peds exam 2

GU External defects of the genitourinary tract, such as hypospadias, are usually repaired as early as possible to ensure A.prevention of separation anxiety B.acceptance of hospitalization. C.development of normal body image. D.prevention of urinary tract complications.

C

CARDIOVASCULAR acquired heart disease

arrhythmia - SVT - WPW cardiomyopathy - restrictive - dilated - hypertrophic infection - endocarditis (CHD) collagen vascular disease (autoimmune) - rheumatic fever - 5-15 years, group A strep, can be prevented with strep diagnosis and treatment, relapses common, acute treatment, life long treatment (monthly PCN G, daily ASA) Carditis Arthritis SQ nodules Erythema marginatum Sydenham's chorea Fever Raised ESR/CRP Arthralgia Prolonged PR interval Previous RF - kawasaki - <5 years, acute febrile illness >5-10 days, 3 phases, early recognition and treatment (IVIG, ASA, < 10 days, coronary artery aneurysms) Conjunctivitis (non exudate) Rash (polymorphous non vesicular) Edema (or erythema of hands or feet) Adenopathy (cervical, unilateral) Mucosal involvement (erythema, fissures, crusting)

RESPIRATORY retractions

- sternal - suprasternal - substernal - supraclavicular - intercostal - subcostal

RESPIRATORY respiratory devices

increase percent oxygen (do not assist ventilation) - nasal cannula, basic support, L/min, 25-40%, sterile water humidifier - simple face mask, higher concentration oxygen, >5 L - nonrebreather face mask, more accurate titrate, >40% oxygen, >6 L increase percent oxygen and make breathing easier - high flow nasal cannula, 21-100% oxygen, NG abdominal distention, 1-2 L/kg/min, decrease airway resistance - CPAP, obstructive airway disorders, respiratory distress, prevent atelectasis, BiPAP with inspiration, nCPAP (nasal prongs) - intubation or ET tube, compromised upper airway, severe respiratory distress - tracheostomy, long term, permanent, secure airway, speech and breathing

RESPIRATORY interventions

ineffective airway clearance - upper airway - goal - clear the airway impaired gas exchange - lower airway - goal: optimize gas exchange fluid volume deficit - fever - ISWL common respiratory interventions - reassess Q 1-4 hours - conserve energy - cluster care, small/frequent feeds - oxygen support (HHFNC) - suctioning - upper or lower - IVF with Strict I&O - infection control - medications - antibiotics or antivirals, inhalers/nebulizers, steroids - ease respiratory effort - promote comfort, hydration, and nutrition - prevent spread of infection - reduce body temperature - observe for deterioration - provide family support

ENDOCRINE T1DM

glucose goals by age - preprandial non diabetic child: 70-110 mg/dL < 6 years 100-200 mg/dL 6-12 90-180 mg/dL 13+ 90-130 mg/dL - why are goals more liberal - to support growth patterns, higher baseline metabolic demands, safety, cannot report s/s hypoglycemia diagnosis - acute s/s of DM AND random plasma glucose >/=200 mg/dL - fasting plasma glucose >/= 126mg/dL - 2-hour plasma glucose >/= 200mg/dL during an oral glucose tolerance test - glycated hemoglobin (A1C) >/=6.5% - goals in childhood are more liberal often ~7.5-8.5%, need glucose to grow, avoid hypoglycemia in young children who cannot report s/s priority conditions - fluid volume deficit, risk for injury, electrolyte imbalance - fluid resuscitation - replace insulin - stabilize and decrease blood sugar - correct electrolyte imbalances - glucose, Na+, HCO3• K+ - family/patient support management - diet - dietician consult, no concentrated sweets, stable complex CHO at every meal based on calories/day, consistent meal times, carbohydrate grams/insulin ration, exchange diet - exercise - helps the body use glucose more effectively, increases HDL and lowers LDL, lowers blood glucose levels◦ Avoid during peak insulin times, give snack prior to exercise with increase CHO load if >45-60 minutes, increases bone mass and muscular strength, weight-bearing activities, relieves anxiety and stress, increases self-esteem - sick day - continue insulin treatment:◦ Children with type 1 diabetes need insulin to live, illness increases insulin needs, insulin should never be withheld, stay close to meal plan, sick day foods (10-15 g carbohydrates in 4 oz fruit juice), clear liquids that contain carbohydrates can be substituted for solids, give plenty of liquids, hydration is essential to offset diuresis - illness management - OTC medications (alcohol free, sugar free flavoring, decongestants should be avoided, any CHO need to counted) management (DKA) - continuously monitor Q 15 minutes in critical period - VS, respiratory status, neuro/LOC, ECG, strict I&O hourly - glucose levels Q 1 hour - chem panel Q 2 hours - urine ketones with every void - IV access and maintenance of fluids & electrolytes (3 lines), 20ml/kg 0.9NaCl bolus, maintenance/replacement of losses - administer insulin & dextrose complications - DKA - body can't use glucose for energy, thinks in "starvation state" despite excess glucose, utilizes fat/protein as alternate, byproduct of fat metabolism =ketones, ketones are acidic = metabolic acidosis, kussmaul respirations develop to blow off excess acid, early s/s (abdominal pain, n/v, "flu", progresses to dehydration, altered LOC, kussmaul respirations) - hyperglycemia - not enough insulin, larger food intake than usual, less exercise than usual, emotional and physical stress, illness such as cold or flu, puberty, growth spurts - cerebral edema - typically occurs during first 24 hours of treatment, guides principles of slow correction of glucose and electrolytes, immediate intervention, neuro, reduce IVF rate, medications (mannitol, hypertonic 3% NS), advanced airway placement with mechanical ventilation - hypoglycemia - too little glucose, too much insulin, exercise, no IV access (oral carbohydrate (simple, 15 g), repeat if no improvement 15 min, glucagon IM or SQ, follow with some protein and complex carbohydrate), IV access (IV dextrose can be given at a dose of 0.25 g/kg (maximum single dose 25 g), test and monitor blood sugar once symptoms subside)

RESPIRATORY upper airway disorders edema, airway obstruction

epiglottitis - life threatening - bacterial, haemophilus influenza - assessment, 4D - dyspnea, dysphagia, drooling, distress, do not assess oropharynx - urgent intubation - IV abx, IVF - HIB vaccine - s/s - sore throat, pain, tripod positioning, retractions, inspiratory stridor, mild hypoxia, distress croup (larynx/trachea) - self limited - viral - assessment - barky cough, worse at night - symptomatic treatment - cool humidified air, racemic epinephrine, dexamethasone, IVF

GI abdominal pain

- acute vs chronic - medical vs surgical - consider age at presentation - history - onset, duration, tiggers, location, periumbilical most common, associated symptoms (GI, systemic) - abdominal cues - severe localized pain, blood, fever, appears ill, lethargic, losing weight, nocturnal pain, periumbilical pain - assessment - general appearance & activity, growth chart, VS (fever), inspect, auscultate, palpate, percuss, CBC, CMP, UA, inflammatory markers ESR, CRP, pregnancy test, stool cultures +/-, ultrasound vs CT, barium enema and x-rays, endoscopy, colonoscopy

GU development

- amniotic fluid - urine, kidney development, GI & lung development - born with total nephron mass - premature low mass = at risk CKD - kidneys grow through puberty - tubular maturity (2 years), infants unable to concentrate urine, excessive, dilute urine, less responsive to ADH (vasopressin), aldosterone, naturally high K, transient acid/base disturbances common

CARDIOVASCULAR congenital heart disease

- blood flows downhill or from higher to lower pressure - no flow=no grow

CARDIOVASCULAR CHD surgical care

- correct underlying defect - failed medical management - surgical staging - curative vs palliative - interventional cardiac catheter - bleeding - vascular compromise of extremity

RESPIRATORY respiratory distress failure

- distress - compensatory mechanisms maintain oxygenation and ventilation, increased RR, HR, WOB - compare and contrast - WOB, sounds, behavior - respiratory distress becomes failure - air hunger, fatigue, apnea, hypoxemia, poor perfusion - compensatory mechanisms fail - oxygenation and ventilation cannot meet metabolic demands, PO2 < 60 (room air), PCO2 > 50 (acidosis) - ABG interpretation room air (FiO2 0.21)

GU nursing care

- fluid volume deficit (pre-renal AKI) to fluid volume excess (CKD from post-renal) - alteration in urinary elimination - anuria, oliguria, diuresis, polyuria, hematuria, proteinuria - risk for injury - electrolyte imbalances (K+), HTN, respiratory distress, neuro

GI belly aches and kids

- gastroenteritis - appendicitis - functional - constipation - causes other than GI need to be considered

CARDIOVASCULAR priorities

- hemodynamic stability, prevent cardiogenic shock/failure, bridge to surgery (corrective or palliative), transplant - limit secondary complications - get the kids home - educate parents

GI colic

- increased utilization of health service - peaks 4-8 weeks - excessive crying x 3+ hours/day, most days of the week - parental reassurance - no known cause

GU CKD complications

- long term - growth failure - anemia - endocrine disorders (delayed puberty) - metabolic abnormalities and bone deformities - neurocognitive delays - CVD - inflammation, vascular tone & HTN, edema

CARDIOVASCULAR infant/toddler vs adult dynamics

- myocardial tissue less effective <2 years - increased risk cardiogenic shock - decompensate quickly - cardiac output dependent on HR = FAST baseline, Ca+, glucose and volume, less reserve to meet increased metabolic demands, unstable fluid shifts - brachial and femoral pulses - apical pulse x 1 minute fetal vs neonatal dynamics - L heart (high pressure system: arterial) - R heart (low pressure system: venous) - prenatally reversed - fetal pulmonary vascular resistance (PVR) is high, lungs are filled with "fluid" vs. air - R ventricle is dominant in the fetus and carries mixed oxygenated blood

CARDIOVASCULAR patent ductus arteriosus

- pathologic or palliative - can be forced open/close with medical management - Indomethacin vasoconstrict, close duct - Prostaglandin vasodilate, open duct

CARDIOVASCULAR digoxin

- positive inotrope - prescribed in mcg vs mg - narrow therapeutic window 0.5-2.0 mg/mL - apical pulse before - 2 RN dose check - Q12 hours not BID - do not give with food - K+ - do not take extra dose if missed - vomiting

ENDOCRINE priority condition alteration in growth and development

- r/t - over/under production of a hormone, target cells not responsive to hormones (receptor defect) - interventions - hormone management, reduce risk of complications - outcome - optimize growth & nutrition, neuro, physical development

GU kidney function

- regulates fluids and osmolality - regulates electrolyte balance - regulates acid/base balance - removes metabolic waste - urea - excretes medications and toxins - regulates BP - stimulates RBC production - synthesizes various hormones - RAAS erythropoietin - regulates bone formation - conversion of vitamin D, site of action for PTH

RESPIRATORY pediatric differences

- until 4 weeks newborns obligate nose breathers, breathing remains primarily nasal until 5-6 months - infants normally breathe with irregular rhythm (periodic) - children breathe abdominally and diaphragmatically - infant airway width of straw and increases in length until 5 years, tracheal size triples by adulthood - child's flexible larynx susceptible to spasm - tonsillar tissue normally enlarged in early school age - close proximity of trachea to bronchi and its branching structures allows rapid transmission of infectious agent from one anatomic location to another - smaller airways and undeveloped supporting cartilage predispose child to increased risk of obstruction

CARDIOVASCULAR James is a 4-year-old who presents to the clinic with a fever of 104.8 degrees Fahrenheit, red lips, and a "strawberry" tongue. The provider orders a rapid strep test, which is negative. 1. Based on these findings, what condition does the nurse suspect? 2. What causes this condition to occur? 3. What does the nurse tell the mother when she asks how James will be treated?

1. kawasaki 2. autoimmune, reason unknown 3. high dose ASA, IVIG

GI Beau is a 2-day-old male in the newborn nursery who has not passed a stool since birth. On physical assessment, his nurse finds significant abdominal distention, and calls the provider, who orders an abdominal radiograph which reveals a significantly dilated bowel gas pattern. 1. What are some possible diagnoses based on Beau's clinical manifestations? 2. Beau is ultimately diagnosed with__________________________. How was this diagnosed? 3. What interventions should the nurse expect to perform immediately? What is the common treatment regimen for this diagnosis? 4. If Beau's diagnosis went undetected to childhood, what is a common finding associated with this diagnosis?

1. meconium plug/ileus, anorectal malformation, hirschsprungs, atresias 2. hirschsprungs, rectal biopsy, aganglionic colon 3. abdominal distention, tx surgery 4. foul smelling, ribbon like stools

GU renal care plan

excess fluid volume - r/t - AKI resulting in decreased glomerular filtration and fluid retention, hypoalbuminemia secondary to nephrotic syndrome or nephritis, CKD secondary to CAKUT or chronic GN resulting in decrease in urinary elimination - evidenced by s/s pulmonary and systemic overload - azotemia, altered electrolytes, crackles and pleural effusion, decreased UO, dependent edema, moderate blood pressure increase, intake > output, periorbital edema, pleural effusion, puffiness in face, weight gain - outcomes - normal fluid balance as evidenced by absence of edema, VS WNL, balanced intake and output - interventions - Q4 VS, auscultate lung sounds, daily weight, strict I&O, daily abdominal girth, diuretics, maintain fluid restrictions, Q2 position change, elevate edema extremity, low sodium diet

GI disorders

infant puke - GER - motility, benign - GERD - motility, pathologic - pyloric stenosis - obstructive, surgical motility - GER - happy spitters, peaks 4-6 months - GERD - pain, FTT, aspiration, apnea, requires treatment (famotidine, PPI) - interventions - decrease reflux, maintain airway, positioning, diet, burp, education (expectations, CPR) obstructive - pyloric stenosis - look ill and hangry, peaks 2-4 weeks - intussusception - peak age toddlers, telescoping of intestine, decreased tissue perfusion, septic shock/death, surgical emergency, barium enema can be treatment - hirschsprung disease - congenital aganglionic colon, life threatening enterocolitis, assessment (FTT, VS (fever), distended abdomen, BS hyperactive before obstruction, hypoactive AFTER), diagnosis rectal biopsy, rectal irrigation and stimulation management, surgery 1 vs 2 step (temporary ostomy and pull through), lifelong bowel stimulation and regulation - surgical intervention necessary, life threatening, obstruction decreases perfusion to GI tissue/necrosis, recognize surgical disorder, localized severe pain, fever, prepare for surgery (IVF, NPO, pain) structural/congenital - midline defect - cleft lip and palate - trachea esophageal fistula or atresia - prenatal diagnosis, respiratory emergency, 3 Cs coughing, choking, cyanosis, first feeds observed by RN, if three Cs noted stop feed - abdominal wall defects - prenatal diagnosis, inadequate tissue perfusion, risk for infection, sepsis - surgical intervention necessary, life threatening, aspiration, obstruction decreases perfusion to GI tissue/necrosis, recognize surgical disorder, localized severe pain, fever, prepare for surgery (IVF, NPO, pain) inflammatory - appendicitis - acute, surgical, inflammation - inflammatory bowel disease - chronic, FTT, autoimmune - assessment - school age and adolescents, general appearance & activity, VS (fever), inspect, auscultate, palpate, percuss malabsorptive (chronic) - celiac disease - avoid gluten, FTT before diagnosis - cystic fibrosis - malabsorption, pancreatic insufficiency, DM, bowel obstructions

ENDOCRINE function

water and electrolyte balance - water retention - ADH - mineralocorticoids - ACTH energy production and glucose homeostasis - insulin - glucagon - epinephrine - cortisol - GH metabolic rate - thyroid hormones - leptin - ghrelin - resistin - insulin growth and sexual maturity - GH - E/P - LH - oxytocin - prolactin - testosterone circulatory - aldosterone - epinephrine - norepinephrine - renin - vasopressin - cortisol negative feedback system - The hypothalamus stimulates the pituitary gland to secrete "releasing" hormones that stimulate target organs to produce specific hormones. As hormonal secretions of the target organs increase, they signal the pituitary gland to decrease the secretion of the "releasing" hormone

CARDIOVASCULAR CHD decreased pulmonary blood flow tetralogy of fallot

R to L shunt 4 defects - overriding aorta - VSD - pulmonary stenosis - RV hypertrophy tet spell - hyper cyanotic spell - decreased pulmonary blood flow, increased O2 need - caused by stress - crying, feeding, tantrum - interventions - knee to chest, tripod, O2, morphine, phenylephrine, fluid

CARDIOVASCULAR CHD decreased pulmonary blood flow

R to L shunt Decreased blood to lungs - cyanotic complications - chronic hypoxemia - blood bypasses lungs, recycles unoxygenated blood to body, always cyanotic, activity intolerance - extreme cyanosis - R to L shunt, obstructive, blue, dusky, ruddy, O2 not always effective - polycythemia - CVA, compensatory mechanism, to increase O2 to tissues, high hemoglobin, increases blood viscosity (clot) - minimize chronic complications - growth and development delay, thrombosis, neuro (IVH, CVA), CKD, high risk infections, coping

RESPIRATORY 1. A humidified atmosphere is recommended for a young child with an upper respiratory tract infection because it a. improves oxygenation. b. promotes ventilation. c. soothes inflamed mucous membrane. d. liquefies secretions. 2. It is important that a child with acute streptococcal pharyngitis be treated with antibiotics to prevent a. nephrotic syndrome. b. acute rheumatic fever. c. diabetes insipidus. d. otitis media. 3. The most appropriate nursing intervention for a child following a tonsillectomy is to a. encourage gargling to reduce discomfort. b. apply warm compresses to the throat. c. watch for continuous swallowing. d. position the child on the back for sleeping. 4. A 4-year-old child is brought to the emergency department. The child has a "frog like"croaking sound on inspiration, is agitated, and is drooling. The child insists on sitting upright. The priority action by the nurse is to a. auscultate the child's lungs and make preparations for placement in a mist tent. b. examine the child's oropharynx and report the assessment to the health care provider. c. notify the health care provider immediately and be prepared to assist with a tracheostomy or intubation. d. make the child lie down and rest quietly. 5. The mother of a 20-month-old tells the nurse that the child has a barking cough at night. The child's temperature is 37° C (98.6° F). The mother states the child is not having difficulty breathing. The nurse suspects croup and should recommend a. trying over-the-counter cough medicine and coming to the clinic tomorrow if there is no improvement. b. controlling the fever with acetaminophen (Tylenol) and call the primary careprovider if the cough gets worse tonight. c. trying a cool-mist vaporizer at night and watching for signs of difficultybreathing. d. bringing the child to the hospital to be admitted and to be observed forimpending epiglottitis. 6. A child with asthma is having pulmonary function tests. What explains the purpose ofthe peak expiratory flow rate (PEFR)? a. Identifies the "triggers" of asthma b. Assesses the severity of asthma c. Confirms the diagnosis of asthma d. Determines the cause of asthma 7. A 4-year-old boy needs to use a metered-dose inhaler (MDI) of an inhaledcortocosteroid to treat his asthma. What should the nurse anticipate as being requiredto correctly adminster this type of medication? a. An incentive spirometry b. A trial of chest physiotherapy c. A spacer d. A peak expiratory flow meter 8. One of the goals for children with asthma is to prevent respiratory tract infection because infections a. encourage exercise-induced asthma. b. lessen effectiveness of medications. c. can trigger an episode or aggravate asthmatic state. d. increase sensitivity to allergens. 9. The parent of a child with cystic fibrosis calls the clinic nurse to report that the child hasdeveloped tachypnea, tachycardia, dyspnea, pallor, and cyanosis. The nurse should tellthe parent to bring the child to the clinic because these symptoms are suggestive of a. pneumothorax. b. carbon dioxide retention. c. increased viscosity of sputum. d. bronchodilation. 10. An infant with a congenital heart defect is receiving palivizumab (Synagis). Based on thenurse's knowledge of medication, the purpose of this medication is to a. make isolation of the infant with RSV unnecessary. b. prevent secondary bacterial infection. c. decrease toxicity of antiviral agents. d. prevent respiratory syncytial virus (RSV) infection

1. a 2. b 3. c 4. c 5. c 6. b 7. c 8. c 9. a 10. d

ENDOCRINE insulin delivery systems

T1DM or T2DM - current systems - syringes, insulin pens, pumps, continuous glucose monitoring needless - future delivery systems (not yet FDA approved) - powdered inhalers, nebulizers

ENDOCRINE disease

DM - insulin - T1DM - insulin-dependent DM or juvenile-onset diabetes, autoimmune: destruction of beta cells, NO INSULIN, genetic, cystic fibrosis, may account for 5% to 10% of all cases - T2DM - non-insulin dependent DM or adult-onset diabetes, lifestyle, insulin resistance, increasingly being diagnosed in children and adolescents, may be asymptomatic congenital adrenal hyperplasia CAH = addison/adrenal crisis, life threatening - ACTH, cortisol, aldosterone, sex hormones, kewpie doll appearance, dysmorphic features, muscle tone, activity, dehydration, exophthalmos, tachycardia, fatigue, lethargy, pallor, hypothermia, respiratory distress, weakness, wasting, vomiting - glucocorticoids (cortisol) not produced, always an issue, cortisol regulates glucose and metabolism, responds to stress, immune function LACK OF CORTISOL, cannot meet metabolic demands of body, worse case scenario cardiogenic shock - does NOT respond to IVF/ionotropes, need glucose - mineralocorticoids (aldosterone) not produced, not every child affected, aldosterone regulates Na+, K+, volume, and BP LACK OF ALDOSTERONE, excessive salt wasting, hyponatremia, volume depletion, can't regulate BP, hypotension, hypovolemic shock - hypovolemic shock early s/s - VS elevated, weakness, fatigue, n/v/d ,poor suck, hypotonia, alteration in LOC, seizure, hypoglycemia, hypotension, poor perfusion, restore hydration/perfusion - secondary issue - ACTH doesn't "shut off" (loss of feedback), excessive stimulation, hyperplasia of gland, increased androgen (sex hormone) release - females affected/virilization - ambiguous genitalia (birth), precocious puberty, excess muscle mass, advanced bone age, short stature, premature pubic hair, hirsutism, irregular menses, delayed menses CAH education/prevention - home regimen - daily glucocorticoid (hydrocortisone) - divided dosing to mimic normal circadian rhythm - salt additives for excess heat or humidity - sick day management - "stress dose" 2-3 times baseline dose, ED for any s/s that do not improve with home management congenital hypothyroidism - TSH, T3, T4 - absent, underdeveloped, or ectopic thyroid gland - s/s - LGA, puffy face, swollen tongue, hoarse cry, poor muscle tone, cold extremities, constipation, bloated abdomen, lethargic, poor activity, profound cognitive delay, poor linear growth, often appears normal at birth why screening vital - interventions - confirm newborn screening, monitor growth and development, parental education of lifelong thyroid hormone replacement therapy (improvement 7-21 days, single dose am, thyroid levels Q1-3 months) inborn error of metabolism - class of genetic disease - absence or deficiency of an enzyme essential to cellular metabolism - protein, cholesterol, or fat metabolism can be affected - absence of enzyme results in a toxic accumulation of metabolic substance - intellectual impairment, death if not detected/treated PKU - phenylketonuria - inability of liver to produce an enzyme to break down phenylalanine (essential amino acid) - newborn screening, genetics for confirmation - lifelong treatment - dietary restriction of phenylalanine's, special formula first 2 years, low protein diet as child gets older, possible to go off diet after 6-8 years when neurologic development is complete - nursing considerations - education/adherence precocious puberty - sex hormones - onset of puberty - girls before age 6-8 years, boys before age 9 years - appearance of secondary sexual characteristics, advanced growth rate, and bone maturation - major implication - short stature as an adult, premature closure of epiphyseal ends of long bones - idiopathic most common - obesity - diagnostic/endocrine evaluation to exclude secondary - hormone-secreting tumors, brain injury caused by head trauma, thyroid dysfunction, ovarian dysfunction - nursing considerations - psychosocial, body image, bullying, mood swings, physical, delay/reverse pubertal changes, GnRH blocker, monthly lupron injections, implantable devices, discontinue therapy puberty

CARDIOVASCULAR CHD

classification - increased pulmonary blood flow ASD, VSD, PDA - decreased pulmonary blood flow TOF, TGV - obstructive - mixed

GU creatinine

limitations - affected by muscle mass - myth of <1.0 mg/dl infant <. 2 preschool .4 school age .6 adolescent >.8 kidney function - decreased GFR (function), increased serum creatinine, inverse relationship - small bump significant - AKI often unrecognized

RESPIRATORY respiratory disorders

upper (airway obstruction) - croup - epiglottitis lower (impaired gas exchange) - pertussis - bronchiolitis (RSV), pneumonia - chronic lung disease, cystic fibrosis, asthma prevention - vaccines - avoid second hand smoke resistance - immune system deficiency - allergies, asthma - cardiac anomalies - cystic fibrosis - exposure to infection and second hand smoke

RESPIRATORY

#1 cause of cardiac arrest in children is respiratory failure

GU incidence of CKD

- 12-74 cases/million of children <20 years - mean onset 7 years - african american > caucasian - male > female

RESPIRATORY age

- <3 months maternal antibody protection - 3-6 months infection rate increases - toddlers and preschoolers high rate of viral infection - >5 years increase in GABHS and mycoplasma pneumonia (spring and fall) - increased immunity with age

RESPIRATORY Kimberly, age 9 years, is brought to the clinic because of acute respiratory distress. She appears anxious and is clinging to her father. The diagnosis is asthma. 1. Albuterol is ordered to be given via nebulizer. The purpose of albuterol is to a. promote relaxation. b. reduce inflammation. c. relieve bronchospasm. d. correct respiratory acidosis. 2. Kimberly needs instructions about using a metered-dose inhaler (MDI). The nurseshould explain that the MDI is used to a. improve oxygenation. b. assess severity of symptoms. c. distribute prescribed medication directly to airways. d. distribute prescribed medication systemically without the need for injection. 3. Instructions for using the MDI include to a. avoid breathing too deeply. b. breathe medication in slowly. c. hold inhaler in the mouth. d. breathe in through nose and out through mouth. 4. Kimberly's father asks the nurse whether she can still participate in sports. The nurse's response should be based on an understanding that a. exercise should be encouraged. b. exercise should be discouraged. c. organized sports are too strenuous for children with asthma. d. quiet activities such as reading are best for children with asthma.

1. c 2. c 3. b 4. a

ENDOCRINE An 8-year-old who has been healthy has lost weight in the past 2 weeks. His mother noticed that he is getting up several times during the night to go to the bathroom. He was drinking a great deal more in the past week, and she thought that was the reason for needing to use the bathroom. However, today he has a headache and is too tired to go to school. She also notices that he has wet the bed during the night. She becomes alarmed and calls the pediatrician for an appointment the next day. She has a brother with diabetes and thinks that the symptoms are similar to her brother's problems when he was first diagnosed as a child. The next day at the pediatrician's office the nurse performs a history and assessment. Which findings in the child's history and assessment findings would require the nurse to immediately investigate further? Select all that apply. A.Tiredness B. Headache C. Increased thirst D. Increased urination E. Wetting the bed at night F. Oral temperature 98.8 F G. Pulse 60 beats per minute H. Blood pressure= 94/60 mmHg I. Respirations 20 breaths per minute Day 1, 2:30 pm At the pediatrician's office, several tests are completed, and results are listed below. •random blood glucose = 230 mg/dl • hemoglobin (Hgb) A1c level = 10.5%. • hematocrit = 35% • platelets= 250,000/mm3 • white blood cells= 8,000/mm3 • urine dip test is positive for glucose and ketones He is admitted to the hospital for further evaluation to establish a diagnosis. Based on the child's H&P, labs, the nurse suspects a diagnosis of 1, because his 2 and 2 are high. His s/s may be caused by an increased concentration of 3 in the bloodstream. He has met the criteria for the diagnosis of Type 1 Diabetes Mellitus. He will start with a twice-daily insulin regimen combining a rapid-acting (regular) insulin with an intermediate-acting (neutral protamine Hagedorn [NPH]/Lente) insulin. The nurse meets with the mother and patient to begin insulin therapy teaching. The mother asks why two types of insulin are needed. What are the most appropriate responses for the nurse to provide to help the mother and child understand about types of insulin? Select all that apply. A. "Rapid-acting insulin peaks in about 30-90 minutes and may last about 5 hours." B. "Short-acting insulin reaches the blood in about 5 minutes and peaks in about an hour." C. "Extended insulin takes 4 hours to start working and can stay in the blood for up to 14 hours." D. "Intermediate-acting insulin peaks in about 4-14 hours and can stay in the blood for 14-20 hours." E. "Long-acting insulin takes 6-14 hours to start working and can stay in the blood for up to 24 hours." F. "The types of insulin are based on how soon they start working, when the insulin works the hardest and how long it lasts." 1500 the patient experienced hypoglycemia after receiving insulin. he did not eat breakfast after the injection. What are the most important teaching topics for the nurse to include at this time? Select all that apply. A. "Signs of hyperglycemia or high blood sugar include fever, headache, seizures, and cough." B. " The blood sugar should be maintained within a target range of 90 to 180 mg/dl during the day." C. "Signs of hypoglycemia or low blood sugar include headache, dizziness, shaking, sweating and the pulse is fast." D. "Your child should no longer participate in any sports of physical activity that would cause his blood glucose to fall." E. "Learning how to plan meals, understanding specific good groups and making good food choices will be an important part of managing his diabetes." F. "The health care provider should be contacted when your child has fever for 2 days, vomiting and diarrhea, is unable to keep fluids down, and his glucose levels are above the target range."

A, B, C, D, E 1. DM 2. glucose and A1C 3. glucose A, D, E, F B, C, E, F

CARDIOVASCULAR terms

- CARDIAC OUTPUT (CO). HR x stroke volume (volume of blood pumped per beat) - afterload (resistance in pipes) - preload (pump: maximum distension of ventricle prior to ejection) - work load (excessive leads to strain on ventricles) - stenosis, narrow valves/vessels - atresia, membrane closure over valve, no blood flow - septum: fibrous tissues that divides ventricles - shunting, abnormal pathway for blood to flow through heart

CARDIOVASCULAR discharge

- CPR - apnea/cardio monitor training - s/s HF - how to respond to tet spells - nutrition/feeding - medication instructions - how to check pulse, BP, O2 - infection prevention - support groups

CARDIOVASCULAR A.J. is a 4-week-old who is seen in the clinic for a well-check and has a loud, systolic "machine-like" murmur that has not been previously heard. He is tachypneic and his mother reports that he has not been breastfeeding well over the past two days. The nurse also reports auscultating crackles throughout A.J.'s lungs. The provider suspects a persistent patent ductus arteriosus (PDA). 1. What would the nurse expect the provider to order to confirm this diagnosis? 1. Chest radiograph. 2. Complete blood count (CBC). 3. Echocardiogram. 4. Electrocardiogram (ECG). 2. Describe the location and function of the ductus arteriosus in-utero. 3. How, and when, does the ductus arteriosus usually close? 4. What are some of the initial interventions and/or treatments used to attempt nonsurgical closure of a PDA? 5. A.J.'s mother asks if cardiopulmonary bypass is needed during surgery to close the PDA. How should the nurse respond? 6. Under what circumstances would the health care team want the ductus arteriosus to remain open?

1. 3 2. connection/opening between pulmonary artery and aorta, sends the oxygen poor blood to the organs in the lower half of the fetal body--> allows for the oxygen poor blood to leave the fetus through the umbilical arteries and get back to the placenta to pick up oxygen 3. functional closure, approximately within 48 hours after birth, anatomic closure within 14-21 days of life 4. NSAIDS, indomethacin or ibuprofen 5. no bypass is needed, extracardiac 6. if another defect present PDA can allow blood flow

CARDIOVASCULAR The nurse attends a vaginal delivery for a term infant. The infant is born vigorous and breathing well, pinking up rapidly. The infant has a normal hospital course and is discharged home with his parents at 48 hours of life. At 8 days old, the infant presents to the emergency room because he is cold and not breastfeeding well. Assessment findings include bounding pulses in the upper extremities and absent pulses in the lower extremities. The provider examines the infant and suspects coarctation of the aorta(CoA), which is confirmed by echocardiogram. The mother asks, "what does this all mean?" 1. How does the nurse explain this cardiac defect to the mother, specifically the consequences pertaining to the infant's circulation? 2. What differences would the nurse expect to see in blood pressure? 3. What must remain open until surgery is performed? a. Why? b. How will this be accomplished? 4. What surgical interventions will take place?

1. 4 point BP - in all extremities, bounding pulses in UE, weak pulses in LE 2. differences expected UE vs LE 3. blood can shunt between aorta and PA to get oxygen delivered appropriately, prostaglandin IV 4. stent placed or removal/repair the coarctation - dependent upon severity

GU Sam, age 17, was admitted to the hospital three days ago after a motor vehicle accident. He has undergone surgery to repair a fractured femur and several large lacerations.In addition, Sam experienced severe abdominal pain caused by blunt force trauma during the accident, but it is now subsiding. Today, Sam is experiencing high blood pressure and decreased urine output. He has worsening edema. 1.Based on his history and new clinical manifestations, what is the most likely new diagnosis? What lab values would you expect to be elevated? 2. Sam's diagnosis is confirmed to be ______. His parents ask what might have caused this to happen. How do you respond? 3. The most important nursing interventions needed to monitor Sam's renal function include: (select all that apply) A. Strict intake and output B. Abdominal girth C. Dietary intake of sodium and potassium D. Ensure medication safety E. Daily weights F. Complete blood count (CBC) G. Blood urea nitrogen (BUN) and creatinine 4. Sam's condition worsens, and he becomes edematous and increasingly hypertensive. The provider orders a dose of albumin followed by furosemide (lasix) intravenously. The parents ask how these medications work. What is your explanation? 5. After 10 days in the hospital, Sam is making progress and will be discharged home on a sodium- and potassium- restricted diet, until his renal function normalizes. What teaching regarding his diet is incorrect? A. Eating fruits and vegetables is the healthiest option. He should avoid fried foods and those high in fat. B. Protein intake will vary and specific intake instructions will be provided. C. Canned foods and pre-packaged meats should be avoided. D. Sodium-free salt alternatives, such as "NoSalt," may be used as desired

1. AKI 2. AKI, trauma to kidney, acute illness (decreased perfusion to kidney) 3. a, c, d, e, g 4. albumin (pull fluid into intravascular space), lasix (promotes diuresis) 5. d

GU 1. Tara's probable diagnosis is urinary tract infection (UTI). Which of the following are factors that place Tara at risk for developing UTIs A. Anatomical structure B. Recent toilet training C. Submersion in water during bathing or swimming D. All of the above 2. Tara's RN is preparing to educate the nursing student about factors that could lead to the development of urinary tract infections. Which critical aspect should the nursing instructor prioritize to focus on first? A. Maintaining proper hydration B. Urinary frequency C. Concept of urinary stasis D. Over distention of the bladder 3. Tara is admitted to the hospital for intravenous antibiotic therapy. Her urine culture is positive for Escherichia coli, and her antibiotics are changed to better treat this organism. Tara's mother asks for information regarding this bacterium. What is an appropriate response? 4. After Tara has remained afebrile for 24 hours, she is discharged from the hospital on oral antibiotics. What is the most appropriate teaching priority to discuss with Tara's mother? A.Tara's toileting and wiping habits should be closely monitored. B.Tara should drink plenty of water when taking oral antibiotics. C.Tara should complete all her medication. D.Tara needs to practice appropriate hand washing.

1. D 2. C 3. E. coli is the most common bacterium that leads to UTIs, causing approximately 80% of these infections. It is a very common bacterium in the intestines that is excreted in the stool. Improper wiping and poor hand washing after toileting can lead to E. coli UTIs. 4. C

CARDIOVASCULAR Jennifer is a 3-year-old from Bethel who was born with a large ventricular septal defect(VSD) along with severe mitral regurgitation. She has had a long, complicated course with multiple hospitalizations. Jennifer and her mother have been to Anchorage andSeattle for multiple tests and procedures. Today, Jennifer presents to the clinic with concerns for severe congestive heart failure (CHF). The plan was for Jennifer to gain more weight before her surgical repair, however waiting may no longer be an option. 1. What signs and symptoms of CHF would the nurse expect to find? 2. What are the main treatment goals to improve cardiac output in CHF? 3. What is the most common medication that Jennifer may be prescribed to help manage CHF? a. Why? 4. What should the nurse teach Jennifer's mother about the signs of toxicity associated with this medication? 5. What additional medications might Jennifer be prescribed to treat CHF?

1. SOB, tachycardia, diaphoresis, rapid labored breathing, difficulty with feeding/growing, enlarged liver 2. help heart pump as effectively as possible, ensure not fluid overloading patient, improving ability to grow, good organ perfusion 3. digoxin, improve contractility/CO 4. nonverbal, GI s/s, n/v/d 5. diuretics, heart ineffective pump, overflow, back flow, edema into lungs

GI Olin is an 11-year-old male who presents to the emergency room with severe abdominal pain, a low-grade fever of 99.7 degrees Fahrenheit, and mild diarrhea. The provider tells the nurse that she suspects appendicitis. All of a sudden, Olin reports that he is feeling better. 1. What does the nurse suspect has happened? 2. Olin's mother asks what causes appendicitis. What does the nurse say in response? 3. What care should Olin's nurse expect to provide postoperatively?

1. appendix ruptured 2. obstruction with fecal matter, lymphoid tissue or pinworms 3. pain, wound care, monitor GI function

RESPIRATORY David is the 3-year-old son of parents who are 38 and 40 years old. His parents underwent fertility therapy in order to become pregnant with him. David has a history of frequent colds which have been increasing in severity over the past year. David has also been losing weight despite eating well, and has been experiencing large, bulky, foul-smelling bowel movements. He is admitted to the pediatric floor for a workup for cystic fibrosis. 1. If David is diagnosed with cystic fibrosis, what genotype would each parent have to be? a. Based on your answer, each future child would have what percent chance of inheriting cystic fibrosis? 2. David's parents are concerned that fertility therapy contributed to cystic fibrosis. What is the appropriate response? 3. What is the significance of sodium and chloride in diagnosing cystic fibrosis 4. When discussing nutrition with David's parents, you recommend continued supplementation of vitamins A, D, E, and K, which is important because: A. pancreatic enzymes are administered with meals. B. children with cystic fibrosis cannot receive a well-balanced diet. C. uptake of fat-soluble vitamins is decreased in cystic fibrosis. D. excretion of water-soluble vitamins is increased in cystic fibrosis. 5. Why will chest physiotherapy be important for David? How is this done?

1. autosomal recessive inheritance 2. no, a gene was inherited by each parent 3. increased sodium and chloride in saliva and sweat, sweat chloride test, abnormal > 60 4. c 5. break up mucus, CPT

CARDIOVASCULAR Liam is a 10-year-old who presents to the clinic with red, swollen joints. He is also tachycardic with muffled heart sounds. A chest radiograph is performed, which reveals cardiomegaly. An electrocardiogram (ECG) is performed, which reveals a long PR interval. The provider suspects rheumatic fever and orders an antistreptolysin (ASO)titer. 1. The nurse understands that the provider suspects this diagnosis due to which factor in the child's medical history? A. Exposure to herpes simplex virus (HSV) one month ago. B. Untreated pharyngitis two weeks ago. C. Hepatitis B carrier status due to exposure at birth. D. Gastroenteritis one week ago

1. b

GI Jason is a 3-week-old male who is brought in to the clinic with projectile, non- bilious vomiting after most feedings. The nurse performs a physical assessment and palpates an olive-like mass in the right upper quadrant of Jason's abdomen. 1. Based on the clinical manifestations, what is the most likely diagnosis? 2. What is the cause of the olive-like mass?What other findings would the nurse expect based on Jason's diagnosis? (Select all that apply.) a. Weight loss b. Weight gain c. Abdominal distention d. Respiratory alkalosis 3. Jason's mother asks what the treatment entails for this diagnosis? What does the nurse tell her?

1. hypertrophic pyloric stenosis, thickening of pyloric sphincter, obstruction 2. a, c, e, f, g 3. surgery

GI Claire is an 18-month-old female who has been generally healthy. Her father calls the clinic because her nanny found a red jelly-like substance in her diaper. He also reports that Claire is clutching her abdomen and is crying out in pain. 1. Based on these clinical manifestations, what diagnosis does the nurse suspect? 2. What does the nurse tell the father to do? 3. How is this diagnosis confirmed? How is it treated?

1. intusscesupction, bring child to the ER immediately 2. contrast enema, surgical intervention if recurrent or enema not successful 3. surgical emergency

ENT cleft lip cleft palate 1. When assessing a child with a cleft palate, the nurse is aware that the child is at risk for more frequent episodes of otitis media due to which of the following? A. Lowered resistance from malnutrition B. Ineffective functioning of the Eustachian tubes C. Plugging of the Eustachian tubes with food particles D. Associated congenital defects of the middle ear 2. While assessing a newborn with cleft lip, the nurse would be alert that which of the following will most likely be compromised? A. Sucking ability B. Respiratory status C. Locomotion D. GI function 3. When providing postoperative care for the child with a cleft palate, the nurse should position the child in which of the following positions? A. Supine B. Prone C. In an infant seat D. On the side 4. An 18-month-old is scheduled for a cleft palate repair. The usual type of restraints for the child with a cleft palate repair are? A. Elbow restraints B. Full arm restraints C. Wrist restraints D. Mummy restraints 5. A home care nurse provides instructions to the mother of an infant with cleft palate regarding feeding.Which statement if made by the mother indicates a need for further instructions? A. "I will use a nipple with a small hole to prevent choking." B. "I will stimulate sucking by rubbing the nipple on the lower lip." C. "I will allow the infant time to swallow." D. "I will allow the infant to rest frequently to provide time for swallowing what has been placed in the mouth."

1. b because of the structural defect, children with cleft palate may have ineffective functioning of Eustachian tubes creating frequent bouts of otitis media 2. a because of the defect, the child will be unable to to from the mouth adequately around the nipple, thereby requiring special devices to allow for feeding and sucking gratification 3. b postoperatively children with cleft palate should be placed on their abdomens to facilitate drainage 4. a the least restrictive restraint for the infant with cleft lip and cleft palate repair is elbow restraints 5. b an infant with cleft palate would have difficulty in feeding despite stimulation for sucking

RESPIRATORY John is a 10-week-old male who was born at 28 weeks gestation and weighed 0.8 kg (1pounds, 12.2 ounces) at birth. His Neonatal ICU stay was essentially uneventful. John has an older sister, Jane, who just started preschool. Last week Jane was ill with a respiratory infection, and now John is starting to seem ill as well. He initially became ill with a runny nose, sneezing, coughing, and wheezing, and he has not been breastfeeding well. He has since been admitted to the pediatric floor with worsening respiratory symptoms that include consistent tachypnea, moderate retractions, circumpolar cyanosis, and periods of apnea. 1. Based on John's medical history and clinical manifestations, the nurse suspects that his most likely medical diagnosis is: 2. How is this illness diagnosed? 3. John now weighs 6 pounds. The provider orders D10 1/2 NS maintenance fluids.Using the "4-2-1 Rule," what is the correct hourly infusion rate? 4. As John's nurse, what are some interventions that you would expect may be included in his plan of care? 5. What type of isolation do you expect that John will be placed in? What personal protective equipment (PPE) should be used when entering his room? 6. What medication therapy do you expect John to receive if his illness becomes very severe (i.e. he requires intubation)? Who should not handle this medication? 7. What product is given to certain infants in the NICU prior to discharge to prevent contraction of this illness? a. What are the criteria that makes an infant eligible to receive this product?

1. bronchiolitis (RSV) 2. nasal swab, ELISA 3. 10.9 mL/hr 4. respiratory support, O2, frequent suction, IVF, no feedings, corticosteroids 5. contact, droplet precautions 6. ribavirin, pregnant 7. synagis (palvizumab), monthly during RSV season, prematurity, cardiac disease, CLD

RESPIRATORY Bill, age 8 years, is brought to the clinic because of acute respiratory distress. He appears anxious and is quiet and anxious. The diagnosis is asthma. 1. What symptoms support the diagnosis of moderate persistent asthma in a child over 5years of age? a. FEV1 ≥ 80% of predicted value b. Nightly nighttime symptoms c. Daily symptoms d. Use of a SABA less than twice weekly 2. Match the diagnostic test with what it measures. A. Pulmonary function test B. Peak expiratory flow rate C. Chest radiograph D. Skin prick testing Lung hyperinflation Air flow forcefully expelled in 1 second Lung function Specific allergens 3. Bill needs instructions about using a metered-dose inhaler (MDI). The nurse should explain that the MDI is used to a. improve circulation. b. distribute prescribed medication directly to airways. c. assess severity of breathing difficulty. d. distribute prescribed medication systemically without the need for injection. 4. Instructions for using the MDI include to a. breathe medication in slowly. b. avoid breathing too deeply. c. hold inhaler at about a 45-degree angle to the mouth. d. breathe in through nose and out through mouth. 5. Bill's father asks the nurse whether he can still participate in sports. The nurse's response should be based on an understanding that a. exercise should be encouraged. b. exercise should be discouraged. c. organized sports are too strenuous for children with asthma. d. quiet activities such as reading are best for children with asthma.

1. c 2. c, b, a, d 3. b 4. a 5. a

RESPIRATORY Allen is a 5-year-old male who is status post tonsillectomy with adenoidectomy. 1. Which of the following should alert the nurse to the likelihood of postoperative hemorrhage? A. Expectoration of dark, reddish-brown saliva B. Hypertension C. Frequent swallowing D. Bradycardia 2. If postoperative hemorrhage is suspected, what action should the nurse take immediately? 3. What nursing interventions are most important for Allen postoperatively? 4. In preparing Allen for discharge, the nurse teaches his parents the importance of: A. giving Allen aspirin when he complains of pain. B. avoiding foods that are hot or coarse. C. calling Allen's provider if his temperature is greater than 99 degrees Fahrenheit in the first 48 hours after discharge. D. the need for brushing teeth more frequently. 5. Allen's mother calls the clinic approximately 48 hours after discharge and reports that Allen has mild ear pain and foul mouth odor. What does the nurse tell the mother?

1. c 2. call the provider 3. comfort, pain, meds, ice, prevent activities that aggravate surgical site (increase risk bleeding) such as coughing, blowing nose, clear throat 4. b 5. normal 5-10 days post op, call if s/s worsen beyond week 4 post op

RESPIRATORY Elise is a 3-year-old female who is brought to the emergency department by her father because she is having difficulty breathing. Her symptoms include stridor, a fever of 104.4 degrees Fahrenheit, and a sore throat. She is agitated, is drooling, and does not want to lie down. 1. What action should the nurse take first? A. Administer intravenous fluids. B. Swab the throat and send it for culture. C. Have Elise lie down to help her breathing. D. Bring emergency tracheostomy supplies to the bedside. 2. Elise is diagnosed with acute epiglottitis. Describe the pathophysiology of this illness: 3. Elise's father asks what causes this illness. Based on the nurse's knowledge of this illness, the most appropriate response is the bacteria: A. Chlamydia trachomatis. B. Staphylococcus aureus. C. Haemophilus influenzae. D. Klebsiella pneumoniae. 4. The nurse should anticipate that the pharmacologic treatment for this illness will be: 5. The physician orders a STAT lateral radiograph of the neck. What can the nurse do to promote patient safety? 6. The nurse understands that this illness is often preventable. How?

1. d 2. acute epiglottitis 3. c 4. antibiotics 5. portable x-ray, do not send pt to radiology 6. HIB vaccine

RESPIRATORY Alice is an 8-year-old female who is brought in to the emergency room with acute respiratory distress. She is diagnosed with asthma. The provider orders albuterol to be given via nebulizer. 1. The father asks how this medication will help Alice. The nurse explains that the purpose of albuterol is to: 2. When performing a physical assessment on Alice, the nurse expects to see which of the following? (Select all that apply.) A) Coughing B) labored breathing C) Fever D) Wheezing E) runny nose F) Restlessness G) Stridor H) Hypertension Alice is discharged from the emergency room with a prescription for a metered- dose inhaler (MDI). 1. What is the purpose of the MDI? What instructions should be provided to Alice and her parents? Alice is seen in the clinic the following day and an asthma action plan is developed, which includes daily peak flow measurements. 1. What is the significance of a peak flow rate in the "red zone?" 2. The nurse educates Alice and her parents on asthma "triggers." What is a trigger that a child in Colorado would commonly be exposed to? 3. Alice's parents ask about her ability to exercise. What is the best reply by the nurse?

1. open her airways 2. a, b, d, f 1. slow deep breaths and hold for 5-10 seconds 1. severe airway narrowing 2. environmental allergen 3. unrestricted exercise ok if asthma is well controlled

CARDIOVASCULAR Jack is a 3-week-old who presents to the emergency room in respiratory distress. He is cyanotic and limp, and eventually becomes apneic. He is intubated and placed on a ventilator. After performing a physical exam, the provider suspects a congenital heart defect and orders an echocardiogram, which confirms a diagnosis of tetralogy of Fallot(ToF). Jack's father asks the nurse, "what does this all mean?" The nurse explains that there are four defects associated with this condition, including: 1. ___________________________ 2. ___________________________ 3. ___________________________ 4. ___________________________ 1. How does the nurse explain this cardiac defect to the father, specifically the consequences pertaining to the infant's circulation? 2. What causes the cardiac silhouette to have a "boot-shaped" appearance on chest radiograph? 3. Jack's mother arrives and asks how this condition will be treated. How does the nurse respond? 4. What is a "tet spell," and what causes it? 5. Jack is too small to undergo surgery at this time. What important education does the nurse provide to his parents at the time of discharge?

1. ventricular septal defect (VSD) 2. right ventricular hypertrophy 3. pulmonary stenosis 4. overriding aorta 1. degree of disease varies based on severity of pulmonic stenosis, when calm healthy in mild PS baby will be healthy/not clinically sick most of the time, in increasing PS severity, tet spells start to occur. 2. right ventricular hypertrophy 3. baby will need surgery, likely multiple different operations, which would be decided by surgeon 4. hypoxic episode caused by shunting and loss of oxygen in circulating blood, put infant in knee to chest, older children will squat on their own instinctively 5. knee to chest, calming/consoling techniques that will calm infant quickly, importance of staying healthy/hydrated, immunizations UTD

GU A urinalysis is needed for diagnostic evaluation and the nurse is preparing the child and mother for a clean voided urine specimen for evaluation. What does the nurse need to be aware of before obtaining the urine sample? Select all that apply. A. Children who are toilet trained can provide a clean voided urine sample for culture. B. The nurse should obtain the urine specimen through suprapubic aspiration. C. Because children who have a UTI will have painful urination, have the child drink a large amount of fluid before obtaining the sample. D. The specimen should be sent to the laboratory less than 8 hours after voiding with storage at room temperature or less than 8 hours after voiding with refrigeration. E. The child should be told to urinate in the toilet and that midway through urination a small amount of urine should be collected in a sterile container. F. Because the child is febrile, the nurse should immediately start an antimicrobial and then obtain a urine culture.

A, E

CARDIOVASCULAR CHD obstructive

coarctation of aorta (COA) - decreases blood supply post obstruction - mild or severe - immediate intervention - poor pulses and perfusion - difference in pulses UE vs LE

GU The parent of a child hospitalized with acute glomerulonephritis (AGN) asks the nurse why blood pressure readings are being taken so often. Based on the nurse's knowledge of AGN, the most appropriate response by the nurse is A.blood pressure fluctuations are a common side effect of antibiotic therapy. B.hypotension leading to sudden shock can develop at any time. C.acute hypertension must be anticipated and identified. D.blood pressure fluctuations are a sign that the condition has become chronic.

D

CARDIOVASCULAR CHD mixed

HLHS - hypoplastic left heart syndrome

CARDIOVASCULAR CHD increased pulmonary blood flow

L to R shunt PDA - left to right shunt increased blood to lungs - acyanotic complications - pulmonary HTN - increased volume to lungs, pulmonary congestion, fibrosis of capillary bed, HTN in lungs, caused by L to R shunt, R volume overload leads to impaired gas exchange and vascular fibrosis, progress to RHF, uncorrected by 6 months leads to dysfunctional compensation, R to L shunt, cyanosis, O2 therapy, manage HF, pulmonary vasodilators (nitric oxide, PDE5 inhibitors) - HF - increased workload on RV, poor CO and perfusion, s/s of venous congestion, generally acyanotic, increased HR/rhythm, neurohormonal (vasoconstriction, release renin/aldosterone), eventually becomes dysfunctional (ventricles hypertrophy/dilates, heart fatigues, cell death arrhythmia), murmurs, edema, poor weight gain, fatigue, GERD, abdominal pain from lack of perfusion, fussy (neuro), developmental delay, respiratory distress, sweaty, decreased UO, end organ s/s from lack of perfusion (CKD, neuro, growth), conserve energy, O2, high caloric feeds, strict I&O, cluster care, low stimulating environment, prevent infection

RESPIRATORY chronic lung disease

asthma - inflammation of airways - environmental allergens, URI, triggers - s/s - "silent chest", wheezing, breathlessness, chest tightness, cough (night) - treatment - SABA, LABA, steroids - prevention - asthma action plan, avoid triggers, vaccines, flu shot, inhaler use - asthmatic bronchitis more frequent in cold weather cystic fibrosis - genetic, infection leading COD - autosomal recessive disorder - exocrine gland dysfunction - caucasian males - excessive loss NaCl - thick/dehydrated secretions - diagnosis - newborn screening, high false + rate, sweat test (Cl-), gold standard, >2 weeks, >60 mEq/L - lungs - airway obstruction (mucus), chronic infection, chronic inflammation, impaired gas exchange, fibrosis - s/s - salty skin, chronic respiratory problems, lung infections, poor growth, weight loss, meconium ileus - treatment (COPD) - respiratory care, optimize oxygenation, mobilize secretions, prevent infection (hand hygiene), treat infection early (nebulizer, mucolytics, hydration, know baseline cough, O2 low flow, vaccines, abx 10-14 days, IV, PO, inhaled, based on culture) - other - diet to meet metabolic needs, high fat/protein, supplemental enzymes with meals, high salt diet, adequate hydration (IWL), exercise balanced with rest, cardiac, endocrine, GI complications - airway clearance (ACT) - increase positive pressure, huff cough, TID-QID, postural drainage

RESPIRATORY anatomical differences

smaller nasopharynx, lymph tissue grows rapidly, smaller nares, small oral cavity, large tongue, long floppy epiglottis, larynx and glottis higher in neck, cartilages immature may collapse, muscles can't compensate, more soft tissue - small airways, easily obstructed - alveolar development, lack surfactant, poor alveolar compliance, air trapping - weak respiratory muscles, fatigue easily, poor reserves, accessory muscle use

RESPIRATORY lower airway disorders poor gas exchange

bronchiolitis and RSV - viral infection < 2 years - 80% RSV - transmission - droplet, winter, spring - supportive treatment - < 2 months routinely hospitalized - premature high risk, Synagis vaccine pertussis "100 day cough" - preventable - bacterial, abx - droplet precautions - 3 stages catarrhal stage - mild URI s/s 1-2 weeks paroxysmal stage symptoms - 4-6weeks, high pitched whoop, posttussive emesis convalescent stage - additional 2-3 weeks pneumonia

GU Tara is a 4-year-old girl who has been toilet trained for about 9 months. She loves the water, has been enrolled in swimming classes, and likes to take bubble baths. She is brought to the emergency department after having fever up to 102° F for 2 days and abdominal pain. Her mother states that Tara has been complaining of pain since yesterday and that she had two toileting "accidents." identify priority assessment cues list anticipated nursing actions Based on the Tara's presentation, what type of physician orders would the nurse anticipate receiving first? A. Urinalysis and urine culture B. Blood culture and CBC C. Lumbar puncture D. Abdominal x-ray

clean catch, U-bag, catheter s/s - poor feeding, vomiting, poor weight gain, rapid RR acidosis, respiratory distress, pneumothorax, polyuria, poor urine stream, jaundice, seizure, dehydration, enlarged kidneys & bladder, thirst, fever A - urinalysis and urine culture must be obtained by either clean catch or catheterization to correctly diagnose the probable UTI. The presence of nitrites and leukocytes on the urinalysis will confirm the diagnosis. The urine culture will be needed to identify the organism to ensure the appropriate antibiotic is used to treat the infection. A blood culture and CBC would be necessary if the patient had fever of unknown origin. Although a WBC count would reveal infection, the urinalysis and urine culture tests are more focused on Tara's physical findings and chief complaint. Like the blood culture and CBC, a lumbar puncture may be indicated if the child had a fever of unknown origin and headache or dizziness. However, her symptoms are strictly related to her urinary tract. An abdominal x-ray is indicated only if Tara experienced abdominal pain without a probable cause. Her symptoms suggest a UTI as the cause.

ENDOCRINE developmental considerations

infants - rapid growth - brain development - avoid hypoglycemia - erratic sleeping/eating habits toddlers and preschoolers - picky/inconsistent eating habits - more regulated activity/sleep patterns - difficult to distinguish low blood sugar reaction from normal temper tantrum - self care task - select food from 2 options, hold still for injections, term for "feeling bad" school age - eager to learn and follow rules - eating/sleeping more consistent - increased activity and play - some peer issues can begin to develop early adolescence - puberty, erratic growth, erratic glucose control affects insulin requirements - concerned about body image - greatly influenced by friends - may challenge authority - begin to understand abstract concepts and consequences - self care tasks: log glucose, draws up insulin with supervision, knows meal plan mid to late adolescence - increased time away from home - risk taking behaviors including not taking insulin and not performing blood sugar tests - many social activities are unpredictable - counseling regarding contraception, alcohol, vaping, and smoking - have cognitive ability to manage disease

GI nursing care

nursing diagnoses - alterations in nutrition, F&E balance, growth and development - FTT or impaired weight gain - fluid volume deficit - pain - delayed growth and development - risk for aspiration interventions - optimize weight gain, balance fluids & electrolytes, avoid aspiration/safe feeding technique, relieve pain, monitor for life threatening complications, education on bowel habits/regimen - general - IVF, I&O, PEWS/VS, focused GI/respiratory, surgical care, g-tube care, bowel regimens, pain management, +/- pharmacologic - increase weight gain - dietician, enteral feedings, supplemental nutrition - decrease risk of aspiration - clear airway, positioning, small feeds

GU kidney disease

prerenal (AKI) - need good blood flow to kidney - UO < 1 mL/kg/hr intrarenal - healthy tissue within kidney - glomerular disease - nephrotic syndrome - toddlers, proteinuria only, normal serum creatinine, significant fluid volume overload, HTN +/- - glomerulonephritis - school age, teenagers, proteinuria AND hematuria, elevated serum creatinine, fluid overload varies, always HTN - minimal change nephrotic syndrome - cause genetic, environmental, most kids outgrow, assessment, massive proteinuria >4+, hypoalbuminemia < 2 mg/dL, edema, treatment, steroids x 12 weeks minimum, low Na+, fluid restrictions, diuretics, vaccines, hand hygiene, fluid volume overload/deficit, complications, infection, peritonitis, sepsis, thrombosis, cushing syndrome - acute glomerulonephritis post infectious glomerular nephritis (PIGN) - post strep infection most common, self limited hemolytic uremic syndrome (HUS) - e. coli, wide spectrum, severity, RRT high risk for CKD and need transplant nephritis - proteinuria, hematuria, azotemia, HTN postrenal - obstructed urinary tract - CAKUT - congenital anomaly of kidneys and urinary tract, male common, major complications (CKD, neurogenic bladder, hydropnephrosis, recurrent UTI cannot be diagnosed on UA), abnormal genitalia, urinary obstruction, disruption of stream, phimosis, epispadias, hypospadias, cryptorchidism (undescended testicle) hydronephrosis - water on kidney nephrotoxic agents - contrast media - TPN - drugs - NSAIDS, antibacterial, antiviral, immunosuppressants, antineoplastic, angiotensin-converting enzyme inhibitors, diuretics, anti-ulcer (cimetidine) and PPIs, lithium - anesthetics - methoxyflurane, enflurane

ENDOCRINE management

priority condition diabetes - stabilize glucose levels - avoid complications - short term hypoglycemia, DKA, hyperkalemia, long term - optimize nutrition and growth - daily weight, monthly heigh - emotional/community support - school T1DM therapeutic management, outpatient/stable - insulin therapy general considerations - general starting dose: 0.5-1 unit/kg/day, titrated to glucose goal, SQ injection, rotation of sites, mix insulin clear to cloudy, timing of injections in relation to meals, insulin can be stored at room temperature for 30 days, only regular insulin may be administered intravenously, 3-4 day trend of hyperglycemia warrants insulin adjustment, honeymoon period nursing diagnosis - imbalanced nutrition - appropriate for "stable" patients - routine VS and PEWS - focused assessment for s/s hypo/hyperglycemia - strict I&O - lab monitoring (acid/base, electrolytes) - monitor meals/adherence - reinforce Education - provide support - child life - monitor glucose levels - before meals and when symptomatic, more frequently with acute illnesses - monitor urine ketones - during illness with each void, sustained hyperglycemia >180mg/dL or random>250 mg/dL - administer insulin - basal/bolus regimen per pump, combination of short and long acting insulin

CARDIOVASCULAR CHD prevent cardiogenic shock

recognize assessment cues: decrease in CO - poor perfusion parameters - cap refill > 2 sec, HR above baseline, cyanosis, cool temperature (central v peripheral),pale, weak pulses, murmurs, edema, respiratory distress (tachypnea, pulmonary congestion), diaphoretic, weight gain - end organ effects - neuro: Irritable with long term cognitive delays, GI: hepatomegaly, poor feeding & weight gain, GERD, renal: decreased UOP with chronic kidney disease - what's going on - increased pulmonary blood flow leads to HF - priority - reduce myocardial workload and increase CO - interventions - PEWS, pulse ox >90%, O2 +/-, IV access +/- IVF, medications to improve CO, digoxin, diuretics, ACEi, strict I&O with daily AM weight—same scale; weigh all diapers, conserve energy, decrease environmental stimuli/cluster care, feedings: small, frequent & limited <20 minutes, high calorie, nasogastric feeding - interventions impaired gas exchange - O2, monitor pulse O2, clear upper airway, HOB, new dry cough early sign of distress, conserve energy, too much blood going to lungs