Exam #3 Reading Questions & Key Points

TAKE NOTE: ACE Wrap

if the child's fingers or toes become increasingly swollen or discolored, remove the wrap IMMEDIATELY

TAKE NOTE: Traction Alignment

AVOID sudden bumping or movement of the bed as this may disturb alignment and cause additional pain to the child as the weights are jostled

TAKE NOTE: Emergency Situation

in an emergency situation when airway + breathing are compromised, SubQ epinephrine followed by IV Diphenhydramine and corticosteroids is necessary

CASE STUDY: John Shaw, 7 years old, is brought to the clinic by his parents with a fever. His father states, "John seems to get fevers and colds more often than our other children. He's also very tired these days. He hardly ever wants to go out and play with his friends. He complains of headaches frequently and just doesn't really seem like himself."

1. Ask about pallor, unusual bleeding or bruising, abdominal pain, nausea/vomiting, bone pain. Determine the child's history of varicella zoster immunization or disease. Assess temperature, look for petechiae, purpura, unusual bruising, signs of infection, listen for adventitious breath sounds, palpate abdomen for tenderness/organomegaly. 2. Nursing diagnoses could include risk for infection or fatigue activity intolerance. 3. Answers should include information about safe handling and administration of chemotherapeutic drugs. Calculate dose based on body surface area. Monitor and intervene for adverse effects of alopecia (scalp cooling) + infection—administer granulocyte colony-stimulating factor (GCSF) as ordered to promote neutrophil growth and maturation (Brundige, 2010). Administer varicella zoster immunoglobulin (VZIG) within 72 hours of exposure to active chickenpox. Refer to Teaching Guidelines 46.2 for further information about infection prevention at home. Use neutropenic precautions when absolute neutrophil count is low (per institution policy). Hemorrhage—Assess for petechiae, purpura, bruising, or bleeding. Encourage quiet activities or play to avoid trauma. Avoid rectal temperatures and examinations. Avoid intramuscular injections and lumbar puncture. If bone marrow aspiration must be performed, apply a pressure dressing to the site to prevent bleeding. Anemia—limit blood draws to the minimum volume required. Encourage the child to eat an appropriate diet that includes adequate iron. Administer erythropoietin injections as ordered. Teach families to give the injections at home if prescribed. Nausea, Vomiting, and Anorexia—Provide foods the child desires or asks for in order to increase the likelihood of eating. Prevent nausea by administering antiemetic medications prior to the administration of chemotherapy and on a routine schedule around the clock for the first 1 to 2 days rather than on an as-needed (PRN) basis. Ginger may be helpful. Keep the child's environment dimly lit and calm. Relaxation therapy and guided imagery may be helpful.

KEY CONCEPT: Scaling may occur in which two skin disorders?

1. Atopic Dermatitis 2. Psoriasis Nursing Interventions - includes keeping the skin well moisturized for management

CASE STUDY: Paige is a 5-year-old recently diagnosed with type 1 diabetes. She is currently in kindergarten at a local elementary school. Her mother is very concerned about learning all her care. She states "How can I send her to school if I am still learning how to take care of her?"

1. Children with DM and their families may have difficulty coping if they lack confidence in their self-management skills. Role-play specific situations related to symptoms or complications to help them see different ways to solve problems. Work with the child and family to enhance their conflict resolution skills. Provide opportunities for them to express their feelings.To enhance the child's confidence and promote feelings of mastery and inclusion, refer him or her to a special camp for children with DM. Also refer families to local support groups, parent-to-parent networks, or one of many national support resources and foundations.Daily management of the child with DM is complex and dynamic. It will require frequent monitoring of blood glucose levels, medications (including oral diabetic medications and insulin injections), and individual meal plans, including snacks, while the child is at school. The school nurse will be a principal contact person for both staff and family. Ensure communication with the school nurse so she is prepared and educated on Paige's needs. With appropriate management, involvement of the community, and confidence and compliance by the family, the child can maintain a happy, productive life. 2. Find out her blood sugars and insulin dosages given prior to the drop. Assess her intake and activity levels prior to the drop. Assess if Paige has a current illness. If the child has had poor intake, (for example they did not like the food being served), increased activity, such as gym or a very active recess, or have an illness the sliding scale will have to be adjusted for this to prevent a drop in blood sugar. 3. Paige should be offered 10 to 15 grams of a simple carbohydrate such as orange juice followed by a more complex carbohydrate like peanut butter and crackers. Giving a glucose tablet would also be appropriate. Re-check Paige's blood sugar in 15 minutes and assess for symptoms of hypoglycemia.

CASE STUDY: Nicole Ashton, 16 years old, is seen in your clinic due to weight loss. Her mother states that she has lost noticeable weight over the past few months and has stopped menstruating.

1. Determine the health history, noting risk factors such as family history, female gender, Caucasian race, preoccupation with appearance, obsessive traits, or low self-esteem. Also note history of constipation, syncope, secondary amenorrhea, abdominal pain, periodic episodes of cold hands and feet, or depression. Evaluate the child's self-concept, noting multiple fears, high need for acceptance, disordered body image, and perfectionism. Upon physical examination note signs found with anorexia: underweight, low body mass index (BMI), cachectic appearance, dry sallow skin, thinning scalp hair, soft sparse body hair, nail pitting, low temperature, bradycardia, hypotension, murmur and/or the signs found with bulimia: calluses on the backs of the knuckles, split fingernails, eroded dental enamel, red gums, and inflamed throat. 2. Consult the nutritionist for assistance with calculating caloric needs and determining an appropriate diet. Aim for a weight gain goal of 0.5 to 2 lb per week. Instruct the child and family to keep a daily journal of intake, bingeing (excessive consumption) and purging (forced vomiting) behaviors, mood, and exercise. The journal may be used as an assessment tool as well as to document progress toward recovery. Assist the child and family to plan a suitably structured routine for the child that includes meals, snacks, and appropriate physical activity.Educate Nicole about the physical changes. Refer, as appropriate, to behavior or group therapy. Provide emotional support and positive reinforcement to Nicole and family. Refer the family to local support groups or online resources such as the Academy for Eating Disorders or the National Eating Disorders Association.

CASE STUDY: Mary Stillman, a 3-year-old girl, is brought to the clinic by her mother for worsening of her atopic dermatitis. During your assessment the mother states that even though the doctor told her that milk makes Mary's skin worse, she likes it so much, she just can't take it away from her.

1. Determine the onset of the rash; its location, progression, and severity; and response to treatments used so far. Note medications used to treat the rash, as well as other medications the child may be taking. What is Mary's moisturizing routine? Upon physical assessment observe whether Mary is actively scratching. Carefully inspect the skin documenting dry, scaly, or flaky skin, hypertrophy, lichenification, dry lesions, weepy papules or vesicles. Note locations of the rash, presence of erythema or warmth, areas of hyperpigmentation or hypopigmentation. Inspect the eyes, nose, and throat for symptoms of allergic rhinitis. 2. Counsel Mary's mother to avoid known food allergens. Explain the impact of the allergen on the rash development/worsening. Offer suggestions of foods to substitute for milk products. Educate Mary's mother about medications and moisturization/hydration of skin. 3. Avoid hot water and any skin or hair product containing perfumes, dyes, or fragrance. Bathe Mary in warm (not hot) water. Use a mild soap to clean only the dirty areas. Slightly pat the child dry after the bath, but do not rub the skin with the towel. Leave Mary's skin moist. Apply prescribed topical ointments or creams to the affected area. Apply fragrance-free moisturizer over the prescribed topical medication and all over the child's body. Apply moisturizer multiple times throughout the day. Avoid clothing made of synthetic fabrics or wool.Cut Mary's fingernails short and keep them clean. Avoid tight clothing and heat. Use 100% cotton bed sheets and pajamas. Use behavior modification to help to keep Mary from scratching. The use of diversion, imagination, and play may also help to distract Mary from scratching.

CASE STUDY: Jake Reddington, a 2-year-old diagnosed with HIV infection, is brought to the clinic by his aunt for his regular check-up. His aunt has recently taken over the care of Jake since his mother is too ill with HIV infection to care for him.

1. Educate the family about the medication regimen, the ongoing follow-up that is needed, and when to call the infectious disease provider. Inform the aunt to check with the specialist prior to vaccinations. Provide nutrition education. The day care center or school that the child attends will need education about HIV, which can be provided only if the parent or caretaker consents to divulging the child's diagnosis to that agency. 2. Families may face financial concerns. Refer as needed to for funding to the Ryan White Comprehensive AIDS Resources Emergency Act. Jake is young for diagnosis disclosure but the family must anticipate that in future, and how they will handle disclosure to others. When Jake is old enough to know, he may exhibit anger or depression, or have school problems. The child may experience a spiritual dilemma. The family may experience anticipatory grieving or may use denial in order to cope. Jake may experience emotional or cognitive problems as well, as possibly social isolation. If needed, refer the caregivers to the appropriate professional for additional psychological and emotional intervention.

KEY CONCEPT: Major Bleeding Disorders

1. Idiopathic Thrombocytopenic Purpura 2. HenochSchonlein Purpura 3. Disseminated Intravascular Coagulation (DIC) 4. Hemophilia 5. vWD Nursing Assessment - will focus on determining its EXTENT & SEVERITY

CRITICAL THINKING EXERCISE: Develop a prioritized list of nursing diagnoses for a child with HIV infection, candidiasis, poor growth, and pneumonia requiring oxygen.

1. Ineffective gas exchange 2. Ineffective protection related to inadequate body defenses. 3. Imbalanced nutrition, less than body requirements. 4. Pain related to mouth sores. 5. Risk for (or actual) delayed growth and development.

KEY CONCEPT: Major Forms of Anemia (4?)

1. Iron-Deficiency Anemia 2. Lead Poisoning 3. Folic Acid Deficiency 4. Pernicious Anemia 5. Sickle Cell Anemia 6. Thalassemia 7. G6PD Deficiency Nursing Assessment - includes hypoxia, fatigue, and pallor

CASE STUDY: Turner Wilson was just born with an obvious defect on his spine. Upon assessment, the nurse notes flaccid extremities and a distended bladder. The parents are devastated.

1. Observe the baby's general appearance and assess whether the sac covering is intact. Assess neurologic status and look for associated anomalies. Assess for movement of extremities and anal reflex, which will help determine the level of neurologic involvement. Flaccid paralysis, absence of deep tendon reflexes, lack of response to touch and pain stimuli, skeletal abnormalities such as club feet, constant dribbling of urine, and a relaxed anal sphincter may be found. 2. Initial nursing management of the child with myelomeningocele involves preventing trauma to the meningeal sac and preventing infection before surgical repair of the defect. Risk for infection related to the presence of the meningeal sac and potential for rupture is a central nursing concern in the newborn with myelomeningocele. Until surgical intervention occurs, the goal is to prevent rupture or leakage of CSF from the sac. Keeping the sac from drying out is important, as is preventing trauma or pressure on the sac. Use sterile saline-soaked nonadhesive gauze or antibiotic-soaked gauze to keep the sac moist. Immediately report any seepage of clear fluid from the lesion, as this could indicate an opening in the sac and provide a portal of entry for microorganisms. Position the infant in the prone position or supported on the side to avoid pressure on the sac. To keep the infant warm, place the infant in a warmer or isolette to avoid the use of blankets, which could exert too much pressure on the sac. Pay special attention while the infant is in a warmer or isolette because the radiant heat can cause drying and cracking of the sac.Keep the lesion free of feces and urine to help avoid infection. Position the infant so that urine and feces flow away from the sac (e.g., prone position, or place a folded towel under the abdomen) to help prevent infection. Placing a piece of plastic wrap below the meningocele is another way of preventing feces from coming into contact with the lesion. After surgery, position the infant in the prone or side-lying position to allow the incision to heal. Continue with precautions to prevent urine or feces from coming into contact with the incision. 3. Myelomeningocele is a serious disorder that affects multiple body systems and produces varying degrees of deficits. It is a disorder that has lifelong effects. Thanks to medical advances and technology most children born with myelomeningocele can expect to live a normal life, but challenges remain for the family and child as they learn to cope and live with this physical condition. Adjusting to the demands this condition places on the child and family is difficult. Parents may need time to accept their infant's condition, but as soon as possible they should be involved in the infant's care.Teaching should begin immediately in the hospital. Teaching should include positioning, preventing infection, feeding, promoting urinary elimination through clean intermittent catheterization, preventing latex allergy, and identifying the signs and symptoms of complications such as increased ICP. Due to the chronic nature of this condition, long-term planning needs to begin in the hospital. These children usually require multiple surgical procedures and hospitalizations, and this can place stress on the family and their finances. The nurse has an important role in providing ongoing education about the illness and its treatments and the plan of care. As the family becomes more comfortable with the condition, they will become the experts in the child's care.

TAKE NOTE: Trauma/Suspected Trauma

in cases of trauma or suspected trauma, do NOT perform any assessment that involves movement of the head or neck until cervical injury is ruled out; maintain COMPLETE IMMOBILIZATION of the cervical spine until that time

A child with leukemia received chemotherapy about 10 days ago. She presents today with a temperature of 100.4°F, an absolute neutrophil count of 500, and mild bleeding of the gums. What is the priority nursing intervention? A. Administer IV antibiotics as ordered. B. Provide vigorous oral care frequently with a firm toothbrush. C. Monitor pulse and blood pressure for changes. D. Administer packed red blood cell transfusion.

A. Administer IV antibiotics as ordered. The neutropenic child must have IV antibiotics started as soon as possible in the event of fever to prevent overwhelming infection and sepsis.

The nurse is caring for a child who has just been admitted to the pediatric unit with sickle cell crisis. He is complaining that his right arm and leg hurt. What is the priority nursing intervention? A. Administer pain medication every 3 hours intravenously until pain is controlled. B. Perform passive range of motion of the arm and leg to maintain function. C. Try acetaminophen for pain first, moving up to opioids only if needed. D. Use narcotic analgesics and warm compresses as needed to control the pain.

A. Administer pain medication every 3 hours intravenously until pain is controlled. The priority in a sickling crisis is to bring pain under control quickly as this brings the child relief; also, the significant stress resulting from pain can contribute to the further sickling of cells.

The mother of a child with hypogammaglobulinemia reports that her child had a fever and slight chills with an intravenous gammaglobulin infusion last month. She wants to know what other course of treatment might be available. What is the best response by the nurse? A. Administration of acetaminophen or diphenhydramine prior to the next infusion may decrease the incidence of fever or chills. B. Giving the gammaglobulin intramuscularly is recommended to prevent a reaction. C. Talk to her physician or nurse practitioner about alternative medications that may be used to boost the gammaglobulin level in the blood. D. If the child is no longer experiencing frequent infections, then the IV infusions may not be necessary.

A. Administration of acetaminophen or diphenhydramine prior to the next infusion may decrease the incidence of fever or chills. Use of antipyretics and antihistamines prior to administration of intravenous immunoglobulin may decrease the incidence of fever or chills with the infusion.

The nurse is caring for a child who has received significant partial-thickness burns to the lower body. What is the priority assessment in the first 24 hours after injury? A. Fluid balance B. Wound infection C. Respiratory arrest D. Separation anxiety

A. Fluid balance In the child with a serious burn, fluid balance is of priority importance in the first few days of care.

CRITICAL THINKING EXERCISE: A 5-year-old girl, diagnosed with myelomeningocele, is admitted to the hospital for a corrective surgical procedure. Choose four questions from below that the nurse should ask when obtaining the health history that would assist in planning the child's care. A. What is the child's current mobility status? B. Is there a family history of myelomeningocele? C. What is the child's genitourinary and bowel function and regimen? D. Does this child have a history of hydrocephalus with presence of shunt? E. Does she have known latex sensitivity? F. Were there any complications during the pregnancy or birth of this child? G. Did the mother take prenatal folic acid supplementation?

A. What is the child's current mobility status? C. What is the child's genitourinary and bowel function and regimen? D. Does this child have a history of hydrocephalus with presence of shunt? E. Does she have known latex sensitivity? The answers to these questions will assist the nurse in developing a plan of care for the child.

KEY CONCEPT: Who should be screened for lead exposure?

ALL young children should be screened for lead exposure

CRITICAL THINKING EXERCISE: A 14-year-old boy with moderate intellectual disability is able to feed himself but is incontinent. Discuss the issues with which his family must deal.

As the boy gets older, it may become more difficult for the family to provide care. Incontinence affects the boy's self-esteem, his ability to interact with others, and other children's acceptance of him. The family must think about the long-term vocational plan for the boy, as school will end at age 18.

The nurse is teaching about skin care for atopic dermatitis. Which statement by the parent indicates that further teaching may be necessary? A. "I will use Vaseline or Crisco to moisturize my child's skin." B. "A hot bath will soothe my child's itching when it is severe." C. "I will buy cotton rather than wool or synthetic clothing for my child." D. "I will apply a small amount of the prescribed cream after the bath."

B. "A hot bath will soothe my child's itching when it is severe." Hot baths should be avoided, as they are more dehydrating to the skin. Warm baths are preferred, followed by patting the child dry and rubbing on a small amount of prescribed cream, then a liberal amount of fragrance-free moisturizer. Wool clothing should be avoided in the child with atopic dermatitis.

The nurse is caring for an adolescent who says, "I'm sick of this. I wish I weren't alive anymore." What is the best response by the nurse? A. "I often feel sad and sick of things." B. "Have you thought about hurting yourself?" C. "Are you trying to escape your problems?" D. "Do your parents know about this feeling?"

B. "Have you thought about hurting yourself?" Statements about wanting to die should be further explored by the nurse, as the depressed adolescent is at risk for suicide. The other responses are inappropriate, as they do not address the child's concern and minimize the child's problem.

The nurse is caring for a 2-year-old with myelomeningocele. When teaching about care related to neurogenic bladder, what response by the parent would indicate that additional teaching is required? A. "Routine catheterization will decrease the risk of infection from urine staying in the bladder." B. "I know it will be important for me to catheterize my child for the rest of her life." C. "I will make sure that I always use latex-free catheters." D. "I will wash the catheter with warm soapy water after each use."

B. "I know it will be important for me to catheterize my child for the rest of her life." Children with adequate upper extremity function and normal intelligence usually learn to catheterize themselves around age 6.

A mother has received instructions about avoiding wheat and soy allergens. Which response by the mother would indicate that further education is needed? A. "I will not feed my child any breads made with wheat flour." B. "I will allow my child to eat semolina pasta, the kind he loves." C. "I will not feed my child shakes made with soy protein." D. "I will read labels to be sure I am avoiding wheat and soy."

B. "I will allow my child to eat semolina pasta, the kind he loves." Semolina contains wheat and thus should be avoided by those with a wheat allergy. Educate families about hidden sources of allergens.

The nurse is caring for a 6-year-old with juvenile idiopathic arthritis. The mother states that she has trouble getting her daughter out of bed in the morning and believes the girl's behavior is due to a desire to avoid going to school. What is the best advice by the nurse? A. Refer the girl to a psychologist for evaluation of school phobia related to chronic illness. B. Administer a warm bath every morning before school. C. Give the child her prescribed NSAIDs 30 minutes before getting out of bed. D. Allow her to stay in bed some mornings if she wants.

B. Administer a warm bath every morning before school. Heat or warmth helps ease the stiffness resulting after a period of inactivity in a child with juvenile arthritis.

The nurse is caring for a 14-year-old boy with type 1 DM. He takes NPH insulin every morning at 7:30 AM. Which assessment data will the nurse use to evaluate the therapeutic effectiveness of the medication? A. Presence of signs and symptoms of hypoglycemia or hyperglycemia during the morning physical assessment B. Blood glucose level at 1630 C. Appetite and food intake at lunch D. Blood glucose level before breakfast

B. Blood glucose level at 1630 NPH is a long-acting insulin used to lower blood glucose levels. Its peak action is at 2to4 hours with a duration of 10to16 hours. Blood glucose monitoring provides evaluation of the therapeutic effectiveness.

CRITICAL THINKING EXERCISE: A 3-year-old is going to be starting chemotherapy for rhabdomyosarcoma. Develop an age-appropriate teaching plan for this child.

an age-appropriate teaching plan for this child will be related to surgical removal of the tumor, as well as an explanation of radiation & chemotherapy

A varsity high-school wrestler presents with a "rug burn" type of rash on his shoulder that is not healing as expected, despite use of triple antibiotic cream. Two other wrestlers on his team have a similar abrasion. What infection should the nurse be most concerned about, based on the history? A. tinea cruris B. MRSA C. impetigo D. tinea versicolor

B. MRSA MRSA may be nonresponsive to antibiotic ointments and is becoming common in the community, particularly among athletes. Impetigo is a possibility, although it is usually responsive to antibiotic cream. Tinea cruris and tinea versicolor also would not improve with an antibiotic cream, as they are fungal infections, but the description of the skin lesion does not fit.

When trying to manage aggressive or impulsive behaviors in children or adolescents, what is the best nursing intervention? A. Train the child to be assertive. B. Provide consistency and limit setting. C. Allow the child to negotiate the rules. D. Encourage the child to express feelings.

B. Provide consistency and limit setting. Maintaining consistency and adhering to appropriate limits are critical in the management of impulsive and aggressive behaviors.

During a well-child examination which of the following comments made by the parent would indicate the possibility of a growth hormone deficiency? A. "I have to buy my child new clothes every 2 to 3 months" B. "I have to buy my child much larger shirts than pants but then the sleeves are too long." C. "My child wears out his clothes before he outgrows them." D. "I can hand down my child's clothes to his younger brother."

C. "My child wears out his clothes before he outgrows them." Children with growth hormone deficiency have poor growth and short stature. They also have a higher weight-to-height ratio; therefore, clothes that fit the body may be long in the sleeves or legs.

A 14-year-old with thalassemia asks for your assistance in choosing her afternoon snack. Which choice is the most appropriate? A. Peanut butter with rice cake B. Small spinach salad C. Apple slices with cheddar cheese D. Small burger on wheat bun

C. Apple slices with cheddar cheese Children with thalassemia should avoid foods that are high in iron. Spinach, peanut butter, a burger, and whole-grain bread are high in iron. Apples and cheese are not.

A child on the pediatric unit has morning laboratory results of Hgb 10.0, Hct 30.2, WBC 24,000, and platelets 20,000. What is the priority nursing assessment? A. Assess for pallor, fatigue, and tachycardia. B. Monitor for fever. C. Assess for bruising or bleeding. D. Determine intake and output.

C. Assess for bruising or bleeding. The extremely low platelet count places the child at significant risk for bleeding, so this takes priority over borderline anemia and possibility of infection.

The nurse is caring for a child in the emergency department who was bitten by the family dog, who is fully immunized. What is the priority nursing action? A. Administer rabies immunoglobulin. B. Refer the child to a counselor. C. Assess the depth and extent of the wound. D. Administer a tetanus booster.

C. Assess the depth and extent of the wound. Fully assess the extent of the wound before initiating other care. A full assessment allows the nurse to determine the next course of action.

A 5-year-old has been diagnosed with Wilms tumor. What is the priority nursing intervention for this child? A. Educate the parents about dialysis, as the kidney will be removed. B. Measure abdominal girth every shift. C. Avoid palpating the child's abdomen. D. Monitor BUN and creatinine every 4 hours.

C. Avoid palpating the child's abdomen. Excessive palpation of the abdomen in a child with Wilms tumor can cause seeding of the tumor, leading to metastasis.

A child with hemophilia fell while riding his bicycle. He was wearing a helmet and did not lose consciousness. He has a mild abrasion on his knee that is not oozing. He is complaining of abdominal pain. What is the priority nursing assessment? A. Perform neurologic checks. B. Assess ability to void frequently. C. Carefully assess his abdomen. D. Examine his knee frequently.

C. Carefully assess his abdomen. The child's complaint of abdominal pain indicates that undetected bleeding may be present in the abdomen. Determining whether internal bleeding is present would take priority over the knee abrasion, which has nearly stopped bleeding.

The nurse is caring for a child with cerebral palsy who requires a wheelchair to attain mobility. Which intervention would help the child achieve a sense of normality? A. Encourage follow-through with physical therapy exercises. B. Restrict the child to a special needs classroom. C. Encourage after-school activities within the limits of the child's abilities. D. Ensure the school is aware of the child's capabilities.

C. Encourage after-school activities within the limits of the child's abilities. Children in wheelchairs enjoy activities such as choir, scouts, and art classes, just as typical children do. Sometimes additional modifications may need to be made for the child to succeed in the activity.

A 7-year-old child with cerebral palsy has been admitted to the hospital. Which information is most important for the nurse to obtain in the history? A. Age that the child learned to walk B. Parents' expectations of the child's development C. Functional status related to eating and mobility D. Birth history to identify cause of cerebral palsy

C. Functional status related to eating and mobility. Each child with cerebral palsy has individual strengths. The nurse must know this child's functional status, as mobility and feeding may both be affected in the child with cerebral palsy.

A child with cancer is receiving chemotherapy, and his mother is concerned that the nausea and vomiting associated with chemotherapy are reducing his ability to eat and gain weight appropriately. What is the most appropriate nursing action? A. Administer an antiemetic at the first hint of nausea. B. Offer the child's favorite foods to encourage him to eat. C. Start antiemetic drugs prior to the chemotherapy infusion. D. Maintain IV fluid infusion to avoid dehydration.

C. Start antiemetic drugs prior to the chemotherapy infusion. Give the antiemetic prior to the chemotherapy drug to prevent nausea and vomiting.

What is the priority nursing intervention for the child recently admitted with Guillain-Barré syndrome? A. Perform range-of-motion exercises. B. Take temperature every 4 hours. C. Monitor respiratory status closely. D. Assess skin frequently.

C. Monitor respiratory status closely. Although range of motion and skin integrity are also important, the progressive paralysis associated with Guillain−Barré syndrome may lead to respiratory distress/arrest, so monitoring for respiratory involvement is critical.

An adolescent girl who has been receiving treatment for anorexia nervosa has failed to gain weight over the past week despite eating all of her meals and snacks. What is the priority nursing intervention? A. Increase the teen's daily caloric intake by at least 500 calories. B. Ensure that the teen's entire fluid intake includes calories. C. Supervise the teen for 2 hours after all meals and snacks. D. Assess the teen's anxiety level to determine need for medication.

C. Supervise the teen for 2 hours after all meals and snacks. The teen may be concealing and later disposing of food, and because she may be inducing vomiting, she should not be allowed to visit the bathroom independently after the meal.

A young mother brings her new baby, diagnosed with congenital hypothyroidism, to the clinic so she can learn how to administer levothyroxine. The nurse should include which of the following instructions? A. Crush the medication and place it in a full bottle of formula to disguise the taste. B. Administer the medication every other day. C. Use an oral dispenser syringe or nipple to give the crushed medication mixed with a small amount of formula. D. Tell the mother that the medication will not be needed after the age of 7.

C. Use an oral dispenser syringe or nipple to give the crushed medication mixed with a small amount of formula. Hypothyroidism is a lifelong condition and requires daily medication indefinitely. It is important for the infant to ingest the complete amount of the medication each day, so it should be mixed with only a small amount of formula; giving the medication in a full bottle may not ensure the complete administration of the medication if the child does not drink the full bottle.

A 14-year-old with systemic lupus erythematosus wants to know how to care for her skin. What should the nurse teach this adolescent? A. Careful sun tanning will give her skin an attractive color. B. No special skin care is needed. C. Use sunscreen daily to avoid rashes. D. Use makeup to camouflage the butterfly rash on her face.

C. Use sunscreen daily to avoid rashes. Children with SLE experience photosensitivity that results in skin rashes. Daily sunscreen use (minimum SPF 15) is recommended.

A 4-month-old infant born to an HIV-infected mother is going into foster care because the mother is too ill to care for the child. The foster mother wants to know if the infant is also infected. What is the best response by the nurse? A. "It's too early to know; we have to wait until the infant has symptoms." B. "Since the mother is so ill, it's likely the child is also infected with HIV." C. "The ELISA test is positive, so the child is definitely infected." D. "The PCR test is positive; this indicates HIV infection, which may or may not progress to AIDS."

D. "The PCR test is positive; this indicates HIV infection, which may or may not progress to AIDS." The PCR tests for actual HIV genetic material in the child. A positive PCR test indicates active infection.

CRITICAL THINKING EXERCISE: Develop a discharge teaching plan for a 14-year-old with systemic lupus erythematosus who will be taking corticosteroids long term.

Corticosteroids should be administered with food to decrease incidence of GI upset. Report suspected infection to the health care provider. Monitor blood pressure and teach the family to test the urine for glucose. Medication should never be stopped abruptly as acute adrenal insufficiency may occur. Monitor the child for new onset of joint pain, particularly with weight bearing, or limited range of motion as these signs may indicate the development of avascular necrosis (lack of blood supply to the joint), which might occur as an adverse effect of long-term corticosteroid use.

The nurse is caring for an infant on the pediatric unit who has a very red rash in the diaper area, with red lesions scattered on the abdomen and thighs. What is the priority nursing intervention? A. Administer griseofulvin with a fatty meal. B. Institute contact isolation precautions. C. Apply topical antibiotic cream. D. Apply topical antifungal cream.

D. Apply topical antifungal cream. An angry red rash with satellite lesions is typical of diaper candidiasis. Topical antifungal preparations are indicated.

A child with leukemia has the following AM laboratory results: Hgb 8.0, Hct 24.2, WBC 8,000, platelets 150,000. What is the priority nursing assessment? A. Monitor for fever. B. Assess for bruising or bleeding. C. Determine intake and output. D. Assess for pallor, fatigue, and tachycardia.

D. Assess for pallor, fatigue, and tachycardia. The Hgb and Hct indicate anemia, which results in fatigue, pallor, and tachycardia.

The nurse is caring for orthopedic children who are in the postoperative period following spinal fusion. What is the most appropriate activity to delegate to unlicensed assistive personnel? A. Ambulate the children twice daily to promote mobility. B. Encourage commode use to promote bowel function. C. Provide diversionary activities, as the children must stay flat on their backs. D. Assist with log-rolling the children every 2 hours.

D. Assist with log-rolling the children every 2 hours. Frequent position changes promote pulmonary, gastrointestinal, and genitourinary functioning; in the child who has had a spinal fusion, the appropriate method of changing position is by log-rolling to avoid flexing the spine. The nurse also has the opportunity to assess the spinal bandage for drainage or bleeding when the child is log-rolled.

When monitoring the blood glucose level of a 12-year-old child with type 2 DM, your reading is 50 mg/dL. Which is the most appropriate action? A. Encourage the child to get out of bed and increase activity. B. Take the child's vital signs. C. Ask the child about frequent urine output. D. Give the child 4 oz of orange juice.

D. Give the child 4 oz of orange juice. The child's glucose level is too low. Orange juice will provide quick sugar to raise the child's blood glucose level. Increased exercise would be contraindicated since it would lower blood glucose even further.

A boy with Duchenne muscular dystrophy is admitted to the pediatric unit. He has an ineffective cough. Lung auscultation reveals diminished breath sounds. What is the priority nursing intervention? A. Apply supplemental oxygen. B. Notify the respiratory therapist. C. Monitor pulse oximetry. D. Position for adequate airway clearance.

D. Position for adequate airway clearance. Positioning for airway clearance is the priority intervention, although suctioning may also be required. Interventions for airway maintenance take priority over other issues.

A 15-year-old girl has been making demands all day, exaggerating her every need. She is now crying, saying she has nothing to live for and threatening to kill herself. What is the priority nursing action? A. Ignore her continued exaggerated and melodramatic behavior. B. Consult with the physician or nurse practitioner to increase her antidepressant dose. C. Leave the girl alone for a little while until she composes herself. D. Take the girl's suicidal threat seriously and provide close supervision.

D. Take the girl's suicidal threat seriously and provide close supervision. Always take suicidal verbalizations seriously. Closely observe the girl, providing ongoing support.

The nurse is caring for a child with ADHD. Which behavior would the nurse not expect the child to display? A. moody, morose behavior with pouting B. interruption and inability to take turns C. forgetfulness and easy distractibility D. excessive motor activities and fidgeting

D. excessive motor activities and fidgeting Excessive motor activity, fidgeting, interruptions, distractibility, forgetfulness, and inability to take turns are all expected findings in the child with ADHD; moodiness and morose affect are not.

KEY CONCEPTS: Bones

bones of the infant and young child are more flexible, and have a thicker periosteum plus MORE ABUNDANT blood supply than an adult; as a result, bending occurs more frequently than breaking of the bone FRACTURE BONE heals more QUICKLY

TAKE NOTE: Diabetic Ketoacidosis (DKA)

DKA is a MEDICAL EMERGENCY requiring early recognition and prompt intervention; remain alert to the increased chance of DKA during times of stress (ex. illness, infection, surgery) as hormones produced by the body in times of stress result in decreased insulin sensitivity plus increased glucose production

CRITICAL THINKING EXERCISE: An 11-month-old comes to the primary care office with his mother for evaluation of a significant flaking red rash on both cheeks. The child is diagnosed with atopic dermatitis. What additional information should be obtained in the health history? What information should be included in the teaching plan for this family?

Determine if the rash is causing the child discomfort or itching. Does the infant wiggle or scratch? Is the baby irritable or having difficulty staying asleep? Have the parents noticed any scratch marks? Are other areas of the baby's skin dry? What treatments have they tried and what was the response? Is there a family history of atopic dermatitis (eczema), allergic rhinitis, or asthma? Does the infant have asthma, allergic rhinitis, or food or environmental allergies? Teach families that atopic dermatitis is a chronic disorder requiring ongoing attention. Promoting skin hydration is essential. Hot water, perfumes, dyes, and fragrance should be avoided. Only mild soap should be used, and the child should be patted dry after the bath. Prescribed anti-inflammatory ointments or creams should then be applied while the skin is still moist, followed by hydrating moisturizers. Hydrating moisturizers should be applied several times a day. Keep the child's fingernails short. An antihistamine at bedtime may help to decrease pruritus at night and allow the child to rest.

CRITICAL THINKING EXERCISE: A mother tells you that her son's behavior is unmanageable, and she is having difficulty coping with it. The boy is argumentative and is bullying others. He is struggling with his schoolwork because he has difficulty staying on task, gets out of his chair often, and frequently distracts others. What additional assessments should you obtain? What interventions would be helpful in managing the boy's behavior?

Determine the boy's behavior as an infant and younger child. Ask the mother about his ability to concentrate, his prior school performance, and whether he participates in overtly hostile acts. How does the boy deal with frustration? Has he been evaluated for specific learning disorders? What are the results of the most recent hearing and vision screenings? Determine what behavioral methods and discipline have been used at home and in school and what the response has been. Interventions should include enhancing the boy's ability to interact with peers and adults; behavioral therapy and a positive reinforcement system to promote appropriate behaviors; limit-setting with consequences; and promotion of self-esteem as positive behaviors replace the negative ones.

KEY CONCEPT: Contact & Atopic Dermatitis

both present as pruritic rashes (scaling may occur with ATOPIC Dermatitis - consider the patient's itch/rash/itch cycle that may affect sleep, school functioning, and self-esteem of the child)

KEY POINT: ELISA v. PCR HIV Test

ELISA - ONLY detects antibodies to HIV in the infant which may be maternal in origin PCR - tests for HIV genetic material, making it more accurate to test for HIV infection in infants + young children

TAKE NOTE: Carboxyhemoglobin Levels

HIGH levels of Carboxyhemoglobin as a result of smoke inhalation may contribute to FALSELY HIGH SpO2 readings

KEY POINT: Preventing HIV Infection

HIV infection may be prevented in infants by prenatal screening and maternal treatment, as well as postnatal treatment with Zidovudine infection may result in encephalopathy + developmental delay

KEY CONCEPT: Burns

burns may result in significant weeping and fluid loss; focus on nursing interventions such as pain management, prevention of infection, and rehabilitation

KEY CONCEPT: Which type of cancer presents similarly to those in adults?

LYMPHOMAS (often with enlarged, non-tender lymph nodes)

Chapter #50

Nursing Care of the Child With an Alteration in Behavior, Cognition, or Development

Chapter #46

Nursing Care of the Child with an Alteration in Cellular Regulation/Hematologic or Neoplastic Disorder

Chapter #47

Nursing Care of the Child with an Alteration in Immunity or Immunologic Disorder

Chapter #48

Nursing Care of the Child with an Alteration in Metabolism/Endocrine Disorder

Chapter #44

Nursing Care of the Child with an Alteration in Mobility/Neuromuscular or Musculoskeletal Disorder

Chapter #45

Nursing Care of the Child with an Alteration in Tissue Integrity/Integumentary Disorder

TAKE NOTE: Catheterization of the Pediatric Patient with Myelomeningocele and/or Neurogenic Bladder

ONLY LATEX-FREE catheters and gloves should be used for catheterization of these patients as these children exhibit a high incidence of latex allergy

CRITICAL THINKING EXERCISE: A 4-year-old presents with his mother for evaluation of a yellowish, runny sore on his head. What questions would be most appropriate to ask the mother when taking the history? Should this child be placed in isolation? If so, why?

Questions - How did the sore start and how has it progressed? What treatment has she tried and what has been the effect of the treatment? Has the child been running a fever? Yellowish sores are often impetigo. The child should be isolated according to the institution's policies if the child is admitted to the hospital (definitely if MRSA is confirmed). Otherwise, good handwashing is all that is necessary at home and standard precautions in health care facilities.

KEY POINT: Which HIV Test is more accurate to use in infants and young children?

PCR (this tests for genetic material and NOT maternal antibodies as the other HIV test does)

CRITICAL THINKING EXERCISE: A 5-year-old child is admitted to the pediatric unit with a history of cerebral palsy sustained at birth. The child is admitted for a scheduled tendon lengthening procedure. Based on your knowledge about the effects of cerebral palsy, list three priorities to focus on when planning her care. Compare this to a child admitted for surgical correction of a broken femur with no significant past medical history.

PRIORITIES for this patient include respiratory status, mobility status, nutritional status, and communication ability as all of these can be effected by cerebral palsy. Respiratory status is important because this can lead to postoperative complications and the child with CP may have a decreased ability to cough and deep breathe as compared to a child with no significant past medical history. A child with CP will need to continue therapies such as physical, occupational, and speech therapies while the child with a broken femur and no significant past medical history may require physical therapy of a limited duration. A child with CP often will have difficulties with eating and swallowing and may require nutritional interventions to prevent poor nutrition and promote postoperative healing while a child with a broken femur and no significant past medical history will return to a regular diet during the postoperative period. A child with CP may be nonverbal or have articulation problems and may utilize alternative means of communication while this will not be an issue with a child with a broken femur and no significant past medical history.

CRITICAL THINKING EXERCISE: Determine an appropriate nursing plan of care for an infant who has undergone bone marrow transplantation for SCID.

The nursing care plan should include nursing diagnoses and interventions that address infection and bleeding prevention, treatment of electrolyte imbalance, and promotion of appropriate growth and development. Pre-transplant care should include protective isolation and administration of gammaglobulin, antivirals, or antibiotics. During the post-transplant phase, the child should be closely monitored for symptoms of graft-versus-host disease.

CRITICAL THINKING EXERCISE: A mother brings her baby to the clinic after receiving a phone message from the clinic saying there was a problem with the baby's thyroid test. She says the trip on the bus took a long time, but the infant slept the entire way. She says that the baby is sleeping much of the time and does not want to eat very much. The baby was discharged from the hospital 2 weeks ago. The birth was without difficulty and there were no problems during labor. Why is this visit urgent? What would the test show if the disorder was due to a pituitary gland problem and not the thyroid gland?

The newborn screening test for thyroxin (T4) and TSH levels indicates the possibility of congenital hypothyroidism, and another test would be needed to confirm the disorder. An elevated TSH level would indicate that the disease originated in the thyroid, not the pituitary. The T4 level is below normal.

CRITICAL THINKING EXERCISE: A 12-year-old boy with type 1 DM has the flu. His mother calls the diabetes clinic to report that he stayed home from school and does not have an appetite, so he is not eating. The mother asks the nurse how much insulin the boy should take. He is currently taking three injections daily with regular and NPH in the morning before breakfast, regular and NPH in the evening after dinner, and regular before bedtime. What questions should the nurse ask before answering the mother's question? Based on the answers to these questions, how would you instruct the mother?

The nurse should ask the following: How long has the boy been ill? Can he keep fluids down? If so, what types and how much fluid has he taken? Does he have a fever? What were his last four blood glucose results? Is he urinating, and are there ketones in his urine? The nurse should instruct the mother to continue to give the insulin, but a sliding scale might be needed with regular insulin, and glucose testing should be performed every 3 to 4 hours to determine the dose. If ketones are present, the mother should encourage calorie-free fluid intake to clear ketones and should offer small meals of foods the boy likes. The mother should promote rest without exercise. She should continue to check ketones and should call the clinic again if the child continues to have moderate to high urinary ketones, signs of hyperglycemia, acetone or fruity breath, lethargy, or deep, rapid respirations, which are signs of DKA.

CRITICAL THINKING EXERCISE: The mother of Robin, a 5-year-old girl, reports that Robin has a body odor. She is developing breasts and some pubic hair and was teased when she had a sleepover with friends. The review of her growth charts reveals that Robin went from the 50th percentile to the 93rd percentile in the past 6 months. Based on this information, what are the three major nursing diagnoses to begin establishing a plan of care for the child and family? What are the expected outcomes and major interventions associated with the nursing diagnosis of knowledge deficit?

The three nursing diagnoses are knowledge deficit related to diagnostic procedures and testing and general information about the possible disorder; risk for disturbed body image related to early development of secondary sexual characteristics; and altered growth and development: accelerated growth and development related to secondary sexual characteristics and pathology of the condition. The expected outcome for the knowledge deficit nursing diagnosis is as follows: The child and family will explain, at their level of understanding, the diagnostic procedures and the physical and potential emotional changes that occur with the early onset of puberty as evidenced by verbalizing key concepts and complying with requirements for diagnostic testing. Major interventions are as follows: Assess the understanding the child and family have regarding the onset of puberty; provide information about normal pubertal developments and the changes with the early onset; provide information to the child at the level appropriate for a 5-year-old; explain all diagnostic procedures, especially what is expected of the child and what, if any, adverse effects may occur.

CRITICAL THINKING EXERCISE: A child with recurrent infections is being evaluated. Other than information about onset of symptoms and events leading up to this present episode, what other types of information would the nurse ask while obtaining the history?

What is the family history and the mother's pregnancy history? Has the child experienced frequent otitis media, sinusitis, pneumonia, chronic cough, or recurrent low-grade fever or had two or more serious infections in early childhood? Has the child had recurrent deep skin or organ abscesses, persistent oral candidiasis, or extensive eczema? What has the child's growth pattern been? Does the child have any allergies?

KEY POINT: Systemic Lupus Erythematosus (SLE)

a chronic autoimmune disorder that can affect ANY organ system, primarily causing vasculitis Nursing Management - includes prevention of flare-ups + complications

KEY CONCEPT: Erythema

a common finding with many skin disorders in children

CRITICAL THINKING EXERCISE: Devise a developmental/education plan for a child who will be confined to traction for 6 weeks. Choose a child in the clinical area whom you have cared for or choose a particular age group and develop the plan.

a developmental/education plan for a child who will be confined to traction for six weeks should be based on child/age and include general ideas to promote normal growth + development (ex. placing age-appropriate toys within the child's reach, encouraging visits from friends, providing diversional activities, working with school to receive schoolwork the child will miss); diversional activities may include drawing, coloring, or video games

TAKE NOTE: Intravenous Immunoglobulin (IVIG)

administration of exogenous immunoglobulin every several weeks can DECREASE the frequency & severity of infections in children with various forms of hypogammaglobulinemia; do NOT shake as this may lead to foaming and may cause the immunoglobulin protein to degrade many children who have had previous reactions to IVIG can tolerate the infusion WITHOUT reaction if they are premeditated, AND if the infusion is given at a slower rate; this may be administered every several weeks which allows children to lead a healthier life with fewer infections

TAKE NOTE: Neurovascular Assessment in the Child with a Cast or in Skeletal Traction

an ongoing, careful neurovascular assessment is critical in the child with a cast or in skeletal traction; the physician or NP should be notified IMMEDIATELY if the patient experiences signs of Compartment Syndrome Compartment Syndrome Signs & Symptoms = extreme pain (disproportionate to the situation), pain with passive ROM of digits, distal extremity pallor, inability to move digits, or loss of pulse(s)

TAKE NOTE: Injury Assessment

assess the injured site last, and do so gently

TAKE NOTE: Extremity Assessment & the "5 P's"

assess the injured, splinted, or casted extremity frequently for the "5 P's" which may indicate COMPARTMENT SYNDROME and should be reported IMMEDIATELY 1. Pain (increased out of proportion) 2. Pulselessness 3. Pallor 4. Paresthesia 5. Paralysis

TAKE NOTE: Vasopressin Monitoring

be sure to monitor BP closely when initiating this medication as it functions as a vasoconstrictor

KEY CONCEPT: Psychosocial Impact of Pediatric Cancer

cancer is a significant stressor for children and families, requiring support AND education throughout the diagnostic process, treatment, cure, or palliative care that occurs throughout the patient journey; encourage children with cancer to lead as "near normal" a life as possible OPTIMIZE NUTRITION - mange N/V with antiemetics, provide favorite foods, and possibly administer TPN PRN

KEY POINT: Growth Hormone Deficiency

characterized by poor growth and short stature as a result of failure of the anterior pituitary to produce sufficient GH; early treatment enables the child to reach normal growth

KEY POINT: Diabetes Insipidus

characterized by water intoxication as a result of an ADH deficiency that leads to the cardinal signs of polyuria + polydipsia, resulting in hypernatremic dehydration

KEY CONCEPT: Childhood v. Adult Cancer

childhood cancer tends to develop from embryonal tissue and in general, is more RESPONSIVE to therapy than when compared to adulthood cancers (these are derived from epithelial tissues) ADULTS - cancer is also influence to a larger extent by environmental factors, which makes screening measures AND prevention strategies only exist for types of adult cancer

KEY POINT: Hypersensitivity Skin Testing

children with immune disorders often show a DECREASED OR ABSENT response to delayed hypersensitivity skin testing (ex. TB Test)

KEY POINT: Primary Immune Deficiencies

congenital in nature and SERIOUS, yet can only be cured by bone marrow or stem cell transplantation A. Severe Combined Immunodeficiency (SCID) B. Wiskott-Aldrich Syndrome

TAKE NOTE: Administration of Live Vaccinations

do NOT administer live vaccines to the immunocompromised child WITHOUT the expressed consent of the infectious disease or immunology specialist as immunosuppression is a CONTRAINDICATION to vaccination with LIVE vaccines

TAKE NOTE: Defining Burns

due to overlying blistering, it is difficult to accurately distinguish between partial- and full-thickness burns; in addition, in the case of third-degree burns, it is difficult to estimate burn depth during the initial evaluation

TAKE NOTE: Intellectual Disability

due to the extent of cognition required to understand and produce speech, the most sensitive early indicator of intellectual disability us DELAYED LANGUAGE DEVELOPMENT

TAKE NOTE: Fluid Deprivation Test

during a fluid deprivation test, the child may be irritable and frustrated because fluid is being withheld (do NOT drink in front of the child); close monitoring of the child is REQUIRED during this test the physician or NP should be notified if the UOP is GREATER than 1,000 mL/hr for TWO CONSECUTIVE VOIDS

HEALTHY PEOPLE 2020: Antiretroviral Therapy

educate families about the importance of complying with medication therapy (ex. HIGH retroviral therapy - HAART plus receiving regularly scheduled medical evaluations)

KEY CONCEPTS: Hypertonia v. Hypotonia

either hypertonia or hypotonia are BOTH an ABNORMAL finding in the infant or child

TAKE NOTE: Sickle Cell Disease/Anemia

for the patient (infant/toddler) with Sickle Cell Anemia, be sure to IMMEDIATELY report symmetric swelling of the hands + feed which is known as Dactylitis - the ascetic infarction occurs in the metacarpals & metatarsals DO NOT ADMINISTER MEPERIDINE (the opioid analgesic Demerol) for pain management during a Sickle Cell CRISIS as it has been associated with an INCREASED RISK for neurotoxicity when used in children with this disorder

TAKE NOTE: Nickel Dermatitis

form of Contact Dermatitis which may occur from contact with jewelry eyeglasses, belts, or clothing snaps; infants may display a small red circle with scaling at the site of contact with sleeper snaps

TAKE NOTE: Fractures

fractures are rare in children younger than ONE year of age, so carefully evaluate the infant who presents with a fracture for child abuse or an underlying musculoskeletal disorder; fracture in the newborn (with the exception of birth trauma) or infant should rase a HIGH index of suspicion for abuse, as fractures are very unusual in children who cannot yet walk

KEY CONCEPT: Appropriate Hygiene

hygiene is of particular importance in integumentary disorders; teach children (or parents) with CHRONIC disorders such as Atopic Dermatitis, Psoriasis, and acne to cleanse + moisturize the skin properly, avoid particular skin irritants, and proper use of medications minor skin injuries = cleanse with good soap & water

KEY CONCEPT: Hypersensitivity Responses

hypersensitive reactions may result in erythema multiform or urticaria

TAKE NOTE: Iron Deficiency

in order for appropriate growth to occur in adolescence, increased amount of iron MUST be consumed AND absorbed; assure families that as long as appropriate measures are taken to address Iron-Deficiency Anemia, referrals to the WIC Program/Child Services are NOT generally made

KEY POINT: Infant & Young Children Immune System v. Adult

infants and young children have larger lymph nodes, tonsils, and thymus than when compared to adults infants also have DECREASED phagocytic activity which places them at a higher risk for serious infection

TAKE NOTE: Congenital Defects of the Pituitary Gland or Hypothalamus (NEONATAL EMERGENCY)

infants with congenital defects of the pituitary gland or hypothalamus may present as a NEONATAL EMERGENCY; symptoms include apnea, cyanosis, severe hypoglycemia with possible seizures, and prolonged jaundice

KEY POINT: Nursing Interventions for Immunocompromised Pediatric Patients

interventions include promoting proper growth by encouraging the child to eat a balanced diet

KEY POINT: Precocious Puberty

involves early development of secondary sex characteristics as a result of premature activation of the Hypothalamic-Pituitary-Gonadal Axis (HPGA)

KEY POINT: Congenital Hypothyroidism

key findings within Congenital Hypothyrdoism includes a thickened protuberant tongue, an enlarged posterior fontanel, feeding difficulties, hypotonia, and lethargy early diagnosis & treatment of hypothyroidism can prevent impaired growth + severe cognitive impairment

KEY CONCEPTS: Nursing Management of the Child with Myelomeningocele

management of Myelomeningocele focuses on preventing infection, promoting bowel + urinary elimination, promoting adequate nutrition, preventing latex allergy reaction, maintaining skin integrity, providing education plus support to the family, and recognizing complications (ex. hydrocephalus or increased ICP associated with the disorder)

KEY CONCEPT: Bacterial Skin Infections

most bacterial skin infections are caused by Staph or B-Hemolytic Strep

Chapter #44: Nursing Care of the Child with an Alteration in Mobility/Neuromuscular or Musculoskeletal Disorder (Nursing Diagnoses)

nursing diagnoses for patients with this disorder may include maximizing physical mobility, promoting adequate nutrition, promoting successful bladder emptying, promoting appropriate bowel elimination, maximizing self-care, promoting skin integrity, easing sorrow, preventing injury, providing child + family teaching, promoting appropriate family functioning, and promoting development

Chapter #50: Nursing Care of the Child with an Alteration in Behavior, Cognition, or Development (Nursing Diagnoses)

nursing diagnoses include improving nutritional intake, promoting development, reducing confusion, promoting hope, and decreasing role strain

TAKE NOTE: Thyroid Hormone Overdose (OD)

observe for signs of Thyroid Hormone overdose such as irritability, rapid pulse, dyspnea, sweating, and fever OR ineffective treatment ineffective treatment - signs include fatigue, constipation, and DECREASED appetite

KEY CONCEPTS: Frequent Pain Status Assessment

perform frequent assessments of pain status and the effect of pain medication in the child with a musculoskeletal disorder

KEY CONCEPT: Impetigo

physical manifestations include a honey-colored crusting

Chapter #47: Nursing Care of the Child with an Alteration in Immunity or Immunologic Disorder

potential nursing diagnoses for patients of this disorder include preventing infection, promoting adequate nutritional intake, preventing skin impairment, promoting activity, and enhancing growth & development

Chapter #48: Nursing Care of the Child with an Alteration in Metabolism/Endocrine Disorder (Nursing Diagnoses)

potential nursing diagnoses for this patient includes enhancing growth & development, promoting healthy body image, promoting knowledge required for self-management, encouraging healthy family processes, encouraging healthy family processes, maintaining adequate nutrition, maintaining adequate fluid volume, and encouraging compliance

Chapter #46: Nursing Care of the Child with an Alteration in Cellular Regulation/Hematologic or Neoplastic Disorder

potential nursing diagnoses include decreased fatigue, promoting physical mobility, educating parents about effective health maintenance, relieving anxiety, promoting effective family coping, preventing injury, preventing infection, promoting comfort, restoring healthy oral mucosa, alleviative N/V, promoting adequate nutrition, preventing or managing constipation, managing diarrhea, promoting skin integrity, promoting activity, promoting body image, promoting self-esteem, promoting child & family coping, and supporting grieving family

Chapter #45: Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder (Nursing Diagnoses)

potential nursing diagnoses include restoring skin integrity, prevent infection, promote appropriate body image, promote fluid balance, and promote nutrition

KEY CONCEPT: Psoriasis

presents as generally non-pruritic, flaky skin (scaling may occur too)

KEY CONCEPT: Priorities in Sickle Cell Anemia Management

priorities for care management of the child with Sickle Cell Anemia includes A. Prevention of Infection B. Prevention of Vaso-Occlusive Episodes C. Multimodal Pain Management (NOT MEPERIDINE/DEMEROL) D. Astute Physical Assessment (for serious complications)

TAKE NOTE: Supplement Safety & Parent Education

provide parental teaching to keep iron-containing supplements out of reach for young children in order to prevent accidental ingestion leading to OD or poisoning

KEY CONCEPT: Common Treatment for Blood Disorders

purpura bleeding disorders are usually self-limiting and administration of Factor VII or Desmopressin are the key nursing treatment interventions for children with bleeding disorders; remember that significant anemia may result in HYPOXIC TISSUES (HYPOXIA)- also that prolonged bleeding times place the child at risk for hemorrhage focus on PREVENTION OF INJURY

KEY CONCEPTS: Rapid Muscle Growth

rapid muscle growth in the adolescent years places the teenager at an increased risk for injury compared with other age groups

TAKE NOTE: GH Therapy

reports have found NO evidence linking GH therapy to higher risk of leukemias or brain tumors

KEY CONCEPTS: Muscular Dystrophy & Spinal Muscular Atrophy

respiratory compromise occurs in both disorders, eventually leading to death

KEY POINT: Juvenile Idiopathic Arthritis

results in chronic PAIN and affects growth & development, as well as school performance Nursing Management - includes pain management, maintaining mobility, and administering disease-modifying medications Parent Education - teach methods to DECREASE PAIN while increasing or maintaining mobility of the child

TAKE NOTE: Warning Signs of Autism

screen ALL infants and toddlers for warning signs of autism including NOT babbling by 12 months, NOT pointing or using gestures by 12 months, NO single words by 16 months, NO two-word utterances by 24 months, and losing language or social skills at ANY age social interactions - often impaired in these patients as well as altered communication

KEY CONCEPT: Sebum Production

sebum production increased in the preadolescent and adolescent years, contributing to the development of acne at this development time

TAKE NOTE: Nursing Considerations with Splinting

significant swelling may occur initially after immobilization with a splint, delaying casting for a few days provides time for some of the swelling to subside (allows for successful casting a few days after the injury) do NOT attempt to straighten or manipulate an injured limb

TAKE NOTE: Cholinergic Crisis Signs & Symptoms

signs & symptoms of a CHOLINERGIC Crisis include severe muscle WEAKNESS, sweating, increased salivation, bradycardia, and hypotension (think of the Muscarinic Receptors)

TAKE NOTE: Myasthenic Crisis Signs & Symptoms

signs & symptoms of a MYASTHENIC Crisis include severe muscle WEAKNESS, respiratory difficulty, tachycardia, and dysphasia

KEY CONCEPT: Teenager Integumentary System

skin thickness & characteristics reach adult levels in the LATE teenage years

TAKE NOTE: Corticosteroid Use

teach families to report any new onset of joint pain, especially with weight-bearing or limited ROM to the physician or NP due to the adverse effect of Avascular Necrosis AVASCULAR NECROSIS - lack of blood supply to a joint, resulting in tissue damage as an adverse effect of long-term or high-dose corticosteroid use

KEY POINT: Diabetes Mellitus

the MOST common endocrine disorder seen in children; management is focused on regulation of glucose control which is accomplished by medications, diet, and exercise Patient/Parent Education - involves instruction in glucose monitoring, administration of insulin or oral hypoglycemics, meal planning, and promotion of a healthy lifestyle

KEY CONCEPT: Iron-Deficiency Anemia

the key intervention for this type of anemia includes iron supplementation, providing patient/family education on promoting a diet HIGH in the deficient nutrients

CRITICAL THINKING EXERCISE: Develop a nursing care plan for an adolescent with cancer who is undergoing radiation and chemotherapy and experiencing a significant number of adverse effects from his treatment.

the nursing care plan should focus on the nursing diagnoses of pain, risk for infection, impaired oral mucous membranes, nausea, imbalanced nutrition, impaired skin integrity, activity intolerance, and disturbed body image; this plan should be individualized depending on the adolescent's particular response to therapy while integrating concepts related to communicating with adolescents as appropriate

CRITICAL THINKING EXERCISE: An 8-year-old girl has been diagnosed with iron-deficiency anemia. Formulate a nutrition plan for this child.

the plan should include a balanced diet with adequate iron intake and should also be reasonable for a typical 8-year-old's food preferences

KEY CONCEPT: Priority Intervention of Thalassemia Management

the priority intervention for management of thalassemia is the CHRONIC transfusion of PRBCs and chelation (binding) of iron

CRITICAL THINKING EXERCISE: A 17-year-old girl has recently been diagnosed with osteosarcoma. She is worried about how treatment will affect her plans for college, marriage, and children. How will you respond to her concerns?

the response will vary depending upon the treatment planned (amputation vs. limb sparing procedure), allow the teen to verbalize her concerns + respond with honest answers related to the effects of radiation & chemotherapy; following treatment, she should be able to attend college and get married (assuming that chemotherapy does not impair her reproductive capability, she should still be able to bear a child even with amputation or limb sparing)

STUDY ACTIVITY: Identify the role of the registered nurse in the multidisciplinary care of the child with a debilitating neuromuscular disorder.

the role of the registered nurse in the multidisciplinary care of the child with a debilitating neuromuscular disorder will include providing direct care, providing education, coordinating care of multiple disciplines and therapies, and supporting + advocating for the child & family; the nurse's role in relation to the various therapies also includes providing ongoing follow-through with prescribed exercises, positioning, or bracing

KEY CONCEPTS: Mobile Spine

the spine is very mobile in the newborn and infant, especially the cervical spine region (resulting in a high risk for cervical spine injury)

STUDY ACTIVITY: Plan an educational activity for parents of school-age children about prevention of contact dermatitis (related to poison ivy).

the teaching plan for prevention should include wearing long sleeves/pants on outings in the woods, identifying plus removing offending plants in the yard by using a commercial weed or underbrush killer, use of vinyl gloves (NOT rubber or latex) as an effective barrier (oil residue from the plant may be on clothes, pets, toys, garden, or sports equipment which need to be washed well with soap & water); if contact occurs, wash vigorously with soap + water within 10 minutes of contact Zanfel & Tecnu Oak-N-Ivy Outdoor Skin Cleanser soap mixtures may prevent rash if used to wash the skin soon after exposure, Ivy Block (organoclay) is the only FDA-approved preventive treatment for contact dermatitis related to poison ivy, oak, or sumac (applied to the skin before possible exposure) TREATMENT = treatment should include wash lesions daily with mild soap + water, mildly debride crusted lesions, tepid baths (colloidal oatmeal such as Aveeno are helpful to decrease itching), avoid hot baths or showers as they aggravate itching, apply corticosteroid preparations topically as directed (if using high-potency preparations, do NOT cover with an occlusive dressing), weeping lesions may be wrapped lightly, and avoid occlusion

STUDY ACTIVITY: Plan an educational activity for parents of babies about the treatment and prevention of diaper dermatitis.

the teaching plan should include changing diapers frequently, changing stool-soiled diapers ASAP, avoid rubber pants, gently wash the diaper area with a soft cloth, avoid harsh soaps, use baby wipes in most children (but avoid those that contain fragrance or preservatives); if there is a rash already present allow the infant or child to go diaper-less for a period of time each day to allow the rash to heal, blow-dry the diaper/rash area with the dryer set on the warm (not hot) setting for 3-5 minutes

CRITICAL THINKING EXERCISE: Develop a discharge teaching plan for the parent of a toddler who has just been diagnosed with hemophilia and received factor infusion treatment for a bleeding episode.

the teaching plan should include education about factor infusion as well as safety information (Teaching Guidelines 46.2 shares information related to the prevention of bleeding)

CRITICAL THINKING EXERCISE: Develop a discharge teaching plan for a child who has just completed the induction phase of chemotherapy for acute lymphocytic leukemia.

the teaching plan will vary depending upon the medications prescribed following induction and teaching should also focus on prevention of infection, promoting growth, and promoting a normal life

TAKE NOTE: Chemotherapy & Hair Loss

the use of a cooling cap to cool the scalp during chemotherapy administration may reduce hair loss for the cancer patient

TAKE NOTE: Duchenne Muscular Dystrophy

there is NO cure for this type of muscular dystrophy; however, the use of corticosteroids may help slow the progression and Ca++ Supplements & Vitamin D are prescribed to prevent osteoporosis researchers continue to search for a way to stop or reverse this disease- gene therapy clinical trials for treatment are currently in progress BOYS with Duchenne Muscular Dystrophy initially learn to walk but later lose the ability to

KEY CONCEPTS: Muscles, Tendons, Ligaments, & Cartilage

these are all present and functional at birth, though intentional, purposeful movement develops ONLY as the infant matures

TAKE NOTE: Modern Fiberglass Cast

these materials are available in a variety of colors, as well as a few patterns; allowing the child to choose the color will increase the child's cooperation with the procedure TAKE NOTE #2 - persistent complaints of pain may indicate compromised skin integrity underneath the cast

TAKE NOTE: Lantus Insulin

this insulin is long-acting and is usually given in a single dose at bedtime, and do NOT mix this with other insulins

KEY CONCEPTS: Long Bone Epiphysis

this location is known as the "growth center" of bones in children, so injury to this area may result in long-term extremity deformity (altering growth + development)

CRITICAL THINKING EXERCISE: A 5-year-old with β-thalassemia is resistant to nightly chelation therapy at home. Devise a developmentally appropriate teaching plan for this child.

this plan should include strategies such as coloring and puppets which are developmentally appropriate for a preschooler; in addition, mutual agreement on a bonus/reward system for cooperation with the treatments should be developed (ex. sticker chart)

TAKE NOTE: Guillian-Barre Syndrome (GBS)

tickling may be a successful technique for assessing the level of paralysis in the child with GBS (either initially or within the recovery phase) serial measurement of TIDAL VOLUMES may reveal respiratory DETERIORATION in the child with GBS

KEY POINT: Physiologic Hypogammaglobulinemia

waning (decreasing) of maternal antibodies in early infancy while humoral immunity is developing, leads to this condition which places the young infant at RISK for overwhelming INFECTION

KEY CONCEPT: Child Integumentary System

when compared to other age groups, the infant's epidermis is THINNER; therefore, the infant loses heart more readily, absorbs substances more easily, and is MORE accessible to bacterial invasion than the skin of the adult the increased water content of the infant places the infant at an INCREASED RISK for blister development + other skin alterations