FINAL EXAM OB and PEDS

Stages of Labor

1st stage of labor Cervix effaces/dilates Begins w/ onset of true Uterine Contraction Ends when cervix fully dilated at 10 cm Latent stage of labor - LATENT Latent phase: Last 8 or 9 hours Cervix dilated until 4cm, contractions mild intensity every 5- 30 mins with duration of 30-45 seconds. Become increasingly regular with shorter intervals between contractions. The mother will be happy and talkative. Preventing harm to mother and fetus: Monitoring maternal vital signs: If membrane are ruptured you should monitor temperature every 2 hours An elevated temp may be associated with dehydration or infection BP, Pulse, RR: every 60 mins during latent stage BP, Pulse, RR, every 30 mins during active labor and transition Monitor Hydration status: strict i and o encourage voiding every 2 hours check for presence of glucose or protein in urine Provide comfort measures: Increase in bloody show may be a sign of advancing labor Heavy bleeding is a sign that a complication of labor is developing Monitor maternal coping: Provide supportive care to the women and her partner Monitor Fetal Heart Rate: For low risk every 1 hour during latent and every 30min during active phase For at risk every 30 mins and every 15 min during active phase labor Before and after medication administration, invasive procedures, ambulation, increase in frequency, duration, and intensity of uterine contractions. Monitor uterine contraction pattern each time the FHR is assessed Report fetal bradycardia, tachycardia, or any decelerations Report tetanic contractions lasting longer than 90 seconds Monitor status of membranes Observe spontaneous rupture of membranes Observe the color of the fluid(should be clear) Document method of rupture, characteristics, and amount of the fluid Monitor for signs of umbilical prolapse after membranes rupture the highest risk for prolapse. transition phase the end of stage one labor as the fetus begins moving through the cervix and down the birth canal Contraction every s lasts 32-3mins 0mins to 2 hours. Intense and long back-to-back contractions. Intense pressure to the rectum Nursing interventions: support, breathing patterns, vital signs of mother and baby, fetal positioning, and what station the baby is in. Most difficult phase of labor. The cervix is 8cm and ends will full cervical dilation The woman feels a strong urge to push as the fetus descends and should resist the urge to push until the cervix is fully dilated. This can result in swelling of the cervix which slows labor or lead to hemorrhage Active stage of labor The active phase begins at 4cm cervical dilation and ends when the cervix is dilated at 7cm. Contractions typically occur every 2- 5mins. The last 45 to 60 seconds are moderate to strong intensity. Water may break want to check the color of the fluid for possible meconium stained fluid the baby can aspirate this into lungs and can be a sign of fetal distress(brown yellow tinged fluid) Nitrazine paper test for amniotic fluid Nursing interventions: Comfort non pharmacological or pharmacological: Epidural Make sure to keep bladder empty as this can keep the uterus from contracting Make sure to monitor mom and baby vital signs Mom will be serious in pain and anxious Oxytocin should be discontinued during the active phase of labor once the cervix has dilated to 5cm 2nd stage Complete dilation but check effacement, no pushing until 100% effacement shortest phase pressure in the perineum and birth canal Encourage to use abdominal muscles to bear down during contractions Will start to feel really intense pressure Will start descending through the birth canal Longer for new moms 1-2 hours and 20 mins for mom with previous babies. contractions 2-3 min 60-9omins Nursing interventions: Teaching mom to push esp. if she had epidural, high fowlers, lithotomy, recording birth time Increase in the bloody show. Starts with the cervix fully dilated and ends with the delivery of the bay. 3rd Stage Birth of baby, spontaneous placenta delivery. Should see a gush of blood, vital signs, APGAR, vital signs on mom. Starts with the delivery of the baby and ends with the delivery of the placenta. Last 5-15mins, the risk for hemorrhage, ss of the placental delivery uterus will change shape from oval to globular shape Monitor moms blood pressure will receive Pitocin after the delivery of the placenta Encourage bonding 4th stage 4th stage: 1-2 hours after the placenta is Recovery watch for hemorrhage occurs in the first 24 hours after birth caused by uterine atony. Watch temperature or HR for hemorrhage Watch for clot size Watch how many pads a patient can go to Pain relief Peri-care Medications: Oxytocin, misoprostol, Cytotec, methylergonovine, carboprost, dinoprostone help with hemorrhage Should assess fundus, consistency and finger depth, bleeding color and amount, vs, bladder scan, o2 can be given non-rebreather facemask 10-15 mls of oxygen Iv line, frequent vital signs, urinary output For uterine atony when the uterus fails to contract: massage the uterus, and administer ordered oxytocin

Diarrhea/Gastroenteritis/Dehydration Diarrhea and Gastroenteritis

Diarrhea in children fairly common symptom of a variety of conditions May be mild, accompanied by slight dehydration or extremely severe, requiring prompt and effective treatment Simple diarrhea that does not respond to treatment can quickly turn into severe, life-threatening diarrhea Causes: Chronically malnourished children w/ diarrheal symptoms is a common problem in many areas of the world Prevalent in areas lacking adequate clean water and sanitary facilities Certain metabolic diseases, such as cystic fibrosis May be caused by antibiotic therapy Many diarrheal disturbances in children caused by contaminated food or human or animal fecal waste through fecal-oral route Some conditions that cause diarrhea require readjustment of child's diet Allergic reactions to food are common Controlled by avoiding the offending food Adding less sugar to formula or reducing bulk or fat in the diet may be necessary Gastroenteritis = Infectious diarrhea Caused by: Salmonella Escherichia coli Dysentery bacilli Rotavirus Difficult to determine causative factor Due to seriousness of infectious diarrhea and danger of spreading diarrhea Child with moderate or severe diarrhea is until causative factor has been determined Clinical Manifestations Mild diarrhea may present as: Loose stools Frequency of defecation may be 2-12 per day Irritable Loss of appetite Dehydration is minimal Mild diarrhea can quickly become severe Vomiting usually accompanies the diarrhea Together, they cause large losses of body water and electrolytes Severe diarrhea/vomiting symptoms: Skin becomes extremely dry and loses its turgor Fontanelle becomes sunken Pulse weak and rapid Stools become greenish liquid and may be tinged w/ blood Diagnosis Stool specimens collected for culture sensitivity to determine if causative infectious organism present If infectious organism identified, effective antibiotic prescribed Treatment Treatment to stop diarrhea must be initiated immediately Primary concern for gastroenteritis Establishing normal fluid and electrolyte balance Child w/ acute dehydration may be given oral feedings of commercial electrolyte solutions unless there is shock or severe dehydration Oral rehydration therapy (ORT) Pedialyte Rehydralyte Infalyte As diarrhea clear, food may be offered Salty broths and beverages w/ high sugar content should be avoided Infants can return to breast-feeding, if they have been NPO Formula-fed infants are given their formula Foods can be added as child's condition improves, returning to a regular diet Early return to usual diet has been shown to reduce number of stools and decrease weight loss and length of illness BRAT diet no longer used b/c its high in calories, low in energy and protein, and does not provide adequate nutrition Severe diarrhea w/ shock and severe dehydration Oral fluids are discontinued IVF to replace electrolyte lost Frequent labs to determine child's blood chemistries Necessary to guide replacement therapy For child w/ serious bout of diarrhea, health care provider may prescribe soybean formula for a few weeks to avoid a possible reaction to milk proteins **Review Nursing Process for the Child with Diarrhea and Gastroenteritis, pg. 796-799** Assessment (Data Collection) Specific information about the child: bowel patterns and the onset of diarrheal stools with details on number and type of stools per day Terms that describe: color, odor of stool to assist caregiver Inquire about feeding patterns, nausea, and vomiting ask about fever and other signs of illness in child and ss of illness in any other family members Assess: skin turgor and condition, including excoriated diaper area; temperature; anterior fontanelle (depressed, normal, or bulging); apical pulse rate (observing for weak pulse); stools (character, frequency, amount, color, and presence of blood); irritability; lethargy; vomiting; urine (amount and concentration); lips and mucous membranes of the mouth (dry, cracked); eyes (bright, glassy, sunken, dark circles); and any other notable physical signs. Outcome Identification and Planning The major goal for the ill child is to control and stop the diarrhea while minimizing the risk for infection transmission Other important goals for the child include maintain good skin condition, Improving hydration and nutritional intake, satisfying sucking needs in the infant Major goal for the family eliminating the risk for infection transmission, family should be supported and educated regarding the disease and treatment for the child Implementation Controlling Diarrhea and Reducing the Risk of Infection Transmission Follow standard precaution: wear gloves, place contaminated linens and clothing especially marked containers to be processed, place disposable diapers and other disposable items in specially marked bags Visitors are limited to family only Reinforce teaching with the family about aseptic technique: Good handwashing must be carried out and taught to family members Promoting Skin Integrity To reduce irritation and excoriation of the buttocks and genital area, cleanse those areas frequently and apply a soothing protective preparation such as lanolin or and d ointment Try different types of diapers to see which are the less irritating to the infant Leaving the diaper off and exposing the buttocks and genital area to the air is often helpful. Placing disposable pads under the infant can facilitate east and frequent changing Remind caregivers that waterproof diapers covers hold moisture in and do not allow air circulation, which increases irritation and excoriation of the dapper area. Preventing Dehydration Carefully count diapers and weight them to demonstrate the infant output accurately Measure each voiding in the older child, closely observe stool, document the number and character of the stools, as well as the amount and character of any vomitus. Maintaining Adequate Nutrition Weigh the child on the same scale Take measurements in the early morning before the morning feeding Maintain precaution to prevent contamination of equipment while weighing the child Strict I and O In severe dehydration, IV fluids are given to rest the GI tract, restore hydration, and maintain nutritional req Monitor IV placement every 2 hours, restraints may be necessary Half strength formula maybe introduced usually lactose-free or soy milk If a breastfed infant can continue breast-feeding. If NPO breast milk can be frozen for later use if desired, Maintaining Body Temperature Monitor vital signs every 2hours if there is a fever Do not take temp rectally Supporting Family Coping Rub and pat the child, child may be held if IV sites are not at risk for being jeopardized. Promoting Family Teaching Explain the importance of GI rest. The family may not understand the necessity for NPO status Evaluation: Goals and Expected Outcomes **Review Family Teaching Tips: Diarrhea, pg. 798** Diarrhea The danger in diarrhea is dehydration (drying out). If the child becomes dehydrated, he or she can become very sick. Increasing the amount of liquid the child drinks is helpful. Solid foods may need to be decreased so the child will drink more. Suggestions • Give liquids in small amounts (3 or 4 tbsp) about every half hour. If this goes well, increase the amount a little each half hour. Don't force the child to drink, because he or she may vomit. • Give solid foods in small amounts. Do not give milk for a day or two, because this can make diarrhea worse. • Give only non salty soups or broths. • Liquids recommended for vomiting may also be given for diarrhea. Avoid beverages high in sugar content. • Soft foods to give in small amounts: applesauce, finely chopped or scraped apple without peel, bananas, toast, rice cereal, plain unsalted crackers, rice, potatoes, or lean meats. Call the Health Care Provider If ... • Child develops sudden high fever. • Stomach pain becomes severe. • Diarrhea becomes bloody (more than a streak of blood). • Diarrhea becomes more frequent or severe. • Child becomes dehydrated (dried out). Signs of Dehydration • Child has not urinated for 6 hours or more. • Child has no tears when crying. • Child's mouth is dry or sticky to touch. • Child's eyes are sunken. • Child is less active than usual. • Child has dark circles under eyes. Warning Do not use medicines to stop diarrhea for children younger than 6 years of age unless specifically directed by the health care provider. These medicines can be dangerous if not used properly. Diaper Area Skin Care • Change the diaper as soon as it is soiled. • Wash the area with mild soap, rinse, and dry well. • Use soothing, protective lotion recommended by your healthcare provider. • Do not use waterproof diapers or diaper covers; they increase diaper area irritation. • Wash hands with soap and water after changing diapers or wiping the child. **Review Family Teaching Tips: Vomiting, pg. 799** Vomiting Vomiting will usually stop in a couple days and can be treated at home as long as the child is getting some fluids. Warning Some medications used to stop vomiting in older children or adults are dangerous in infants or young children. DO NOT use any medicine unless your healthcare provider has told you to use it for this child. Give the child clear liquids to drink in small amounts. Suggestions • Pedialyte, Lytren, Rehydralyte, Infalyte • Flat soda (no fizz). Use caffeine-free type; do not use diet soda. • Jell-O water. Double the amount of water, let stand to room temperature. • Ice popsicles • Gatorade • Tea • Solid Jell-O • Broth (not salty) How to Give Give small amounts often. One tbsp every 20 minutes for the first few hours is a good rule of thumb. If this is kept down without vomiting, increase to 2 tbsp every 20 minutes for the next couple of hours. If there is no vomiting, increase the amount the child may have. If the child vomits, wait for 1 hour before offering more liquids.

Leopolds Manuever

Step 1. The top of the uterus (fundus) is felt (palpated) to establish which end of the fetus (fetal pole) is in the upper part of the uterus. If either the head or breech (buttocks) of the fetus are in the fundus then the fetus is in vertical lie. Otherwise the fetus is most likely in transverse lie. Step 2. Firm pressure is applied to the sides of the abdomen to establish the location of the spine and extremities (small parts). Step 3. Using the thumb and fingers of one hand the lower abdomen is grasped just above the pubic symphysis to establish if the presenting part is engaged. If not engaged a movable body part will be felt. The presenting part is the part of the fetus that is felt to be in closest proximity to the birth canal. Step 4. Facing the maternal feet the tips of the fingers of each hand are used to apply deep pressure in the direction of the axis of the pelvic outlet. If the head presents, one hand is arrested sooner than the other by a rounded body (the cephalic prominence) while the other hand descends deeply into the pelvis. If the cephalic prominence is on the same side as the small parts, then the fetus is in vertex presentation. If the cephalic prominence is on the same side as the back , then the head is extended and the fetus is in face presentation.

VBAC

VBAC: Vaginal birth after cesarean Much controversy surrounds VBAC deliveries. The greatest concern in a VBAC delivery is the increased risk for uterine rupture during labor. The woman most likely to have a successful VBAC has only had one previous cesarean, has previously delivered a child vaginally, and whose labor has spontaneous onset and does not require augmentation. History of a classical uterine incision or a previous uterine rupture is a contraindication for VBAC. The women should not have had a prior cesarean for CPD. Must have staff available to perform an immediate c section if needed. Must have a consent form signed. Must watch and monitor tracings because it can recognize the signs and symptoms of uterine rupture. Contraindications: Risk for uterine rupture is much higher when a woman has a classical uterine incision from a previous c section. Placenta previa, history of previous uterine rupture, and lack of facilities or equipment to perform an immediate emergency c section Risk and benefits: The greatest risk is uterine rupture higher risk for women who have had a uterine scar Emergency situation Depends on several variables including the number of previous c sections the woman has had. Prior infection The amount of time between pregnancies Type of uterine scar If current labor needs to be induced Factors that increase the likelihood of success include history of a prior vaginal delivery or successful VBAC and onset of spontaneous labor with a ripe cervix Factors that decrease a successful VBAC include Obesity Short stature Increased maternal age Fetal macrosomia Induction of labor Nursing care: Written consent just incase the women is needed and the woman is prepared for a c section delivery Dramatic onset of fetal bradycardia or deep variable decelerations • Reports by the woman of a "popping" sensation in her abdomen • Excessive maternal pain (can be referred pain, such as to the chest) • Unrelenting uterine contraction followed by a disorganized uterine pattern • Increased fetal station felt upon vaginal examination (e.g., station is now −3 when it has been −1) • Vaginal bleeding or increased bloody show • Easily palpable fetal parts through the abdominal wall • Signs of maternal shock

Hematologic Anemia's - Iron deficiency

Common nutritional deficiency in children RBC's are deficient in production of hemoglobin and are smaller than normal Most common between ages 9 months and 24 months and adolescent girls b/c of improper dieting to lose weight Full-term newborn: Has high hemoglobin level (needed during fetal life to provide adequate oxygenation) that decreases during the first 2-3 months of life Usually sufficient quantity to last for 4-9 months of life Intake of dietary iron is inadequate Anemia quickly results Daily intake of 7-10 mg of iron Only 10% of dietary iron is absorbed During first years of life, obtaining this quantity is often difficult Iron-Deficiency Anemia Infants - drinking more milk than they are eating iron-rich foods Have a history of consuming 2-3 quarts of milk daily while not accepting any other foods Many children w/ iron-deficiency anemia are undernourished b/c of: Family's economic problems Caregiver's knowledge deficit about nutrition <16 years: Therapeutic ranges have not been established for patients who are under 16 years of age. In adults, the suggested serum free digoxin therapeutic range is 0.4-0.9 ng/mL. Toxic concentration: ≥3.0 Iron-Deficiency Anemia Clinical Manifestations Picky eaters Vegans Below-average body weight Pale mucous membranes Pallor , almost translucent skin Anorexia Growth retardation Fatigue Lethargy and listlessness Spooning of fingernails Susceptible to infections Iron-Deficiency Anemia Diagnosis Hemoglobin level < 11g/dL Hematocrit < 33% Stool tested for occult blood to r/o gastrointestinal bleed as a cause Iron-Deficiency Anemia Treatment and Nursing Care Improved nutrition, including iron-rich foods in the diet, cast iron skillet Ferrous sulfate Administered between meals w/ juice Orange juice b/c promotes aids in iron absorption For best results, iron should not be given w/ meals but between meals Teach caregivers: Ferrous sulfate can: Cause constipation or turn stools black Cause staining of teeth - important to brush teeth after administration and use straw Should be on a high fiber diet Diet and nutrition information is needed When reinforcing teaching w/ caregivers remember that attitudes and food choices are often influenced by cultural differences **See Family Teaching Tips: Iron-Deficiency Anemia, pg. 774** Iron-Deficiency Anemia Iron-deficiency anemia is a common nutritional deficiency in children. It is difficult to get enough iron from food the child eats, and if the iron intake is inadequate, anemia quickly results.

Congenital Tailpipes Equinovarus: CLUB FOOT

Congenital clubfoot is deformity in which the Entire foot is inverted Heel is drawn up Forefoot is adducted Usually evident at birth Most common congenital foot deformity Occurs in 1 in 1,000 births May be unilateral or bilateral Cause is unclear Hereditary factor is observed occasionally Clinical Manifestations Easily detected in newborn but must be differentiated from positional deformity Positional deformity Corrected easily by use of passive exercise Explain to parents immediately to prevent anxiety True clubfoot Fixed: It will not straighten due to skeletal deformity Treatment Nonsurgical treatment Manipulation or bandaging Casting Applied while a newborn Applied over the foot and ankle to mid-thigh to hold knee in right-angle flexion Changed frequently to provide gradual, atraumatic correction Every few days for the first several weeks, then every 1-2 weeks Continued for a matter of months Until radiograph and clinical observation confirm complete correction Family must be taught cast care Denise Browne splint w/ shoes attached Used to maintain correction for 6 months or longer After overcorrection has been attained, child should wear a special clubfoot shoe A laced shoe who's turning out makes it appear the shoe is being worn on the wrong foot May continue to be worn at night Caregivers must perform passive exercises of the foot

PDA, Patent Ductus arteriosus

Failure of the fetal ductus arteriosus to close in the first few weeks after birth Fetal vessel between the pulmonary artery and the aorta and into the systemic circuit. After birth the duct normally closes, eventually becoming obliterated. If remains patent after birth the higher pressure in the aorta reverses the direction of blood flow in the ductus. Blood shunted from the aorta into the pulmonary artery Results in flooding of the lungs and overloading of the Left heart chamber Common in preterm newborn weight less than 1200gs and newborns w/ Down Syndrome and newborns who exhibit the rubella syndrome Symptoms: Often absent during childhood G&D may be retarded in some children w/ easy fatigue and dyspnea on exertion Machinery-like murmur over pulmonary area on upper left side of the heart Wide pulse pressure: High top and low bottom number Bounding pulses Possibly asymptomatic Heart failure DX: cardiac catheterization Management: Indomethacin(Indocin) a prostaglandin inhibitor may be administered to premature newborns to promote closure. Surgery is indicated in all diagnosis cases even if asymptomatic. If medical management fails to close ductus surgery indicated Closure of the defect by ligation or by division of the ductus Optimal age for surgery is before the age of 2 years

Bronchiolitis/RSV Acute Bronchiolitis EXAM (Respiratory Syncytial Virus Infection) Acute bronchiolitis (acute interstitial pneumonia)

is most common during the first 6 months of life and is rarely seen after the age of 2 years. The bronchi and bronchioles become plugged with thick, viscid mucus, causing air to be trapped in the lungs. The child can breathe air in but has difficulty expelling it. This hinders the exchange of gases, and cyanosis appears. Clinical Manifestations: The onset of dyspnea is abrupt, sometimes preceded by a cough or nasal discharge. Manifestations include a dry and persistent cough, extremely shallow respirations, air hunger, and often marked cyanosis. Suprasternal and subcostal retractions are present. The chest becomes barrel-shaped from the trapped air. Respirations are 60 to 80 breaths per minute. Fever is not extreme, seldom higher than 101°F to 102°F (38.3°C to 38.9°C). Dehydration may become a serious factor if competent care is not given. The infant appears apprehensive, irritable, and restless. Bronchiolitis/RSV is caused by a viral infection. Dyspnea occurs as well as a dry and persistent cough, extremely shallow respirations, air hunger, and cyanosis. Suprasternal and subcostal retractions(barrel chest) are present with respirations as high as 60 to 80 breaths per minute. Diagnosis is made from clinical findings confirmed by laboratory testing (enzyme-linked immunosorbent assay [ELISA]). Mucous sent to lab The child is hospitalized, placed on contact and droplet transmission precautions, and treated with high humidity by mist tent, rest, and increased fluids. Acute Bronchiolitis (Respiratory Syncytial Virus Infection) Rest Increase fluids possibly by IV Fomite lives on surfaces Ribavirin (Virazole), an antiviral drug, may be used if high risk (chemo, No antibiotics, it is viral immunosuppressed, etc.) No pregnant caretaker drug is teratogenicity No kissing on newborn babies

Rh incompatibility

ABO & Rh incompatibility The risk also increases during active labor or a spontaneous abortion, or when the placenta separates at birth. Two types of blood incompatibilities are Rh incompatibility and ABO incompatibility. If a woman who is Rh-negative is exposed to Rh-positive blood, such as through an incorrectly cross matched blood transfusion, her immune system produces antibodies to fight the Rho(D) antigen. Once her body has produced antibodies to the Rho(D) factor, she is sensitized to Rh-positive blood, a condition referred to as isoimmunization. The problem arises when a woman who is Rh-negative carries a fetus with Rh-positive blood. If the pregnant woman has been sensitized, the antibodies to the Rho(D) factor readily cross the placenta and attack the fetus's blood cells. The fetus develops hemolytic anemia and often requires exchange transfusions in utero or shortly after birth woman receives anti-D immunoglobulin (RhoGAM) within 72 hours of delivering an Rh-positive baby. Clinical manifestations: Routine blood and Rh typing during the first prenatal visit identify the woman at risk for Rh incompatibility. Antibody screening determines whether the woman is already sensitized. If sensitization has occurred (i.e., the antibody screen is positive), the woman will have no symptoms at all; however, the fetus may be severely affected. The physician often performs amniocentesis or cordocentesis to diagnose and assess hemolytic disease in the fetus. If sensitization has not occurred (i.e., the antibody screen is negative), the woman will be instructed about treatment and prophylaxis with RhoGAM.: Rhogam can give after birth, after amino, after miscarriage or abortion Treatment: It is critical for a woman who is Rh-negative to receive RhoGAM after any invasive procedure (e.g., amniocentesis or chorionic villus sampling), trauma of any kind (e.g., motor vehicle collision or physical trauma), and delivery, whether it be by abortion, miscarriage, removal of ectopic pregnancy, or vaginal or cesarean birth. It is during these times that fetal blood is most likely to contact maternal blood. Most health care providers also administer a prophylactic minidose of RhoGAM at 28 weeks of pregnancy. If the woman is sensitized, she is not a candidate for RhoGAM, and the fetus requires close observation. As the pregnancy progresses, fetal well-being is assessed with amniocentesis, cordocentesis, BPP, NSTs, or contraction stress tests. If hemolytic disease is severe, the fetus may require exchange transfusions, or the physician may opt to deliver the fetus prematurely It is important to note that Rh incompatibility does not occur if the woman is Rh-positive An Rh-negative woman who delivers an Rh-negative child is also not a candidate for RhoGAM. Because the gene for Rh-negative blood is autosomal recessive, if the woman's partner is Rh-negative and she is Rh-negative, the fetus will be Rh-negative, and RhoGAM will be unnecessary. The newborn is never a candidate for RhoGAM. Nursing Considerations: • The woman must be Rho(D)-negative. • The woman must not have anti-D antibodies (i.e., must not be sensitized). • The infant must be Rho(D)-positive (the fetus's blood type is not checked after an abortion). • A direct Coombs test (a test for antibodies performed on cord blood at delivery) must be weakly reactive or negative.

Immunizations - infant & toddler Pediatric vaccine schedule Pediatric Vaccine Schedule:

Birth: Hepatitis B (1st dose) 2 months: Hepatitis B (2nd dose) DTaP (diphtheria, tetanus, pertussis) Hib (haemophilus influenzae type B) treats against epiglottis Polio PCV (pneumococcal conjugate vaccine) RV (rotavirus) 4 months: DTaP (2nd dose) Hib (2nd dose) Polio (2nd dose) PCV (2nd dose) RV (2nd dose) 6 months: Hepatitis B (3rd dose) DTap (3rd dose) Hib (3rd dose) Polio (3rd dose) PCV (3rd dose) RV (3rd dose) Influenza (yearly) 12-18 months: DTaP (4th dose) Hib (4th dose) PCV (4th dose) MMR (1st dose) Varicella (1st dose) Hepatitis A (2 dose series....given 12 months and 18 months) Influenza (yearly) 4-6 years old: DTaP (5th dose) Polio (4th dose) MMR (2nd dose) Varicella (2nd dose) Influenza (yearly) Vaccines children with aids should avoid live vaccines Measles, mumps, rubella (MMR combined vaccine) Rotavirus Smallpox Chickenpox Yellow fever

ADHD

Characterized by: inattention, impulsive behavior, and hyperactivity Boys are more commonly affected Cause is unclear Affects every part of the child's life Clinical Manifestations: Impulsive Easily distracted Fidgeting or squirming Difficult standing still Problems following through with instruction due to inattention Innateness when spoken to may look as if their day-dreaming or not listening Frequently losing things One incomplete activity to another Difficulty taking turn Frequent and excessive talking Engaging in dangerous activities without considering the consequences Clumsiness or poor coordination Diagnosis: After child is 3 years of age but often not until child is school age Often dismissed during pre-school aged Symptoms are subjective and rely on care-givers and teachers for feedback Multi-dispernaly approach includes: Peds and educational specialist, psychologist, classroom teacher, family caregiver. Detailed history including school, social functioning, psychological testing, physical and neuro exams to rule out anything else Treatment: Learning situation should be structure Minimize distractions Supportive and patient teacher Home support structured consistent guideline from family Consistent behavior at home and routine Medications: can also be used ex: stimulant medications helps stimulant parts of the brain for concentration side effects: suppresses appetite and can stunt growth may not gained weight Families should maintain and calm and patient attitude When giving instructions it should be done one simple instruction at a time until they learn control Limit distractions, use consistency, and praise for good accomplishments.

Nutrition - infant

During the first year of life, the infant's rapid growth creates greater need for nutrients more than any other time of life · Per Academy of Pediatrics Committee on Nutrition, breastfeeding best method · First 4-6 months of life, use of breast milk or commercial infant formulas exclusively · May need supplemented vitamins C and D, iron, and fluoride · Breastfed infants need c and d vitamin iron and fluoride also can be supplemented with vitamin drops o Need for vitamin drops · Fluoride needed in small amounts for strengthening calcification of teeth and preventing tooth decay o Recommended for breast-fed and commercial formula-fed babies Addition of Solid Foods · At about 4-6 months, infant's milk consumption alone is not enough · iron supply becomes low, and supplements of iron rich food foods are needed Infant Feeding · Extrusion reflex - thrusting the tongue forward as if to suck, has the effect of pushing solid food out of the infant's mouth · Started in small amounts - smooth, thin, lukewarm, and bland · Offer one food at a time, waiting 4-5 days before introducing a new solid o Will help to determine if there is a reaction to a new food · When teeth start erupting between 4-7 months of age, infant may enjoy teething biscuit for comfort · 9-10 months chopped food can be substituted for pureed foods · Breast milk or formula given for first 12 months · Whole milk introduced between 12-13months Self-Feeding · 7-8 months, baby will explore the use of spoon · Use of fingers to feel texture and feed self · Very messy eaters Weaning the Infant · 5-6 month of age can start using a cup to drink, reluctant to give up bedtime bottle · Infant must never be permitted to take a bottle of formula, milk, or juice to bed o Discouraged b/c sugar from formula or juice coats infant's teeth for long periods and cause erosion of the enamel of deciduous teeth = early childhood caries o Liquid from milk, formula, or juice can pool in mouth and flow into Eustachian tubes causing otitis media if infant falls asleep with bottle · Milk need can be met by offering yogurt, custard, cottage cheese if resist drinking from cup · Cautioned use honey or corn syrup to sweeten milk b/c of danger of botulism; infant's system is not strong enough to combat WIC: The foods prescribed by the program include iron-fortified infant formula and cereal, milk, fruits and vegetables, whole wheat bread, fish (canned), dry beans, peanut butter, cheese, juice, and eggs

Insulin therapy/ Reaction

Essential part of treatment Dosage adjusted according to blood glucose levels so levels are maintained near normal Many children prescribed an insulin regimen Dose containing a short-acting and an intermediate-acting insulin given at two times during the day One before breakfast Second before the evening meal Types of insulin vary as to their time of onset, peak action, and duration of action Types of Insulin: Onset, Peak, and Duration (Table 38-4, pg. 815) Action Preparation Onset Peak Effect (Hrs.) Duration of Effect (hr.) Rapid-acting Lispro: Humalog Aspart: Novolog 0.25hrs 0.5-1.5hrs 3.5hrs Short acting Regular 0.5-1.5hrs 2-4 4-6hrs Intermediate NPH 1.5-2 4-6 8-16hrs Long-acting Glargine: Lantus Detemir: Levemir 1-2 No peak 12-24hrs Caused by insulin overload → metabolism of body's glucose is too rapid Attributable to: Change in body's requirement Carelessness in diet Error in insulin measurement Excessive exercise Symptoms include: Odd, unusual, or antisocial behavior Weakness Nervousness Lethargy Headache Blurred vision Dizziness Other symptoms include: Pallor Sweating Convulsions Coma Children often have hypoglycemic reactions in the early morning Observe child at least Q2H during night until child is regulated Blood glucose monitoring is often scheduled for early morning in an effort to detect abnormal glucose levels Treatment of insulin reaction: Give child sugar, candy, orange juice, or one of the commercial products designed for this emergency If child cannot take a sugar source orally, glucagon should be administered SubQ Repeated or impending reactions require consultation w/ health care provider

False vs. True Labor

False Labor: Non-stress test Contractions aren't hard enough to cause accelerations in baby heart rate and are irregular. Braxton Hick contractions can make moms feel that they are truly in labor Braxton Hicks contractions occur more frequently and are more noticeable as pregnancy approaches term. These irregular contractions usually decrease in intensity with walking and position changes. These contractions are not part of labor and do not cause effacement or dilation to occur. Signs of true labor: Anticipatory signs of labor include gastrointestinal disturbances, expelling the mucus plug, lightening, a burst of energy, and cervical ripening and dilation. The woman may experience gastrointestinal disturbances, such as diarrhea, heartburn, or nausea and vomiting, as labor approaches. • True labor results in progressive effacement and dilation of the cervix. In true labor, contractions become progressively stronger and occur more frequently and are not stopped with walking. Approximately 2 weeks before labor, engagement may occur, causing the pregnant woman to sense that the baby has "dropped." This subjective feeling is called "lightning." The woman is able to breathe more easily, and she may need to urinate more frequently because of the pressure of the fetus on the urinary bladder. Multiparous women often do not experience lightening until labor begins. When the mucus plug passes, the woman will notice a one-time clear or pink-tinged discharge that is the consistency of jelly. Clinical signs that labor is approaching include ripening (softening) and effacement (thinning) of the cervix. Dilation of the cervix may accompany ripening and effacement, particularly in multiparous women. The health care provider informs the woman of these changes if a pelvic examination is done during a scheduled office visit. After the initial assessment by the health care provider, the woman may be instructed to walk for an hour or two. Then, a vaginal examination is repeated to determine any cervical changes. If there are no changes, the woman may go home with instructions to return if the contractions become stronger, more regular, or if other signs of true labor occur, such as increased bloody show or rupture of the membranes.

Fundus

Fundal height decreases at a rate of one fingerbreadth 1cm per day until the uterus is no longer palpable on the 10th to 14th-day postpartum EXAM Day two fingerbreadth below the umbilicus NEED TO KNOW Vagina Feels soft after delivery May have small tears Rugae obliterated, should return in approximately 3 weeks Regains tone, size decreases The hymen is permanently torn, heals with small separate tissue tags Vaginal mucosa thickens with the return of ovarian function Tempt may be elevated after 24 hours should be under 100 degrees afterward LOCHIA Lochia assessment Rubra: Dark red 3-4 days Serosa: Pink brown 4-10 days Alba: Whitish yellow: 10-28 days Bleeding may increase with exercise and excretion Palpate fundus Heavy lochia with clots Saturated pad check last time changed Mild bradycardia 50-60 bpm Watch for DVT May experience shakiness Bowel function may return to normal after the first-week pp Maybe sluggish due to progesterone since it relaxes intestinal muscle Tempt May increase due to dehydrating effects of labor. After 24 hours should be afebrile Deviation after 1st 24 hours indicates possible puerperal sepsis, mastitis, UTI, or endometriosis BP: orthostatic hypertension can occur within the first 48 hrs due to splanchnic engorgement Deviation: Low or decreasing-hypovolemia secondary to hemorrhage; increased BP possible excessive use of vasopressor or oxytocic meds or HTN Pulse: elevated for the first hour Deviation: Rapid or increasing rate-possible hypovolemia due to hemorrhage Respirations: should decrease to normal pre-birth by 6-8 weeks Deviation: Hypoventilation after an unusually high spinal block or epidural narcotic after C/S Breast: Check size and shape of nipples, cracks or fissures and shape, soreness watch for engorgement or mastitis.

ADOLESCENT Accident Prevention

Increasing numbers of adolescents dying because of violence Motor vehicle accidents Homicide Suicide Unintentional injuries and homicide rank as leading causes of death 15 to 19-year-old Minority youth on the rise in schools Victims of violence in their own homes Date rape and other violence in dating relationships are common As a nurse, become an advocate and educator for adolescents to promote Safe driving Wearing a helmet and safety practices when using a motorcycle, all-terrain vehicle, bicycle, skateboard, or in-line skates Internet Safety Signs that might indicate online risks in a child or adolescent are the following: • Spends large amounts of time online, especially at night. • Has pornography on computer. • Receives phone calls from adults you don't know. • Makes calls, especially long distance, to numbers you don't recognize. • Receives mail, gifts, and packages from someone you don't know. • Turns computer monitor off or changes screen when you enter room. • Becomes withdrawn from family. To minimize online concerns are as follows: • Communicate and talk with child; openly discuss concerns and dangers. • Spend time with child online. • Use blocking software and devices. • Use caller ID to determine who is calling your child. • Maintain access to child's online account and monitor activity. Sex education

Injury Prevention Infant Safety

Infant Safety Be one step ahead of a child's development and prepared for the next stage. Aspiration/Suffocation • Always hold the bottle when feeding, never prop bottle. • Crib and playpen bars should be spaced no more than 2 3⁄8 in apart. • Check toys for loose or sharp parts or small buttons. • Keep small articles (such as buttons, marbles, safety pins, lint, balloons) off the floor and out of infant's reach. • Store products such as baby powder out of child's reach. • Keep plastic bags out of child's reach. • Do not use pillows in a crib. • Avoid giving child foods such as hot dogs, grapes, nuts, candy, and popcorn. • Remove bibs at nap and bed times. • Do not tie pacifier on a string around the child's neck. Falls • Never leave child unattended on a high surface such as a high chair, bed, couch, or countertop. • Place gates at the tops and bottoms of stairways. • Raise crib rails and be sure they are securely locked. Motor Vehicle • Place infant in an approved infant car carrier in the back seat when in a car. Follow the manufacturer's instructions regarding the age and size of the infant regarding placement of the carrier (rear- or front-facing). • Never leave child unattended in a car. Drowning • Never leave child alone in the bathtub, or near any water, including toilets, buckets, or swimming pools. • Fence and use locked gates around swimming pools. Burns/Injuries • Cover unused plugs with plastic covers. • Keep electrical cords out of sight. • Remove tablecloths or dresser scarves that the child might grasp and pull. • Pad sharp corners of low furniture or remove them from the child's living area. • Turn household hot water to a safe temperature—120°F (48.8°C). Poisoning • Check toys for nontoxic material. • Move all toxic substances (cleaning fluids, detergents, insecticides) out of reach and keep them in locked areas. • Remove any houseplants that may be poisonous. • Protect child from inhaling lead paint dust (from remodeling) or chewing on surfaces painted with lead paint. • Place medicines in locked cupboards; remind family and friends (especially those with grown children or no children) to do the same.

Types of Variabilty

Normal fetal HR: 120-170 Variability Fluctuations in baseline FHR of two cycles per minute or greater; creates jagged appearance Absent (nonreassuring) Minimal (Less than 5 beats/min) Moderate (6-25 beats/min) Presence of accelerations and no decelerations Marked (greater than 25 beats/min) Accelerations Transient increases in FHR above baseline The peak at least 15 beats/min above baseline lasting 15 seconds or more Indicative of fetal well-being Early decelerations The gradual decrease in FHR baseline greater than or equal to 30 seconds and returns to baseline, associated with uterine contraction Make sure it does not dip under 120 Occur simultaneously with contractions. Cause : fetal head compression Normal/ No interventions Mirrors a normal contraction Late Decelerations The shallow deceleration in FHR is characterized by a gradual decrease. Stays at baseline during contraction and then dips Begin after the contraction and return to baseline after the contraction has ended Cause : Uteroplacental insufficiency Nonreassuring/ Need interventions Shaped like an upside-down U Should turn mom on the left side and administer oxygen IF oxytocin is being administered it should be stopped Variable decelerations An abrupt decrease in FHR below the baseline At least 15 beats/min or more, lasts at least 15 seconds and returns to baseline in < 2 minutes Cause: The cord can be wrapped around the baby's neck and bradycardia can occur cord compression Will cause vs on baby heart rate Nonreassuring/ Needs intervention Shaped like an upside-down v or w Nursing intervention turns mom on the side and stops Pitocin if being administered. Administer oxygen

Developmental Dysplasia of the Hip

Results from defective development of the acetabulum w/ or w/o dislocation Malformed acetabulum permits dislocation, w/ head of femur becoming displaced upward and backward Often bilateral More common in girls Clinical Manifestations Early recognition and treatment extremely important for successful correction Before an infant starts to stand or walk risk for fracture due to instability of hip Use the Barlow sign and Ortolani maneuver Tests used together on one hip at a time Show a tendency for dislocation of the hip in adduction and abduction Experienced examiners may detect an audible click when examining Tests effective only for first month; after this time, click disappears Signs after 1st month include: Asymmetry of the gluteal skin folds Limited abduction of the affected hip Tested by placing infant in a dorsal recumbent position w/ knees flexed, then abducting both knees passively until they reach the exam table w/o resistance If dislocation is present, the affected side cannot be abducted more than 45 degrees After child has started walking, later signs include: Lordosis Swayback: curvature of the back Protruding abdomen Shortened extremity Duck-waddle gait Positive Trendelenburg sign To elicit sign, child stands on the affected leg and raises the normal leg The pelvis tilts down, rather than up toward the unaffected side X-rays usually made to confirm diagnosis in older newborn Uncorrected dislocation causes: Limping Easy fatigue Hip and low back discomfort Postural deformities Treatment Correction may be started in the newborn period by placing two or three diapers on the infant to hold the legs in abducted in a frog-like position Cloth diapers work best for this purpose When dislocation is discovered during first few months consists of manipulation of the femur into position and application of a brace Most common brace used is Pavlik Harness Primary care provider assesses infant weekly while the infant is in the harness and adjusts the harness to align the femur gradually The physician is the only person who can adjust straps If treatment is delayed until after the child has started to walk or if earlier treatment is ineffective Child may be placed in Bryant traction Followed by surgery and casting **Review Nursing Process for the Newborn in an Orthopedic Device or Cast, pg. 477-478** Assessment (Data Collection) Outcome Identification and Planning Implementation Providing Comfort Measures Promoting Skin integrity Providing Sensory Stimulation Providing Family Teaching Evaluation: Goals and Expected Outcomes

Gastro-esophageal Reflux Gastroesophageal Reflux (GER)

Sphincter in lower portion of esophagus, which leads to stomach, is relaxed and allows gastric contents into esophagus Usually starts within first week after birth and resolved within the first 18 months May correct itself as esophageal sphincter matures, child eats solid foods, and child is more often in a sitting/standing position Premature infants and children w/ neurologic conditions frequently have GER Clinical Manifestations Almost immediately after feeding : Child vomits contents of stomach Vomiting is: Effortless Not projectile in nature Irritable Hungry Aspiration after vomiting → respiratory concerns → apnea & pneumonia Child takes in adequate nutrition, but d/t vomiting → failure to thrive and lack of normal weight occurs Diagnosis and Treatment Complete history will offer information regarding: Feeding Vomiting Weight patterns Endoscopy will confirm the relaxed esophageal sphincter Correcting nutritional status of child includes: Conservative Management Positioning : upright, semi-prone during and after feeding to promote gravity resistance to reflux _______________: thicken feedings 1 teaspoon to 1 tablespoon of rice cereal per ounce of formula or breast milk may be recommended _______________ modifications: small feedings with frequent burping to decrease gastric distention Pharmacologic Therapy Medications to reduce symptoms including antacids or histamine-2 blocking agents Histamine-2 blocker: ranitidine or famotidine → reduce acid secretion, lessens complications gastric acid may have on esophageal tissue Proton pump inhibitors: omeprazole and lansoprazole → reduce gastric acid Surgical Management Nissen fundoplication - wraps fundus of stomach around distal esophagus to decrease chance of reflux Nursing Care Thicken feedings w/ rice cereal to ↓ likelihood of aspiration Immediately report any signs of respiratory distress Offer small frequent feedings and burp frequently Semi-prone position after daytime feedings and for several hours before the child goes to sleep Semi-prone position is an exception to the recommendation that children be placed in supine position for sleeping normally Child put in side-lying or supine position for sleeping Monitor and document: I/O Daily weight Emesis for amount and character If NG or GT inserted, provide good skin care to maintain skin integrity Reinforce teaching w/ caregiver regarding: Feeding Positioning Medication administration

APGAR

The RN attending the birth assigns the Apgar score at 1 and 5 minutes after birth. If the newborn receives a score of less than 7 at 5 minutes, the RN continues to assign a score every 5 minutes until the score is 7 or above, the newborn is intubated, or the newborn is transferred to the nursery. Scores of 7 to 10 at 5 minutes are indicative of a healthy baby who is adapting well to the extrauterine environment. Apgar quick assessment tool used to assess the status of a newborn Appearance: skin color Pink: 2 Cyanotic and pallor extremities: 1 Cyanotic all over: 0 Pulse: HR Greater than: 100: 2 Less than 100: 1 Absent: 0 Grimace: reflex irritability Cries when stimulated: 2 Grimaces when stimulated: 1 No response to stimulation Activity: Muscle tone Maintain a position of flexion with brisk movements Minimal flexion of extremities Limp and flaccid Respiratory: Effort Strong vigorous cry weak cry, slow difficult respirations No respiratory effort 1 and 5 mins after birth reassess at 10 min if less than 6 Higher the score the better the better the baby is doing Rare to have 10 due to acronymous Interventions based on score: 7-10 routine post-delivery care 4-6 some resuscitation, oxygen, suction, stimulate baby, rub back 0-3: full resuscitation The RN performs immediate assessments in the delivery room, including assigning the Apgar score. The Apgar score is a way of determining how well the newborn is transitioning to life outside the womb. Five parameters (respiratory effort, heart rate, muscle tone, reflex irritability, and color) are used to assign a score at 1 and 5 minutes of life. Activity and muscle tone 2 A healthy, vigorous newborn has a 5-minute score of 7 or greater.

Cardiac Cath

The gold standard Usually femoral vein Cardiac cath. gives precise measurements of oxygen saturation and pressures in each chamber and vessel, also identifies anatomic alterations. Diagnostic Diagnosis specific heart disorders in anticipation of surgery Interventional Used to correct an abnormality Cardiac Catheterization Pre-catheterization responsibilities Prepare the child for procedure based on developmental age Baseline vital signs Obtain a nursing hx. and physical exam Evidence of infection, such as diaper rash may lead to cancellation Check allergy status, Especially shellfish and iodine NPO status 4-6 hours prior to procedure Obtain baseline vital signs, including oxygen saturation Locate and mark both dorsalis pedis and posterior tibial pulses on both extremities Cardiac Catheterization Post-catheterization responsibilities Provide for continuous cardiac monitoring and oxygen saturation to check for: Bradycardia Dysrhythmias Hypotension Hypoxemia Check heart rate and respiratory rate for 1 full minute Monitor pulses for equality and symmetry Monitor temperature and color of extremity A cool extremity w/ skin that blanches may indicate arterial obstruction Intake and output Monitor insertion site for bleeding and hematoma he body Cardiac Catheterization Maintain clean dressing Q5 min x 15 min, Q15 min x 1 hr., then Q1 hr. If bleeding occurs - apply firm, continuous pressure and notify the doctor Prevent bleeding by maintaining the affected extremity in a straight position for 4-8 hours Monitor I & O for adequate urine output, hypovolemia, or dehydration Monitor for hypoglycemia IVF's w/ dextrose may be necessary may be a bolus Encourage oral intake, starting w/ clears Encourage the child to void to promote excretion of contrast medium Teach Parents: Dressing removed after 24 hours Monitor for site for s/s of infection Monitor temperature x3 days Omit tub baths and strenuous activity/exercise for 2-3 days Encourage fluid intake to help removal of the dye from t Things to remember for exam VSD: murmur with systolic thrill COA: nosebleed, headache, vertigo, leg pain, faint PDA: machinery like murmur, wide pulse pressure, and bounding pulses ASD: Overloads the left side of the heart Inta: prostaglandin for PDA TOF: know all four amonimlities Tet spells: knee chest position Cardiac cath postoperative i and o, distal pulses, tempt and color of extremities of the side that the cath was

Ectopic pregnancy

The term "ectopic" refers to an object that is located away from the expected site or position. An ectopic pregnancy is a pregnancy that occurs outside of the uterus. "tubal" pregnancy. Adhesions, scarring, and narrowing of the tubal lumen may block the zygote's progress to the uterus. Any condition or surgical procedure that can injure a fallopian tube increases the risk. Examples include salpingitis (infection of the fallopian tube), endometriosis, pelvic inflammatory disease, history of prior ectopic pregnancy, any type of tubal surgery, congenital malformation of the tube, or multiple elective abortions. Clinical manifestations: Symptoms usually appear 4 to 8 weeks after the last menstrual period, although the woman may not seek medical treatment until 8 to 12 weeks. The most commonly reported symptoms are pelvic pain and/or vaginal spotting. Other symptoms of early pregnancy, such as breast tenderness, nausea, and vomiting, may also be present. Rarely, a woman may present with late signs, such as shoulder pain or hypovolemic shock. These signs are associated with tubal rupture, which occurs when the pregnancy expands beyond the tube's ability to stretch. The risk of tubal rupture increases with advancing gestation. Therefore, prompt diagnosis is critical to preventing rupture. If the tube ruptures, hemorrhage occurs into the abdominal cavity, which can lead to hypovolemic shock. Manifestations of shock include rapid, thready pulse; rising respiratory rate; shallow, irregular respirations; falling blood pressure; decreased or absent urine output; pale, cold, clammy skin; faintness; and thirst. Treatment: If she presents in shock with abdominal bleeding from a ruptured tube, she requires immediate surgery for exploratory laparotomy, control of hemorrhage, and removal of the damaged tube. The surgeon leaves the ovaries and uterus intact if possible. The woman may need volume expanders and blood transfusions if massive hemorrhage occurs. In non-emergent diagnosed cases of tubal pregnancy, the physician must decide how best to remove the pregnancy. Laparoscopic surgery is the most common method of removing an ectopic pregnancy. If the woman desires to have children in the future, the physician makes every attempt to save the tube by using microsurgical techniques and minimally invasive surgery. A salpingectomy, removal of the fallopian tube, is performed when the tube is not salvageable or if the woman has finished childbearing. A newer method of treating a small, unruptured ectopic pregnancy is intramuscular injections of methotrexate, an antineoplastic (anticancer) drug.

Endometritis

inflammation of the inner (lining) of the uterus (endometrium) Anemia may be present Blood cultures or intrauterine cultures are used to diagnose. Treatment - IV broad-spectrum antibiotics (PCN, cephalosporins, or clindamycin and gentamicin) Vaginal and blood cultures Good hand hygiene Semi-fowler's position promotes uterine drainage and prevents the infection from spreading. Encourage frequent ambulation to promote drainage, unless contraindicated. Risk factors; most frequently after a Csection; Placenta fragments Prolonged rupture of membranes Internal monitoring prophylactic antibiotics are used Usually develops a fever between the 2nd and 10th day after delivery. The rise in tempting is the most significant finding, tachycardia, chills anorexia, and general malaise. May also have abdominal cramping pain, including strong after pains, Uterine subinvolution and tenderness are present. Lochia typically increases in amount and is dark, purulent, and foul-smelling. Treatment includes: antibiotic therapy Oxytocic agents: may be ordered to promote uterine involution. Should discard breast milk until the antibiotic treatment is over

Diaper rash

· Common in infancy · Some more susceptible than others, possibly b/c of inherited sensitive skin · Causes: · Prolonged exposure to wet or soiled diapers · Use of plastic or rubber pants · Infrequently changed disposable diapers · Inadequate cleaning of the diaper area (especially after bowel movements) · Sensitivity to some soaps or disposable diaper perfumes · Use of strong laundry detergents w/o rinsing · Yeast infections, notably candidiasis Clinical Manifestations · Bacterial decomposition of urine produces ammonia, which is irritating to child's skin · Diarrheal stools also produce a burning erythematous area in anal region Treatment and Nursing Care · Primary treatment is prevention how to properly care for the diaper and cleaning · Diapers must be changed frequently w/o waiting for obvious leakage o Regular checking is necessary · Exposure to air · Clean diaper area from front to back w/ warm water and drying thoroughly w/ each diaper change can be more irritating due perfume and alcohol. o If soap is necessary, be certain to rinse soup completely before diapering o Use of commercial wet wipes may aggravate the condition · If area becomes excoriated and sore, health care provider may prescribe an ointment · Diapers washed at home: reusable diapers o Should be presoaked o Washed in hot water w/ mild soap o Rinsed thoroughly w/ antiseptic added to final rinse o Drying diapers in the sun or in a dryer also help destroy bacteria

Head Lice Pediculosis

· Pediculus humanus capitus (Head lice) are most common infestation in children · Transferred by direct or indirect contact o Head to head o Combs o Headgear o Bed linen · Animal lice are not transferred to humans Clinical Manifestations · Lice lay their eggs(nits) at the base of the hair shaft o Pearly white flecks § Look like dandruff, but unlike dandruff they do not come off easily § Nits are tightly attached and not easily removed o Hatch in 7-10 days and become sexually active in 2 weeks Treatment and Nursing Care · Nonprescription medications available o RID, Nix o Same and effective in killing the lice themselves o 2nd treatment suggested in 7-10 days to kill nits after they have hatched · If over-the-counter medications do not effectively kill the lice, prescription medication may be needed o Malathion (Ovide) is effective in killing lice and nits § Few side effects reported, but if used on open sores, may cause the skin to sting · Should not be used if the head has been scratched o Lindane (Kwell) is most commonly used and is usually safe § Overuse, misuse, or accidental swallowing can be toxic to brain and nervous system § Used only in cases that do not respond to other treatments · Shampooing w/ medication: o After the hair is wet w/ warm water, apply medication like any shampoo o Lather for several minutes and then rinse thoroughly and dry o After hair is dried: § Comb w/ a combing tool or fine-toothed comb dipped in warm white vinegar to remove remaining nits and nit shells o Shampooing may be repeated in 2 weeks to remove any lice that may have been missed as nits and have hatched o Avoid getting medication in eyes or mucous membranes o When treating child in the hospital: § Wear disposable gown, gloves, and head cover for protection Live 48 hours off a human body · Family Teaching o Family caregiver are often embarrassed o Reassure family that lice infestation is common and can happen to any child § It is not a reflection on their housekeeping o All family members should be inspected and treated as needed o ** See Family Teaching Tips: Eliminating Pediculi Infestations, pg. 865**

Impetigo

· Superficial bacterial skin infection · In newborn - primary causative organism is S. aureus o Usually bullous (blister-like) · Older child - most common causative organism group A beta-hemolytic streptococci (GABHS) o Lesions non-bullous: flat not like blisters o Rare, but complications from GABHS infection can result in rheumatic fever or acute glomerulonephritis Treatment Contagious anyone can become infected with direct contact of the area. · Oral penicillin or erythromycin if there an allergy to penicillin is an for 10 days · Daily washing of the crusts helps speed the healing process · Mupirocin (Bactroban) ointment may be used TOPICAL antibacterial ointment Nursing Care · Young child who has impetigo and is hospitalized o Must follow contact precautions (skin and wound) precautions, including gown and gloves o Child should be segregated from other children to deter spread o Crusts can be soaked off w/ warm water o Followed by application of topical antibiotic - Bacitracin and Neosporin o Cover child's hands or apply elbow restraints to prevent scratching of lesions o Careful hand-washing by nursing personnel and family members is essential even for the patient too. · Older child w/ impetigo can be treated at home o Family caregivers must follow good hygiene practices to prevent spread § Other children in household No sharing of item ex: towels § Other contacts of the child in daycare, nursery school, elementary school limit direct contact and not touching things o Lesions occur primarily on the face, but may spread to any part of the body o Crusts and drainage are contagious § Lesions are puratic: Itchy § Must keep fingers and hands away from the lesions § Nails should be trimmed to prevent scratching of lesions which can leave scarring behind § Family members should be reminded to share towels and washcloths

Communicable Diseases - Chicken Pox Varicella (Chickenpox)

Itchy rash, headache, fever, tired Various stages of lesions Could have a high fever when bumps appear but than becomes a low grade fever Never give aspirin Isolation: airborne and contact No longer contagious once lesions have crusted

Scoliosis

Lateral curvature of the spine Structural EXAM Involves rotated and malformed vertebrae Most cases are idiopathic Few cases are caused by congenital deformities or infection Seen in school-aged children at 10 years of age and older due to puberty in rapid growth spurt Occurs more frequently in females Functional (postural) More common type Several causes: Poor posture Muscle spasm caused by trauma Unequal length of legs When primary problem corrected: ex poor posture and unequal leg lengths Elimination of functional scoliosis begins Diagnosis Based on screening Begins in 5th-6th grade and last through at least 8th grade School nurse often does initial screening Screened during regular well-child visits During examination: Observe the undressed child from the back Note any lateral curvature of the spinal column asymmetry of shoulders, shoulder blades, or hip unequal distance between arms and waist Ask child to bend at the hips and touch toes Observe for prominence of scapula on the side and curvature of spinal column Hips are symmetrical and one scapula is protruding more than the other Treatment Depends on many factors and is either nonsurgical or surgical Is long-term and often lasts through the rest of the child's growth cycle Curvatures less than 25 degrees = observed Curvatures between 25-40 degrees (mild to moderate) Electrical stimulation may be used, effectiveness is unclear Stimulate muscles on convex side of curvature to contract as impulses are transmitted Causes spine to straighten Corrected w/ brace EXAM Nursing process on the test Boston or TLSO brace commonly used Made of plastic and customized to fit child Should be worn constantly to achieve greatest benefit Exception during bathing or swimming Worn over a t-shirt to protect the skin Fit monitored closely should be a tight fit should not adjust straps Teach child and family to notify health care provider if there is rubbing should assess skin During 1st couple of weeks of wearing brace can give mild analgesic for discomfort and aching Provider may prescribe certain exercise to be performed with the brace on stretching Curvatures greater than 40 degrees (severe) Halo traction Reduce spinal curves and straighten spine Use of stainless steel pins inserted into the skull while counterattraction is attained by gentle pull against the child's body weight Weights gradually increased to promote correction When curvature has been corrected, spinal fusion performed Magnifies the problem of body image Head may need to be shaved Needs thorough explanation of what will occur during procedure Give opportunity to talk about their feelings Frequent shampooing, cleansing of pin sites, and observation for signs of complications are critical Corrected surgically Use of rods, screws, hooks, and spinal fusion Rods remain in place permanently Placed along the spinal column to realign the spine, then spinal fusion is performed to maintain the corrected position Frightening to child and family Must be well prepared Child can expect to have: Post-op pain Endure days of remaining flat in bed, being turned only in logrolling fashion After surgery: Neurovascular status of extremities is monitored closely Given PCA pump to control pain Indwelling urinary catheter d/t child remaining flat 6-months post-op child can take part in most activities, except contact sports Because bones are fused and rods implanted Arrests child's growth in height, contributes to emotional adjustment for child and family **Nursing Process for the Child with Scoliosis Requiring a Brace, pg. 854-855** Assessment (Data Collection) Outcome Identification and Planning Implementation Promoting Mobility Preventing Injury Preventing Skin Irritation Promoting Positive Body Image Promoting Compliance with Therapy Evaluation: Goals and Expected Outcomes

ASD, ASD Atrial septal defect (ASD)

Abnormal opening between the two right and left atria Allows blood to pass directly from L→ R atria May be result of an incompetent foramen ovale or incorrect development of the atrial septum Symptoms: Loud harsh murmur no thrill Enlarged right side of the heart Possibly asymptomatic Heart failure Management: Many close spontaneously Low surgical mortality risk Surgical closure with sutures or Dacron patch

Respiratory Tonsillitis & Tonsillectomy Tonsillitis pharyngitis

2yr-10yrs Enlarge Ring of lymph node Hypertrophied interfere with breathing Partial deafness Fever 101 or more Dysphagia Exudate Sore throat Infection Throat culture-B hemolytic strep Tonsillitis Treatment select all of the apply Antibiotics Increase fluid intake Popsicles Cool humidity Make sure to complete all antibiotic exam Soft and liquid diet Tonsillectomy Immediately after a tonsillectomy, place the child in a partially prone position with the head turned to one side until the child is completely awake. This position can be accomplished by turning the child partially over and by flexing the knee where the child is not resting to help maintain the position. Keeping the head slightly lower than the chest helps facilitate drainage of secretions Avoid placing pillows under the chest and abdomen, which may hamper respiration. Encourage the child to expectorate all secretions, and place an ample supply of tissues and a waste container near him or her. Discourage the child from coughing. Check vital signs every 10 to 15 minutes until the child is fully awake, and then check every 30 minutes to an hour. Note the child's preoperative baseline vital signs to interpret the vital signs correctly. Hemorrhage is the most common complication of a tonsillectomy. Bleeding is most often a concern within the first 24 hours after surgery and the fifth to seventh postoperative day. Observe and document; document, and report any unusual restlessness or anxiety, frequent swallowing, or rapid pulse that may indicate bleeding. Vomiting dark, old blood may be expected, but bright, red-flecked emesis or oozing indicates fresh bleeding. give small amounts of clear fluids or ice chips. Synthetic juices, carbonated beverages that are "flat," and frozen juice popsicles are good choices. Tonsillitis and Adenoiditis #1 Exam The child with tonsillitis may have a fever, sore throat, difficulty swallowing, hypertrophied tonsils, and erythema of the soft palate. Exudate may be visible on the tonsils. Treatment of tonsillitis consists of analgesics, antipyretics, and antibiotics. Soft liquid diet Surgical removal of the tonsils and adenoids may be indicated. Controversial Pain medications: Liquid acetaminophen with codeine is often prescribed Rectal or intravenous analgesics may be used. Encourage the caregiver to remain at the bedside to provide soothing reassurance. Crying irritates the raw throat and increases the child's discomfort; thus, it should be avoided if possible. Tonsillitis and Adenoiditis #2 The most common complication of a tonsillectomy is hemorrhage or bleeding. The child must be observed, especially in the first 24 hours, after surgery and in the 5th to 7th postoperative days for unusual restlessness, anxiety, frequent swallowing, or rapid pulse. Vomiting bright, red-flecked emesis or bright red oozing or bleeding may indicate hemorrhage. If noted, these should be reported immediately. Dark blood is expected Loose tooth Wont do surgery if tonsil is infected Risk for aspiration Drink flat sodas No ice cream or milk but nothing red NRSG, deficient knowledge,

PRESCHOOL Accident/injury prevention

Accident Prevention See Family Teaching Tips: Safety Suggestions for Preschoolers; pg. 553 Adults need to be attentive b/c child's curiosity exceeds their judgement Burns, poisoning, and falls are common accidents Preschoolers often victims of motor vehicle accidents B/c they dart into the street or driveway Fail to wear proper restraints Preschool age is an excellent time to begin teaching safety rules Rules for crossing the street and playing in an area near traffic Adults should serve as role models Infection Prevention Preschoolers are learning to share, including infections with family and playmates Teaching basic precautions can help prevent the spread of infection

Child maltreatment

Child Abuse/Neglect Child Maltreatment Table 33-1 Signs of Maltreatment in Children, pg. 682 Type Physical Signs Behavioral Signs Physical Bruises and welts may be on multiple body surfaces or soft tissue, may form regular pattern ex: belt buckle Burns: cigar or cigarette, immersion,(stocking/glove-like on extremities or doughnut-sha[ed on butticks or genitals), or patterned as an electrical appliance ex: iron Fractures: single or multiple, may be in various stages of healing Lacerations or abrasions: rope burns, teats in and around mouth, eyes, ears, genitalia Abdominal injuries: ruptured or injured internal organs CNS: subdural hematoma, retinal or subarachnoid hemorrhage Less compliant than average Signs of negativism, unhappiness Anger, isolation Destructive Abusive towards other Difficulty developing relationships Either excessive or absent separation anxiety Inappropriate caregiving concern for parent Constantly in search of attention, favors, foods, Various developmental delays(cognitive, language, motor Emotional Delays in physical development Failure to thrive Distinct emotional symptoms or functional limitations Deteriorating conduct Increased anxiety Apathy or depression Developmental lags Neglect Malnutrition Repeated episodes of pica Constant fatigue or listlessness Poor hygiene Inadequate clothing for circumstances Inadequate medical or dental care Lack of appropriate adult supervision Repeated ingestions of harmful substances Poor school attendance Exploitation: forced to bed, steal, excessive household work Role reversal with parent Drug or alcohol use Sexual Abuse Difficulty walking or sitting Thickening or hyperpigmentation of labial skin Vginal opening measures greater than 4mm horizontally in preadolescence Torn, stained or bloody underclothing Lax rectal tone Vaginal discharge Recurrent urinary tract infection Nonspecific vaginitis Venereal disease Sperm or acid phosphatase on body or clothes Pregnancy Direct or indirect disclosure to relative, friend, or teacher Withdrawal with excessive dependency Poor peer relationships Poor self-esteem Frightened or phobic of adults Sudden decline in academic performance Pseudomature personality development Suicide attempts Regressive behavior Enuresis or encopresis Excessive masturbatin Highly sexualized play Sexual promiscuity

Physical abuse

Child Maltreatment Broad term used to define all types of child abuse including: Physical Sexual Emotional Acts of negligence Usually committed by a person responsible for the care of the child Teacher, Coch, babysitter, significant other Child Abuse - describes acts which result in harm or a threat of harm to the child Child Neglect - used to describe acts of omission in which there is failure to provide for the child's needs or to protect the child from harm Not limited to one age group and can be detected at any age Age group of children from birth - 4 years of age has highest number of victims of abuse Abusive parents: Found at all socioeconomic levels Have inadequate parenting skills; unrealistic expectations of the child, may not respond appropriately to child's behavior State laws require health care personnel to report suspected child abuse Mandatory reporters Overrides concern for confidentiality Laws enacted that protect the nurse who reports suspected child abuse from reprisal by family caregivers (being sued for slander), even if found that child's situation is not a result of abuse If nurse does not report suspected child abuse, penalty can be loss of your nursing license Health care facility can hold a child for concern of suspected child abuse for a certain amount of time to investigate 72 hour hold Types of Child Maltreatment Physical Abuse May occur when family caregiver is unfamiliar w/ normal child behavior Inexperienced caregiver becomes frustrated when child does not respond in a way they expect Inexperience coupled w/ dysfunctional coping, may result in physical abuse Caregiver may attribute injury to: Some action by the child that is not within the child's age or level of development An action of a sibling When symptoms do not match the injury the caregiver describes, be alert for possible abuse Do not accuse the caregiver before a complete investigation take place Young, active children often have several bruises from their usual activity Over bony areas: Knees, Elbows , shins, and forehead Signs of possible evidence of child abuse include: Bruises that occur in areas of soft tissue: Buttocks, genitalia, thighs , back of knees, upper back, and nose and eyes Bruises in the inner aspect of upper arms may indicate the child raised the arms to protect the face and head from blows Bruises w/ distinctive outlines, may indicate the instrument used Cigarettes Hangers Belt buckles Electrical cords Handprints Teeth (from biting) Sticks Fractures On x-ray bone fractures in various stages of healing Spiral fractures of long bones in young child are highly suspicious There has to be enough twisting force on bone Burns Cigarette burns Immersion of a hand in hot liquid Hot register as evidenced by grid pattern Steam iron or curling iron Immerse buttocks in hot water

Celiac Syndrome Celiac Syndrome

Used to designate the complex malabsorptive disorders Intestinal malabsorption w/ steatorrhea (fatty stools) d/t various causes Most common being cystic fibrosis and gluten-induced enteropathy (idiopathic celiac disease) Idiopathic celiac disease is a basic defect of metabolism precipitated by ingestion of wheat gluten or rye gluten → impaired fat absorption Exact cause is unknown Most acceptable theory is: inborn error of metabolism w/ allergic reaction to gliadin fraction of gluten (protein factor in wheat) as a contributing or sole factor Signs generally do not appear before age of 6 months and may be delayed until 1 year of age or later Mild disturbance in intestinal absorption of rye, wheat, and oat gluten Common Manifestation Manifestations include: Chronic diarrhea w/ foul, bulky, greasy stools Progressive malnutrition Retarded G&D Distended abdomen Thin, wasted buttocks and legs Anorexia Fretful, unhappy disposition typical Onset is insidious w/: FTT: Failure to thrive organic Bouts of diarrhea Frequent respiratory infections Vomits copious amounts, large watery stools, and becomes severely dehydrated. Prenatal fluid therapy is essential to combat acidosis and to achieve normal fluid balance Diagnosis To determine if a small child's FTT is caused by celiac disease: Initiate a trial gluten-free diet and observe results Improvement in nature of stools and general well-being w/ weight gain should follow Several weeks may elapse before clear-cut manifestations can be confirmed Conclusive diagnosis: Biopsy of jejunum through endoscopy shows changes in villi Serum screening: Immunoglobulin G and immunoglobulin A antigliadin antibodies Show presence of condition Aids in monitoring the progress of therapy Treatment Started on a gluten-free, low-fat diet Avoid all wheat, rye, and oat products If condition is severe diet consists of: Skim milk, glucose, and banana flakes Lean meats, pureed vegetables, and fruits are gradually added to diet Eventually fats may be added, and child maintained on a regular diet w/ exception of all wheat, rye, and oat products Restricted foods include unless made w/ corn flour or cornmeal: Wheat products Malted milk drinks Some candies Many baby foods Breads Cakes Pastries Biscuits: Unless made from cornmeal Vitamins A and D in water-miscible (able to be mixed w/ water) solutions needed in double amounts to supplement the deficient diet Dietary indiscretion or respiratory infection can cause relapse The omission of wheat products should continue through adolescence because the ingestion of wheat appears to inhibit growth in these children Nursing Care Primary focus is to help caregivers maintain a restrictive diet for child Reinforcement of family teaching should include: Information regarding the disease Need for long-term management Guidelines for a gluten-free diet Caregiver must learn to read list of ingredients on packaged foods carefully Diet of young child may be monitored fairly easily, but when child attends school the challenge becomes greater Additional support may be needed as the child grows to help with dietary modifications

Endocrine Type 1 Diabetes Mellitus

Estimated to affect 1 in 600 children between ages 5-15 years of age Incidence continues to ↑ Absolute or relative deficiency of insulin This disease is due to the body's inability to produce or use insulin Pathophysiology: Results from immunologic damage to beta(insulin-secreting) cells of islets cells in susceptible individuals Why autoimmune destruction of islet cells occurs is unknown With a deficiency of insulin, glucose is unable to enter the cell and remains in blood, causing hyperglycemia When serum glucose exceeds renal threshold, glucose spills into urine glycosuria Accompanied by a large loss of fluid Polyuria Which triggers the thirst response Polydipsia Polyphagia: Hunger response Cells break down fat and proteins for source of energy Clinical Manifestations Abrupt Onset of symptoms is usually accompanied by weight loss or failure to gain weight and lack of energy even with increased food intake Parents notice increased thirst, urination, and hunger May be recognized as bedwetting in previously toilet trained child Weight loss, fatigue, increase in infections, rapid onset If symptoms progress → Diabetic ketoacidosis Diabetic ketoacidosis symptoms: Drowsiness Dry skin Flushed cheeks Cherry-red lips Acetone breath w/ fruity smell Kussamaul respirations N/V Untreated children: Coma Dehydration Electrolyte imbalance Rapid pulse Subnormal temperature and BP Diagnosis Children w/ family history of diabetes should be monitored for glucose using: Fingerstick glucose test Urine dipstick test → ketones If blood glucose level is elevated or ketonuria is present, a fasting blood sugar is performed Fasting blood sugar result 200 mg/dL or more almost certainly is diagnostic for diabetes when other signs are present → 3 P's Treatment Management includes: Insulin therapy Short acting and intermediate gives two doses a day. One before breakfast and one before the evening meal. Insulin regimens are individualized to children. Meal plan Exercise plan Treatment involves the family, child, and a number of health team members Insulin reaction: Change in body requirements, Carelessness of diet, not doing carb counting, error in insulin measurement, excessive exercise, Symptoms: Odd or unusual antisocial behavior diff from child baseline, weakness, nervousness, lethargy, dizziness, blurred vision, headache. Pallor, sweating, convulsions, or sweating. Hypoglycemic reactions early in the morning. Child sugar should be checked every 2 hrs in the night until they regulate and observe them closely. Treatment: Sugar, candy, orange juice, oral glucose gel or glucagon sq

UTI Urinary Tract Infections (UTIs)

Fairly common in the "diaper age", in infancy, and between 2-6 years of age Greater risk for Ecoli More common in girls than boys Ecoli accounts for about 80% of acute episodes Female urethra shorter and straighter than males → easily contaminated w/ feces Inflammation may extend into the bladder, ureters, and kidneys Clinical Manifestations Fever; occasionally little or no fever Nausea Vomiting is common Diarrhea may occur Foul-smelling urine Weight loss Increased urination Irritable Acute pyelonephritis - inflammation of the kidney and renal pelvis Onset is abrupt High fever for 1-2 days Convulsions may occur during period of high fever Bed-wetting - common in younger children in a child who is potty trained Diagnosis Based on finding of pus (WBC's) and bacteria in urine Under microscopic exam "Clean catch method" voided urine is essential for exam depends on age of child Used for a cooperative, toilet-trained child Culture if needed by catheterization - usually avoided if possible Suprapubic aspiration may be done to obtain sterile specimen Treatment Simple UTIs may be treated w/ antiinfectives: antibiotics at home Usually trimethoprim-sulfamethoxazole, ampicillin, or amoxicillin, nitrofurantoin or cephalosporins know generic names for exam Acute pyelonephritis treated in hospital Fluids given freely Symptoms usually subside within a few days after antibiotic therapy therapy initiated NOT an indication that infection is completely cleared Medication must be continued after symptoms disappear Intravenous pyelogram or U/S ultrasound May be performed to assess for possibility of structural defects if child has recurrent infection, UTI **Review Nursing Process for the Child with a Urinary Tract Infection, pg. 829-830** Assessment (Data Collection) Outcome Identification and Planning Implementation Maintaining Body Temperature Promoting Normal Elimination Providing Family Teaching ** Review Family Teaching Tips: Urinary Tract Infection, pg. 830** Drinking water Changing diapers Changing pads tampon Do not leave wet clothes on

GTPAL

G: Gravida—the total number of pregnancies o T: Term—the number of pregnancies that ended at term (at or beyond 38 weeks' gestation) o P: Preterm—the number of pregnancies that ended after 20 weeks and before the end of 37 weeks' gestation o A: Abortions—the number of pregnancies that ended before 20 weeks' gestation o L: Living—the number of children delivered who are alive when the history is taken

Maternal VS PP

HR: 60-80 Temperature will be high but should go down after 24hrs Normal BP: 120/80 RR: low

Cerebral Palsy (CP) Cerebral Palsy

Group of disorders arising from a malfunction of motor centers and neuro pathways in the brain One of the most complex of the common permanent disabling conditions Causes Non known cause can be identified May be caused by damage to the parts of the brain that control movement; this damage generally occurs during fetal or perinatal period Particularly in premature infants Common prenatal causes: Any process that interferes w/ oxygen supply to the brain such as separation of the placenta, compression of the cord, or bleeding Maternal infection (e.g., cytomegalovirus, toxoplasmosis, rubella) Nutritional deficiencies that may affect brain growth Kernicterus (brain damage caused by jaundice) resulting from Rh incompatibility Teratogenic factors, such as drugs and radiation Common perinatal causes: Anoxia immediately before, during , and after birth Intracranial bleeding Asphyxia or interference w/ respiratory function Maternal analgesia (e.g., morphine) that depresses the sensitive neonate's respiratory center Birth trauma Prematurity b/c immature blood vessels predispose the neonate to cerebral hemorrhage Common postnatal causes: Head trauma (e.g., d/t fall, MVA) Child abuse/ Maltreatment Infection (e.g., encephalitis, meningitis) Neoplasms CVA Prevention Because brain damage in CP is irreversible, prevention is most important aspect of care Focuses on: Prenatal care to improve nutrition, prevent infection, and decrease the incidence of prematurity Perinatal monitoring w/ appropriate interventions to decrease birth trauma Postnatal prevention of infection through breast-feeding, improved nutrition, and immunizations Protection from trauma of MVA, child abuse, and other childhood accidents Clinical Manifestations Difficulty controlling muscle movements Delayed gross motor development Abnormal motor performance ( e.g., poor sucking and feeding behaviors) Abnormal posture not sitting up straight Persistence of primitive reflexes: Bimbiski reflex, Tonic neck reflex Accompanying disorders: Seizures Intellectual disability Hearing and vision impairments Behavior disorders Types: Spastic is most common type EXAM Hyperactive stretch reflex in associated muscle groups Increased activity of deep tendon reflexes Clonus - rapid involuntary muscle contraction and relaxation Contractures affecting the extensor muscles, especially heel cord Scissoring caused by hip adduction When present, child's legs are crossed and toes are pointed down When standing, child is on toes → difficult for child to walk on heels or to run Athetoid Ataxic Rigidity Mixed Diagnosis Seldom occurs before 2 months of age May be delayed until 2nd or 3rd year, when toddler attempts to walk and caregivers notice obvious lag in motor development Based on observation of delayed growth & development through a process that rules out other diagnosis CT, MRI, U/S For infants before closure of skull sutures may be used help determine cause Treatment and Special Aids Focuses on helping child make the best use of residual abilities and achieve maximum satisfaction and enrichment in life Multidisciplinary approach to help family set realistic goals Dental care important b/c: of loss of fine motor control Enamel hypoplasia common Children whose seizure disorders controlled w/ phenytoin are likely to develop gingival hypertrophy Common medications used to decrease spasticity: Baclofen Diazepam Dantrolene Physical Therapy Body control needed for purposeful physical activity must be consciously learned Physical therapists attempt to teach activities of daily living Methods must be suited to needs of each child individually Based on principles of conditioning, relaxation, use of residual patterns, stimulation of contraction and relaxation of antagonistic muscles, and others Various techniques used Orthopedic ; Management Braces used as supportive and control measures to facilitate: Muscle training Reinforce weak or paralyzed muscles To counteract the pull of antagonistic muscles Orthopedic surgery sometimes used: Improve function and correct deformities Release of contractures and lengthening of tight heel cords Technologic Aids for Daily Living Various devices to help become more functional and less dependent Child who has difficulty maintaining balance while sitting Need high-backed chair w/ side pieces & a foot platform Feeding may be a challenge Controlling and stabilizing the jaw by hand will help Feeding aids include: spoons w/ enlarged handles for easy grasping or w/ bent handles that allow the spoon to be brought easily to mouth Plates w/ high rims and suction devices to prevent slipping Covered cup set in holders w/ a straw helps for a child w/ poor hand control May need a NG ot GT Manual skills can be aided by Games that must be manipulated, such as peg boards and cards Computer programs designed to enable communication and improve learning skills Nursing Care Individualized care to meet a client's needs Monitor developmental milestones Evaluate need for hearing and speech evaluations Promote independence w/ selfcare activities as much as possible Assist patient to maintain a positive self-image and high level of self-esteem Determine the extent of family coping and support Determine family's awareness of available resources Determine child's developmental level Structure interventions and communications around the child's developmental level rather than chronological age Communicate w/ child directly, but include caregivers Help child to use augmented communication Electronic devices for speech and other types of communication tools Include family in physical care during hospitalization Ask family about routine care, encourage them to provide it if appropriate Encourage family to help verify child's needs if communication is impaired Maintain an open airway by: Elevating HOB Important for child with ↑ secretions Suction equipment available if needed Suction oral secretions PRN Monitor for pain, especially w/ muscle spasms, Using developmentally appropriate pain tool: FLACC Administer medications for pain/muscle spasms as prescribed Ensure adequate nutrion Monitor for possibility of aspiration Determine child's ability to take oral nutrition Positioning for feeding → head positioning and manual jaw control methods as needed Provide foods similar to foods eaten at home Administer supplements as prescribed Administer feedings by gastric tube as prescribed Maintain growth charts Provide Skin care Monitor skin under splints and braces if applicable Maintain skin integrity by turning the child to keep pressure off bony prominence Keep skin clean and dry Provide rest periods as needed

Sickle Cell

In sickle cell anemia, the abnormal hemoglobin causes the red blood cells to assume a sickle shape. When sickling occurs, the affected red blood cells become crescent-shaped and the blood viscosity increases (blood becomes thicker), causing slowdown and sludging of the red blood cells. The impaired circulation results in tissue damage and infarction. Sickle Cell Anemia Hereditary trait occurring most commonly in African Americans 50% probability that each child born to one parent carrying the sickle cell trait will inherit the trait from that parent When the trait is inherited from both parents, child will have sickle cell disease and anemia develops Persons who inherit the gene for the sickle cell trait from only one parent have no symptoms Normal hemoglobin levels and normal RBC count Occurs in about 1 out of every 365 African American infants in the U.S Sickle Cell Anemia Characterized by production of abnormal hemoglobin RBC's assume sickle shape Sickle Cell Anemia Clinical Manifestations Symptoms usually don't appear until 6 months or later b/c sufficient fetal hemoglobin is still present to prevent sickling Chronic anemia w/ hemoglobin level 6-9 g/dL (normal level in infant 11-15 g/dL) Causes child to be tired, poor appetite, and pale mucous membranes Sickle Cell Anemia Denotes a sudden, severe onset of sickling Pooling of many new sickled cells in blood vessels causing consequent tissue damage beyond the blockage - a Vaso-occlusive Crisis Precipitating factors: Increased oxygen levels Respiratory infection Dehydration → increase blood viscosity After extremely strenuous exercise - enough to lead to tissue hypoxia Acidosis Stress Sickle Cell Anemia Sickle cell crisis may be first clinical manifestation of disease and may recur frequently during early childhood Most common symptoms: Severe, acute abdominal pain (caused by sludging → enlargement of spleen Board-like abdomen Absence of bowel sounds Muscle spasm Fever Severe leg pain that may be muscular, osseous (bony), or localized in joints Become hot and swollen Several days after crisis: Jaundice present evidenced by yellow sclera d/t result of hemolysis Complications: Fatal outcome caused by cerebral, cardiac, or hemolytic complications Sickle Cell Anemia Sickle Cell Anemia Diagnosis Newborn screening at birth Sickledex (sickle solubility test) screening tool that can detect the presence of HbS but cannot differentiate between trait and disease Hgb electrophoresis ("fingerprinting" of the protein) separates the various forms of Hgb and is the definitive diagnosis of sickle cell anemia Genetic testing to identify carriers and children who have disease Sickle Cell Anemia Treatment Prevention of crises is the goal between episodes 1500-2000 hydration is vital Avoid extremely strenuous activities Avoid visiting areas of high altitude Small blood transfusions help bring hemoglobin to near-normal level, temporarily Iron preparations have no effect in sickle cell disease Treatment for a crisis: Supportive for each presenting symptom, and Bed rest is indicated Oxygen may be administered to prevent further desaturation_ Analgesics given for pain Dehydration and acidosis vigorously treated Sickle Cell Anemia Nursing care: focused on maintaining comfort and relieving pain, increasing fluid intake, conserving energy, improving physical mobility, and maintaining skin integrity Work closely with the caregiver to decrease anxiety and increase their nowledge about the cause of crisis episodes **Review Nursing Process for the Child with Sickle Cell Crisis, pg. 775-776** Assessment (Data Collection) Outcome Identification and Planning Implementation Relieving Pain Maintaining Fluid Intake Promoting Energy Conservation Improving Physical Mobility Promoting Skin Integrity Promoting Family Coping Providing Family Teaching Evaluation: Goals and Expected Outcomes

Insulin Regimen/ Administration

Most children w/ newly diagnosed diabetes experience a "honeymoon period" Decreased need for insulin in first weeks/months after control is established Educate family on "honeymoon period" to avoid false hope As child grows, need for insulin increases Insulin often administered SubQ at different times of day or continuously by pump Have to be regulated before using a pump. Child may not be able to take over management of the insulin injection as early as blood glucose monitoring Can watch preparation of syringe and learn technique for drawing up the dosage May be helpful to encourage child to watch the process until it becomes routine By 8 or 9 years of age, children should be encouraged to talk w/ caregiver about dose and practice working w/ syringe. Maybe they can do it themselves. Child may also draw-up and prepare for self-administration; ages varies Child should be encouraged to take over the management of therapy when ready Insulin pump is method of continuous insulin administration Delivers a steady low dose of insulin Extra insulin is released at mealtimes and as needed can give a bolus dose if needed Does not sense the blood glucose level; careful monitoring at least 4x/day is necessary to adjust dosage as needed

Seizure Disorders (Epilepsy)

May result from a variety of causes Recurrent and chronic seizure disorder Classified as: Primary or idiopathic w/ no known cause - most common Onset generally between ages 4-8 Secondary resulting from: Infection: Meningitis Head trauma Hemorrhage Tumor Clinical Manifestations Seizures are characteristic clinical manifestations of both types of epilepsy Partial = limited to a particular area of the brain Symptoms depend of area of involvement Loss of consciousness or awareness may not occur Simple Partial Seizures Complex Partial Seizures Generalized = involve both hemispheres of the brain Tonic-Clonic Seizures Absence Seizures Atonic or Akinetic Seizures Myoclonic Seizures Infantile Spasms Status Epilepticus Medical Emergency Term used to describe a seizure lasting longer than 30 minutes or a series of seizures in which the child does not return to previous normal level of consciousness Immediate treatment likelihood of permanent brain injury, respiratory failure, or even death Diagnosis Types of seizures differentiated through use of: Electroencephalography Video and ambulatory Skull x-ray CT or MRI Brian scan Physical and neurological exam Seizure history important part of determining diagnosis Treatment Main goal =complete control of seizures Anticonvulsive drug therapy Drug chosen based on its effectiveness in controlling seizures, side effects, and degree of toxicity Phenytoin (Dilantin) - Most popular drug Carbamazepine (Tegretol) Clonazepam (Klonopin) Ethosuximide (Zarontin) Phenobarbital (Luminol) Valproic acid (Depakene) **Review General Nursing Considerations w/ Anticonvulsant Therapy, Table 35-2, pg. 720** Surgical Intervention If focal point of seizure in area of brain that is surgically accessible and not critical to functioning If cause of seizure is d/t tumor or other lesion, surgical removal may be possible not as common last resort Ketogenic diets High in fat and low in carbohydrates and protein Causes child to have high levels of ketones → help to reduce seizure activity Diets are prescribed, but long-term maintenance is difficult Difficult to follow and may be unappealing to child Nursing Care MAIN FOCUS Safety during seizure is highest priority Reinforce teaching w/ caregiver about how to prevent injury ** See Family Teaching Tips: Precautions Before and During Seizures, pg. 721** Hospital setting Safety Side rails padded and raised Objects that could cause harm are kept away from the bed Oxygen and suction at bedside Bed in lowest position Seizure management Place child on side w/ head turned to one side Stay calm Remove objects from around the child Protect the child's head Loosen tight clothing During seizure note the following: Time the seizure started and ended What the child was doing when seizure began Any factor present just before the seizure (bright light, noise) Part of the body where seizure activity began Movement and parts of body involved Any cyanosis Eye position and movement Incontinence of urine/stool Child's activity after seizure Following seizure: Monitor child paying close attention to LOC, motor functions, and behaviors Document the information noted during the seizure If child is able to describe the aura - important to document Education and counseling Child and family caregiver need complete and accurate information about disorder and expected realistic results from treatment Restrictions Should not participate in sports in which a fall could cause serious injury Driving Should never just stop taking anticonvulsant therapy it should be titrated down.

Meningitis Haemophilus Influenzae Meningitis

Purulent meningitis in infancy and childhood caused by variety of agents: Meningococci Tubercle bacillus H influenzae type B most common Infectious disease Spread by droplet infection Peak occurrence is 6-12months of age Clinical Manifestations Onset may be gradual or abrupt after a respiratory infection Infants: High pitched cry Bulging fontanel: increased ICP Fever Irritability Children: Headache Nuchal rigidity Photophobia Delirium Projectile vomiting Generalized seizures common Meningococcal meningitis produces a purpuric rash (caused by bleeding under the skin) in addition to other symptoms Tends to occur as epidemics in older children Diagnosis Early diagnosis and treatment essential for uncomplicated recovery Lumbar puncture done by doctor ex: febrile fever will treat like meningitis until it is ruled out Performed whenever symptoms raise suspicion of meningitis Done before antibiotics are started Spinal fluid under ↑ pressure Early in disease may be clear, but rapidly become purulent Laboratory findings: Increased protein Decreased glucose Causative agent determined by stained smears of spinal fluid: will start off on broad spectrum antibiotics Enabling specific medication to be started early without culture growth Treatment Child is initially isolated and treatment is started using IV antibiotics after lumbar puncture is done Standard and droplet transmission precautions observed for 24 hours start of antibiotics 3rd generation Cephalosporins commonly used in combination w/ other antibiotics Ceftriaxone (Rocephin) Antibiotics chosen depend on sensitivity studies Treatment depends on progress of condition and continues as long as there is: Fever Signs of subdural effusion Fluid accumulates in subdural space between dura and brain Needle aspiration through open suture lines in infant or burr holes in skull of older child to remove accumulated fluid Repeated aspirations may be required Otitis media IV Steroids early in course has ↓ incidence of deafness as complication Anticonvulsants if seizures present Complications w/ long-term implications include: Hydrocephalus Nerve deafness Intellectual disability Paralysis Prevention: HIB vaccine 2, 4, 6, and 12 months Protection against bacteria **Review Nursing Process for the Child w/ Meningitis, pg. 722-723** Assessment (Data Collection) Outcome Identification and Planning Implementation Monitoring for Complications Preventing Aspiration Promoting Safety Monitoring Fluid Balance Providing Family Teaching Regarding Spread of Infection Promoting Family Coping Evaluation: Goals and Expected Outcomes

Hypertrophic Pyloric Stenosis Pyloric Stenosis

Pylorus is the muscle that controls the flow of food from the stomach to the duodenum Characterized by hypertrophy of the circular muscle fibers of the pylorus w/ severe narrowing of its lumen Pylorus is thickened to as much as twice the size, elongated, and consistency resembling cartilage As a result of obstruction at distal end of stomach → becomes distended Congenital defect Cause unknown More frequently in white males and familial tendency Clinical Manifestations At 3rd weeks of age, infants typically begin to vomit almost immediately after each feeding Projectile vomiting shortly after feeding (30 to 60 minutes) Vomited material is: Sour, undigested food Never contains bile, since it never progressed past the stomach Infant constantly As condition progresses: Weight loss (in severe cases growth failure - failure to thrive) Irritable and dehydrated Metabolic Alkalosis d/t loss of potassium and hydrochloric acid Constipation becomes progressive b/c little food gets into intestine Urine scanty Visible gastric peristalsis waves that move left to right across epigastrium can be seen during or after feedings Diagnostics Usually made of clinical evidence Nature, type, and times of vomiting are documented When infant drinks, gastric peristaltic waves are observed Hx of: weight loss w/ hunger and irritability Ultrasonographic or radiographic studies X-ray studies w/ barium swallow Show an abnormal retention of barium in the stomach and ↑peristalsis Treatment Pylorus repair - Pyloromyotomy Incision splits the hypertrophic pyloric muscle down to submucosa Allows pylorus to expand so food may pass Hypertrophic pyloric stenosis. A, Enlarged muscular area nearly obliterates the pyloric channel. B, Longitudinal surgical division of muscle down to the submucosa establishes an adequate passageway. **Review Nursing Process for the Child with Pyloric Stenosis, pg. 800-802** Assessment (Data Collection) Ask: when vomiting stated, character of the vomit Constipation and scanty urine Physical examination reveals an infant who may show signs of dehydration. Obtain the infant's weight and observe skin turgor and skin condition (including diaper area); anterior fontanelle (depressed, normal, or bulging); temperature; apical pulse rate (observing for weak pulse and tachycardia); irritability; lethargy; urine (amount and concentration); lips and mucous membranes of the mouth (dry, cracked); and eyes (bright, glassy, sunken, dark circles). Observe for visible gastric peristalsis when the infant is eating. Document and report signs of severe dehydration to help determine the need for fluid and electrolyte replacement. Preoperative Phase Outcome Identification and Planning: Before surgery improve nutrition and hydration, Implementation: Preoperative Phase Maintaining Adequate Nutrition and Fluid Intake Hypertrophy of the pylorus narrows the passage from the stomach into the duodenum. As a result, food (breast milk or formula) cannot pass. The infant loses weight and becomes dehydrated. If severely dehydrated and malnourished, rehydration with IV fluids and electrolytes are necessary. Thickened formula with a large hole nipple Smooth muscle relaxant may be ordered Feed infant slowly while sitting up in a infant seat or being held Make sure to burp to avoid gastric distention Fluid and electrolyte balance must be restored and the stomach must be empty NG tube may be placed Providing Mouth Care A pacifier can satisfy the baby need for sucking because of th interruption in normal feeding and sucking habits Promoting Skin Integrity Important of added IV fluids to improve electrolyte balance and rehydrate the infant The function of NG tube and saline lavage Promoting Family Coping Evaluation: Goals and Expected Outcomes - Preoperative Phase

Treatment of Diabetic Ketoacidosis

Requires skilled nursing care Child may be admitted to PICU Fluid depletion is corrected Blood and urine glucose levels and other blood studies monitored closely To evaluate degree of ketoacidosis and electrolyte imbalance If child unable to urinate, catheter inserted Regular insulin given IV along w/ electrolyte fluids Bun and creatine, electrolyte levels Monitor Is and Os Treatment: normal saline bolus if cells are dehydrated then insulin can not get into the cells Can get regular insulin then regulate and balance electrolytes. Hydration, Insulin, then manage electrolytes. **Review Nursing Process for the Child with Type 1 Diabetes Mellitus, pg. 817-822** Assessment (Data Collection) Outcome Identification and Planning Implementation Ensuring Adequate and Appropriate Nutrition **Review Family Teaching Tips: Child's Diabetic Food Plan, pg. 818** Preventing Skin Breakdown Preventing Infection Regulating Glucose Levels Providing Child and Family Teaching in the Management of Hypoglycemia and Hyperglycemia Child's Diabetic Food Plan • Plan well-balanced meals that are appealing to the child. • Be positive with the child when talking about foods that he or she can eat; downplay the negatives. • Space three meals and three snacks throughout the day. Daily caloric intake is divided to provide 20% at breakfast, 20% at lunch, 30% at dinner, and 10% at each of the snacks. • Calories should be made up of 50% to 60% carbohydrates, 15% to 20% protein, and no more than 30% fat. • Avoid concentrated sweets such as jelly, syrup, pie, candy bars, and soda pop. • Artificial sweeteners may be used. • Child must not skip meals. Make every effort to plan meals with foods that the child likes. • Include foods that contain dietary fiber such as whole grains, cereals, fruits and vegetables, nuts, seeds, and legumes. Fiber helps prevent hyperglycemia. • Dietetic food is expensive and unnecessary. • Keep complex carbohydrates available to be eaten before exercise and sports activities to provide sustained carbohydrate energy sources. • Teach child day by day about the food plan to encourage independence in food selections when at school or away from home. **Review Family Teaching Tips: Signs of Hypoglycemia and Hyperglycemia, pg. 820** Providing Child and Family Teaching on Insulin Administration Providing Child and Family Teaching about Exercise and Activity Promoting Family Coping Evaluation: Goals and Expected Outcomes Hypoglycemia • Shaking • Irritability • Hunger • Diaphoresis • Dizziness • Drowsiness • Pallor • Changed level of consciousness • Feeling "strange" Hyperglycemia • Polyphagia (excessive hunger) • Polyuria (excessive urination) • Dry mucous membranes • Poor skin turgor • Lethargy • Change in level of consciousness

Congestive Heart Failure - management & nursing care

The signs and symptoms seen in the child with CHF often include fatigue; feeding problems; failure to gain weight; pale, mottled, or cyanotic color; tachycardia; rapid respiration; dyspnea; flaring of the nares; and use of accessory muscles with retractions. Such children may also have edema, heart enlargement, and liver enlargement. Congestive Heart Failure Acquired Cardiovascular Disorders Congenital heart disorder often occurs in infants because the heart is not formed properly ot the structure do not close at birth At birth: Both right and left ventricle are about the same size Few months of age, left ventricle is about 2x the size of the right Infant HR is higher than the older child or adult so that the infant cardiac output can provide adequate oxygen to the body If infant has fever, resp distress, or any increased need for oxygen, the pulse rate goes up to increase the cardiac out By the age of 5 year, heart as mature and function as the adult heart Blood volume in the body is proportional to the body's weight. Congestive Heart Failure (CHF) The inability of the heart to pump an adequate amount of blood to the systemic circulation to meet the metabolic demands of the body. d/t disease: Congenital heart defects Rheumatic Fever Pathophysiology If congested heart failure is not corrected the heart muscle itself becomes damaged. A damaged heart muscle🡪to decreased cardiac output, which🡪decreased blood flow to the kidneys This decrease of blood flow to the kidneys will cause the kidneys to reabsorb NA & H2O. Reabsorption 🡪hypervolemia, increased workload on the heart & congestion of pulmonary and systemic circulation. Congestive Heart Failure Congestive Heart Failure Clinical Manifestations: Impaired myocardia function: Diaphoresis Decreased urine output Fatigue Pallor Anorexia Cool extremities with weak peripheral pulse Hypotension Gallop rhythm Cardiomegaly Pulmonary Congestion: Tachypnea Dyspnea TRetractions Nasal flaring Activity intolerance Orthopnea Cough Cyanosis: Late sign Wheezing Grunting Systemic Venous Congestion: Weight gain Hepatomegaly Peripheral edema Ascites Neck vein distention Periorbital edema feeding problems, rapid respirations, expiratory grunt, flaring of nares, sternal restrictions. Infant may refuse bottle after 1 or 2 oz but soon become hungry again Infant may become diaphoretic, periorbital edema may present and failure to gain weight First signs tachycardia, difficulty lying flat In older children: Failure to gain weight, weakness, fatigue, restlessness, irritability, pale, molted, or cyanotic color Rapid respirations, dyspnea, coughing with blood sputum Edema and enlargement of the liver and heart may be present Diagnosis Based primarily on clinical manifestations. CXR - Shows cardiomegaly and pulmonary congestion Electrocardiography - may indicate ventricular hypertrophy Echocardiogram - may be done to note cardiac function Congestive Heart Failure #2 Treatment includes improving the cardiac function, removing excess fluids, decreasing the workload on the heart, and improving tissue oxygenation. Nursing care is focused on improving cardiac output and oxygenation, relieving inadequate respirations, maintaining adequate nutritional intake, and conserving energy. Congestive Heart Failure Treatment Improving cardiac function Increase contractility and decrease afterload Digoxin is the drug of choice to improve myocardial contractility Increases cardiac output Decreasing heart size Decreasing venous return Relieves edema Digoxin (Lanoxin) is used almost exclusively: Given as a digitalizing dose to produce optimum cardiac effect Infant dose is in micrograms (1000 micrograms = 1mg) Give 1 hr. before or 2 hrs. after feeding Direct to the side of the mouth and rinse with water to avoid staining of teeth ALWAYS check dosage with another R.N. before administration Nurses must know the signs of toxicity: Nausea, vomiting, anorexia, bradycardia, dysrhythmias MUST be withheld and MD notified. Do NOT administer if heart rate (bpm) is: Less than 90-110 bpm in the infant Less than 70-85 bpm in the older child The Safe Dose Range Of Digoxin (Lanoxin) For Preterm Neonates Is 15-25 Mcg/Kg. What Would The Safe Dosage Range Be For A Neonate Who Weighs 1.6 Kg? 24 Mcg 40 Mcg Congestive Heart Failure Nursing responsibility includes but not limited to: Know serum Digoxin levels Checking calculations of digoxin is essential and checking dose with another nurse Teach parents how to administer side effects, toxicity, and counting apical pulse for one full minute prior to administration. <16 years: Therapeutic ranges have not been established for patients who are under 16 years of age. In adults, the suggested serum free digoxin therapeutic range is 0.4-0.9 ng/mL. Toxic concentration: ≥3.0 Congestive Heart Failure Excessive Accumulated Fluid and Sodium Decreases preload Furosemide is the diuretic of choice Blocks reabsorption of sodium and potassium May need to restrict water or salt or both A potassium wasting diuretic and may enhance effects of digoxin🡪toxicity never use together May need K+ supplement (know K+ levels) 3.5-5 Nurses need to know and monitor serum K+ levels especially before administer Lasix Always assess effectiveness of the drugs given Daily weight most important I & O and edema assessment Teach: About foods that contain K+ (bananas, oranges, whole grains, legumes etc.) Congestive Heart Failure Improve Cardiac Demands (↓ workload on the heart) Bedrest Organize & consolidate care to allow for rest. Very important for healing and G&D Maintain body temp. An elevated temp may increase metabolic needs Monitor and treat infections promptly Keep vaccines up to date (UTD) Reduce efforts of breathing Increased RR may be an early sign of increasing CHF Place pt. in semi-fowlers (HOB 30-45°) Monitor O2 sat levels Use of supplemental oxygen, usually a standing order May be on prophylactic therapy to prevent infection Decrease anxiety Having parents at the bedside will decrease the pt. anxiety Keeping parents calm will also calm the child Congestive Heart Failure Increased Tissue Oxygenation and decreased O2 Consumption Monitor oxygenation May need supplemental O2 Maintain nutritional status Give small frequent feedings Use a soft nipple w/ large opening to ease child's workload May need to supplement Increase calories in iron formula (22-24 cal/oz.) May need gavage (NG) feedings

Cystic Fibrosis Cystic Fibrosis

When first described, as called "fibrocystic disease of the pancreas."The major organs affected are the lungs, pancreas, and liver. Cystic Fibrosis #1 Genetic Testing can help prevent pass down by hereditary Know different organs involved in cystic fibrosis History of failure to thrive CF causes the exocrine (mucus-producing) glands to produce thick, tenacious mucus, rather than thin, free-flowing secretions. These secretions obstruct the secretory ducts of the pancreas, liver, and reproductive organs. The sweat chloride test, which shows elevated sodium chloride levels in the sweat, is the principal diagnostic test used to confirm CF. Family history, analysis of duodenal secretions for trypsin content, history of failure to thrive, chronic or recurrent respiratory infections, and radiologic findings also help diagnose the disorder. Cystic Fibrosis #2 The most common and serious complications of CF arise from respiratory infections, which may lead to severe respiratory concerns. Staph infections Pancreatic enzymes given with meals and snacks are used in the dietary treatment of children with CF. Dietary Treatment: Pancreatic enzymes are inactivated in acidic environment of the stomach. The child's diet is high in protein and carbohydrates, and salt in large amounts is allowed. No restrictions of fats The use of chest physiotherapy, antibiotics, and inhalation therapy help in the prevention and treatment of respiratory infections. Cystic Fibrosis Treatment Clinical Manifestations: Bile-stained emesis, Newborns may taste salty when kissed because of the high sodium chloride concentration in their sweat. A hard non productive cough may be the first sign. Later frequent bronchial infections occur. Development of a barrel chest and clubbing of fingers indicate lack of oxygen. Meconium obstr. Becomes sticky and obstructs airway Distended abdomen No stool Hyperosmolar enema Surgery if fails Older child Correct pancreatic deficiency Improve pulmonary function Prevent infection Bowel obst. Increase fluids, dietary fiber, oral mucolytics, Lactulose, mineral oil Cystic Fibrosis Dietary Treatment: Should be high in protein and fat Pancreatic enzymes with meals and snacks Aid digestion to absorption of fat & protein Microencapsulated or enteric coated May need two times normal caloric intake to promote growth Salt options: breadsticks and saltine crackers Vitamins: A,D, E, and vitamin K Cystic Fibrosis Pulmonary Treatment: Hyperosmolar enmeas administered gently if this does not resolve then surgery may be required. Prevent infections Postural drainage and clapping loosening and drain secretions Prophylactic antibiotics Immunizations up to date Encourage physical activity to help break up mucous membranes Wheelbarrow walk on hands younger Older hang upside down on monkey bars Inhalation therapy Bronchodilators- Albuterol nebulizers Humidifiers Cystic Fibrosis Lung involvement determines progression 50 % live to be 18 yrs Atelectasis and lung abscesses Bronchiectasis and emphysema Right ventricular hypertrophy-cor pulmonale Right sided heart failure Males-sterile vas deferens blocked Females thick cervical secretions Cystic Fibrosis Diagnosed by: Family history, increase sodium chloride in sweat,Elevations of 60 mEq/L or more are diagnostic, with values of 50 to 60 mEq/L highly suspect. Chronic respiratory infections Trypsin in duodenal secretions Bronchial wall thickening Home Care Financial stress Family provide most home care Immunization most important Flu, Pneumonia, COVID Only 50% live to 18 years old Lung abscesses Lipase, Tripson, Amylase deficient Secretes a lot of salt Rectal prolapse Lots of meds and supplemental vitamins

PP Hemorrhage

hemorrhage occurs in the first 24 hours after birth caused by uterine atony. Watch temperature or HR for hemorrhage Watch for clot size Watch how many pads a patient can go to Pain relief Peri-care Medications: Oxytocin, misoprostol, Cytotec, methylergonovine, carboprost, dinoprostone help with hemorrhage Should assess fundus, consistency and finger depth, bleeding color and amount, vs, bladder scan, o2 can be given non-rebreather facemask 10-15 mls of oxygen Iv line, frequent vital signs, urinary output For uterine atony when the uterus fails to contract: massage the uterus, and administer ordered oxytocin Definition MEDICATIONS : Oxytocin, misoprostol, Cytotec, methylergonovine, carboprost, dinoprostone help with hemorrhage Loss >500 mL of blood after vaginal birth Loss >1000mL of blood after C/S C Section blood transfusion and fluids and watch for pieces of placenta fragments Subinvolution on exam Signs and symptoms: Boggy uterus, Saturation more than 1 pad, Pass of large clots, Rising pulse, decrease BP, Clammy, pale skin, Decrease urine out Frequent causes: infection, subinvolution: uterus does not shrink) and retained placental fragments. Early: uterine atony, Lacerations, Hematoma, medications Late: Placenta fragments v Postpartum Hemorrhage #1 v Early postpartum hemorrhage occurs in the first 24 hours after birth and is most frequently caused by uterine atony. v Late postpartum hemorrhage can occur anytime after the first 24 hours. v Frequent causes are infection, subinvolution (uterus does not shrink), and retained placental fragments. § Postpartum Hemorrhage #2 v Nursing interventions for the woman with postpartum hemorrhage are focused on identifying the cause and stopping the bleeding. v Establishing an IV line, if not already in place, and frequent monitoring of vital signs and urinary output are critical actions. v For uterine atony(???), massage the uterus, and administer ordered oxytocics. v For lacerations and hematomas, notify the RN or the health care provider. v Postpartum Hemorrhage #3 o Most common complication o Risk highest within first hour after birth o Possible causes: § Early PPH - within 24 hours of delivery · Uterine atony · Lacerations · Hematoma v Postpartum Hemorrhage #4 § Late PPH - more than 24 hours but less than 6 weeks · Retained placental fragments · Subinvolution · Endometritis v Postpartum Hemorrhage #5 v Signs/Symptoms of PPH v (see Table 19-1, p. 404) o Boggy uterus o Saturation of more than 1 pad during first hour o Passage of large clots o Rising pulse, decrease BP o Clammy, pale skin o Decrease urine output o Complications § Orthostatic hypotension § Anemia § Fatigue § Hypovolemic shock § Possible DIC v Nursing Interventions § Assess · Fundus for firmness · Bleeding for color and amount · VS § Establish or maintain venous access § Notify primary health care provider § Provide explanation of interventions to the patient and family § Assess for bladder distention § O2 can be given nonrebreather facemask § Medication administration per MD order

Naegele's rule

o Add 7 days to the date of the first day of the LMP(last missed period), then subtract 3 months There are several ways to date a pregnancy. The most common way to calculate the EDD is to use the Naegele rule. To determine the due date using Naegele rule, add seven days to the date of the first day of the LMP, then subtract three months. This is a simple way to estimate the due date, but it is dependent upon the woman knowing when the first day of her LMP was and is also based upon the woman having a 28-day menstrual cycle. Sometimes the EDD is impossible to determine based upon Naegele rule, particularly if the woman experiences irregular menstrual cycles, or if she cannot remember the date.

Toddler

12-15mo: Postural control, able to stand and take a few independent steps 18mo: walks alone; gait may be unsteady 24mo: Runs well throws and kicks ball, waks up and down stairs one at a time 3-4yrs: Hops on one foot and jumps 24mo: Adept at building a tower 3-4mo: copies a circle and a straight line, grasp sppon between thumb and index finger, hold cup by hands

VSD, VSD Ventricular Septal Defect (VSD) MOST COMMON

Abnormal opening between the two ventricles. No unoxygenated blood leaks into the the left ventricle so cyanosis does not occur Allows blood to pass directly from L→R ventricle during systole Most common cardiac defect Small, isolated defects usually asymptomatic, discovered during routine physical exam Symptoms: Acyanotic Produces loud harsh murmur associated w/ systolic thrill Hx of frequent respiratory infections may occur during infancy G&D unaffected, leads a normal life Usually found during check up exam Heart failure Management: Many close spontaneously Corrective surgery may be postponed until 18 months to 2 years Cardiac cath with placement of a septal occluder device during surgery Closely observed and may be prescribed prophylactic antibiotics to prevent frequent respiratory infections

Ballard score

Determine if mature or premature Neuromuscular: Posture: Well flexed: Mature Extended flaccid: Premature Square window: Should bend down to touch the arm: Mature If it will not bend more than 90 degrees: Premature Arm recoil: Should recoil: mature No recoil: premature Popliteal angle: Can not extend leg more than 90 degrees: Mature Can extend leg greater than 90 degrees: premature Arm resistance: indicates maturity If can wrap around head than that indicates: premature Physical maturity assessment: Skin texture: Premature: sticky and transparent Post mature: leathery and wrinkled Lanugo: Premature: Abundant lanugo Mature: Bald Planter: Creases on sole of foot Premature: none Breast tissue: Premature: no areola Mature: 5-10 cm areola Premature: Eye fused shut Ears will stay in place Mature: Eyes will open Ears will recoil back Genitalia: Male Premature: scrotum flat and smooth Mature:pustule and ruga present Premature: Female Prominent clit and flat Mature labia will cover the inner labia

Pathological and Physiological jaundice

Physiologic jaundice is characterized by jaundice that occurs after the first 24 hours of life (usually on days 2 or 3 after birth); bilirubin levels that peak between days 3 and 5; and bilirubin levels that do not rise rapidly (no greater than 5 mg/dL/day). Pathological jaundice: Jaundice that appears within the first 24hours

Hyperemesis gravida

Potassium, fluoride, watch electrolytes Hyperemesis gravidarum: Hyperemesis gravidarum is a disorder of early pregnancy that is characterized by severe nausea and vomiting that results in weight loss, nutritional deficiencies, and/or electrolyte and acid-base imbalance Clinical Manifestations: This disorder is distinguished from "morning sickness" because the nausea and vomiting are severe and result in dehydration, weight loss, and electrolyte imbalances, particularly hypokalemia. Acid-base imbalances may occur. Before the health care provider diagnoses hyperemesis gravidarum, other causes of nausea and vomiting need to be excluded, such as hepatitis, hyperthyroidism, and disorders of the liver, gallbladder, and pancreas.An ultrasound is done to rule out a molar pregnancy. Clinical features: of the disorder includes symptoms of dehydration, such as poor skin turgor, postural hypotension, and elevated hematocrit. Although rare, esophageal tears or perforation can occur with ongoing, forceful vomiting. Prolonged starvation from severe or untreated hyperemesis can lead to thiamine deficiency and Wernicke encephalopathy, a severe neurologic disorder marked by inflammation and hemorrhage in the brain. Treatment: Nonpharmacologic treatment is aimed at avoiding triggers such as odors, heat, and iron preparations; eating frequent, small meals; consuming peppermint teas or candy; and eating cold foods that are not spicy or odorous. Alternative therapies such as hypnosis, acupressure, or acupuncture may help some women. Ginger, found in lollipops or teas, has shown to be beneficial Normal saline or lactated Ringer solutions are typical intravenous (IV) solutions used to treat the dehydration. Additives may include glucose to give the woman an energy source so that the body does not break down protein and fat for energy. Potassium is added if the woman's potassium is low because untreated hypokalemia can lead to cardiac disturbances. Other electrolytes or multivitamins may be added to the IV fluids as indicated to correct imbalances. Antiemetics, if prescribed, are usually more effective when given on a regular, around-the-clock schedule versus as-needed (PRN) dosing. Many health care providers order thiamine supplements to prevent Wernicke encephalopathy. Nursing care: Monitor the woman for nausea and administer medications, as ordered. It is also important to observe the amount and character of emesis. Record intake and output, and weigh the woman daily. Monitor for signs of dehydration, such as poor skin turgor and weight loss. Check laboratory values. An elevated hematocrit is associated with dehydration. Observe potassium levels as ordered. Hypokalemia may result from severe vomiting, or hyperkalemia can occur with potassium supplementation. The woman may be placed on a cardiac monitor to observe for any cardiac arrhythmias. Monitor the fetal heart rate (FHR) at least once per shift. Remove or avoid any of the woman's triggers if possible. Immediately remove any emesis basis or bedside commodes. After the vomiting has stopped, implement measures to promote intake. A relaxed, pleasant atmosphere is conducive to eating. The area for eating should be well ventilated and free of unpleasant odors. In addition, eating with others can promote intake. Instruct the woman to eat before or as soon as she notices that she is hungry, because an empty stomach aggravates nausea. Make every effort to provide foods that the woman enjoys. Carbohydrates, such as breads, cereals, and grains, are sometimes easier to tolerate than other food types. She should avoid foods high in fat because such foods may exacerbate nausea.

Nutrition - toddler

Daily Nutritional Needs of the 1-3-year-old o 1000-1400 calorie diet from the major food groups Eating problems commonly occur and is part of normal development o Growth has slowed, leading to want and need less food than before o Strong drive for independence and autonomy compels an assertion of will to prove individuality to both self and others o Appetite varies according to the find of food offered Food jags - desire for only one kind of food for a while To minimize eating problems and ensure a balanced diet; caregivers should plan meals w/ an understanding of the developing toddlers feeding skills o See Family Teaching Tips - Feeding Toddlers; pg. 532 Mealtime for the toddler should not exceed 20 minutes One or two teaspoonfuls is an adequate serving for the toddler. Too much food on the dish may overwhelm the child. Messiness is to be expected; gradually diminishes as the child gains skill in self-feeding At 15-months: Sit through meals Prefers finger feeding Wants to self-feed Tries using a spoon, but difficulty w/ scooping & spilling o Grasps cup w/ thumb and forefinger, but tilts the cup instead of head At 18-months: Improved control of the spoon, puts spilled food back on spoon Holds cup with both hands Spills less often May throw cup when finished if no is there to take it At 24-months: Clearly defined likes and dislikes and food jags Grasps spoon between thumb and forefinger Can put food on the spoon w/ one hand Continues to spill Accepts no help ("Me do!") At 30-months: Refusals and preferences are less evident Some toddlers hold spoon like an adult w/ palm turned inward Tilts head back to get every drop from a cup

Finnegan's score (NAS)

o Nursing care of NAS newborn § Neonatal abstinence scoring (Finnegan) · Score infant every 3-4 hours, corresponding to the frequency of feedings · Behaviors should be assessed throughout the 3-4 hours interval Score all that apply Diaphoretic Temp greater than 37.8 High pitched cry Irritable Tachypnea Diarrhea Congestion Sneezing Excessive sucking on the pacifier Poor feeding Tremors Hypertonic Recheck during feedings and assessment and observe the trend Low stimulation Will be weaned off drug in intervals

Nephrotic Syndrome Nephrotic Syndrome

Most common type is idiopathic nephrotic syndrome or referred to as minimal change nephrotic syndrome (MCNS) Cause unknown Most commonly seen under the age of 6 Insidious onset Course of remissions and exacerbations that usually last for months Clinical Manifestations Edema is usually the presenting symptom Appearing first around eyes and ankles Advances to becoming generalized edema Masks loss of body tissue Chubby appearance Doubles weight Ascites Respiratory difficulty may be severe Edema of scrotum on male is characteristic Shifts when changes position from lying to walking about Loss of appetite Poor intestinal absorption Malnutrition may become severe Irritability Diuresis: excessive urination Malnutrition becomes apparent Susceptible to infections Repeated acute respiratory conditions are usual pattern Use of immunosuppressants intensifies susceptibility can a Diagnosis Marked proteinuria Especially albumin in urine makes urine look frothy Hypoalbuminemia blood levels are also low Hyperlipidemia: makes lipoproteins lager due loss of protein in body Which results in high lipid levels in the blood Treatment Long process w/ remissions and recurrence of symptoms is common Use of corticosteroids → induce remissions and ↓ remissions Produces diuresis in about 7-14 days can result in malnutrition Continued until remission occurs Prednisone most commonly used Daily urine testing for proteins Important to track patterns of protein loss Diuretics not commonly used b/c diuresis induced by steroids not effective in reducing edema fluids are in tissue and not the circulatory system Loop diuretic, like furosemide may be administered if edema → respiratory compromise Immunosuppressant therapy for children who do not respond to corticosteroids May be used to reduce symptoms and prevent further relapses Cyclophosphamide (Cytoxan) most commonly used Used for 2-3 months Side effects: Leukopenia GI symptoms Hematuria Alopecia Diet considerations: Used as treatment General diet that appeals to child's appetite w/ frequent, small feedings Salt is discouraged Occasionally put on a Low-Sodium diet High protein diet Foods high in potassium if on a loop diuretic or potassium supplement Family caregiver support and encouragement **Review Nursing Process for the Child with Nephrotic Syndrome, pg. 833-834** Assessment (Data Collection) Outcome Identification and Planning Implementation Monitoring Fluid Intake and Output Improving Nutritional Intake Promoting Skin Integrity Promoting Energy Conservation Preventing Infection Providing Family Teaching and Support Evaluation: Goals and Expected Outcomes

Integumentary system - NB

Integumentary Vernix cheesy cream-colored lubricant to protect baby from fluid in utero Lanugo is fine downy hair covering baby. Mottling- patchy reddish and white spots exposed to cold Milia-white small pimples on face Integumentary Mongolian spots appear at spine Rash red Port wine stain Bruising General Exam Nose-check nostrils Mouth-cleft palate- tongue tie Ears-shape and hearing screening Neck- head lag should fall back Chest-symmetrical Abdomen-symmetrical Genitalia-swollen Extremities Back and rectum Reflexes

Mastitis

usually unilateral can be characterized by flu-like symptoms The best way to prevent handwashing is to avoid cracked nipples. Antibiotics are given and emptying the breastfeeding, and warm compresses or cold cabbage leaves. Symptoms: chills, low-grade fever, malaise Local breast tenderness Lactation can be maintained, Red hard spot on one side of breast. Treatment: antibiotics, analgesics, bed rest, and fluids If antibiotics should continue to breastfeed unless contraindicated if so mom should dump expressed breast milk until she is able to resume breastfeeding when the medication course is complete. Proper positioning, while breastfeeding can help avoid cracks, rub nipples with a few drops of expressed milk after breastfeeding, and allow nipples to air dry, Lanolin cream may also be helpful. The women should breastfeed at regular, frequent intervals. Milk stasis can lead to obstruction of a duct which can result in inflammation and then infection. Mom should empty breast to prevent infection Breast pads in her bra should be changed when they become damp to help prevent maceration of the nipples.

Epiglottis Epiglottis--- NO TONGUE BLADES: spasms can't

Age 2yr-7yr No oral temps No throat cultures: which can cause spasms Acute inflammation Haemophilus influenza B Fever 102-104 Dysphagia Anxious Tripod sitting to breath Tongue out EMERGENT Epiglottis Treatment EXAM Intubation or tracheostomy Moist air Continuous O2 sat monitor IV antibiotics 10 days total Extubate after 24-48 hrs NOT common but scary

NB discharge teaching

An emphasis is placed on teaching the new parents to care for their newborn. Chapter 15 explores issues related to infant nutrition. Breast-feeding and formula-feeding are presented, along with factors that affect a woman's selection of a feeding method, as well as advantages and disadvantages of each method. Physiology of breast-feeding, including breast anatomy, is covered here. The nurse's role in assisting the woman who is breast-feeding and the woman who is formula-feeding is also discussed.

Uterine atony

Atony: Most common cause of postpartum hemorrhage Usually caused by magnesium sulfate The failure of the uterus to contract adequately following a delivery The most common cause of postpartum hemorrhage. If the uterus feels boggy or soft to palpation, massage it until it firms up beneath your fingers. Notify RN of the condition Oxytocics such as Pitocin may be ordered to prevent uterine atony. Monitor strictly I and O acute renal failure can occur Tetany: Increased uterine tone cause uterine tetany Muscle cramps, spasms, or tremors; when your muscles contract uncontrollably Risk factors: Uterine Atony • Multiparity • Intrauterine infection • Previous uterine surgery • Prolonged or difficult labor • History of postpartum hemorrhage • Placenta previa or abruptio placentae • Use of oxytocin for labor stimulation or augmentation • Use of agents during labor that relaxes the uterus (tocolytics), such as ■ magnesium sulfate ■ terbutaline ■ certain anesthetics ■ nitroglycerin • Overdistention of the uterus, such as occurs with ■ multiple gestations ■ polyhydramnios ■ fetal macrosomia

PP assessment

B-reasts: should be soft until it fills with milk on the 3rd day U-terus: The uterus should not be tender B-owels: monitor for bowel sound can possibly not have bm for 3-5 days. High fiber diet Possible stool softner B-ladder: Bladder should not be full should be 150cc per void. L-ochia: Episiotomy/laceration/C-section incision

Gestational diabetes

During pregnancy, tissues become resistant to insulin to provide sufficient levels of glucose for the growing fetus. The result in a normal pregnancy is threefold and composes the diabetogenic effect of pregnancy (Negrato, Mattar, & Gomes, 2012). The three normally occurring responses in pregnancy are: Glucose can get into urine and can cause preeclampsia. It can also cause yeast infection and uti 1. Blood glucose levels are lower than normal (mild hypoglycemia) when fasting. 2. Blood glucose levels are higher than normal (mild hyperglycemia) after meals. 3. Insulin levels are increased (hyperinsulinemia) after meals. Gestational diabetes is similar to type 2 DM. The treatment of the woman does not depend upon the type of diabetes, but rather her symptoms. Pregestational diabetes describes the condition where a woman enters pregnancy with either type 1 or type 2 DM. the woman with poorly controlled pregestational DM, particularly in the early weeks of pregnancy, is at risk for complications such as birth defects, stillbirth, hypertensive disorders, polyhydramnios (excess levels of amniotic fluid), preterm delivery, and macrosomia. Gestational diabetes (GDM) occurs only during pregnancy but is similar to the disease process of type 2 DM. As with type 2 DM, the underlying pathophysiology of GDM is insulin resistance. GDM develops when the woman's body cannot tolerate the physiological changes seen with the diabetogenic effect of pregnancy. Box 16-1 lists selected maternal risk factors for GDM. Women who develop GDM do not always experience symptoms; therefore, screening for GDM is a standard of obstetric care for all women, not just those at risk. Screening for GDM is done at approximately 24 to 28 weeks of pregnancy, although some health care providers may screen as early as 20 weeks. . If the woman has a prior history of GDM, screening often occurs at the first prenatal visit. The diagnosis of GDM depends on the results of the oral glucose tolerance test, also known as the glucose challenge test. The woman who develops GDM is at increased risk for developing type 2 DM after pregnancy.within 5 to 20 years after delivery Selected Risk Factors for Gestational Diabetes Mellitus • History of a large-for-gestational age infant • History of gestational diabetes mellitus (GDM) • Previous unexplained fetal demise • Advanced maternal age (>35 years) • Family history of type 2 DM or GDM • Obesity (>200 lb) • Noncaucasian ethnicity • Fasting blood glucose >140 mg/dL • Random blood glucose >200 mg/dL Diagnostic Values for the Oral Glucose Tolerance Test Normal values are the following: • Fasting: <95 mg/dL • 1 hour: <180 mg/dL • 2 hours: <155 mg/dL • 3 hours: <140 mg/dL GDM is diagnosed if two or more values meet or exceed the levels listed above. Fetal Complications These risks include placental issues, fetal growth, hypoglycemia, birth trauma, lung maturity issues, and increased health risks later on in life The diabetic woman is more likely to experience a cesarean birth than is a woman who does not have DM. DM causes damage to blood vessels, affecting major organs like the eyes and kidneys. In the pregnant woman, this also affects the placenta. In a woman with long standing DM, the placenta tends to be smaller, and maternal-fetal circulation is often decreased which may lead to chronic fetal hypoxemia and growth restriction. The fetus born to a mother with DM can also be large for gestational age because of elevated maternal blood glucose levels. Macrosomia is defined as either birth weight over 4,000 g (8.8 lb) or as ≥90th percentile for gestational age. increased risk for birth trauma including shoulder dystocia. The fetus does not have insulin resistance, like the pregnant woman does, so the fetal pancreas produces increased levels of insulin to handle the high sugar. After delivery, this increase in insulin levels can lead to hypoglycemia in the infant of a diabetic mother.Delayed lung maturity is another complication that the fetus of a woman with DM or GDM is at risk for. increased risk later in life for health issues including hypertension, impaired glucose tolerance, and obesity. Treatment: Persistent maternal hyperglycemia (elevated blood glucose levels) is harmful to the growing fetus, particularly during the first 8 weeks of pregnancy when organogenesis is occurring. Cardiac defects can occur from hyperglycemia during the period of organogenesis. A woman with diabetes should also start taking a daily multivitamin supplement that contains at least 1 mg of folic acid. Adequate folic acid intake is the best way to prevent neural tube defects, for which the diabetic woman's fetus is particularly susceptible Glycemic Control: For the woman with pregestational diabetes, the most important goal of treatment is to maintain tight glycemic (blood sugar) control before and throughout pregnancy. Because elevated glucose levels during the first trimester are associated with increased risk of fetal deformities, the goal is for the HbA1C to be less than 8.5% before the woman becomes pregnant. The woman with DM must check her blood sugar frequently. Common times include upon awakening, after breakfast, before and after lunch, before and after dinner, and before bedtime. Maintaining blood glucose levels of less than 95 mg/dL, and to not exceed 120 mg/dL 2 hours after There are three main components to glycemic control for the woman with pregestational DM: insulin, diet, and exercise If diet and exercise fail to control the diabetes, the woman with GDM begins insulin therapy to maintain blood sugar levels at therapeutic levels. Insulin Therapy. In the first few months of pregnancy, the woman's insulin requirements fluctuate widely, and she is at risk for episodes of hypoglycemia, or low blood glucose levels, particularly between meals At the beginning of the second trimester, insulin requirements stabilize and then begin to increase at approximately 24 weeks' fi, continuing to increase until term At the beginning of the second trimester, insulin requirements stabilize and then begin to increase at approximately 24 weeks' gestation, continuing to increase until term During labor, insulin needs are variable, and in the first 24 hours after delivery, insulin requirements fall dramatically. The use of the oral hypoglycemic agents glyburide (Micronase) and metformin (Glucophage) have been shown to be effective in the management of blood glucose levels during pregnancy as possible insulin alternatives for the pregnant woman with diabetes Diet: Consultation with a registered dietitian is recommended, preferably one who is also a certified diabetic educator, because diet requirements are individualized. Exercise: However, the pregnant woman should always consult with her health care provider before exercising. This is important if her diabetes is poorly controlled or if she has diabetes complications such as vascular damage, hypertension, or renal insufficiency. Fetal Surveillance: An initial sonogram during the first trimester determines gestational age and fetal viability. A more detailed, high-level sonogram is done at 18 to 20 weeks to look closely for structural defects, including heart defects, in the fetus. The onset of diabetic ketoacidosis (DKA) is marked by the classic symptoms of hyperglycemia, which include the following: • Polydipsia (excessive thirst) • Polyuria (increased frequency and amount of urine) • Polyphagia (excessive hunger) Triggers for DKA include (but are not limited to) the following: • Too little insulin or too much food • Infection • Tocolytic therapy (to prevent preterm labor) • Corticosteroid use • Insulin pump failure

Unique Needs of the Adolescent

Even when an adolescent has accepted responsibility for self-care, it's not uncommon to: Draw up insulin and give insulin to themself but may still need to be monitored. Rebel against the control that diabetes demands Become impatient and appear to ignore future health May skip meals Drop diet controls Neglect glucose monitoring Go barefoot and neglect proper foot care Special care should be taken to see that adolescents find enough maturing satisfaction in other areas and do not need to rebel in this area They are so unique because they are trying to find independence.

Growth & Development Weight gain - infant

Growth & Development Weight gain - infant Increase rapidly · By 6 months of age the infant will double 12 months should be triple their birth weight height increase about 6 inches · By 1 year of age, the infant had triple their birth weight and has grown 10-12 inches Growth of the child follows an orderly pattern starting with the head and moving downward. This pattern is referred to as cephalocaudal. EX: The child is able to control the head and neck before being able to control the arms and legs Growth also proceeds in a pattern referred to as proximodistal, in which growth starts in the center and progresses toward the periphery or outside

NB VS

Infant Vital Signs Heart Rate 110-160 sleeping 100 Crying 180 or > Respiratory Rate 30-60 Episodic chest and abdominal rise simultaneously Temperature 97.7-98.6 F 36.5-37 C stabilizes 8-10 hour after birth skin to skin with mom Blood Pressure 60-80/40-45 mmHg some also record MAP Always work together abdominal and chest Signs of respiratory distress (see Box 13-1, p. 269) Tachypnea (sustained respiratory rate greater than 60 breaths per minute) • Nasal flaring • Grunting (noted by stethoscope or audible to the ear) • Intercostal or xiphoid retractions • Unequal movements of the chest and abdomen during breathing efforts • Central cyanosis o Surfactant keeps lungs from collapsing, enough by end of 35 weeks o Maintaining adequate oxygen supply- without surfactant becomes exhausted o Sensory and thermal stimulate the newborn to cry

Pica

People who eat things they are not supposed to like wallpaper, dirt, etc.. Psychological effects: They do a depression screen during pregnancy and post-partum. Women can become depressed in 3rd trimester due to insomnia, watch for domestic abuse, Psychosocial: Culture and financial income, Some cultures may avoid funerals Adolescent pregnancies: Prenatal care is the most important and diet.

TORCH

Toxoplasmosis Other: hepatitis B, syphilis, varicella, and herpes zoster Rubella Cytomegalovirus (CMV) Herpes simplex virus (HSV) All cross the placenta and are teratogenic. Fetal effect is determined by gestational age at exposure. TORCH syndrome is characterized by IUGR, microcephaly, hepatosplenomegaly, rash, thrombocytopenia, and CNS findings, such as ventricular calcifications and hydrocephalus Toxoplasmosis: Infection caused by protozoan transmitted by uncooked meat, unfiltered water, contaminated soil, and through cat feces. Newborns may present with chorioretinitis, and hydrocephalus. The newborn will need ophthalmic and hearing evaluations Other Infections: Hepatitis B, Syphilis, Varicella, and Herpes Zoster Hep B If the mother is HBsAg-positive, the neonate should receive hepatitis B immunoglobulin (HBIg) and the hepatitis B vaccine within 12 hours of birth. The immunoglobulin provides immediate protection, and the vaccine provides long-term protection from infection. Regardless of the woman's HBV status, all infants need a three-dose immunization series against hepatitis B with the first dose given at birth. Syphilis Other consequences of active syphilis infection include fetal demise, IUGR, hydrops fetalis, preterm birth, congenital infection, and neonatal death (Norwitz, 2017). The infected infant may be born with birth defects such as blindness, deafness, or other deformities. Hutchinson triad is characteristic of a newborn born with syphilis and includes inflammation of the cornea, deafness, and notched teeth. Another characteristic of early congenital syphilis is snuffles, a nasal discharge that can be bloody. The newborn may have a vesicular or bullous rash that is contagious.

Epidural and Spinal

hypotension Nursing intervention Position mom on her side or position pillow under hip 500-200ml IV fluid bolus is given before an epidural to reduce the risk of hypotension BP is monitored every 3- min, Uterine atony Impaired placental perfusion fetal bradycardia, Ineffective breathing patterns respiratory depression, Spinal headache intense headache resolved with laying down without treatment resolves in 7-10 days and treatment with oral analgesics and caffeine. Epidural blood patch provides lasting relief for severe spinal headache, Lightheadedness, nausea, urinary retention, pruritus if narcotics are used in addition to anesthetics. SEVERE COMPLICATION: Total spinal blockade local anesthesia traveling to high up the woman's body causing paralysis of the women's respiratory muscles which can result in cardiac arrest. SEVERE COMPLICATION: Accidental injection of a local anesthetic into a blood vessel results in seizures as well as respiratory and cardiac arrest can result.

Spina Bifida/myelomeningocele

is failure of the posterior laminae of the vertebrae to close Spinal cord doesn't close all the way Leaves an opening through which spinal meninges and spinal cord may protrude Caused by a defect in the neural arch Generally in lumbosacral region Clinical Manifestations Types of defects: Spina Bifida Occulta Most instances asymptomatic and presents no problems A dimple in the skin or a tuft of hair over the site may cause suspicion or may be overlooked Spina bifida cystica Refers to a visible defect with an external saclike protrusion. Two major forms are: Meningocele No nerve roots are involved No paralysis or sensory loss below the lesion appears Surgical removal of sac w/ closure of skin indicated d/t risk of rupture or perforation of sac → infection into spinal fluid → meningitis Myelomeningocele Protrusion of spinal cord and the meninges w/ nerve roots embedded in the wall of the cyst Effects of defect vary in severity from sensory loss or partial paralysis below the lesion to complete flaccid paralysis of all muscles below the lesion Complete flaccid paralysis involves the lower trunk and legs, as well as bowel and bladder sphincters neurogenic bowel and bladder Diagnosis Elevated maternal AFP levels Indicates probability of central nervous system abnormalities Best performed between 13 and 15 weeks' gestation, when peak levels are reached U/S May show incomplete neural tube: associated with lack of folic acid Newborn w/ spina bifida Made from clinical observation and examination Needs to be examined carefully for associated defects Particularly hydrocephalus, GU defects, orthopedic anomalies Additional evaluation may include: MRI U/S CT Myelography Treatment Multidisciplinary approach After thorough evaluation of newborn → surgical repair and treatment developed: usually 24 hours after birth Highly skilled nursing care necessary in all aspects of newborn's care Child requires years of ongoing follow-up and therapy If found before delivery mom will have a C section mom can not hold baby after delivery Infant is lying prone and sac will have warm wet saline gauze Surgery is required to close the open defect **Review Nursing Process for the Newborn with Myelomeningocele, pg. 454-456** Assessment (Data Collection) Outcome Identification and Planning: Preoperative Care Implementation Preventing Infection Promoting Skin Integrity Promoting Family Coping Providing Family Teaching Evaluation: Goals and Expected Outcomes Surgery for bowel: can create a channel for normal bowel movements colon liter channel Surgery for bladder control: Channel from bladder to surface of abdominal. straight cath through the abdomen: Monty

Intussusception

or invagination of the intestine over itself Most common at the juncture of the ileum and colon, it can appear elsewhere in intestinal tract More common in boys than in girls Highest incidence occurs in infants between 4 and 10 months Unknown cause Clinical Manifestations Suddenly becomes: Pale Cries out sharply Draws up the legs in a severe colicky spasms May last several minutes Reflexes appears well until next episode May occur 5, 10, or 20 minutes later Vomiting Progresses to bile stained Currant jelly -like stool (mucous and blood present) Signs of shock: Weak pulse ↑ temperature Shallow, grunting respirations Pallor Marked sweating Cardinal Signs: Shock Vomiting Currant jelly stools Diagnosis Clinical symptoms Rectal exam Palpation of abdomen during a calm interval when it is soft sausage shaped mass can be felt through abdominal wall Treatment and Nursing Care Emergency treatment Danger of bowel becoming gangrenous Immediate treatment consists of: IVF's NPO status Diagnostic barium enema Often can reduce the invagination Simply by the pressure of the barium fluid pushing against telescoped portion Should not be done if signs of bowel perforation present Surgery performed if barium enema unsuccessful Manual reduction of invagination Resection w/ anastomosis Possible colostomy if intestine gangrenous Post-reduction of invagination care Return to normal feedings within 24 hours and discharged in about 48 hours Carefully observe for recurrence during this period

HIV/AIDS Sexually Transmitted Infections Acquired Immunodeficiency Syndrome (AIDS)

· · Attacks and destroys the T-helper lymphocytes o T-helper lymphocytes are cells that direct the immune response to viral, bacterial, and fungal infections and remove malignant cells from the body · Not all persons who test positive for HIV develop AIDS immediately · CDC has established criteria for classification system for HIV infections and AIDS surveillance o Most significant criteria is the CD4 plus T-lymphocyte count § As disease progresses, CD4 count drops and puts child at risk for developing life-threatening infections o Three categories for HIV/AIDS: Category A Mildly symptomatic HIV-positive as well as 2 or more symptoms: enlarged spleen, liver or lymph nodes, frequent respiratory or ear infections Category B Moderately symptomatic HIV-positive as well as illnesses, chronic diarrhea, herpes simplex virus or herpes zoster, persistent fever Category C Severely symptomatic HIV-positive as well as serious bacterial infections, encephalopathy, lymphoma, tuberculosis, severe failure to thrive, or opportunistic infections · Most children w/ AIDS are between ages 1 and 4 years · Alarming increase among adolescents o Teenagers' attitude of impunity and increasing rate of sexual activity in age group, often involving multiple partners · Incubation: varies from 3-10 years o Those who contract the disease in adolescence will not have symptoms until their 20's, when they are at their reproductive peak Transmission · Occurs through contact: o w/ infected blood or blood products during transfusions o Sharing of infected needles o Exposure to infected body secretions o Sexual contact § Proper use of condom w/ spermicide during any sexual contact is essential o HIV-positive woman to unborn fetus or newborn infant o Cannot be spread by casual contact · Infants usually infected: o Through placenta during prenatal life o In the birth process when contaminated by mother's blood o Through breast-feeding: bodily fluid · Children and teens o Can also be infected through sexual abuse · Adolescents o Most often infected through Iv drug use use Diagnosis · Infants may test positive in the 1st year of life, testing is NOT reliable until 18 months months of age o Infant retains antibodies from the mother for this length of time · For affected infants, younger than 1 year of age, disease can move rapidly to AIDS and serious complications o Failure to thrive o Pneumocystis carinii pneumonia o Recurrent bacterial infections o Progressive encephalopathy o Malignancy Clinical Manifestations and Treatment · Children and adolescent's manifests symptoms of HIV much the same as adults Systemic: Fever, weight loss Pharyngitis: Mouth: Sores, Thrush Espohagus: Sores Muscles: Myalgia Liver and spleen: enlargement Central: Malaise, headache, neuropathy Lymph nodes: lymphadenopathy Skin: rash Gastric: nausea, vomitting · Many women, including adolescents present w/ chronic infection of vaginitis o Caused by C. albicans that has not responded to local antifungal treatment: Yeast infection, thrush o Infections may be controlled by oral systemic medications · Female who tests positive for HIV should have pelvic exam Q6 months to detect early STI's and institute vigorous treatment as needed **Review Nursing Process for the Child with AIDS; pg. 882-885** for treatment Should still be using standard percautions Primary goal is good hand washing Good hand hygiene and hygiene practices help prevent transmission of the virus to others Follow careful standard precaution and avoiding things that can damage to skin and causing infection Pain topical anesthesia, analgesics, non pharmalogic Nutrition: anorexia and poor appetite, dehydration, malabsorption, candidiasis, promoting a good diet Social isolation: a lot of support and counseling for fears and helping them dela with their situation Family: Look up family teaching tips · Assessment (Data Collection) · Outcome Identification and Planning · Implementation o Preventing Infection o Preventing Infection Transmission o Promoting Skin Integrity o Promoting Comfort o Improving Nutrition o Easing Social Isolation and Hopelessness o Promoting Family Coping · Evaluation Goals and Expected Outcomes Supporting the Child or Adolescent with HIV/AIDS • Assist in learning about and accepting diagnosis. • Provide educational literature on HIV. • Explain the difference between being HIV-positive and having AIDS. • Encourage him or her to verbalize feelings (anger, fear, hopelessness, etc.). • Encourage participation in local support groups. • Promote eating an adequate diet, exercising regularly, sleeping 8 to 10 hours/night. • Encourage small, frequent meals or suggest nutritional supplements, such as Ensure, to prevent weight loss. • Discuss prescribed drugs: indications, schedules, doses, and how to recognize and manage side effects. • Make a schedule for medicines and daily eating times that will work for you and your child. • Use reminders, such as a timer or a watch with an alarm, calendars, and a check-off list of when a dose is due or has been taken. • Color-code the bottles of liquid medicines with matching oral syringes. This helps giving the right dose easier. Put the same color for the medicine on the calendar or checklist. • Explain how HIV is spread (by direct contact with infected body fluids, usually through sex, sharing needles, or blood transfusion). • Talk about how to avoid transmitting the virus to others or contracting yet another strain. • Discuss safer sex strategies, such as using condoms. • Discuss why and how to notify sex partners of infection; explain that partners need counseling, testing, and if HIV-positive, referral for treatment; offer to help with the notification process if necessary. • Discuss the importance of primary health care. • Encourage adolescent girls to have regular gynecologic examinations and Pap smears Communicable Disease of Childhood · Incidence of childhood diseases has decreased w/ use of immunization · Occasional outbreak in certain communities where many children are not immunized at all more prone to getting disease. Prevention · Recommended schedule of childhood immunizations found on CDC website · Parents of children whose immunizations are incomplete must be urged to have immunizations brought up to date. · For families of limited means, free immunizations are usually available at clinics Stages of Infectious Disease · Incubation period o Time between the invasion of an organism and the onset of symptoms of infection · Prodromal period o Time between the beginning of nonspecific symptoms such as lethargy, low-grade fever, fatigue, and malaise and onset of disease-specific symptoms such as rash · Convalescent period o Interval between when symptoms first begin to fade and when the child returns to healthy baseline Means of Transmission · Refers to whether the infection is spread by direct or indirect contact · Direct contact: skin to skin · Indirectly by fomites o Inanimate objects such as soil, food, water, bedding, towels, combs, non-refrigerated food, or drinking glasses · Most common means of indirect contact o Mouth and nose secretions through talking, sneezing, coughing, breathing, kissing, and sharing drinking glasses or straws Portal of Entry · Refers to the opening through which a pathogen can enter a child's body such as by inhalation, ingestion, or breaks in the skin from bites, abrasions, or burns Nursing Care Management · Important to assess: What is their recent exposure o Recent exposure to infectious agents o Prodromal symptoms (symptoms that occur between early manifestations of the disease and its overt clinical syndrome) o Immunization history o History of having disease Prevent Spread of Disease · Primary prevention of disease o Immunizations · Control spread of disease to others o Reduce risk of cross-transmission of organisms o Infection control policies ex: if you are sick do not go out o Teach children to wash their hands after sneezing or coughing, before eating, and after using the bathroom o Teach girls to wipe from front to back after defecating or voiding o Teach parents to wash cuts and abrasions before bandaging them up

TODDLER Accident/injury prevention Accident Prevention

Accident/injury prevention Accident Prevention See Family Teaching Tips; pg. 537-538 Toddlers are explorers who require constant supervision in a controlled environment to encourage autonomy and prevent injury o When supervision is inadequate or the environment is unsafe, tragedy often results Accidents are leading cause of death between ages 1 and 4 years of age Provide information and anticipatory guidance about: o Motor Vehicle o Drowning o Burns o Poisoning o Ingestion of Toxic Substances Preventing Motor Vehicle Accidents • Never start the car until the child is securely in the car seat. • If the child manages to get out of the car seat or unfasten it, pull over to the curb or side of the road as soon as possible, turn off the car, and tell the child that the car will not go until he or she is safely in the seat. Children love to go in the car, and they will comply if they learn that they cannot go unless in the car seat. • Never permit a child to stand in a car that is in motion. • Teach the toddler to stop at a curb and wait for an adult escort to cross the street. An older child should be taught to look both ways for traffic. Start this as a game with toddlers, and continually reinforce it. • Teach the child to cross only at corners. • Begin in toddlerhood to teach awareness of traffic signals and their meanings. As soon as the child recognizes color, he or she can tell you when it is all right to cross. • Never let a child run into the street after a ball. • Teach a child never to walk between parked cars to cross. • As a driver, always be on the alert for children running into the street when in a residential area. Preventing Burns • Do not let electrical cords dangle over a counter or a table. Repair frayed cords. Newer small appliances have shorter cords to prevent dangling. • Cover electrical wall outlets with safety caps. • Turn handles of pans on the stove toward the back of the stove. If possible, place pans on back burners out of the toddler's reach. • Place cups of hot liquid out of reach. Do not use overhanging tablecloths that toddlers can pull. • Use caution when serving foods heated in the microwave; they can be hotter than is apparent. • Supervise small children at all times in the bathtub so they cannot turn on the hot water tap. • Turn thermostat on home water heater down so that the water temperature is no higher than 120°F. • Place matches in metal containers and out of reach of small children. Keep lighters out of reach of children. • Never leave small children unattended by an adult or a responsible teenager Preventing Poisoning • Keep harmful products and household cleaning products (laundry and dishwashing detergent "pods") locked up and out of a child's sight and reach. • Use safety latches or locks on drawers and cabinets. • Read labels with care before using any product. • Replace child-resistant closures and safety caps immediately after using product. • Never leave alcohol or electronic cigarettes/nicotine refill cartridges within a child's reach. • Keep products in their original containers; never put nonfood products in food or drink containers. • Teach children not to drink or eat anything unless it is given to them by a trusted adult. • Do not take medicine in front of small children; children tend to copy adult behavior. • Do not refer to medicine as candy; call medicine by its correct name. • Check your home often for old medications and get rid of them following the U.S. FDA drug disposal guidelines (U.S. FDA, 2017). • Keep "button" battery compartments on household products taped and secured, store batteries out of reach and sight of children and don't allow children to play with batteries. • Keep plants off floor and out of children's reach. • Keep lotion, cream, powder, cosmetics, insect repellent out of children's reach. • Post the Poison Help Line (formerly called the Poison Control Center) number near each telephone: (800) 222-1222. • Program the Poison Help Line number into your cell phones and into your home phone.

Otitis Media

Otitis Media One of the most common infectious diseases of childhood Factors that influence: Eustachian tube in infant is shorter , widder, and straighter than that of the older child/adult Nasopharyngeal secretions able to enter middle ear more easily Haemophilus influenzae important causative agent of otitis media in infants/children Clinical Manifestations Infant should be checked for ear infection if: Repeatedly shakes head rub and pull at one ear Older children Can express and describe pain General symptoms: Fever: high if the infection has gone too bad Irritability Decreased activity Lack of appetite Hearing impairment Vomiting or diarrhea Diagnosis Examined w/ otoscope reveals bright red, bulging eardrum Infant - pull ear down and back to straighten ear canal Older child - ear pulled up and back Spontaneous rupture may occur Purulent drainage present → culture → appropriate antibiotic Pain caused by pressure build-up will be relieved Treatment and Nursing Care Antibiotics are used during period of infection and several days after to prevent mastoiditis or chronic infection Amoxicillin most common treatment 10-day course Chronic cases - prophylactic course of oral penicillin or sulfonamide Analgesics and antipyretics Used to control pain, discomfort, and fever Chronic cases Prophylactic course of oral penicillin or sulfonamide Myringotomy - incision of the eardrum Performed to establish drainage and to insert tiny tubes into tympanic membrane to facilitate drainage Tubes fall out spontaneously Complication Permanent hearing loss from frequent cases chronic Primary nursing responsibility: Reinforce teaching w/ family caregivers about prevention and care of child **Review Family Teaching Tips: Otitis Media, pg. 716** The eustachian tube is a connection between the nasal passages and the middle ear. The eustachian tube is wider, shorter, and straighter in the infant, allowing organisms from respiratory infections to travel into the middle ear to cause infection (otitis media). Prevention • Hold infant in an upright position or with head slightly elevated while feeding to prevent formula from draining into the middle ear through the wide eustachian tube. • Never prop a bottle. • Do not give infant a bottle in bed. This allows fluid to pool in the middle ear, encouraging organisms to grow. • Protect child from exposure to others with upper respiratory infections. • Protect child from passive smoke; don't permit smoking in child's presence. • Remove sources of allergies from the home. • Observe for clues to ear infection: shaking head, rubbing or pulling at ears, and fever combined with restlessness or screaming and crying. • Be alert to signs of hearing difficulty in toddlers and preschoolers. This may be the first sign of an ear infection. • Teach toddler or preschooler gentle nose blowing. Care of the Child with Otitis Media • Have a child with upper respiratory infection who shows symptoms of ear discomfort checked by a healthcare professional. • Complete the entire amount of antibiotic prescribed, even if the child seems better before the prescription is complete. • Use heat (such as a heating pad on low setting) to provide comfort, but an adult must stay with the child. • Soothe, rock, and comfort the child to help relieve discomfort. The child is more comfortable sleeping on the side of the infected ear. • Give pain medications (such as acetaminophen) as directed. Never give aspirin. • Give medications such as acetaminophen or ibuprofen (to the child older than 6 months) to control fever. • Provide liquid or soft foods; chewing causes pain. • Know that hearing loss may last up to 6 months after infection. • Schedule follow-up with a hearing test as advised.

SCHOOL AGE accident and prevention

Accidents are leading cause of death School-age children do not require constant supervision Must learn certain safety rules and practice them until routine Children should be taught: To know their full name, caregivers' names, home address and telephone number Appropriate ways to call 911

Seizures Acute or Non-recurrent Seizures (Febrile)

Seizures may be a symptom of a wide variety of disorders Febrile seizures most common between 6 months and 3years Occur in form of generalized seizure early in course of fever Commonly associated w/ high fever 102°-106°F Often one of the initial symptoms of acute infection Less common causes of convulsions: Intracranial infections Meningitis Toxic reactions to drugs or minerals Lead, metabolic disorders, various brain disorders Clinical Manifestations and Diagnosis Can occur suddenly without warning Restlessness and irritability may precede episode Symptoms: Body stiffens and child loses consciousness → in a few seconds, clonic movements occur Quick, jerking movements of arms, legs, and facial muscles Breathing irregular and child cannot swallow saliva Symptoms prompt immediate treatment; further evaluation is made after the urgency of the seizure as passed Treatment Primary concern = Emergency care to protect the child during seizure If seizure activity continues Diazepam or lorazepam may be administered IV Acetaminophen administered to decrease fever **Review Nursing Process for a Child at Risk for Seizures, pg. 717-718** Assessment (Data Collection) Outcome Identification and Planning Implementation Preventing Aspiration Promoting Safety Promoting Family Coping Providing Family Teaching Evaluation: Goals and Expected Outcomes

NAS: Neonatal abstinence syndrome

v Newborn of Mother Dependent on Illicit Drugs v The newborn of a mother who is dependent on illicit drugs may experience withdrawal symptoms. v These include tremors, restlessness, hyperactivity, disorganized or hyperactive reflexes, increased muscle tone, sneezing, tachypnea, vomiting, diarrhea, disturbed sleep patterns, and a shrill high-pitched cry. v Ineffective sucking and swallowing reflexes create feeding problems. v Nursing care for the newborn focuses on providing physical and emotional support. v Neonatal Abstinence Syndrome (NAS) v Term used to describe a set of behaviors exhibited by an infant exposed to chemical substances in utero. v Repeated intrauterine absorption of drugs from maternal bloodstream causing fetal drug dependency v Degree of drug withdrawal depends on type and duration of addiction and maternal drug levels after delivery v Clinical Manifestations Poor feeding, vomiting, regurgitation, diarrhea excessive sucking Irritability, tremors, shrill cry, little sleep, convulsions Sneezing and hypereflexes Metabolic, vasomotor, respiratory o Nasal congestion, sweating, tachypnea, frequent yawning, RR > 60, T > 37.2 C o Nursing care of NAS newborn § Neonatal abstinence scoring (Finnegan) · Score infant every 3-4 hours, corresponding to the frequency of feedings · Behaviors should be assessed throughout the 3-4 hours interval · Score all that apply § Nonpharmacological interventions first · Swaddling · Pacifier · Soothing voice § Treatment of withdrawal with medications possible if scoring 8 or above § Effective dose maintained for 3-5 days and then tapering can begin. § Scoring continues and tapering should only occur if there is not a marked increase in the score § Taper medication by 10% every 1-2 days as tolerated § Monitoring VS and pulse oximetry § Small frequent feedings v Nonpharmacological interventions first § Positioning on the right side-lying or semi-Fowler's § Monitoring frequency of diarrhea and vomiting § Adequate nutrition and hydration § Swaddle newborn with arms flexed and hands close to mouth § Keep head elevated to reduce risk of aspiration § Cluster nursing care to reduce exogenous stimulation § Place newborn in quiet, dimly lighted area of the nursery § Pacifier use v Administration of medications · Phenobarbital · Morphine/Methadone · Chlorpromazine · Diazepam · Clonidine

Elements of Contraction

Primary (involuntary) force is uterine muscular contractions Responsible for effacement and dilation of cervix Includes frequency, duration, and intensity. Counting and measuring with monitors and mom should be counting and measuring as well. The primary force of labor comes from involuntary muscular contractions of the uterus. These labor contractions cause effacement and dilation of the cervix during the first stage of labor. The increment, or building up of the contraction, is the longest phase. During the increment, the contraction gains strength until it reaches the acme, or peak, of the contraction. The decrement is the letting-up phase, as the uterus relaxes gradually to baseline. Contractions are documented using three descriptors: frequency, duration, and intensity. Intensity is recorded as mild, moderate, or strong and can be estimated by palpating the fundus at the peak of the contraction. Intensity can also be measured directly with an intrauterine pressure transducer. Relaxation is also necessary so that maternal muscles do not become overly fatigued and allows the laboring woman momentary relief from the discomfort of labor. Secondary (voluntary) force is the use of abdominal muscles during the second stage of labor: When you start pushing, it does not have any effect on cervical dilation. It must already be dilated. Must remind mom not push before dilated and effacement is thin or it could cause swelling to the uterus. Do not push until effacement and cervix are completely dilated. Bearing down No effect on cervical dilation The cervix begins to get shorter and thinner, a process called effacement Cervical effacement is recorded as a percentage at 1cm the cervix is 50% effaced. When completely effaced the cervix is paper-thin and is 100% effaced. Cervix is completely dilated when it measures 10cm First-time moms effacement happens before dilation for multiple moms it happens at the same time First-time moms are more resistant than moms with multiple births Phases of uterine contractions: OB QUIZ Increment: Beginning Acme: Peak Decrement: End Period of relaxation

Infant

Gross motor: 2mo: moves head from side to side, tract eyes, make verbal noses, smile 6wks: Can turn head from side to side when lying prone 2-3mo: No longer has moro reflex 3mo: plays with hands, balances head and body for short periods in sitting position 4mo: able to sit, can roll over and roll to abdomen 8mo: sits alone in high chair, rolls over from abdomen 2mo: can lift head up when in supine position 7mo: crawls around 1yr: stands alone; begins to walk can change from prone to sitting Fine motor: 4wks: Hands flexed 6wks: Hands open 2mo: No longer has grasp reflex 3mo: grasp obj. with 2 hands: eye hold coordination beginning 5mo: Holds a bottle 6mo: Holds a cup, transfer obj. with 2 hands 9mo: plantar grasp lesson and pincer grasp develops 1 yr: stack blocks, hold crayon to scrible on paper

TOF Tetralogy of Fallot (TOF)PICMONIC

Group of heart defects Allows a shunt of unsaturated blood from right ventricle into aorta or into left ventricle Usually fatal Four anomalies present: Pulmonary stenosis: usually seen as a narrowing of the upper portion of the right ventricle and may include stenosis of the valve cusps. Overriding aorta Right ventricular hypertrophy Ventricular septal defect causes pulmonary stenosis Tetralogy of Fallot (TOF) Most common to cause cyanosis Symptoms: Tetralogy of Fallot is the most common defect causing cyanosis in clients surviving beyond 2 years of age. Cyanosis at birth - progressive over 1st year of life Cyanotic stage starting at 4- 6months of age Systolic murmur Feeding difficulties and poor weight gain → retarded G&D Dyspnea and easily fatigued: breathlessness, and increased cyanosis Hypercyanotic or "Tet" Spells: Paroxysmal dyspnea, restlessness, gasping respirations, and increased cyanosis that lead to a loss of consciousness and possibly convulsions Last for several minutes to hours Exercise tolerance depends on severity of defect/disease Child may assume a squatting position for relief of symptoms Squatting rarely seen today b/c newborns' defects usually repaired by 2 years of age Place infant in knee chest position if having a tet spell Tetralogy of Fallot (TOF) Management: Cardiac cath, EKG, chest radiography, and labs determine polycythemia and arterial oxygen saturation Small frequent feedings will help Total surgical correction is preferred Teach parents to minimize hypercyanotic episodes during waiting time Place infant in knee to chest position to reduce symptoms

Psycho social Autism Autism

Abnormal or impaired social interaction or communication. Self absorb and unable to relate to other and exhibit patterns and behaviors 4 times more common in male Abnormal brain development Clinical manifestations: Present in second year of life or earlier Imapired verbal and non verbal communication Delays and deviation in their language development Impaired emotion and social exchanges and relationship with others Restrictive and repetitive behaviors pattern ex: rocking, twirling, flapping and twirling their hands, walking on tippy toes. Can be a way of coping or when their out of their comfort environment Self injurious behavior: Head banging Bitting Slapping Inflexible with routine deviation form routine can cause agitation Slow to develop speech; permanent in inability to speak to others Echolalia: Parrot speech repeats the same phrase and same words common in more severe cases Diagnostic; History Developmental milestones Neuro assessments Observation of behaviors Physical and neurological exam Prenatal, Natal, and Postnatal history Development, nutrition, and family dynamics Diagnostic tools to detect abnormalities: Social interaction and communication Repetitive patterns and behaviors Interest and activities Stuck on one top or interest and that's all they want to do There is no cure goal is to have the child at the highest level of functioning for them AAP recommends structure, direction, and organization for the child Treatment: Behavioral or educational interventions which are individualized and highly structured ABA helps with behavioral and social communication and how to cope with routine changes Early intervention is important Pharmacological Interventions: Treats medical and psych complications Ex: hyperactivity, attention deficit, aggression, anxiety, depression Families should understand what is needed and therapy can help work through behaviors Nursing care: Creates stress for entire family Families are a valuable source of information that can tell habits, communication skills, techniques that help communicate with children. Helps establish trust with the child Try to have consistent caregivers and providers Private or semi private room Visual and auditory stimulation should be minimize some may have sensitivity to lights or noises Keep familiar toys and valued objects to help reduce anxiety May have strange attachments to objects you may not think of ex: pencil, pen, shoe string, or shoe.

Hemophilia

Hemophilia Most common in male Usually treated with fresh blood or plasma newer DDAVP Nursing care: focus on stopping the bleeding, decreasing pain, increasing mobility, and preventing injury Work with the caregiver to increase knowledge about the child condition and care and to help the family learn to cope Inherited disorders of blood Result in decrease coagulation of blood Defects in protein synthesis lead to deficiencies in any of the factors in the blood plasma needed for thromboplastic activity Mechanism of Clot Formation Simplified mechanism of clot formation Prothrombin formed through plasma-platelet interaction Prothrombin is converted to thrombin Fibrinogen is converted into fibrin by thrombin A deficiency in one of the thromboplastin precursors may lead to hemophilia Hemophilia's Common Types of Hemophilia Two most common types of hemophilia are factor VII deficiency and factor IX deficiency Factor VIII Deficiency/Hemophilia A "Classic hemophilia" X-linked recessive trait Females may carrier Pathophysiology Deficiency of factor VIII (antihemophilic factor (AHF) The less AFH found in the blood, the more severe the disease Will bleed and not clot Therefore, they bleed for _____________, but not at a _______________ Hemophilia's Factor IX Deficiency/Hemophilia B Christmas disease X-linked recessive trait Females may be carriers Accounts for 15% of cases of hemophilia Deficiency of one of the necessary thromboplastin precursors: factor IX (plasma thromboplastin component) Hemophilia's Clinical Manifestations Characterized by prolonged bleeding w/ frequent hemorrhages externally and into the skin, joint spaces, and intramuscular tissues Infant w/ hemophilia who begins to creep or walk bruises easily Serious hemorrhages may result from minor lacerations Bleeding often occurs from lip biting or from sharp objects put in mouth Family caregivers must avoid overprotecting the child Preschoolers are active and play hard and injuries are practically unavoidable Hemophilia's Diagnosis Careful examination of family history and type of bleeding present Prolong bleeding time is characteristic finding Partial thromboplastin time (PTT) Treatment Administration of vasopressin Fresh whole blood Fresh or frozen plasma Concentrate of factor VIII Supplied as a powder form that can be reconstituted as needed Hemophilia's Hemophilia's Administration of Desmopressin (DDAVP) Stimulates the of factor VIII, to help prevent contious bleeding **Review Nursing Process for the Child with Hemophilia, pg. 778-780** Assessment (Data Collection) Outcome Identification and Planning Implementation Relieving Pain Preventing Joint Contractures Preventing Injury Providing Family Teaching Promoting Family Coping Evaluation: Goals and Expected Outcomes

Heat loss

The newborn has poor thermoregulation because he or she is prone to heat loss through the skin and because he or she cannot produce heat through muscle movement and shivering. Heat is lost through the processes of convection, conduction, evaporation, and radiation. The newborn conserves heat by maintaining a flexed position and produces heat by metabolizing brown fat. If left untreated, cold stress can lead to hypoglycemia, respiratory distress, acidosis, and even death. Heat Loss Convection- When air currents blow over the newborn' Conduction-occurs when the newborn's skin touches a cold surface, Evaporation- heat loss happens when the newborn's skin is wet. Radiation -to a cold object that is close to but not touching the newborn Physiologic Adaptation #4 The newborn's immature liver may not be able to handle the heavy load from the breakdown of red blood cells, and physiologic jaundice appears. This condition is harmless if bilirubin levels do not rise dramatically and if jaundice is not present before the newborn is 24 hours old. Nutrient rich blood circulates through liver Jaundice Bilirubin (a yellow-colored pigment) is released as the red blood cells are broken down. Normally the liver conjugates bilirubin (i.e., makes it water soluble), and then bilirubin is excreted in the feces The unconjugated bilirubin, which is fat soluble, builds up in the bloodstream, Physiologic jaundice is characterized by jaundice that occurs after the first 24 hours of life (usually on days 2 or 3 after birth); bilirubin levels that peak between days 3 and 5; and bilirubin levels that do not rise rapidly (no greater than 5 mg/dL/day). Physiologic Adaptation #5 Not all of the necessary blood coagulation factors are manufactured directly after birth, and the gut is sterile, so vitamin K is given intramuscularly to stimulate appropriate clotting. Physiologic Adaptation #6 Newborn hypoglycemia is a blood glucose level less than 50 mg/dL. Newborns can be asymptomatic or may demonstrate multiple signs. The most common sign is jitteriness, poor feeding, listlessness, irritability, low temperature, weak or high-pitched cry Glucose is essential for brain tissue Risk Factors for Hypoglycemia Gestational hypertension • Maternal diabetes (pre-existing or gestational) • Prolonged labor • Fetal distress during labor • Ritodrine or terbutaline administered to mother Newborn characteristics that increase the risk for hypoglycemia. Note that many of these conditions result from an at-risk pregnancy. • Intrauterine growth restriction • Macrosomia (a very large baby) • Large for gestational age • Small for gestational age • Prematurity • Post maturity • Hypothermia (cold stress) • Respiratory or cardiovascular depression requiring resuscitation • Infection

Croup Syndromes LTB Croup

1yr-5yrs Unknown cause Infection or allergen Can be severe Runny nose and hoarseness precede Awake after 2-3 hr sleep Bark like cough Increase respiratory distress and stridor Anxious, restless and increased hoarseness Low grade fever Croup Treatment Take to bathroom shut door and turn on hot shower Hospital or Doctor Hospital prolonged stridor Use of accessory muscle Lower lung retraction Restlessness, pallor, increased respirations Acute Laryngotracheobronchitis Acute laryngotracheobronchitis is often caused by the staphylococcal bacterium. The child may become hoarse and have a barking cough and elevated temperature 104-105 Breathing difficulty, a rapid pulse, and cyanosis may occur. Late sign Antibiotics are given and the child is placed in a mist tent with oxygen. Someone must be with them Progresses rapidly Toddlers Marked laryngeal edema Heart failure and acute resp.dist Treatment of Acute Laryngotracheobronchitis IV antibiotics Oxygen mist tent Racemic Epinephrine Bronchodilators Close monitoring for 3-4 hrs Rapid relief Cause vasoconstriction: bronchodilators Intubate if severe Nasotracheal tube Monitor HR, RR, O2 sat, color, stridor, color

Asthma Asthma #1

Asthma Asthma #1 An attack can be triggered by a hypersensitive response to allergens; foods such as chocolate, milk, eggs, nuts, and grains; exercise; or exposure to cold or irritants such as wood-burning stoves, cigarette smoke, dust, and pet dander. Infections, stress, exercise, cold air or anxiety can also trigger an asthma attack. During an asthma attack, the combination of smooth muscle spasms, which cause the lumina of the bronchi and bronchioles to narrow; edema; and increased mucus production cause respiratory obstruction. Asthma Spasm of bronchial tubes Spasms cause luminal of bronchi to narrow Edema and thick mucus 8.5 % of children in USA Intermittent or chronic Affects school attendance Poor confidence Dependency Cause resp. Obstruct Dry hacking cough Wheezing expiratory Asthma Occur at night and awaken child Tripod to breath Short time or several days Thick mucus cough or vomited Can go away after puberty Wheezes generalized over lungs Asthma treatment Peak flow meter Measure obstruction Bronchodilators Corticosteroids-short term anti inflammatory Leukotriene- decreased edema Mast cell stabilizers-prevent mast cell- taste bad Chest Physiotherapy-breathing exercises Build self confidence Increase respiratory function- use in play to make fun Continued treatment Monitor frequently over 1-2 hours Lung sounds Fluid intake or/ IV Tripoding O2 saturation Elevate HOB Watch for nasal flaring Retractions Respond quick to prevent anxiety Patient/family education Asthma #2 NRSG: Ineffective airway clearance The goals of asthma treatment include preventing symptoms, maintaining nearly normal lung function and activity levels, preventing recurring exacerbations and hospitalizations, and providing the best medication treatment with the fewest adverse effects. Nursing care is focused on maintaining a clear airway, maintaining an adequate fluid intake, and relieving fatigue and anxiety. Asthma Assessment PMH, meds, meds taken recently Vomiting affect absorption of meds Respiratory infection- allergens-pets Complete VSS Cyanosis is a late sign

Sexual Abuse

Sexual Sexual Abuse Sexual Contact- between a child and another person in a caregiving position Parent Babysitter Teacher Sexual Assault - sexual contact made by someone who is not functioning in a caregiver role When a person has a power or control over a child, that person, even if a child as well, can be a sexual abuser Occurs in all cultures, races, and religions Abuser is typically a trusted male adult and incest is common Contributing factors: Substance abuse Job loss Poverty Types of sexual contact includes: Fondling of breasts or genitalia Intercourse - vaginal or anal Oral-genital contact Exhibitionism Voyeurism When a child is sexually assaulted by a stranger, family caregiver usually becomes aware of incident, promptly reports it, and takes child for physical exam In cases of incest: Child rarely tells another person what is happening Family member committing the acts often intimidates the child w/ threats Appeals to the child's desire to be loved and to please Convinces the child of the importance of keeping the act secret Physical complaints exhibited by the child: Various aches and pains Gastrointestinal upset Changes in bowel and bladder habits (including enuresis): Bedwetting Nightmares Acts of aggression or hostility Outcome of the abuse is devastating Sexual abuse by a person the child trust seems to be most damaging