs or sit on the lap. Examination Direction: Introduce yourself to caregiver and child, explain most steps to the child and all steps to caregiver, allow child to handle instruments, and Perform most invasive parts last. Preschool Place to perform exam: Some may be willing to sit on examination table with caregiver standing close by with hand on the leg. Examination Direction: Allow child to decide the order of the examination; explain what the instruments do and let the child try them; speak to the caregiver before and after the examination. School-age Place to perform exam: Sitting on examination table where they still have eye contact with caregiver. Examination Direction: Include the child in all parts of the examination; use head-to-toe approach with genital examination last. Speak to the caregiver before and after the examination. Adolescence Place to perform exam: Some may be willing to have their caregiver wait outside the examination room. Explain to the caregiver that the teen needs privacy and that he or she should wait outside the examination room. Examination Direction: Speak to the child using mature language. appeal to his or her desire for self-care. Use a head-to-toe approach with genital examination last. Explain confidentiality to caregiver and teen allow time talking with them together and separately.

Valvular heart disorders precautions

Nitro can WORSEN the situation if they have aortic stenosis. More blood out in the body and less blood around the heart - leading to ischemia

Safety with STATINS

No ETOH Simvastatin: take in the PM (because it helps with the side effects and is best absorbed) Bad thing about STATINS = rhabdomyolysis (muscle break down which can cause severe kidney damage!) You can take COQ10 to help with the side effects

What education should be given post operatively for a wilms tumor?

No contact sports keep that other kidney safe.

stable angina

No damage to heart muscle; basic reflexes surrounding the pain restore blood flow

Acute Radiation Syndrome (ARS) Probable Survivors

No initial symptoms or only minimal symptoms - like N/V Symptoms resolve within a few hours

Are children who are placed on transmission-based precautions allowed to leave their room?

No, Children who are placed on transmission-based precautions are not allowed to leave their rooms and are not allowed to go to common areas such as the playroom or schoolroom. Thus, they are at risk for social isolation, Impaired skin integrity, fluid volume deficit, and deficient knowledge may be appropriate but would depend on the infectious disease diagnosed.

Types of heat stroke

Non exertional and Exertional Heat stroke is the failure of heat-regulating mechanisms At risk population: older people and very young people

Cerebral Perfusion Pressure (CPP)

Normal CPP = 70-100 mmHg Goal is between 70-80 mmHg MAP - ICP = CPP

Measuring the PR interval

Normal range is 0.12 to 0.20 second