N412 final exam

UPPER AIRWAY: Laryngotracheobronchitis = Croup signs/sx

"Cold" (snot, runny nose) progressing to hoarseness, cough then develops to stridor Low grade fever Night-time increase in edema with: - Stridor - "Seal bark" cough - Respiratory distress - Cyanosis Recurs on several nights; less severe each night

Proximodistal

"inside-to-outside rule" motor skills emerge in a sequence of center moving outward. from the center outward An infant will keep all his limbs tightly flexed into their center. Then, he will start moving arms outward then up and down. Next, their fisted hands will open and start moving fingers to pick stuff up. He will just pick up things with entire fist. Then, he will use three fingers and a thumb then two fingers and a thumb then one finger and a thumb (pincher grasp) to pick up things.

the nose

#1 cause of upper airway obstruction is tongue Nose is responsible for 50% of total airway resistance at all ages Infant: blockage of nose = respiratory distress

Figure 22.2 : Developmetal Dysplasia of the Hip: Assessment of techniques

(A) Assess for asymmetry of thigh and gluteal folds. (B) Assess for unequal knee height related to femur shortening. (C) Note limitation in hip abduction. (D) Positive Trendelenburg sign: note pelvis/hip drops when leg is raised. (E) Feel for "clunk" when adduction and depression of femur dislocates hip (Barlow test). Assess for "clunk" when the dislocated hip is abducted and relocated (Ortolani sign).

Muscular dystrophy: the Gower sign

(A) First the child must roll onto his hands and knees. (B) Then he must bear weight by using his hands to support some of his weight, while raising his posterior. (C-E) The boy then uses his hands to "walk" up his legs to assume an upright position

Anticipatory guidance

*Anticipate emerging issues that a child and family may face *Timely, appropriate, & relevant *Attend to the concerns of the parents or caregiver *Organized by the priorities of the visit BF Pocket Guide https://brightfutures.aap.org/families/Pages/Resources-for-Families.aspx

Screening

*Developmental Screens: Denver II (parts are done at each visit), Observation and Parental Reports *Blood tests: Lead, Hgb/Hct, lipids, cholesterol *Vision Screening *Hearing Screening *Depression Screens: (at around 10-11) *Autism Screens *BMI

CONTRAINDICATIONS

*Due to the benefits of vaccinations typically outweighing the risks, there are very few contraindications for childhood vaccinations. 1.Any history of severe allergic reaction (anaphylaxis = seizures, SOB) to prior vaccine dose. Refer to allergists on what to do at that point. 2.Severe immunodeficiency patients should not receive live vaccinations. 3.Egg allergy is no longer contraindicated for the MMR. 4.There are new protocols for egg allergic patients and the influenza vaccine. This has made it possible for the majority of egg allergy patients tolerate the flu vaccine.

15.4 (Theories): Table

*Erickson: psychosocial = trust vs mistrust. Infants learn to rely on caregivers; their basic needs are met* *Piaget: cognitive = sensorimotor. Infants learn about the world through sensations* Freud: psychosocial = oral motor. The infant is focused on oral sensations for pleasure such as sucking and feeding.

Toddler(1 to 3 years)

*Erikson: Autonomy vs. Shame and Doubt - Toilet training *Piaget: Sensorimotor stage (ends); Preoperational stage (begins) - Object permanence is well developed *Rate of growth slows: potbelly bc of underdeveloped of abdominal muscles. *Gross motor activity rapidly develops: kick a ball, scribble, and paint *Social development, parallel play *Safety

Adolescent(12 to 18 years)

*Erikson: Identity vs. Role Confusion *Piaget: Formal operational stage (11 years old through adulthood) *Kohlberg: May progress to Postconventional *Domains of adolescent development *Rapidly changing body, great variability *Puberty—Tanner staging *Change in interview and education *Emotional well being *Safety & risk reduction

School-Age(6 to 12 years)

*Erikson: Industry vs. Inferiority *Piaget: Preoperational (ends); Concrete operational (begins around age 7 years) *Kohlberg: Moving into conventional stage *Meaningful activities in the company of peers *Physical growth and development *Permanent teeth erupt *Cooperative play: organized sports *School *Safety

Preschool (3 to 6 years)

*Erikson: Initiative vs. Guilt *Piaget: Preoperational stage progresses *Kohlberg: Preconventional stage begins (decisions based on pleasing others and avoiding punishment) *Slow & steady growth, shape changes *Physical skills continue to develop *Language skills are well developed *Associative play—more interactive (house, unicorns, dragons) *Safety

Adolescent (12-18) = Table: 19.4(Theories)

*Erikson: Psychosocial* Identity vs. role confusion Is self-conscious about the changing body in early adolescence Is concerned with attractiveness in middle adolescence Has a more stable body image in late adolescence Is forming identity in late adolescence *Piaget: Cognitive* Formal operational Develops abstract thought in early-to-middle adolescence Feels invulnerable during middle adolescence Develops better impulse control by late adolescence Can see others' perspectives Freud: Psychosexual Genital Experiments sexually Settles into relationships *Kohler: Moral* Postconventional Understands that morally right and legally right are not always the same Establishes own set of morals, which may be different from those of the family

School Age (6-12): Table: 18.3 (Theories)

*Erikson: Psychosocial* Industry vs. inferiority Is learning to do more things on own Develops confidence in ability to achieve goals Develops competence Likes to understand how things work *Piaget: Cognitive* Concrete operational Thinks about things in a logical and concrete manner Can put items in a sequential order Learns about objects through manipulation Understands the concept of reversibility Understands the concept of conservation Understands the concept of time Freud: Psychosexual Latent Focuses more on relationships with same-sex peers *Kohler: Moral* Conventional Follows rules Takes societal law into perspective Begins to see things from different perspectives

Preschoolers: 17.1 (Theories) Table

*Erikson: Psychosocial* Initiative vs. Guilt Plans and initiates activities Wants to please parents Asserts self more frequently Makes up games *Piaget: Cognitive* Preoperational Focus on only one aspect of things Imaginary play Magical thinking Knows right from wrong Egocentrism lessens around 4 y of age Animism lessens around 5 y of age Uses transductive reasoning Freud: Psychosexual Phallic Genitals become an area of interest Identifies more with the parents of the same sex Kohler: Moral Preconventional Learns good from bad based on punishment

Infant (1 month-1 year)

*Erikson: Trust vs. Mistrust *Piaget: Sensorimotor - Object permanence *Health promotion visits: 1, 2, 4, 6, & 9 months *Rapid change! *Lots of immunizations at these visits *Nutrition *Safety

16.1 (Theories) Table: Toddlers

*Erikson: pyschosocial = autonomy vs shame and doubt. Toddlers learn to do some things on their own and make choices* *Piaget: Cognitive = sensorimotor (up to age 2) and preoperational (2+)*. *Toddlers manipulate objects to learn and imitate others*. Freud: Psychossexual = anal. The toddler is focused on when and where to defecate. Stool holding is common during toilet training. Kohler: moral = preconventional. Toddler is learning obedience

Other Considerations

*Failure to thrive: inability to grow despite being fed properly; typically a GI issue *NAS - neonatal abstinence syndrome: a group of conditions caused when a baby withdraws from certain drugs he's exposed to in the womb before birth (opioid issues) *Sensory issues: autism *Gender *Chronic illness: CF, DM, cerebral palsy, mental health - home environment, esp with pandemic HEALTHY PEOPLE 2020 Objective=Increase the proportion of children and youth with disabilities who spend at least 80% of their time in regular education programs Nursing Significance Ensure that children younger than age 3 years who may qualify are referred to the local early intervention program. Encourage families to advocate for their child's needs on the individualized education plan.

Components of HP Visit

*General observation - parents usually talk first then kids *Growth & development surveillance - walking, running, learning *Nutrition - breastfeed or what kind of formula. *Physical activity *Oral health - babies without teeth should still have oral care *Mental/spiritual health *Relationships *Disease prevention strategies - handwashing esp with daycare, vaccines *Safety/injury prevention

Surveillance

*Growth Charts: show height and weight for growth curve percentiles *Developmental History *Parental Observations Ongoing assessment, collection of data overtime Head circumference measured regularly until age 2 since fontanels and sutures should be closed by 18mos Be sure to make accurate observations and measurements F/u on previous concerns or delays Keep family history, birth history and environmental issues in mind that may put the child at risk for delays or illness

Monro-Kellie Doctrine

*If one component (CSF, blood, brain tissue) increases, another must decrease to maintain ICP (CSF, blood, brain tissue)* Intracranial vault is incompressible and hold a fixed volume of brain of CSF and blood. ex: A mass appears which decreases CSF and blood OR decrease brain tissue. Decrease in blood decreases oxygen which leads to increased ICP.

*Health supervision

*Measurements: height, weight, HC *History *Surveillance of development: where they are *Review of systems *Observation of parent/child interaction: esp important in infant and teenager stage (is teenager answering alone) *Physical examination *Screening *Immunizations

Pediatric Assessment

*Must be flexible & creative *Developmental approach: where you expect them to be - most of the time, a head to toe assessment will be difficult with infants - school age so it will be more of a developmental approach and what they are comfortable with. -least invasive to most invasive (ears, mouth, and eyes)

Primary vs Secondary HTN

*Primary HTN -unknown etiology -RF = age, race (higher in africans, lower in Asians), obesity, stress, lack of physical activity, high-salt diet - less common in children *Secondary HTN -due to identifiable cause -one ex = renal artery stenosis -inc plasma renin (Ang II = inc resistance via direct contraction of smooth muscle in vessel + promotes adrenal release of aldosterone - which inc resorption of sodium) - OSA; increased hormones - more common in kids, usually obese

Health Supervision

*Priorities help you make the most of your time with the family - Address any concerns of the parent/family first (smokers, vaccination, really comes into play with primary care) - Age-based priorities next Anticipatory Guidance *Age-based, common things parents need to know at that age. - talk to parents what will be coming up

Health Supervision

*Screening *Surveillance *Prevention *Promotion

lumbar puncture nursing care

*infant & toddler: nurse or parent hold infant in an upright sitting position. infant's head rests on the person's shoulder* *older child: nurse or parent lays child on side* - if increased ICP is suspected, lumbar puncture should NOT be performed as this could cause herniation of the brain

Fontanel/suture lines

- *only applicable to infants*; the more hair, the less you will be able to see dilated scalp veins - easy to access problems with ICP - *bulging fontanel* = increased ICP - wide sutures = increased ICP can feel and see indentation in between skull bones - dilated scalp veins = increased ICP Increased ICP makes babies irritable and inconsolable with a high-pitched cat-like cry (See with NAS babies too), a neurological cry bc of agitated neuro system

Kawasaki: convaslescent phase

- 6-8 weeks after onset - can last up to a year - basically normal but may have lingering effects - affected areas in vessel begin to scar then calcify affecting future of child's heart - beau's lines on nails indicates a time of growth arrest associated with kawasaki

When to refer HTN kids for intervention:

- >95% for GAH on 3 diff occasions (same time and cuff) - > 90% for GAH x 3 and has one or more risk factors of CV disease (Risks: obesity, DM, increased lipids, and/or fam hx of stroke, coronary heart disease) -inconsistent BP readings

Rheumatic fever

- A bacterial infection that can be carried in the blood to the joints; can develop from Strept throat or Scarlet fever! - takes 1-5 weeks to develop after infection; not contagious - most common in 5 - 15 years olds - Rheumatic fever once = more likely to develop again

Live vaccines

- ALL INJECTABLE LIVE VACCINES MUST BE GIVEN SUBCUTANEOUSLY, everything else is IM - MMR - Varicella - Rotavirus (given orally) Nasal form of influenza vaccine is live but it can be given nasally.

Acute Epiglottitis S & S: clinical manifestations

- Abrupt onset of a fever & sore throat (worst sore throat)~ progresses to respiratory distress and stridors - Predictive symptoms: absence of cough, presence of drooling & agitation - Tripod position with chin thrust, mouth open, and tongue protruding - Froglike croak on inspiration - Retractions may be present. Protrusion of epiglottis may be seen.

pneumothorax

- Accumulation of extrapulmonary air within the chest - May be primary (just happened, more common) or secondary (something caused it) - May be spontaeneous, traumatic, or iatrogenic - Onset is usually abrupt and severity of symptoms depends on the extent

Community setting of peds

- Acute care - Primary care - Home health - Palliative care

Kawasaki facts

- Acute systemic inflammatory illness - most common cause of acquired heart disease in children - etiology unknown, but frequently preceded by respiratory tract infection -causes widespread systemic vasculitis - self-limiting inflammatory response to a respiratory tract infection - usually kids < 5 years of age - may have genetic component, usually Japanese - prompt treatments decreases incidence of CV damage

Mild dehydration (up to 5%)

- Alert, soft and flat fontanels, normal eyes, pink and moist oral mucosa, elastic skin - normal HR, BP - warm/pink extremities, brisk capillary refill - slightly decreased UOP

X-linked inheritance

- Altered gene is on the X chromosome - pattern of maternal transmission - Female carriers have a 50% chance of passing the altered gene to their child - A daughter who receives will most likely be unaffected (she has an unaltered gene from the father) - A son who inherits the effected X chromosome will display the condition and pass the altered to his daughters (but not his sons) •Examples: Hemophilia A, Duchenne Muscular Dystrophy •Y-linked disorders are not often associated with health problems because the Y chromosome has very few genes.

Bronchiolitis/RSV pt 2: characterizations, communicability, medication, dx

- Annual epidemic from winter to early spring - Highly communicable - Head cold to adults - Synagis given to those at high risk until age 2 - Diagnosed through nasal swab

urticaria tx

- Avoid any known triggers. Educate fam, teachers, and babysitters if food allergy - Oral Antihistamines: 2 types: histamine I = nasal and eye symptoms (claritin, benadryl) and histamine II = helps stomach acid (pepcid). use both blockers to help hives. for emergency, PO or IV benadryl and IV pepcid. Daily antihistamines for chronic urticaria till response is turned off. - Oral Corticosteroids: for emergencies - Avoid hot baths: bc of blood vessel dilation - May require allergen skin testing and evaluation

Chronic Asthma: Management

- B-agonist prn (Albuterol or Xopenex) = rescue medicine - Trigger Avoidance: avoid allergies go to allergist Daily controller meds - Inhaled Corticosteroids -USED ON MOST - Leukotriene Modifiers (Singulair) -USED ON SOME - Steroid-Long Acting B-Agonist Combo for more severe symptoms - Stepped Approach based on Symptoms

Asthma dx

- Based on Hx of recurrent problems - Pulmonary Function Tests (PFT's): use a spirometer to determine airway functioning ability, >6yrs; completed @ initial assessment of asthma, after tx is initiated, then every 1-2yrs for maintenance - Can do Methacholine challenge if unsure of Dx: breathe in powder and lung tests worsen - Peak Expiratory Flow Rate (PEFR): measures max amt of air expelled in 1 second Skin tests: for pts with yr round asthma symptoms

burns

- Burns are 1 of the top 5 leading causes of injury-related deaths among children 1-14 years of age. - 10-25% of all burns in children are due to abuse

secondary lesions

- Burrow - Comedone - Crusting - Erosion - Excoriaton - Fissure - Keloid - Lichenification - Scale - Scar - Ulcer - Telangiectasia

MOLLUSCUM CONTAGIOSUM

- Caused by pox virus. Common with kids with atopic dermatitis from broken skin. - Spread by direct skin contact (including sexual contact) and contact with contaminated clothing, towels etc (can spread through pools too!) - Pearl like or flesh colored papules 1-5 mm in size. Painless!! Lesions will be umbilicated (dip) and can develop cheesy white discharge. - Found on trunk, axillae, antecubital and popliteal fossae - Self resolve within 6 mos!! but can reoccur for 2-4 years - No treatment typically necessary unless secondary infection ocurrs d/t excoriation (oral/topical antibiotics) - For severe infection = cryotherapy or cantharidin (blistering agent to open it and blister it to heal) can be used - Educate importance of decreasing transmission.

Who do you suspect for dylipidemia?

- Child >2 years - Parent has total cholesterol > 240 - fam hx of CV disease in <55 year old - fam hx unavailable

ACNE LESIONS

- Closed comedone: Whiteheads - Open comedone: Blackheads - Nodules: Inflammation of several hair follicles (more severe sign) - Cysts: Compressible nodules without overlying inflammation (more severe sign) - papules - pustules type of lesion and how many determines dx and tx

Aspirated Foreign Body assessment

- Complete obstruction will present as apnea - Partial obstruction may present as cough, labored breathing, retractions, and cyanosis - Objects can lodge in the lower or upper airways depending on size - Object may act as one-way valve allowing air in, but not out

Dyslipidemia in children

- Detection: look at carotid arteries for plaque; genetic hx = primary. Secondary assessment: lifestyle problems (obesity, DM, and hypothyroidism) = secondary - Screening - Early intervention: begins at home; change dinner and nutrition; modify dietary intake #1 cause = obesity. Just dietary modification can bring lipid levels down 15-20%

ATOPIC DERMATITIS MANAGEMENT

- Educate parents there is NO cure and the rash will reoccur. #1 Priority is to keep skin hydrated and well-lubricated at all times. will decrease flare ups - Avoid hot baths and avoid daily baths (bathing every other to every 3 days if possible). - Avoid soaps, lotions, detergents that smell pretty or look pretty (dyes/perfumes) - Apply emollient/barrier creams to damp skin after baths. Pat dry to keep water on skin after showers. major flare ups go away typically during puberty. eczema can come back with pregnancy or menopause.

ATOPIC DERMATITIS (eczema)

- Effects 20% of infants, children & teens - 60% of eczema is developed within the first year of life - Very pruritic, erythematous, papulovesicular lesions w/ exudate, crusting, & bleeding - Can be worsened by both allergic and non-allergic triggers. (high association with allergies) - Can be very disruptive of sleep d/t severe pruritus - Eczema starts on face then to extensor surfaces (elbow, knees) on infants; do not see in flexor (antecubital, behind knee) surfaces till after 2 years; diaper areas spare from eczema bc of good moistness -hypo or hyperpigmentation of the skin can occur bc of chronic eczema flare ups or from over use of corticosteroids

Apparent Life-Threatening Event (ALTE) (aka BRUE = brief resolved unexplained event)

- Episode of apnea accompanied by color change, limp muscle tone, cyanosis, or requiring vigorous intervention such as rescue breathing or vigorous stimulation (Shaking, clearing airway, etc.) - More common in 1wk to 8 wks of age- always before 6 mos in normal infant - Causes can be GERD (99% of cases), seizures, breath-holding, neuromuscular disorders, respiratory disorders, heart issues, obstruction, OSA, metabolic and endocrine issues, head trauma (screen abuse), virus (RSV) - Include abuse in differential (shaken baby = presents apnea from brain trauma) - Testing is determined based on symptoms reported - Tx: CA monitor, work-up and treatment of underlying cause

NURSING MANAGEMENT OF BURNS

- Fluid Replacement/Balance: most important. Rule of 9 = calculates percentage of burns but kids have big heads. 18% for kid head while adult head is only 9%. Kid leg is only 14% while adult leg is 18%. Genital and palms and soles = 1% each. Percentages determine amount of fluid needed - Support both emotional and nutritional: for child and fam. Abuse support. Guilt of fam. - Pain Management: worry about pain after fluid and emotions. Often dependent on surface area - Wound Care: 3rd degree = nerve damage; deeper = harder to heal.

urticaria (hives): common triggers

- Food: usually gone within 12-24 hours; BF mom diet may also affect infant - Medications - Insect bites - Latex - Less common-exercise, cold, pressure (tight socks, shoes, pants), heat, sun, - Viruses - Animal dander and other environmental allergens (usually not something they are touching, has to be inhaled or digested)

RF: infective agent

- Group A Beta hemolytic streptococci

Disorders of the pediatric CV system: Acquired

- HTN - dyslipidemia - rheumatic fever -kawasaki

Vaccine Preventable Diseases

- Hepatitis B - Rotavirus - Diphtheria - Tetanus - Pertussis - Polio - Haemophilus influenza type b - Streptococcus pneumonia -Influenza - measles - Mumps - Rubella - Varicella - Hepatitis A - Neisseria meningitis - HPV

scabies

- Highly contagious and Highly pruritic - Spread skin to skin contact and contact with contaminated objects (sheets, towels etc). Lice is more on hair but scabies is anywhere on skin - Cause erythematous burrows, linear pustules & papules mostly found on hands and feet (especially webbing of digits) - Treatment: Permethrin Cream - whole fam must be treated with the cream! leave cream on head to toe overnight and rinse off in morning. do tx for everyone again in a week - oral histamines can help with itching bc more severe itching than lice, itching lasts till 2nd week of tx

URTICARIA (hives)

- Hive lesions are erythematous, raised wheals, that are pruritic and evanescent (move from place to place). lesion is under skin so there is no fluid, come from inside out. - The lesions should blanch!!! wheal pattern!!! extremely itchy! will not leave mark! - Most episodes of hives in children are acute in nature and are found to be d/t a viral infection. Breakout after eating and disappear next day = food allergy - Chronic urticaria is classified as hive episodes that last or reoccur longer than 6 weeks. Not viral if past 6 weeks. Look for causes. Usually idiopathic in kids. - caused from dilation of vessels under skin from too much histamine released, thus evanescent feature - very rare to find exact cause = frustrating. will resolve mysteriously as well.

gallbladder disease: management

- IV fluids - NPO and gastric decompression - pain medications - antibiotics - cholecystectomy

Pancreatic insufficiency: deficiency in CF

- Impairs digestion and absorption of nutrients - Increased caloric needs: need 1 ½ times typical ADA recommendation of calories

contact dermatitis

- Inflammation of the skin secondary to direct contact with an irritant or allergen (does not mean they are allergic) - Caused by Topical Irritants and Allergens (soaps, lotions, detergents, perfume). (rash only where contact was). Nickel in jeans can trigger. Latex, neomycin, neosporin (ask MD if neosporin can be used!) - Can be mild erythematous areas to painful pruritic red swollen areas and can include vesicles with exudate if contact continues - Treatment includes removal and avoidance of trigger, oatmeal baths and lotions, antihistamines (can be paradoxical and make infants hyper), and topical/oral corticosteroids if severe (poison ivy, oak that can spread)

Obstructive Mechanisms of asthma

- Inflammatory response - Mucus production - Bronchial muscle contraction in response to foreign stimuli Air trapping- can't expire enough air due to airway resistance and narrowed lumens - Leads to hyperinflation, fatigue and eventual resp failure (resp acidosis)

Malrotation & volvulus: management/treatment and nursing care

- LADD procedure to restore blood flow (organs are banded to the correct place with LADD bands) - ostomy, while bowel heals, may be needed so necrotic bowel is removed - nursing care (NPO before hand, protect from infxn, monitor FE)

lesion patterns

- Linear- row or stripe (scabies, poison ivy) - Annular- ring shaped with central clearing (ringworm, target lesions with Lyme disease) - Herpetiform- clustered or grouped (herpes, chicken pox) - Reticulated- networked or lacelike (fifth disease)

impetigo

- MOST common bacterial skin infection in children - Highly contagious - *Causes characteristic: Honey-Colored Crusts* (from vesicle erupts with serous fluid) - Caused by Staph aureus &/or group A beta-hemolytic streptococcus - Most common with infants and up to age 5 years (bc they are more likely to touch everything) - Treatment includes: Mild infections→Topical antibiotics. More Severe or Larger Areas →Oral antibiotics - Educate parents: Keep lesions as clean as possible; hand hygiene for everyone; no sharing of clothes, towels etc.

Care of BPD

- Minimize length of mechanical ventilation and O2 administration - Once diagnosed, focus on symptomatic tx and good nutrition - Most will require prolonged O2 - Some require tracheostomy and home ventilation - Many babies go home on Oxygen - Need increased calories-consider g-tube feeds to support nutrition - Infection control/ no smoke exposure - Illness avoidance / Synagis - Possible bronchodilators, diuretics

ORAL CANDIDIASIS (Thrush)

- Most common in newborns, children using inhaled corticosteroids (esp if not using spacer), strong or repeat oral antibiotic use. Kids with immunodeficiency disorders (chronic issue with thrush in this case) - White plaques on oral mucosa (cannot be scratched off), can bleed with attempts to remove the plaques. Thrush = doesn't scratch off - Treatment: Oral nystatin. If breastfeeding, give mom topical nystatin to use on nipples. - Education: proper use of corticosteroid inhalers and use spacer!

ACNE VULGARIS

- Most common skin disorder in pediatric population - Affects 85% of children 12-25 years of age - Infants can develop acne during 1st month of life-typically resolves within 1-3 mos. Due to maternal hormone storage - Affects all ethnicities and both males and females, although severe acne is more common in males due to androgen hormone - Caused when increased hormones increase sebum production resulting in obstruction of follicle canals with comedones (inflammation of the hair follicle which causes eruption of lesions)

appendicitis: management

- NPO until surgery - pain relief, promote comfort - maintain hydration - administering antibiotics - postop care

Piaget Stage 1: Sensorimotor

- Object permanence: things exist in the world without you being unable to see them. Ex: even tho mom has left the room, she will come back. OP is achieved when babies realize mom will come back. - 0-2 years - children learn through senses, reflexes, and motor activity.

Pneumothorax management

- Observation (if less than 30% of cavity) - 100% oxygenation - Chest Tube - Thoracostomy with Pleurodesis-if recurrent or persistent

Apnea of Prematurity

- Occurs between day 2 and 7 of life - Often resolves by 44 wks gestation (4 weeks past due date) -Immaturity of respiratory control center - Criteria=1 or more spells lasting 15+ secs accompanied by hypoxia or bradycardia - Often see increased events when sick - Usually identified in newborn nursery with child coming home on monitor - Monitor alarms (belt with box to monitor, VERY LOUD) with Apnea, HHR (high heart rate), and LHR (low). Wear monitor when child is not being evaluated by adult. - Typically come off monitor when 44 week gestation (4 weeks/1 month past due date) and 6 weeks event free - For more severe cases Caffeine @ 5 mg / Kg / day (Equiv to 12 can cokes in 155 lbs) to stimulate respiratory center

Extra notes from group assignments

- Oral care for infants: remind parents that they need to wipe their gums at least twice a day. Fluoride toothpaste at 2 years. - With adolescents missing school and not acting right, assess for issues at home through the child. - Reinforce safety around pool for all ages. Supervise at all times, esp young children. - Educate around sport safety if child plays sports. Teach parents signs and symptoms. - Toddlers don't share. They just play beside each other.

post cardiac cath care

- POUNDS of direct pressure to surgical site x 15 min - assess VS, pedal pulses on markings, observe pressure dressing q 15 min x 1 hour, then q30 min x 1 hour - I & O - Observe for dysrythmias, bleeding, hematoma, thrombus - bed rest x 6 hr, limit activity x 24 hour - clear liquids to normal as tolerated - maintain hydration - teach parents signs of complications -The affected leg must be stuck straight out because we don't want to dislodge the clot

Education for sudden infant death syndrome prevention

- Positioning- back to sleep; (4-5 mos they can roll, do not need to place them back to back) - Smoke Avoidance - No co-bedding: few first weeks after birth are exhausting that can lead to issues with baby from mom - No hat - Normal room temp - Pacifier good and go to bed with it but do not put it back in when they are asleep

MIS-C: Multisystem inflammatory syndrome in children

- Possibly how the virus is making itself known, or maybe side effect of body's attack of the virus. Complication of covid 19. - Must have 3 main qualifying criteria for diagnosis 1. Age 21 or less with fever, lab evidence of inflammation & evidence of clinically severe illness requiring hospitalization with multisystem (2+ more) organ involvement AND 2.NO alternative plausible diagnoses AND 3. + for current or recent COVID-19 infection or exposure w/in the 4 weeks prior to onset of symptoms

skin lesions

- Primary Lesions-arise from previously healthy skin and are often the first response to injury or infection. - Secondary Lesions-arise from changes in a primary lesion (can also be something normal such as freckles, moles, and mongolian spots)

DIAPER DERMATITIS: primary infection

- Primary contact reaction to urine, feces &/or moisture. (could be diarrhea or other GI issues) - Raw, moist &/or weeping macules and papules of skin with direct contact to diaper. - *Skinfolds are NOT affected.* - Treat with topical barrier creams (i.e. desitin, aquaphor) - Educate parents to change diapers at least every 2 hours, try diaper free times to help air out (helps with pain as well), use alcohol free wipes or just damp soft rag

FUNCTIONS OF THE INTEGUMENT SYSTEM

- Protection: The integument system is the first and main barrier against microorganisms, trauma - Sensitivity: Provides sense of touch (i.e. pain, pressure, temperature) - Insulation: Regulates body temperature by conserving heat (constriction of blood vessels), and releasing excess heat (dilation of blood vessels and sweating via glands) - Excretion: Rids the body of toxins through sweat glands and protects against dehydration. - Synthesizes Vitamin D: via ultraviolet sunlight

SEBORRHEIC DERMATITIS (Cradle Cap)

- Recurrent inflammation thought to be d/t overgrowth of yeast (common in scalp, forehead, and eyelid bc of increase in sebum from sebaceous glands). - Mild eryethematous, waxy scaling, yellow and red patches with greasy scaling. (usually does not bother baby but parents may scratch it off) - 0-3 mos of age and adolescence - Daily washing of hair with baby shampoo (tearless, good for eyelids), and can use soft baby hairbrush or soft toothbrush to loosen the plaques (do not pick or scratch them off!) - Adolescents may use shampoos with selenium (Head and Shoulders, not for eyelids but adolescents do not usually have it in eyelids)

Diaper dermatitis: secondary infection = diaper candiadis

- Secondary infection d/t Candida albicans. - Typically main cause of severe diaper rash --> yeast infection - Beefy red plaques, and satellite lesions - *Skinfolds typically affected* - Treat with antifungal cream (typically nystatin). Educate parents to continue cream at least 3 days after the rash has resolved

4 major breath sounds

- Stridor - Rhonchi: death rattle; mucus in middle airway - Wheeze: usually breathing out - Crackles: hair twist sound

BURN TYPES (in top 5 leading causes of death age 1-14; 10-25% of burns from abuse)

- Thermal: Exposure to flames, scalds (hot water), or hot objects (stove); most common in children. Handles of pots and pans toward stove. Use back burners. - Chemical: Touching or ingestion of caustic agent - Electrical: When direct current from high voltage wires, electrical wires, or appliances pass through the tissue - Radiation: Exposure to radioactive substance or sunlight; 25% of cases in kids

DERMATOPHYTOSES (tinea)

- Tinea is a fungal infection that can affect all 3 main parts of the integument system (hair, skin, nails) and has different names for different areas (tinea capitis, pedis, etc.) - Can be spread person to person, animal to person, and d/t contact with contaminated objects such as clothing. Athlete's foot is common with PE and sports (educate to not go barefoot) - Treatment involves topical anti-fungals, and in more severe cases oral anti-fungals. Reinfection is common if treatment not completed. Use tx for 2-3 days after lesions disappear. - Do not wash contaminated objects with other objects. - some people can be asymptomatic carriers so other fam members may need to be treated and assess

ATOPIC DERMATITIS MANAGEMENT: medicine

- Topical corticosteroids can be given for mild-severe eczema flares (for 7-10 days, then give a break of 1-2 weeks before using again to prevent thinning and hyper/hypopigmentation ). - Oral corticosteroids should be used sparingly for severe flare-ups (start at lowest potency then move up). - Oral antihistamines can be given for pruritus as well as sedative for nighttime scratching. - If secondary infection occurs (from constant scratching, typically due to staph infection), can use topical &/or oral antibiotics. - Allergy skin testing can be performed to determine possible food and/or environmental allergens. Avoidance of these can be key in keeping eczema under better control. - cover with loosen socks and onesies after application - keep nails short

Boxes: 16.1 (Toys): Toddlers

- Toys that can be pushed or pulled •Tunnels to crawl through •Household items such as wooden spoons and plastic containers •Stackable blocks •Large crayons or chalk •Puzzles with large pieces •Musical instruments •Toys that can be manipulated, such as by putting the appropriate shape in the appropriate opening •Dolls that have clothes with Velcro and large buttons that can be manipulated •Bath toys such as rubber ducks

Assessment of Asthma: clinical manifestations

- Tripod position!!!! - Use of accessory muscles - Speak in short, panting phrases (I. CANT. Breathe) - Breath sounds are coarse and crackled - Inspiratory /Expiratory wheezing

rhonchi

- Wet coarse loud breath sounds - Heard loudest over trachea - Represent mucus in major airway - Sound changes, often dramatically, with cough

functional abdominal pain: assessment, hx/risk factors

- abd pain, may be difficult to describe; usually periumbilical "attacks of pain" - does not usually wake the child from sleep - hx: dietary, medication, social/school stressors - rule out organic causes

physiological hyperbilirubinemia (jaundice): patho

- abnormally elevated serum bilirubin level, usually benign - in newborn: physiological (immature liver) and pathological - accumulation of unconjugated bilirubin - yellow color to skin and mucous membranes

intussusception: signs and symptoms and assessment

- abrupt onset of severe, paroxysmal (fine the severe pain cycle), colicky (sharp, localized pain that can arise abruptly, and tends to come and go in spasmlike waves) abdominal pain - abdominal distension and guarding - "currant jelly" stools from bleeding

administer GI meds

- abx - antiemetics - laxatives - PPIs

necrotizing enterocolitis: patho - can be from indomethacin

- acute intestinal necrosis - hypoxia/ischemia from vascular compromise --> reduced blood flow to gut --> ischemia of bowel --> bacterial invasion --> necrosis --> toxins/gas - distal ileum and proximal colon - preemies more susceptible = decreased immune response, immaturity of GI mucosa mortality: 15-20% = pretty serious

pancreatitis: patho and types

- acute: inflammatory process that occurs in the pancreas, variable involvement of tissues and organ systems. (abd trauma, alcohol and drugs, multisystem disease, infection, congenital anomalies, obstruction of gall stones or tumor, or metabolic disorders) - chronic: defined based on the structural/functional permanent changes occurring in the pancreas

intussusception: management and what to monitor for

- air or contrast enema to reduce intussusception - surgery if this is unsuccessful (important bc can lead to necrosis w/o treatment) - monitor: bowel sounds; vital signs, UOP, emesis, and stool output, NPO for surgery

Cleft lip and palate: management

- airway maintenance, nutrition/fluid balance, family process (monitor weight). Holding infants with cleft lip and palate in an upright position during feeding helps facilitate swallowing and minimizes the risk of otitis media; frequent burping - prevent injury to suture line after repair. DO NOT put anything in baby's mouth postop bc they are NPO so use a syringe or medicine dropper to feed in order to avoid sucking! - lip repaired in 2-6 mos old but palate repaired till 9-18 mos old.

Severe dehydration (10%+)

- alert to comatose, sunken fontanels, deeply sunken orbits, dry oral mucosa, tenting turgor - Increased HR progressing to bradycardia, normal BP progressing to hypotension - cool/mottled/ or dusky extremities; significantly delayed capillary refill - UOP: significantly <1 ml/kg/hr or nonexistent

Moderate dehydration (6-9%)

- alert to listless, sunken fontanels, mildy sunken orbits, pale and slightly dry oral mucosa, decreased skin turgor - Increased HR, normal BP - Delayed capillary refill - UOP = <1 ml/kg/hr

Coarction of the aorta

- aorta is narrowed which obstructs blood flow to the lower part of the body and increases BP above the constriction and decreased pressure distally - increases BP by at least 15% higher of upper extremities than lower extremities. Dx other than echo by doing BP on all 4 extremities.

Patho of coarction of aorta

- aorta narrowing increases resistance to flow - pressure in the aorta proximal to narrowing is increased and the pressure distal to the narrowing is decreased - decreased flow to renal arteries - renin release is stimulated - results in further hypertension in the ascending aorta proximal to narrowing - collateral circulation maintains adequate flow to distal tissue

RF: hallmark signs

- aschoff bodies: uncommon, microscopic areas of degeneration and inflammation of the heart that is dx with a cardiac biopsy - inflamed, painful joints - palpable subcutaneous nodules near joints - spiking fever - sydenham chorea (St. Vitus dance): indicates CNS involvment, difficulty writing, involuntary movements, impaired speech, generalized weakness, emotional lability, facial grimacing. Once writing get better = recovering - elevated ASO antibody tither = streptococcus antibodies - Rash (erythema marginatum)

hepatitis: management

- assess skin, abdomen - diagnosis based on hx, physical exam, and lab data - nursing care often in the home and community (prevent spread of infxn, reduce complications, maintain adeq nutrition, promote rest and comfort, encourage vaccines for Hep A and B)

promote pain relief, comfort, and rest

- assess with developmentally appropriate scale - pharmalogical and nonpharm methods

recommendations for vaccines based on age

- based on age-specific risks - based on potential interference with immune response by passively transferred maternal antibodies. they want to wait till antibodies are gone - based on state of immune response

Screening recommendations for dyslipidemia

- birth-2 years: targeted - 2-8 years: high risk (primary and secondary) - 9-11 years: universal - 12-16 years: targeted - 17-21 years: universal x 1 fasting giver more accurate lipid level. ● Targeted is you look at the parents weight, lifestyle, etc ● Universal is everyone gets it

Pancreatitis: management

- bowel rest (NPO), IV fluids - NG suction - serial monitoring of amylase/lipase levels - oral feedings restarted after amylase/lipase levels normalize

congenital diaphragmatic hernia: when and how and assessment

- can be diagnosed prenatally; chest x-ray in newborn to confirm - severe respiratory distress or failure - lung sounds absent of affected side; heart sounds may be auscultated on right side; bowel sounds may be heard in lung fields

Maintain skin integrity

- caused by disorders such as omphalocele - excessive moisture/irritation - itching (biliary atresia) - surgery

Prevention of RF

- check temp q4h during acute phase (10-15 mg/kg q 4-6 hr prn) - bed rest/monitor for carditis - take abx as prescribed - prophylactic abx - Anti-inflammatory/ASA aka Aspirin for antiinflammatory and fever reducer (90-130 mg/kg/d divided by 4-6 hours). Reye syndrome is caused by viruses and if children have it already, aspirin can cause Intracranial issues. DO NOT WORRY ABOUT REYE's in this situation -emotional patient and family support. screen fam if they are strept carriers

Piaget's Theory of Cognitive Development

- child incorporates experiences via assimilation and changes to deal with these through accomodation - children are active participants in cognitive development - understand the child's thought process and design activities that are stimulating, meaningful, and appropriate - tailor health teaching (teach a 6 year old differently than a 16 year old)

Atraumatic care

- child life specialist: provide programs to support children for procedures - minimizing physical stress during procedures - distraction, therapeutic hugging, age-appropriate education, environment - family-centered care - Promoting a sense of control—communication, include in plan of care

External Ventricular Drainage System

- child who had VP shunt removed due to infection - tip right inside skull and drained on the outside - watch continuously. make sure tubes have no kinking. all based on measurements and angles - also seen in palliative care for brain tumor increasing ICP - typically do not see children wide awake and alert bc you want them as still as possible, but depends on how long it will be in there - lay flat as possible, pillow is okay! or else gravity causes fluid to drain out - usually sedated to keep them still

Maintain effective ventilation and oxygenation

- children have a risk for aspiration (ex: cleft lip palate) - airway patency and breathing patterns post-op - feedings

Bandura's Social Learning Theory

- children imitate or model the behavior they see. if it is positively reinforced, they tend to repeat behavior - people can consciously choose how to act - internal processes and the external environment (the behaviors of others) are key elements - positive role model •Children learn attitudes, beliefs, customs, & values through their social contacts with adults & other children. DIFFERENT THAN KOHLBERG MORAL DECISION MAKING •Importance of modeling behavior—children are more likely to cooperate if they see an adult doing it willingly (i.e. with blood pressure) •Self-efficacy is an important determinant of behavior; this is the expectation that someone can produce a desired outcome (i.e., an adolescent who believes he can avoid the use of drugs or alcohol is more likely to do so).

gallbladder disease: patho

- cholesthiasis: stones in the gallbladder (common bile duct) - cholecystitis: inflammation of gallbladder due to obstruction of bile flow; typically associated with cholelithiasis

IBD: ulcerative colitis = patho

- chronic, idiopathic disorder of GI tract - affects only the large intestine and rectal mucosa, continuous along the colon. COLON = large bowel - usually begins in the rectum and may progress up the large intestine - inflammation is limited to the mucosa

Inflammatory Bowel Disease: Crohn's disease = patho

- chronic, idiopathic inflammatory disorder of the GI tract - primarily affects the large and small intestines with some skipping, but can affect the entire intestinal tract - may "skip" areas of the bowel

Cirrhosis and portal hypertension: patho and causes in children

- cirrhosis --> liver scarring --> fibrotic changes - fibrosis and scarring alter blood flow in and out of the liver, leading to portal hypertension (and end stage liver failure) - causes in children include chronic cholestasis, inborn errors of metabolism, and chronic hepatitis

Total correction goals are to :

- close the VSD - relieve RV outflow obstruction - repair stenotic pulmonary arteries - can have it done at least at 6 months to give pulmonary artery more time to grow but can go up if palliative procedure is not working

Obstructive defect types

- coarction of the aorta - aortic stenosis - interrupted aortic arch - pulmonic stenosis

mouth

- common entry for infectious agents and choking hazards - children frequently put things in their mouths

Facts about tet spells

- common in morning or after naps - common after prolonged agitation and crying - noxious stimuli (eating, bee sting, using the bathroom) can be a precursor

Labs and diagnostics

- common laboratory and diagnostic testing (BOX 23.2 pg 418) - how to collect stool sample and how to educate fam - nurse involved in specimen collection, normal findings, and family education

hirschsprung disease: patho

- congenital aganglionic megacolon - portion of the intestinal tract (usually the rectum or sigmoid colon) is missing neuronal ganglion cells - aganglionosis causes absence of peristalsis and motility

omphalocele: patho contents are sealed in the O

- congenital defect of abdominal wall - internal organs eviscerate in a sac through the umbilical cord (covered by membrane)

What are some safety concerns at this age? (see Pocket Guide)

- cover outlets, esp if crawling (tell pts to get on their level and see what they can reach) - hot water is a big thing

Kawasaki: Sub-acute phase

- cracking lips and fissures - desquamation of skin - joint pain - cardiac disease: aneurysms or thickening of arteries - thrombocytosis - irritable child - decreased appetite - can last 2-4 weeks -give popsicle for decreased appetite - inflammation continues and tissue can get very thick

appendicitis: hx and assessment

- cramping around umbilicus, decreased appetite, nausea, fever - RLQ pain - rebound tenderness at McBurney's point (RLQ) - pain becomes more intense and constant - guarding and abdominal rigidity occur (can't walk or jump right) - sudden, spontaneous relief of pain usually means rupture - monitor for signs and sepsis and shock

Kohlberg Stage 1: Pre-Conventional

- decisions are based to please others and avoid punishments - "rules are rules" "if you steal you go to jail" don't understand there is a reason for the rule - Understand different people have different views/rules - Good in order to be seen as good by others want approval and avoid punishment - "stealing is ok for him b/c he wanted to save his wife" - Rules necessary to please others or keep positive relationships and avoid guilt - 4-7 years

Measles

- declared eliminated in 2000 but recent rise is occurring bc people are not vaccinating and immigrants from measles- countries - 89% of cases where unvaccinated children

Ventricular Septal Defect

- defect in septal wall creates opening between R and L ventricles - hole in lower septum - shunts left from right bc high pressure in systemic circulation and low pressure in right ventricle from lungs - more active than ASD; more of a pump to it bc ventricle is trying to squeze out into the systemic circulation

Anorectal malformation: managment

- depends on severity - supporting the family and providing pre- and post-op care - protect surgical site - NPO until after surgery and return of bowel function - NG tubes to depress stomach, IV fluids and TPN if chronic

Cleft lip and palate: patho

- development of cleft occurs early pregnancy, when the tissue that forms the lip and/or palate fails to fuse - may be unilateral (L or R) or bilateral. - Anomalies (other underlying issues) include heart defects, ear malformations, skeletal deformities, and genitourinary abnormality.

heart cath purposes

- diagnostic: check blood pressures in different heart procedures aka intracardiac procedures. to know what medications to give. - surgical/interventional: balloon septostomy = blow up balloon and pull it across to rip septum open. Plasty = close with purse string stitch. biopsy - electrophysiological studies: check rate and rhythm. map electrical pathways to find pathway causing dysryhtmia to zap/ablate it. (ablation)

Coarction of Aorta signs and symptoms

- difference in BP and pulses of the upper and lower extremities depending on where the stricture is - acyanotic - profound shock (from decreased blood flow), metabolic acidosis, end-organ ischemia (necrotizing enterocolitis) - systolic murmurs: caused by turbulence. tachycardia and defected valves can cause murmurs. - higher pressure in upper extremities can also cause brain bleeds and nose bleeds - critical coarc: very tight leading to profound shock and near to death after days of compromised circulation to lower body -May have dizziness, intolerance to exercise, headaches, might faint, nosebleeds, leg cramps, all of these are due to compromised blood flow to the low extremities and the too high BP in the brain and head because of the effects of renin

fluid balance & loss

- differences in loss and maintenance

Pic: slipped capital femoral epiphysis clinical signs and tx

- displacement of the femoral head due to the disruption of the growth plate - "ice cream falling off its cone" on radiographs - painful limp with referred pain to the thigh or knee - most commonly seen in adolescent obese males -tx: percutaneous screw fixation

where do you put pressure if the patient is bleeding at the cath site?

- do not leave the room and RUN to the pt - MEDICAL EMERGENCY - putting pressure on the cath site where the hole is to the vessel - needle goes through the skin and up - so you do not put pressure at puncture, you put it on the vessel - even put pressure without gloves! - put pressure with heel of hand and other hand and entire body's weight 1 inch above puncture site!!!!! should be where the vessel hole is

biliary atresia: management

- early dx to slow liver damage - hx, physical exam, lab values in conjunction with liver biopsy and exploratory laparotomy to dx - kasai procedure: create a hole to drain the vile through biliary tree - may eventually need a liver transplant - nursing care: reducing risk of complications, supportive care, meeting nutritional needs, prevent infection due to immunocompromised state and presence of central lines, nutrition and hydration (TPN, high protein and carb), moisturize lotion to prevent itching, monitor weight, and prepare fam for liver transplant

cirrhosis and portal hypertension: hx and assessment, early stages, early sx vs progressive dz fig 23.19 pg 461

- early stages: may appear normal, asymptomatic - early sx (poor weight gain, anorexia, fatigue, muscle weakness, N/V) vs progressive disease (GI bleeding, ascites, severe jaundice, hepatic encephalopathy) - assessment: multisystem approach may have collateral vessels from portal HTN, assess mental (lethargy, irritability, fatigue), return of babinski reflex, jaundice skin, itching, spider veins, clubbing, palmar erythema, SOB, tachypnea, compromised lung expansion (d/t enlarged liver), enlarged abdomen and spleen, N/V/D, abd pain, dyspepsia, bleeding in nose/mouth/gums, petechiae

constipation & encopresis: management

- educate fam and child - meds: miralax, enema - diet modification: fluid intake, formula changes - behavior modification: stooling routine -this is a LONG TERM PLAN! STRESS COMPLIANCE watch the POO in YOU video

hypertrophic pyloric stenosis: patho

- elongation and thickening of the pylorus, leading to hypertrophy - may progress to nearly complete obstruction of gastric outlet to intestines

esophogeal atresia & tracheoesophageal fistula: patho

- esophagus and trachea do not separate properly during prenatal development - EA - proximal and distal ends of esophagus do not communicate/connect to stomach - TF - abnormal communication between trachea and esophagus

PDA = patent ductus arteriosus

- failure of the ductus arteriosus to close causes blood to shunt from the left to right into the pulmonary artery and lungs - allows blood to mix between pulmonary artery and aorta - too much blood go to lungs through pulmonary arteries because there is less pressure - causes same problems in VSD and ASD - usually closes in a couple of weeks - common in premature babies but RARE in full term babies

IBD: crohn's disease = hx and assessment

- fever, fatigue, malaise - failure to grow due to suboptimal absorption of nutrients, excessive nutrient loss (DA, vomiting), and inadequate caloric intake - may present with epigastric pain and vomiting, cramping abdominal pain, and abdominal distension

cirrhosis and portal hypertension: management

- focus on minimizing complications - medication administration - monitoring: nutrition, electrolytes, bleeding/coagulatopathy - prevent infection - emotional and psychological needs -many children are cared for at home during early stages but as it progresses, risk of complications go up so lots of parent education to monitor for s/sx of infection, inadequate intake, and bleeding. Teach them what complications require medical treatment and when to call provider

functional abdominal pain: management

- focus on promoting coping skills - dietary changes - medications to relieve changes - counseling, if necessary

Pediatric nursing

- focused on their changing physical, developmental, and emotional needs - family-centered care: a mutually beneficial partnership between the child, family, and healthcare professionals - atraumatic care- use of interventions to minimize physical and psychological distress in children and families - evidence-based practice - use of research to establish and implement care

Variations in Growth - start with 300 bones that fuse at 2-3 years to form our 206 bones

- fontanels: posterior closes at 2 mos; anterior closes 18 mos - growth plates: allow for rapid growth in long bones; complete ossification in early 20s

Erikson's Psychosocial Theory

- for each stage, there is a crisis/challenge that must be overcome for healthy personality development - outcome 1: needs are met and child moves on to future stages - outcome 2: needs are not met and an unhealthy outcome occurs to influence future social development

Piaget Stage 4: Formal Operational Stage

- fully mature cognitive - deductive reasoning - abstract thinking (can think of different outcomes and the consequences and make a decision based on theses.) - can think of consequences -11+ years

Constipation & encopresis: patho

- functional constipation: common in preschool aged children - most causes are functional - encopresis: result of a stretched rectal vault (involuntary defecation)

Anorectal malformations: when dx and assessment

- general diagnosed in first few days of life - failure to pass meconium - stool present in urine (fistula) - sacral anomalies: poorly developed anal dimple

MSK assessment table 27.1 pg 549

- general questions: pain? stiffness? joints? difficulty going up or down stairs? hitting developmental milestones? - body alignment: posture? symmetry of limbs, shoulders, hips, spine, length, abnormal curvatures - gait: turning inward? toe-walking? - range of motion: limping, ROM exercises of all joints, flexion and extension = symmetrical and smooth?

Ensuring every child is vaccinated and providing up to date and safe immunizations is one of the most important jobs a pediatric nurse will have.

- get children caught up on vaccinations - educate public on the great importance of vaccinations - health providers and nurses are parents' most trusted source of vaccine info - media can be misleading, ensure parents have correct EBP info - pharmaceutical companies are not just doing it for money, vaccines make up less than 2% of company revenue. Doctors do not make much money with vaccines as well. They sometimes just send pts to the health department.

Prophylaxis: Abx

- given to person who has a repaired or unrepaired heart defect - usually amoxicilllin - guard against bacteria created during procedures (dental work, invasive procedures, piercing, electrolysis, tattoos, acupuncture, IUD insertion, dx or surgical procedures etc.) -prevents endocarditis and pericarditis - given 1 hour before procedures - guidelines from AHA

celiac disease: management

- gluten-free diet - ensure adequate fluid and nutrient intake - maintain skin integrity

Celiac disease: patho

- gluten-sensitive enteropathy or nontropical sprue - autoimmune reaction to gluten leads to intestinal inflammation, villous atrophy, and malabsorption - as changes in the villi occur, malabsorption of proteins, carbs, fat-soluble vitamins, Ca, Fe, and folate occur - chronic and irreversible

hypoplastic left heart syndrome tx

- heart transplantation - surgical repair - no intervention

Failure of left side development

- high mortality - definite mortality if not fixed

Kawasaki: nursing interventions

- hospitalize when febrile - promote comfort - passive ROM - planned rest periods - discharge teaching - postpone immunizations for 5 months

oral lesions: risk factors, assessment

- hx for risk factors: immune deficiency, chemotherapy, exposure to infectious agents, trauma, stress, celiac, or crohn disease - inspect oral cavity and throat - note presence, distribution, appearance of lesions

Peptic ulcer disease: assessment

- hx of present illness - abdominal pain is the most common complaint (dull, vague) - vomiting, GI bleeding - WAKES child at night (unlike functional abdominal pain)

gallbladder disease: hx, physical exam, labs, dx

- hx: RUQ pain, may radiate substernally or to right shoulder; N/V; Jaundice/fever with cholecystitis - PE: abdominal tenderness, maybe localized; jaundice, fever - LABS: LFTs, bilirubin, CRP, CBC, amylase/lipase - DX: ultrasound, ERCP, HIDA scan

pancreatitis: hx, physical exam, labs, diagnostic imaging

- hx: acute onset of persistent midepigastric/periumbilical pain, may radiate to back or chest; vomiting, especially after meals; fever - physical exam: bowel sounds diminished, abdominal tenderness or distension, jaundice - labs: amylase/lipase (both are increased), liver profile, CRP (measures inflammation), blood work - diagnostic imaging: ultrasound, ERCP (endoscopic retrograde cholangiopancreatography) for chronic pancreatitis, abdominal radiograph

meckel diverticulum hx, symptoms, and assessment, and associations

- hx: imperforate anus, esophageal atresia, omphalocele, various cardiovascular or neurological anomalies - often asymptomatic for first year; symptoms usually arise in first or second year of life - painless rectal bleeding!!! - may be associated with partial or complete bowel obstruction

Types of spinal cord injuries

- hyperflexion: tears or evulsion fractures from extreme bending forward of the neck - rotation injury: unstable spinal fracture and unilateral facet dislocation - hyperextension: ligament tears and evulsion fractures of the vertebral bodies cause injury - compression: when a child falls from a height

acquired disorders

- hypertension - dyslipidmia - rheumatic disease; -kawasaki disease

peptic ulcer disease: management

- if H. pylori, treat with abx. Give acetaminophen for pain or fever (instead of ibuprofen). - histamine agonists and/or PPIs - hemodynamic stabilization if bleeding occurs - prevention, safety precautions, stressors

tennessee concussion law

- if suspected or risk of concussion, child is taken out of sport and immediately evaluated and follow-uped to be cleared to return - problem: not all sports teams have medical professionals - NPs in TN are not allowed to treat, evaluate, or clears pts with concussions

Hypertension

- increase in children due to bad parental habits - idiopathic or essential - affected by a cardiac or renal disease that leads to HTN in kids then adulthood - at age of 2, start taking BP annually

Palliative surgery goals of tet spells

- increase pulmonary flow - allow pulmonary artery growth - eventual total correction - creates shunts to bypass stenotic area for this palliative surgery

patho of tet spell in order

- increased obstruction to pulmonary blood flow - increases R to L shunting - spell triggered by decrease in SVR or a spasm of cardiac muscle - decreased SVR (systemic vascular resistance): more blood shunted right to left - spasm: in region of pulmonary artery outflow tract & increasing R to L shunting - arterial hypoxemia - squatting = defense body mechanism. not taught. just happens. - increases SVR (which is good) - Decrease R to L shunt and Increase in pulmonary blood flow

congenital disorders

- increased pulmonary flow - decreased pulmonary blood flow - obstruction - mixed blood flow

liver transplant

- increasingly more common due to advances in immunosuppression, better candidate selection, and improved surgical techniques and post-op care - waiting list, prioritized based on several criteria - social work intervention (transportation, finances) - transplant coordinator - ICU several days post-op - monitor for several days to weeks for signs of rejection or infection - rejection is the most significant complication - lifetime of immunosuppressive therapy (risk for infection) - assess parents' support system: do they have help at home? what resources do they have?

Hepatitis: patho

- inflammation of the liver - viruses are the most common cause (Hep A is most common) - other causes: bacterial infxn, trauma metabolic disorders, chemical toxicity, autoimmune - fulminant hepatitis after a viral infection or toxic exposure acute liver failure leading cause = tylenol indigestion

thrush: assessment

- inspect oral mucosa - thick, white patches on tongue, palate, mucosa that does not easily wipe off - also assess for diaper rash

malrotation & volvulus: patho

- intestine twists upon itself as a result of gastric or intestinal malrotation - during fetal development, the stomach and intestines fail to grow and fail to make rotations, gastric or intestinal volvulus can occur

hepatitis: hx and assessment, risk factors, lab values

- jaundice, fever, fatigue, abdominal pain - N/V, malaise - hx revealing risk factors: trauma, foreign travel, sick contacts, medication use - lab values: elevated liver enzymes, prolonged pt/ptt, elevated ammonia

Tanner stages: 5 stages

- know order in which the puberty happens - breast development comes before menarche - pubic hair comes after scrotum/testicle enlargement

short bowel syndrome: patho

- large portion of the small intestine has been removed or is dysfunctional - inadequate bowel length leads to inadequate absorption of nutrient - causes vary according to age (NEC, gastrotesis, motility disorders, trauma, crohn's disease) - can lead to intestinal failure

PDA symptoms of large shunt

- learn murmur!!! Murmur = sounds like a loader/machine-like - large shunt - widened pulse pressure - bounding pulses

patho of VSD

- left to right shunting - increased pulmonary blood flow - leads to pulmonary HTN and pulmonary vascular disease

patho of atrial septal defect

- left to right shunting due to low pressure in lungs and high pressure in systemic circulation - right atrial dilation - right ventricular overload - increased pulmonary blood flow - possible pulmonary artery hypertension; could cause permanent damage! amount of shunting depends on size of hole

comparison of annual morbidity and current mobidity: vaccine-preventable disease

- less kids are getting vaccinated bc some parents feel that they are not necessary. Most parents are vaccinated and have not experience the associated diseases. - even if illness is no longer around, vaccination is important

Gastroschisis: patho contents are coming out of the G

- life-threatening congenial malformaiton - intestines are outside the body via a hole beside the umbilicus (no membrane/sac covering organs) - may include intestines, stomach, and liver - exposure can cause irritation, edema, twisting, or shortening of intestines

Developmental dysplasia of the hip: Clinical presentation

- limited hip movement - difference in leg lengths - palpable and audible click as the femoral head moves out of the acetabulum - older children: trendelenburg gait

biliary system

- liver relatively large at birth, easily palpated - pancreatic enzymes reach adult levels around 2 years old

Anatomy of heart

- look at labeled picture! - understand the normal heart!

Hypotonic/hyponatremic (10%)

- loss of electrolytes - serum sodium < 135 - compensatory mechanisms (thus shows up later): ECF shifting into intracellular components, exacerbates already present extracellular dehydration - causes: severe/prolonged V/D, burns, renal disease, IV fluids w/o electrolytes

Hypertonic dehydration (20%)

- loss of water - serum sodium > 145 - delay onset of s/s due to compensatory mechanisms - altered LOC, confusion, lethargy/dizziness - causes: Diabetes inspidus or admin of IV fluids or feeds with high electrolytes

physiological hyperbilirubinemia (jaundice): management

- lower bilirubin to acceptable levels - regular feeding patterns (early and frequent feedings, q2-3hr) - phototherapy when necessary (assess for complications): shielded eyes and under phototherapy light, monitor for loose stools, body temp. risk for dehydration and need to stay under light except during feeding times. Infant can continue to breastfeed.

esophagus

- lower esophageal sphincter not fully developed until 1 month - regurgitation and dysphagia - swallowing is involuntarily until baby is about 6 weeks old

Patho of TOF

- mainly dependent upon the degree of pulmonary stenosis = degree of hypoxemia minimal obstruction: - little restriction of blood flow - may have pulmonary over-circulation and develop CHF - little to no R to L shunting - called PINK tet severe obstruction: - R to L shunting - unoxygenated blood forced through the VSD to the aorta right to left. So circulatory blood would have low oxygen = hypoxemia - increases workload on right ventricle leading to ventricular hypertrophy to get rid of the blood - cyanotic spells

viral

- majority of childhood infections - xanthems: have a rash associated with them - hard to distinguish bc majority are viral with rashes - sometimes, kids are not too sick and they just come with a rash concern

esophageal atresia & tracheoesophageal fistula: hx (maternal hx) and assessment

- maternal history: polyhydramnios (fetus can't swallow or absorb amniotic fluid) - copious frothy bubbles of mucus, drooling (bc they cannot swallow) - abdominal distention (air in stomach) - the three C's (coughing, choking, cyanosis) with feeding (no vomiting bc no stomach content)

omphalocele: maternal RFs, dx, and assessment

- maternal risk factors: alcohol, smoking, use of SSRIs, obese or overweight before pregnancy (she said not to know this but...) - diagnosed on ultrasound or immediately upon delivery - assess respiratory distress and cardiovascular stability (high risk of CV defects and pulmonary hyperplasia with omphalocele)

Hypoplasia left heart syndrome signs and symptoms

- may appear normal at birth - as PDA begins to close, symptoms appear - cyanosis or pallor -poor perfusion - no specific murmur

Restraints

- may be used to ensure the child's safety, perform a procedure, immobilize a body part or limb - use alternative, least restrictive - follow policy at your facility - safety of a child is priority - be creative

children's spinal column

- more flexible and have propensity for extreme mobility - at risk for specific of injury - younger than 8 years old = cervical spine is the most mobile; ligaments that support the neck are elastic and allow for stretching between the vertebrae, but the spinal cord does not stretch with the vertebrae; more injuries C1-C3 - ages 9-15: injure C4- C6

Variations in Nature/Characteristics

- more porous, less dense - more elastic, allowing for greater deformation before breaking so they may buckle before breaking - ligaments and tendons are stronger till puberty

Peptic ulcer disease: patho

- mucosal inflammation --> subsequent ulceration - primary or secondary - duodenal ulcers are more common than gastric in children; secondary is more likely to be gastric - primary peptic ulcers; usually h.pylori - secondary occur as a result of excess acid production, stress, medications, or other underlying conditions

VSD symptoms

- murmurs (also in ASD and most defects) - feeding difficulties (also in ASD, bc too much blood going to lungs from fluid in interstitional tissues creating tachypnea and dyspnea) - failure to gain weight (slow eaters; suck for 30 seconds with 1 min breaks) - respiratory distress (increased work of breathing; can sweat when they eat) - CHF (extra blood in RV) - can have small VSDs = asymptomatic

bilary atresia: history & assessment

- normal at birth, develop progressive obliteration of the bile ducts several weeks into the newborn period - initially asymptomatic; jaundice may be noted 2-3 weeks after birth - bilirubin levels rise, abdominal distention and hepatomegaly - bruising, bleeding, and intense itching - stools may be white; urine is dark & tea-colored

Current vaccine schedule - updated every year

- not responsible to know this entire chart bc chart changes and will be available to look at in the future! KNOW: - doses of each vaccination for a child to be protected rotavirus: 2 doses by 6 mos to be protected hep B: 3 doses by 18 mos to be protected influenza: just annual (CONTINUE THIS)

Patho of hypoplastic left heart syndrome

- nunfunctional left ventricle - routing of pulmonary venous return to RA via ASD or stretched FO -In RA systemic and pulmonary venous return mix - Perfusion is retrogade via the PDA to the arch and ascending aorta - lower body perfusion is antegrade via the descending aorta - flow is dependent upon the PVR and the SVR - must have a PDA and adequate mixing of blood at atrial level

meckel diverticulum: management

- nursing priorities related to surgical resection: NPO preop - monitor blood loss; stool testing for occult blood when no obvious signs of blood are present - fluid and electrolyte monitoring and replacement - pain control

Appendicitis patho

- obstruction occurs in the appendiceal lumen - causes of obstruction include hard fecal mass, stenosis, parasitic infection, hyperplasia of lymphoid tissue, or a tumor - after obstruction, mucus continues to be secreted, bacteria proliferate, and intraluminal pressure increases - elevated pressure leads to lymphatic and venous congestion, impaired perfusion, and eventual ischemia - necrosis occurs - appendix becomes gangrenous and ruptures - rupture can lead to bacterial contamination of the peritoneum, causing bacterial peritonitis

necrotizing enterocolitis: when dx, early sx vs systemic sx assessment, dx

- occurs between 3-14 days, after enteral feedings have started - early (poor feedings, increased residual, bilious emesis, abdominal distension, temperature instability, lethargy and irritability, bloody stools, glucose instability) vs systemic signs/sx (resp failure, decreased peripheral perfusion, circulatory collapse) - abdominal XRAY shows dilated, thickened bowel loops - abdominal girth (increases from inflammation) q4h

meckel diverticulum

- omphalomesenteric duct fails to separate from yolk sac, resulting in residual structures - outpouching of the ileum off of the small intestine

intussusception: patho (idiopathic cause)

- one portion of the intestine prolapses, then telescopes into another (most common site is the ileocolic region) --> obstruction - intussusception becomes engorged with blood and edematous; bleeding from mucosa may lead to intestinal infarction, perforation, peritonitis, and death

Congenital diaphragmatic hernia: patho

- opening between the thoracic and abdominal cavities - abdominal contents can enter the chest wall (thoracic cavity) - often leads to compressed and hypoplastic lung (small lung)

Thrush: management

- oral antifungals: nystatin suspension 4x a day after feedings (so med does not wash away) - fluconazole used but less common - evaluate mom if breastfeeding

thrush: patho

- oral candidiasis: fungal infxn of oral mucosa - most common in infants - others at risk include those with immune disorders, using corticosteroid inhalers, receiving therapy that suppresses immune system, and abx use

oral rehydration therapy

- oral rehydration solution (ORS) should contain Na, K, Cl, and glucose - ex: commercial electrolyte solutions (Pedialyte) and homemade solutions (chicken broth with sugar or salty gatorade) - avoid: fluids high in sugar content (straight juice and diet sodas) - main goal for mild dehydration: promote fluid consumption. Give diluted apple juice if child won't drink anything at all. popsicles - Replacement: 15 ml/kg/hr; small amounts every 5 mins for 3-4 hours

oral lesions: management

- pain management - maintain hydration - magic mouthwash (malox and benadryl combo sometimes with lidocaine) - spit and swish - therapeutic management depends on the cause - topical corticosteroid, acyclovir or supportive only

botulism: sources, complications, expected outcomes

- paralysis progresses - potential sources: honey, rural and farm areas with contaminated dust and soil - infants are more susceptible due to immature gut flora - if untreated, progress to descending paralysis of the respiratory muscles expected outcomes: airway patent, regain maximum mobility, and parents will verbalize foods to avoid such as honey

Schedule for special indications

- particular schedules are available for specific situations (HIV, kidney failure, DM, chronic liver disease) - when in doubt, for a child that is immunocompromised, there is prob a schedule for them .

gastroesophageal reflux (GER): patho

- passage of gastric contents into the esophagus - occurs during episodes of transient relaxation of the LES (lower esophageal stricture), such as swallowing, crying, valsava maneuvers that increase intra-abdominal pressure - delayed gastric emptying - neurologic disease

History assessment

- past hx: medical, surgical, and birth - family history - present illness: DA, C, livestock exposure - growth patterns

gastroesophageal reflux: risk factors, onset and progression of sx, assessment

- past medical hx (prematurity) and risk factors (diet, meds, smoking, alcohol, allergies, feeding positions) - onset and progression of sx (recurrent vomiting, weight loss, resp sx: hoarseness) - physical exam: poor weight gain

Long term effects of RF

- permanent damage due to inflammation of cardiac valves or heart muscles - regurgitation of valves = poor pumping

Cleft lip and palate: preg hx and assessment

- pregnancy history: smoking, maternal age (older), medications - feeding (unable to get enough pressure when sucking) and respiratory difficulties (high risk for infection), speech development, otitis media

esophageal atresia & tracheoesophageal fistula: managment

- preop care: NPO, elevate HOB, may have oral gastric tube placed - emergency equipment available: oxygen, suction - comfort measures, minimize crying, prevent respiratory distress - postop care: TPN, abx till healed - begin oral feedings usually within a week after surgery - parent teaching

celiac disease: presentation in infants vs children, complications, and assessment

- presentation: infants (vomiting, DA, abd distension, anorexia, failure to thrive) vs children (abd pain, C, weight loss) - muscle wasting and hypotonia - steatorrhea (fatty stools): stools are frothy, greasy, foul-smelling

hirschsprung disease: presentation = newborn vs older adult, dx exam, and complication if untreated

- presentation: newborn (no meconium within 48hrs, repeated vomiting, distended abdomen) vs. older adult (chronic constipation, marked abdominal distension, palpable dilated bowel movement) - digital rectal exam reveals an empty rectal vault - if untreated, enterocolitis (fever, pain, bloody DA, frequent foul-smelling stools) can develop

IBD: crohn's = ULCERATIVE COLITIS hx and assessment

- presents with DA and with blood, mucus, and pus in the stool - urgency, abdominal cramping, and nighttime defecation - fulminant (severe and sudden) colitis = fever, anemia, leukocytosis, and >5 bloody stools per day - see table 23.9 pg 453

localized pain

- press on nail bed on left hand and they take their right hand to move away the pressure, trying to get rid of stimulus.

withdrawal pain (flexion-withdrawal)

- press on nail bed on left hand, they try to move left hand away - typically see them flex to remove stimulus

Morbidity of children

- prevalence of a specific illness in a population at a particular time - presented in rates per 100,000 children - Risk factors: homelessness, poverty, low birth weight, chronic disorders, day care attendance, and issues with access to healthcare - most important aspect is the degree of disability it produces, identified as the number of days missed from school or confined to bed

US immunization stats

- prevented 732 deaths and 21 million hospitalizations - JUST KNOW GENERAL TRENDS OF STATISTICS

biliary atresia: patho

- progressive obstruction of the extrahepatic bile ducts - progresses to liver failure and death if untreated - most common form is complete obliteration of the entire extrahepatic biliary tree

Gastroschisis: management

- prompt medical and nursing intervention (tube suction, monitor temp, fluid loss). Temperature is huge here - may need ET tube to relieve respiratory distress - nursing care similar to omphalocele - cover exposed intestines in a way that prevents traction on bowel - prompt surgical intervention (large defects may be staged. NPO till surgery)

Fluid balance: Increased risk for fluid loss

- proportionately greater amount of water than adults - require larger relative fluid intake - excrete relatively greater amount of fluid - until 2 years old, extracellular fluid makes up half of total body water

Gastroesophageal reflux: management

- protecting airway - risk for apnea or ALTE (apparent life threatening event) -maintaining/restoring fluid balance/nutrition - reflux precautions & family education - postop care, if the child requires a fundoplication (bring up stomach and wrap it around esophageal sphincter), limit motion and pressure on abdominal area - upright position in crib, frequent burping

Tranposition of the great arteries

- pulmonary artery and aorta are switched - patent foramen ovale and ductus arteriosus are keeping child alive; allow for mixing of blood - right side flow: body to right side to body - left side flow: lungs to left side to lungs

tx of coarction of aorta

- resection of narrowed area and direct anastomosis of two segments - insertion of graft if section is long - subclavian artery patch - widen area with synthetic patch

RF: type of disorder

- results from an autoimmune response - inflammatory connective tissue disorder - has a genetic susceptibility pattern in cultures

Gastroschisis: maternal RFs, age, morbidity/mortality

- risk factors: young/teenage mom, drinking, and smoking - often premature and SGA (small for gestational age) - significant morbidity and mortality (mortality rate slightly below 10%)

Nursing dx of GI

- risk for deficient fluid volume - DA - C - Risk for Impaired Skin Integrity - Imbalanced nutrition: less than body requirements - Pain - Ineffective breathing pattern - Risk for caregiver role strain: for significant disorders. assess parent's support system - disturbed body image: more from teenager than toddler

seizures cured

- seizure free for 10 years - 5 of those 10 years have to be medication free

short bowel syndrome: hx and assessment

- severe DA, gastric acid hypersecretion, bacterial overgrowth, malabsorption of fats and bile salts - unintended weight loss, failure to gain weight, bloating - assess hydration, electrolyte imbalances, signs of infection (central line and inadequate nutrition increases risk)

Osteogenesis imperfecta: assess for

- signs of fractures - muscle weakness - bone deformities - short stature - hearing loss - sclera for blue tinting

Risk factors for SIDS

- sleep position (should be on back): CO2 sedates instead of stimulating the baby to take a deep breath, vicious cycle. Laying on face creates a pocket of CO2 - leads to death with immature respiratory center - sibling death - nicotine exposure - socioeconomic status, lack of prenatal care, genetics, bedding (lot of bedding can lead to face burying), room temp (should be 70 F, not 78)

stomach

- small capacity - infant cannot hold as much as older children

intestines

- small intestine not functionally mature at birth - small bowel loss in infancy can lead to problems with absorption and diarrhea as an adult

Prevent infection

- some disorders caused by infection (NEC = necrotizing enterocolitis, Hepatitis) - altered skin integrity - compromised immune system - surgical site

maintain adequate hydration and nutrition

- some surgeries and disorders may disrupt the integrity of the GI tract - NPO status - surgical procedures - TPN

Acquired disorders

- spinal cord injury - botulism

Embryology of cardiovascular system

- stem cells in heart form at 3rd week of gestation to create cardiac cells. they take on the movement of beating already! - as they continue to migrate together, they beat together and form tubules at 4th week. - Cardiac formation occurs very early in gestation!! (3 weeks!) - Heart begins to beat at 4th week; mom may not even know she is pregnant. She may be exposed to teratogens! - 12-20th week: most birth defects can be diagnosed

constipation & encopresis: assessment

- stooling patterns (size, frequency, amount, color) - pain, cramping - DA leakage, soiling of undergarments (encopresis) - physical exam, labs/dx as indicated (belly xray = KUB)

hypertrophic pyloric stenosis: signs and symptoms and assessment, when does it happen?

- sudden onset of forceful, *projectile* vomiting (that is immediate postprandial = after meals and nonbilious) - dehydration, metabolic disturbances (metabolic alkalosis) - peristaltic waves on inspection - olive-shaped mass in RUQ - males 4x more affected than females - can happen at 1-12 weeks, but most common around 3-5 weeks

short bowel syndrome: management

- supplementary parenteral nutrition (TPN), IV fluids - central line access - monitor skin integrity - monitor weight, intake, and output carefully

hirschsprung disease: management

- surgical correction: determined by the child's health and comorbidities - short-term colostomy may be necessary - nursing care: pre-and postop care, pain control, prevent infection, monitor VS, ostomy care, NPO

Respiratory effects of increased pulmonary blood flow: PDA

- tachypnea - retractions - hypoxemia - hypercapnia

Kawasaki: nursing care

- temp q4h and before ASA - ASA 80-100 mg/kg/day for fever (every 4-6 hours) - ASA 3-5 mg/kg/day as antiplatelet, post fever (x1/day) - IVIG: strict instructions, watch for reaction. Treat it like a blood product administration. once afebrile, dose of aspirin is decreased.

Defects with decreased pulmonary blood flow

- tetrology of fallot - tricuspid atresia

best outcomes for drowning

- those submerged less than 5 min - CPR for less than 10 min

Pediatric vaccine injection sites

- to 2 years: anterior aspect of thigh - 3+ years and up: deltoid unless there is not much muscle - DO NOT ASPIRATE - Separate injection sites about 1 in apart.

functional abdominal pain: patho

- unclear etiology, but likely multifactorial - may result from alteration in transmission of messages between the enteric and CNS - no structural or biochemical abnormalities identified

Sad HTN facts

- up to 5% of children and adolescents may have essential hypertension, up to 11% in some minorities (highest in AA, then Native Hawaiians/Pacific Northeasts, Asians, and lastly American Indians) - effects of hypertension begin in childhood - HTN kids usually have other health problems (CV issues, renal issues, obesity, DM, dyslipidemia)

omphalocele: managment STERILE ALWAYS

- upon delivery, dress with saline-soaked gauze and impermeable dressing (*STERILE*) - NG to decompress stomach - establish IV access - admin abx - maintain NPO: cannot feed baby - monitor: UOP, temp, FE status, protein losses - assess pain

Prompt tx during acute phase

- use immunoglobulin G

atrial septal defect: shunt from left atrium to right atrium

- used to be foramen ovale but stayed open - opening between RA and LA allows blood to flow from the LA (has already been to the lungs) - returns via the opening in the RA instead of flowing through the LV out the aorta and to the body - low pressure in right side of the low bc lungs are low pressure so blood moves to the right side; but more blood causes a problem -25% of defect and few symptoms unless they are really big - more passive than VSD

treatments for ASD (atrial septal defect)

- usually close spontaneously - incidence of ASD: 25% - can close with a heart catheter in the right atrium to apply a patch on the hole or stitch it with a purse string stitch

Caring for the child undergoing a cardiac cath: pre procedure

- usually outpatient - consent signed - NPO - empty bladder - oral sedative - VS - *check and mark pedal pulses* : highly important, esp for pts with hypotension risk or compromised blood flow

oral lesions: patho

- variety of causes, include apthous ulcers (canker sores), gingivostomatitis (from HSV), and herpangina - affects nutrition bc kid won't eat as much

Malrotation & volvulus: most common sx, hx and assessment (including comprehensive abdominal exam)

- vomiting is the most common sx; *bilious emesis is observed* - signs of small bowel obstruction occur; abdomen is firm and distended - bloody stools may be present - comprehensive abdominal exam; recurring abd pain, distension, absent bowel sounds, tympany on percussion

pt education

- wear helmet when riding a bike!!! - the helmet can take a great force!

When is PDA a good thing?

- when there is not enough blood flow

Anorectal malformations: patho

- wide spectrum of anomalies of the rectum, distal anus, urinary tract, and genital tract (stenotic anal passage, membrane may not connect to anus, anus covered with membrane, fistulas) - imperforate anus, cloacal malformation (urethra opens for vagina and rectum)

physiological hyperbilirubinemia (jaundice): hx and assessment

- yellow discoloration of the skin, sclera, and mucous membranes. not a serious LIVER disease - progresses cephalocaudally - infants may also present with poor feeding and lethargy - if untreated, encephalopathy can occur

roles of the pediatric nurse

-Advocate, educate pts and fam, care management, culturally-focused -providing care across continuum, based on growth and developmental needs, in a variety of settings - preventative care and anticipatory guidance!!! -research -nursing process

Genetic Inheritance of CF

-Autosomal recessive trait -Multisystem disorder of the exocrine glands with increased production of thick mucus both parents must carry the gene for the child to be affected. 70% are diagnosed before the age of 2 years. If both parents have a mutated gene, there is a 25 percent (1 in 4) the child will have CF, a 50 percent (1 in 2) the child will be a carrier but will not have CF and a 25 percent (1 in 4 chance) the child will not be a carrier and will not have CF Exocrine glands- job is to produce mucous

Kohlberg Stage 2: Conventional

-Conscience or an internal set of standards becomes important, but are based on beliefs/teachings of others (such as parents, teachers) - starts to have empathy and compassion for others "wrong to steal but understand b/c doing if for someone they loved" - rules are important to keep order in the world. (if everybody was stealing, the world would be unsafe) - 7-11 years

Replacement fluids

-D5W used to restore water loss, plasma volume, and calories. Lowers Na levels HOWEVER, using glucose can lead to cerebral edema (used for hypertonic issues) - NS used to restore water and sodium loss; maintains Na and CL at present levels (used for isotonic) - ringer's solution used to expand ICF and replaces ECF losses (hypotonic issues) -LR used to replace fluid loss from burns, bleeding, and severe DA (components very similar to ringer's plus added bicarb) (hypotonic) - LR (RL?) or NS is usually used first followed by or accompanied with dilute saline (1/4 or 1/2 NS) **DO NOT ADD KCL UNTIL AFTER THE CHILD HAS VOIDED**

Kawasaki: Acute phase. Most dangerous. 1st 2 weeks

-Fever for 5 days that is unresponsive - irritability - conjunctival hyperemia - red throat - swollen hands and feet - rash on trunk - enlarged lymph nodes - diarrhea - hepatic dysfunction - vessel inflammation leading to aneurysm of vessel -abx or antipyretics don't help bc no infection

Key Nursing Interventions for PNA

-IV Antibiotics Encourage Airway Clearance: -CPT or Vest -Ambulation -Incentive Spirometer -Maintain Hydration (facilitates airway clearance-thins secretions) -Fever Control -Aerosol treatments - Some severe pneumonia will have chest tubes(empyema)

Dominant vs recessive

-Males and females are equally affected -Autosomal dominant: 50% chance an affected parent will pass the altered disease-producing gene to the child. -Autosomal Recessive •Each child born to carrier parents has a 25% chance of inheriting two copies of the gene (to be affected) •50% chance of being a carrier •25% chance of having two "normal" genes

PEDICULOSIS CAPITIS (Lice)

-Most common in ages 3-12 years of age (sharing hats, headbands, playing close together) - ALL socioeconomic populations are affected. Not a matter of being dirty!! - African-American population very rarely affected bc they typically have more oil - Spread through direct hair to hair contact or hair contact with contaminated objects (i.e. towel, brush, hats etc) - Severe pruritus bc of bug anticoagulating-saliva! - Treatment: Pediculicide shampoo (pyrethrin) &/or ovicidal rinse shampoo (Nix-permethrin) Should be applied x 10mins rinsed then nits removed by comb. - Whole fam should be treated! All clothing and sheets need to be washed. Do management again in 7-10 days bc lice are adapting and becoming immune - Mayonnaise and shaving head can help but won't get rid of bugs

hypertrophic pyloric stenosis: management

-NPO until after surgical correction - meet fluid, electrolyte, nutritional needs - prevent infection, promote comfort, support parents

Kohlberg: stage 3 post-conventional

-Not everyone reaches this stage; Person has their own internalized ethical standards that they use to make decisions; - Greater Good, relate human rights to laws. "Laws not always morally correct" -times when rules might work against certain groups of people and need to change "ok to steal ok b/c life is more important" - has own ethical standards and looks at greater good - laws and ethics may collide with each other (ex: someone steals bread to feed starving family) -12+ years

Effort of breathing: Ausculatory findings associated with Respiratory Distress

-Wheeze- where in breath is it occuring? -Inspiratory / Expiratory lengths -Depth of Respiration

lice

-Wingless clear/yellow/brown insect about the size of a sesame seed (hard to find on blonde hair) - Nits are silvery/white, yellow or darker and about 1mm in size - Females can lay up to 10 nits (eggs) a day. Need nit comb

Culture affecting child health

-World view, traditions - cultural competence is important: self-awareness, knowledge, skills and practices, encounter - ethnicity - Changing demographics

Piaget stage 3: concrete operational

-conservation: understand that some matter stays the same when it altered - know that things can be fixed to the original state - understands ABC order and classifications (fruits vs meats) - cannot do deductive reasoning (algebra and calculus) (if a >b and b>c then a>c) -Understand reversibility=broken toy can be fixed and be the same as before it was broken, - 7-11 years

Isotonic/iso-natremic (70%) fluid calculations are based on this

-equal loss of water and electrolytes - serum sodium normal - occurs when fluid loss not balanced by intake - causes: vomiting and diarrhea in children

Family affecting child health

-family structure -types of fam structure - fam roles - parenting styles: authoritarian (more strict and expect obedience), authoritative (rules are enforced but children have autonomy), Permissive (very little control of child's behavior), and uninvolved/rejecting/neglecting. -Discipline: positive reinforcement vs criticism

Necrotizing enterocolitis: management and complications

-gastric decompression, bowel rest, TPN, abx, surgical resection, ostomies - complications: short gut syndromes, intestinal strictures, impaired G & D

Health status & lifestyle influencing child health

-growth and development - disease - nutrition - lifestyle choices - environmental exposure - stress and coping - access to health care - barriers

Developmental theory

-helps us organize our observations of behavior into a description of principles or set stages - helps us understand/explain progression and development, know what to expect - helps identify delays, missed stages; provide anticipatory guidance

ortolani test

-hip abduction w/a resulting clunk as the head relocates into the joint. Hip joint is reduced (or relocated) through abduction.

Piaget stage 2: preoperational

-imaginary play/ vocabulary and comprehension increase greatly, but shows egocentrism (inability to see things from the perspective of another) - animism: magical thinking. imaginary play with vocab increasing ex: tell a child we are taking BP, the child may actual think you are taking blood from their body. - transductive: cause and effect reasoning. ex: they got in trouble from hitting their bro, then, they woke up with the flu. they think they got sick bc they hit their bro. - egocentrism: can only see their perspective. interferes with new siblings -unable to do conservation (when you are able to understand that matter does not change when it is altered; discerning between quantitative and appearance.) Ex: a 0.5 cup of water and pour it in a bowl. It is the same amount, but the 4 year old cannot identify that they are the same amount. - 2-7 years

Family-centered care

-prevent or minimize separation of the child and fam- even in code situations - respect, collaborate - culture, ethnic, socioeconomic diversity - identify strengths, empower families - assess support systems - flexibility, maintain home routines when possible

patho of PDA

-pulmonary vascular resistance falls (normal in newborn) - shunt develops - blood pushed out of aorta into pulmonary artery

Community affecting child health

-school - peer groups - neighborhoods - violence: home, school, crimes, and suicide

Hospital : pediatric nursing

-separation anxiety, regression, fear - affected by developmental level, previous experience, parental response, reaction - Nurses' role: admission, departments, education, support, safety, development, play - care for the whole family

Mercury in Vaccines

-tiny amounts of mercury used as a preservative in vaccines from temerisol -mercury is known to cause brain damage -was removed from vaccines in the early 90s, but autism rates continued to rise -CDC & NIH concluded that there is no link between mercury and autism

congenital diaphragmatic hernia: management

-to NICU, intubated and placed on ventilator - once stabilized, surgical repair occurs - monitor VS, frequent resp assessment - cardiac assessment (risk for pulmonary HTN and HF) - neuro assessment (risk for rising CO2 levels)

mixed lesions types

-tranposition of the great arteries - hypoplastic left heart

Patho of transposition of the great arteries

-unoxygenated systemic blood enters RA to RV to aorta to body - Oxygenated pulmonary blood enters LA to LV to PA to lungs - profound hypoxemia and cyanosis - must have additional defect to survive BIGGEST problem: hypoxemia and cyanosis

15.7 (Language) Table

1 mo Has different types of cries for hunger, discomfort, sleepiness 2 mo Coos Makes gurgling noises 4 mo Turns to voices Makes extended cooing sounds 6 mo Babbles by stringing vowels together Begins to make consonant sounds Has sounds for joy and displeasure 9 mo Copies sounds Says "mama" and "dada" nonspecifically Looks around when someone says, "Where's your toy?" Understands "no" 12 mo Uses "mama" and "dada" specifically Says one word other than "mama" and "dada" Follows one-step directions Uses simple gestures

15.8 (Social/Emotional Develop) Table

1 mo Looks at parent Calms down when picked up or spoken to 2 mo Has a social smile Has sounds that differentiate between happy and upset 4 mo Laughs out loud Copies some facial expressions 6 mo Looks at self in a mirror Knows familiar faces Notices strangers 9 mo Plays games such as "peek-a-boo" and "pat-a-cake" Has a favorite toy Waves bye-bye May be afraid of strangers 12 mo Imitates parents and caregivers Cries when parents leave Can put arms up to help with dressing

15.5 (Gross motor) Table

1 mo = moves arm and legs together. holds chin up when lying down 2 mos= lift head and chest while on stomach, keeps head steady in sitting position 4 mos = supports self on elbows and wrist when on stomach, rolls from stomach to back 6 mos = rolls from back to stomach, sits in tripod position, sits briefly without support 9 mos = sits without support, pulls to stand, lying to sitting position, crawling 12 mos = stands independently, may take first steps

15.6 (Fine Motor) Table

1 mos = open fingers slightly 2 mos = brings hands together. opens and closes hands 4 mos = keeps hands relaxed, grasps objects, brings hands to the mouth 6 mos = transfers objects from one hand to the other, raking grasp, bangs objects on surface 9 mos = feeds self, 3 fingers and thumb to pick up stuff, lets go of objects on purpose, bangs objects together 12 mos = pincer grasp, feeds self with cup and spoon, holds crayon with whole hand

Patent airway: compromising conditions

1) Head: Foreign Body, Nasal Obstruction, Tongue 2) Mid airway - larynx and Trachea: croup, FB, Epiglotitis, laryngomalacia 3) Distal/lower airways - bronchus and bronchioles: Asthma, bronchitis, F.B., C.F., atelectasis

Role of lungs

1)Get Oxygen into the body 2)Eliminate CO2 out of body

ILAE seizure classification

1. *focal onset* 2. *generalized onset* 3. unknown onset

Types of skull fractures (know this)

1. *linear: most common, least serious* 2. depressed: indentation of skull bone 3. diastatic: along suture lines 4. *basilar: MOST SERIOUS bc close to brain stem, uncommon*

Box 20.2: formula for fluid maintenance

1. 100 ml/kg for first 10 kg (1000mg max) 2. 50 mL/kg for next 10 kg (500mg max) 3. 20 mL/kg for the remaining kg - Add together for total mL needed per 24 hour period - then divide by 24 for ml/hr fluid requirement. Answer can have a tenths place. - WATCH OUT FOR 1.5 maintenance bc that means you have to multiple the rate 1.5x

Two types: Hydrocephalus do not need to know difference

1. Communicating - the blockage of flow or absorption of CSF in the subarachnoid space. 2. Non-communicating - a blockage of the ventricular system that prevents CSF from entering the subarachnoid space.

Indications for ICP Monitoring

1. Glasgow coma scale 2. Deteriorating neurologic condition 3. Subjective judgment

Erikson stages (first 5 stages)

1. Infant: (0-1yr). Trust vs. Mistrust. "HOPE" -depend on caregivers for basic needs and developing trust as needs are met -neglected children have social mistrust -ex: baby is hungry and gets a bottle 2.Toddler: (1-3yr). Autonomy vs. Shame/Doubt."WILL" -terrible twos and strong-willed children who learn to do things independently. give children autonomy -kids will often say no even if it's something they want because they are learning to have some control over things in their life -potty training stage. positive reinforcement is needed for healthy development. 3. Preschool: (3-6yr). Initiative vs. Guilt."Purpose" -setting goals (drawing things) and working towards them. -ex: wanting to help parent with tasks. miniature kitchen - feel guilty if cannot complete goals, so give achievable goals. no constant criticism! 4. School: (6-11yr). Industry vs. Inferiority. "Competence" - listen to feedback from adults and peers to get a sense of self esteem - praise from completing big tasks = positive self-esteem - negative feedback = low self-esteem - balance positive feedback with a sense of realistic perspective. (no one is perfect. no trophies for everyone.) 5. Adolescent: (12-20yr)/ Identity vs. Role Confusion. "Fidelity" - separation from caregivers and closer to peers - peers and age groups are important. bullying can really take into effect. - trying out roles to find their fit and beliefs. - confusion = cannot find fit

Tanner stages for females

1. breast = no change. pubic hair = none 2. breast = elevated, enlarged areola. pubic hair = scant, light color 3. breast & areola enlarged, no contour between. pubic hair = darker curls 4. areola forms mound separate from breast. pubic hair resembles adult but scant 5. adult breast with nipple projected. adult pubic hair

intracranial hemorrhage (know this): epidural vs subdural hematoma

1. epidural (extradural) hematoma: accumulation of blood between the inner skull and dura matter; outside of brain - can be from blunt force, sheering, skull fracture self-tearing underlying blood vessels 2. subdural hematoma: between surface of brain and dura matters; bleeding by brain tissue - can be from stretching and/or tearing of veins; see it with head injuries where head is jolted or brain is shaken (shaken baby syndrome)

4 types of spinal muscular atrophy

1. infantile onset (most severe and earliest, before <6 mos): without intervention, kids do not live past 2 years old. - unable to sit without assistance - progressive difficulty swallowing, feeding, breathing - resp insufficiency and resp failure are from weakness of intercostal muscles and general mobility Type 2. 6-12 mos of age. - can sit and maybe stand without assistance - won't walk - difficulty swallowing and chewing - resp insufficiency and scoliosis Type 3: later in childhood, less severe sx - walk but fall frequently - eventually lose ability to walk as disease progresses - likely need a wheelchair Type 4: onset after age 18

Tanner stages for males

1. penis = no change. testicles = no change. no pubic hair 2. penis = no change. testicles = enlarges scrotum. pubic hair = scant, light colors 3. penis = increased length. testicles = increased size. darker curls pubic hair 4. penis = increased breadth. darkened scrotum. scant, but adult-resembling pubes 5. adult size penis and testicles with adult pubic hair

Key components of respiration

1. respiratory muscle function 2. patent airway 3. functioning alveoli (O2 and CO2 exchange) 4. pulmonary blood flow 5. adequate respiratory rate

Piaget's stages of cognitive development

1. sensorimotor 2. preoperational 3. concrete operational 4. formal operational stages can overlap unlike erikson's stages

Treating dehydration: calculating percent dehydration (percent weight loss) and severe dehydration tx; math for fluid replacemtn

1. subtract present weight from original weight 2. divide loss by the child's original weight ex: 36 kg - 32 kg = 4 kg 4 kg/36 kg = 0.11 = 11%loss ***For severe dehydration - BOLUS: 20 ml/kg of NS or LR**** (final exam) Fluid replacement: %dehydration x 10 = ml/kg/24 hours ex: 11 x 10 = 110ml/kg/day 110 ml x 32 kg = 3520 ml/day = 146 ml/hr give half in first 6-8 hours

ACNE TREATMENT: education

1.Daily hygiene! (remind family improvement can take up to 8 weeks after any acne treatment begins). Wash face 2xday (AM and PM) 2.Sweating, heat, humidity, and emotional stress may cause worsening in flare-ups even with treatment. (active and sweaty = wash face more) 3.Misconceptions: No foods have been identified as a cause but any skin injury requires good nutrition to aid in healing. (however if body not healthy, it can't repair skin injury) 4. DO NOT pick or squeeze lesions. Worsens inflammation and increases risk of infxn. 5. Wash hands first before washing face 6. Assess emotional status. Acne is a major reason for decreased self esteem = decreases social interaction = poor emotional health = depression = suicidal ideation.

3 main layers of the skin

1.Epidermis: The outermost layer. It is a thin layer that sheds repeatedly. Contains the melanocytes. 2.Dermis: The middle layer that is mostly connective tissue which helps skin to stretch and contract. Contains hair follicles, nerves, muscles, sweat & sebaceous glands, blood vessels, and lymph channels. 3.Subcutaneous Layer: Fatty layer which helps to connect dermis to muscle and insulate.

ACNE DIAGNOSES

1.Mild Acne: Non-inflammatory comedones. (whiteheads) 2.Moderate Acne: Inflammatory comedones, papules & pustules (whiteheads + papules and pustules) 3.Moderate/Sever Acne: Inflammatory, numerous papules, localized cysts OR nodules, face, chest, & back involvement 4.Severe Acne: Nodular & Cystic acne on face, back and chest, numerous cystic lesions & pustules may be present

3 main glands contained in the skin

1.Sebacious Glands: Help to lubricate the skin by secreting sebum (lipid substance) directly onto the skin or into the hair follicles. (found everywhere except soles and palms) 2.Eccrine Sweat Glands: These open into the skin surface. Responsible for releasing odorless sweat when the body temperature rises. (fever) 3.Apocrine Sweat Glands: Glands found mostly in the axillary and genital region. Secretions from these glands contain more lipids and proteins than the eccrine gland secretions which causes "body odor".

Acne tx: meds

1.Topical medications include topical antibiotics, benzoyl peroxide, azelaic acid, and retinoid. 2.Oral medications include antibiotics, oral contraceptives (for females to help hormone balance), and spironolactone (androgen blocker for females). 3.Isotretinoin (Acutane)- used as last resort d/t major side effects (educate pts and fam to look for suicide ideation and teratogenic effects = female teenagers can create severe fetal defects). iPLEDGE program to monitor pt's tx regimen and pledges to be on 2 forms of BC (condoms, abstinence, pills). Males have to be in iPLEDGE bc some males can share meds with females.

Patho of Bronchiolitis

1.virus invade mucosal cells; 2.cells die causing debris which clogs airway. 3.Causes irritation, causes more mucus & bronchospasm. 4. Air can come in - trapped & difficult getting out. Air trapping

16.4 (Language) Table: TOddlers

15 mos Follows simple commands Names a familiar object Uses jargon 18 mos Says single words Shakes head no Names two body parts Names five objects 24 mos Uses two-word sentences Follows simple directions Names five body parts Points to pictures when named Has a vocabulary of around 50 words 36 mos Uses three-word sentences Repeats a story from a book Understands prepositions such as "over," "under," and "in" Strangers can understand 75% of the child's speech. Says name and age Uses plurals

16.5(Social/Emotional Develop) Table

15 mos Hugs parents Points to things he or she wants May have a security object 18 mos Looks at an adult if something new happens May have temper tantrums Begins to indicate when diapers are wet or soiled Plays simple pretend games 24 mos Imitates others Likes to be with other children Shows defiance Shows more independence Likes to talk about what is happening 36 mos Eats independently Begins to share Separates easily from parents Shows affection and concern

16.3 (Fine Motor) Table: Toddlers

15 mos Marks with a crayon Puts objects in and out of cups 18 mos Scribbles spontaneously Rolls a ball Eats with a spoon Helps undress self 24 mos Copies straight lines and circles Stacks objects Turns pages Throws a ball overhand 36 mos Turns a door handle Screws lids on and off Copies a circle Builds a tower of six or more blocks Undresses self

16.2 (Gross Motor) Table: Toddlers at 15 mos, 18 mos, 24 mos, and 36 mos

15 mos Squats to pick up objects Crawls up steps Drinks from a cup 18 mos Walks independently Pushes and pulls toys when walking 24 mos Runs Kicks a ball Jumps with two feet Climbs on furniture 36 mos Pedals a tricycle Jumps forward Walks up and down stairs with one foot on each step

degrees of burns (just know that this is how they are diagnosed)

1st = (superficial thickness) epidermis; pain, redness, swelling 2nd (partial thickness): epidermis and dermis; pain, redness, swelling, blistering 3rd: (full thickness) into deeper tissues; white or blackened, charred skin that may be numb

Whooping cough/ Pertusis

2012 : slight increase. worldwide = thousands die, esp infants US = babies cannot get DTap till 3 months. If you have a cold, do not touch or kiss baby! They are not 100% protected till kindergarten (age 5 or 6). Educate that boosters are important

Mumps

2016 - had a ton of cases bc of college students. Recommended to revaccinate before college. Prevalent in Midwestern colleges

17.5 (Social/Emotional Develop) Table: preschool (3-5)

3 Goes to the bathroom by self Cooperates and shares Understands "mine" and "yours" Separates easily from mom and dad Copies adults Shows concern 4 Likes to do new things Engages in creative and imaginative play Likes to play with other children Talks about interests Follows simple rules May not be able to differentiate "real" from "make-believe" 5 Follows simple directions Wants to please friends Understands gender Differentiates between "real" and "make-believe" Is likely to follow rules

17.3 (Fine Motor) Table: preschool age

3 Is able to put on a coat by self Draws a single circle Draws a person with a head and one body part Does puzzles with three or four pieces Builds a tower of more than six blocks Turns pages one at a time Holds a pencil with the whole hand 4 Draws a person with three body parts Draws a cross Buttons and unbuttons large buttons Grasps a pencil with the thumb and finger Uses a pair of scissors 5 Draws a person with at least six body parts Prints some letters and numbers Copies shapes Uses a fork and spoon

17.4 (Language) Table: preschool (3-5)

3 Speaks in three-word sentences Strangers can understand 75% of the child's language. Follows instructions with two or three steps Names a friend 4 Uses "he" and "she" correctly Sings songs Tells stories Strangers can understand 100% of the child's language. Uses four-word sentences Knows some colors and numbers 5 Counts to 10 Names at least four colors Uses full sentences Knows name and address Understands and uses the future tense

17.2 (Gross Motor) table: preschool age

3 Walks up and down stairs with one foot on each step Pedals a tricycle Runs well Jumps forward 4 Climbs and hops Stands on one foot Catches a bounced ball 5 Swings Climbs Stands on one foot for 10 s Somersaults

Tetralogy of Fallot (TOF)

4 required defects: 1. pulmonic stenosis 2. right ventricular hypertrophy 3. ventricular septal defect (VSD) 4. *overriding aorta*: overides medially!!! -HYPOXEMIA = major symptom bc of decreased blood flow due to stenotic area

SpO2

95% is normal 90-95% -abnormal but doesn't necessarily require O2 < 90 => supplemental O2

Sudden Infant Death Syndrome

<12 months - 90%: age of 2 weeks - 6 months Autopsy (discover underlying problem), history, & death scene investigation (child abuse is possible) Unexplained cause, unobserved Differing thoughts on causes: immaturity of respiratory center (majority: 90%), brain stem defects, infections, cardiac arrhythmia, acidosis Probably more than one cause

increased pulmonary blood flow under high pressure (systemic)

= interstitial water development making lungs stiffer = decreased lung compliance = increased WOB (work of breathing)

Dermatome

A localized area of skin that is has its sensation via a single nerve from a single nerve root of the spinal cord

Defects with increased pulmonary blood flow

ASD, VSD, PDA

Hydrogen Ion Regulation in Body Fluids

Acid-base balance is what keeps [H+] in normal range -For best results, keeps pH 7.35-7.45 Ventilation ↑ CO2 + H2O ← H2CO3 ← HCO3- (from kidneys) + H+ H+ is Acid - the more you have, the more acidic the body is decrease CO2 = alkalosis; increase CO2= acidosis

Provide emotional & psychosocial support

Acute: anxiety and fear Chronic: lifestyle changes Congenital anomalies: overwhelming Provide support: clear and concise explanations, time for questions, express frustrations, process information, write down questions, allow time for parents to bond with child, provide resources

Asthma: Management-what we can do

Airway Breathing -Sitting position -Humidified O2 titrate based on O2 sats: Dry O2 dries mucus, worsens plugs - Monitor for Respiratory Failure - Encourage coughing in recuperative stage if atelectasis present - Consider intubation, assisted ventilation Asthmatics are also prone to development of atelectasis or mucous plugging which can result in full or partial collapse of one or more lobes of the lung.

EMERGENCY/RESCUE MEDICATIONS (just know types)

Albuterol (Maxair, Ventolin, Proventil, ProAir, Xopenex) -short-acting bronchodilators* - can also take albuterol before exercise -induced asthma Oral / IV steroids - Prednisolone , Dexamethasone and Solu-Medrol

Hospital Help: 17.1: preschoolers

Allowing the hospitalized preschooler to play with medical equipment can help alleviate anxiety. Having the child perform pretend procedures on dolls or stuffed animals gives him or her the opportunity to become familiar with medical equipment and can help alleviate fears of being in the hospital

Treatment of Pulmonary Exacerbations

Antibiotics ¢Intravenous (usually takes two meds) -Peripheral IVs -Implanted venous access/ports -PICC line Aggressive airway clearance - Oxygen- Intermittent with exacerbations - Nutrition

Live Virus Vaccines

Are attenuated (weakened) form of the virus. §Because it is the closest thing to a natural infection, these vaccines are good "teachers" of the immune system. §They elicit strong cellular and antibody responses and often confer lifelong immunity with only one or two doses. §They are unstable and have to be refrigerated. §Examples: MMR, Varicella - can mutate and cause mild forms of the disease

Developmental Dysplasia of the Hip: Assessment

Assessment is the most important means of detecting - limited leg movement, esp adduction - diff leg lengths - uneven skin folds of thigh of affected limb •_ortolani_ Test: hear the palpable audible clonk when there is abduction and depression of the femur (nice ABs, ortolani) •_barlow_ Test: hear palpable audible clonk when the dislocated hip is *adducted* and relocated

Understanding Piaget's Theory

Assimilation - taking a new experience/information and adding it to what you already know. Ex: a 2-year-old who has a dog at home and has only seen dogs is going think all animals with four legs are dogs and the child may call a horse a dog. Accomodation - taking existing information and adapting it to new information. Ex: the 2 year old identifies that horse correctly.

Asthma vs Bronchiolitis

Asthma - Age - > 2 years - Fever - usually normal - Wheeze - Family Hx - positive - Response to Alb. - positive - Response to Steroid-positive Bronchiolitis - Age - < 2 years - Fever - positive - crackles - Family Hx - negative - Response to Alb. - negative - Response to Steroid- negative

Status asthmaticus

Asthma attack unresponsive to b-2 adrenergic agents Increasingly severe asthma unresponsive to vigorous treatment Medical emergency leading to respiratory failure, death May require Intensive care unit / ventilation NPO, IV, O2, ABG's, serum electrolytes, pulse ox

Epilepsy is defined by the International League Against Epilepsy (ILAE) as a disease of the brain with the presence of any of the following: do NOT need to memorize, just know that epilepsy has a complex dx

At least 2 unprovoked (or reflex) seizures occurring greater than 24 hrs apart 1 unprovoked (or reflex = have a specific trigger like flashing lights or patterns) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after 2 unprovoked seizures occurring over the next 10 years Diagnosis of an epilepsy syndrome

Complete obstruction interventions

Attempt to clear using BLS techniques (Heimlich maneuver) Attempt removal with direct laryngoscopy and Magill forceps Cricothyrotomy may be indicated

understanding fetal circulation is key to understanding congenital heart lesions

Baby has 3 shunts: 1) Ductus venosus 2) foramen ovale: shunts highly oxygenated blood right to left across the foramen ovale (hole in atrial septum) so the rest of the body can have highly oxygenated blood 3) ductus arteriosus: protects against circulatory overload and strengthens right ventricle bc of the pressure - shunts function to protect lungs. lungs in utero are in very high pressure for a defense mechanism of having too much blood flow to it. the systemic pressure is low in utero. this is opposite from what is going on right now.

Rocky Mountain Spotted Fever

Bacteria: rickettsia rickettsii Tick bite transmission. American Dog Tick - prodromal: fever, malaise, N/V, headache, photophobia, mental confusion - exanthem: 2-5 days after inoculation, causing a blanching response, non-pruritic, erythemaous macule rash that spreads to hand palms and soles of feet; rash become petechial or purpura rash Incubation: 2-14 days Treatment is doxycycline (within 4 days of symptom onset, based on presumptive reasoning even without rash). -cycline not given children under 8 bc of staining of teeth; however, this is the only drug that will treat this fever. More concern about treating this fever than teeth staining. Prevention via protection from vector Complications: meningoencephalitis, liver impairment, myocarditis, death - lab work takes a while and you need to be treated within 4 day window. go ahead and treat with doxcycline

Lyme disease #1 reported vector

Bacteria: spirochete borrelia burgdoorferi Deer tick bite transmission exanthem: 3 clinical stages: 1. early/localized: 7-14 days after bite. erythema migrants. starts as a macule then expands to lesion patch. fever. headache. arthralgias 2. early dissemination: 3-5 weeks after inoculation. multiple erythema migrants. cranial neuropathies added to symptoms 3. late stage: weeks to months after inoculation. arthritis and encephalopathy Incubation: 1-55 days Treatment is amoxicillin (< 8 years) and doxycycline (>8 years). Is cured within the first 2-4 weeks if abx tx was started Prevention via protection from vector. Education for tick prevention. Complications: CNS deficits if untreated

Hospital Help: 16.1

Before any procedures, allow the toddler to touch safe medical equipment to see that it is not harmful. Use positive words. When measuring blood pressure, tell the toddler you are "going to give his arm a hug." When inserting an intravenous catheter, tell the toddler you are "going to put a straw in her arm because she is too sick to drink." Avoid phrases such as "take your blood" or "give you some dye" when explaining procedures.

CF and the liver

Bile ducts in liver may become obstructed by thick mucous secretions Can result in biliary cirrhosis

pertussis on rise bc immune effects of last vaccination was not as effective and less people getting vaccinated "100 day cough"

Bordetella pertussis Droplet, respiratory membrane discharge Communicability: 1 week post exposure to 5-7 days after antibiotics started Incubation: 6-21 days Stages: - Catarrhal: nasal congestion, rhinorrhea, fever, mild non-productive cough (2 weeks) - Paroxysmal: more severe cough (expel mucous plug), forceful inspiration (whooping) (1-4 weeks) - Convalescent: up to 6 weeks, reduction of symptoms Treatment: antibiotics. suctioning! pushing fluids! Prevention: Vaccination! Boosters! most vulnerable = children < 3 mos. and <1 year complications: pneumonia, otitis media, encephalopathy, seizures and death esp under 1 year of age

Development of Neuro system

Brain and spinal cord develop early in gestation from the neural tube. Insults during early gestation can result in central nervous system malformation. - Infants are born with all the nerve cells they will have but they are immature and glial cells and myelination of the nerve fibers continue to mature throughout childhood. - Brain cells continue to develop so drug, alcohol abuse, and brain injuries should be educated upon in adolescents, esp bc they think they are incapable of bad things happening to them.

Respiratory Illnesses Causes (4)

Breathing Cessation Upper Airway Mid Airway Lower Airway

CF & the Respiratory System

Bronchial mucous creates a great environment for bacterial growth - results in pulmonary exacerbations Chronic & progressive disease -98% of morbidity and mortality is pulmonary -Impaired gas exchange & hypoxemia lead to respiratory failure Frequent hospitalizations of CF patients for antibiotic tx related to bacterial infections

Early Increased ICP: additional signs in infants (know this)

Bulging fontanel Wide sutures, increased head circumference - VOMITING AND POOR FEEDING Dilated scalp veins (depends on hair) *High-pitched, catlike cry, difficult to soothe* (nervous system is causing this cry)

Patient Teaching: 16.1 = Safety in Toddlers

Burns •Use the back burners when cooking on the stove. •Keep the hot water heater set to no higher than 120°F •Keep toddlers away from hot objects such as grills, ovens, and irons. Falls •Do not allow children to climb on furniture. •Supervise children when they are going up and down stairs. •Supervise children when they are on playground equipment. •Have gates at the top and bottom of stairs. •Have toddlers wear helmets as they learn to pedal a tricycle. Poisoning •Keep all cleaning products out of reach; use cabinet locks if kept in low cabinets. •Keep all medications out of reach. •Have the number for poison control easily accessible. •Keep plants off of the floor. •Keep any alcohol or tobacco products out of reach. Choking •Avoid giving children foods that can cause choking: ᴑNuts ᴑHard candies ᴑHot dogs ᴑWhole grapes ᴑMarshmallows •Supervise children while they are eating. •Cut food into small bites. Drowning •Have a fence around backyard pools. •Supervise children when they are around water. •Have locks on toilet seat lids. •Do not leave buckets of water around. Firearm Safety •Remove firearms from areas where children play and sleep. •Lock all firearms in a cabinet. •Make sure firearms are not loaded. Motor Vehicle Safety •Children can ride facing forward in a seat with a five-point harness, but it is recommended to keep them rear facing until they are 2 y old. •Children must remain in a forward-facing seat with a five-point harness until they are 4 y old.

Each Respiratory Component may require a different intervention

By correctly identifying the affected component and performing an accurate respiratory assessment we as nurses can intervene effectively!!!!!!! Key Components of Respiration 1) Respiratory Muscle Function 2) Patent Airway 3) Functioning alveoli 4) Adequate respiratory rate Check practice case studies on ppt

CF and the Endocrine System

CF related Diabetes CF patients cannot absorb fats due to lack of enzymes Fat build-up in the pancreas disrupts insulin secretion Insulin deficiency is the hallmark

Common causes of respiratory acidosis

CNS Depression: anesthesia, sedative drugs, narcotic analgesics NMS Disease: poliomyelitis, mysathenia gravis, guillain-barre syndrome Trauma: spinal cord, brain, chest wall, severe restrictive disorders, obesity (Pickwickian syndrome), kyphoscoliosis Abnormal lungs: COPD, acute airway obstruction

Why is CO2 elimination important??

CO2 is critical to maintaining the pH (acidity) of our body

airway clearance techniques: directions

CPT: chest physical therapy in the AM & PM Increase amt of CPT during resp infections FLUTTER- helps remove mucous by breaking it up and coughing it out Aerosols are administered before CPT to help open up the bronchioles for the evacuation of secretions Dornase Alfa: Enzyme that when inhaled via nebulizer will reduce sputum viscosity (thins mucous)

Otitis media

Can be both bacterial or viral: Most common is S. pneumonia and H. influenza More common in children d/t anatomical differences of the Eustachian tube that lay parallel to jaw bone so nothing drains out; nasal drainage, saliva, and other fluid just stays there. Symptoms: Fever, ear pain, irritability, Two main types: Acute Otitis Media (AOM) & Otitis Media w/Effusion (OME)-build up of fluid in middle ear w/o sxs of infection (clear fluid that can last after infectious fluid goes away) . Treatment: Antibiotics. Educate parents to stay away from respiratory illnesses and getting vaccinated. risk factors: immunocompromised. repeated respiratory infections. allergies. second-hand smoke. severe cases: PE (pressure equalizer tubes) will be put in place to act as a drain. Prevnar (pneumonia) and Hib (H. influenza) vaccine dropped infection cases complications: hearing loss, speech delay, scarring of tympanic membrane called tympanosclerosis that can lead to severe hearing loss or rupture of tympanic membrane, mastoiditis which can lead to intracranial infections and brain abcesses.

Conjunctivitis

Causes: Infection (viral or bacterial), allergic Highly contagious (except allergic) Risk Factors: age, day care, school, chronic URI's Treatment depends on cause (bacterial drops, antihistamine drops): antivirals only if serious Nursing Implications: Medications, warm compresses. - Education re: treatment, and prevention of future infection, avoidance of allergens Bacterial: yellow-green drainage causing irritation from crusting and eyelid swelling Viral: no swelling, redness, extreme amount of watering and tearing, mucoid (watery) discharge, going to have photophobia - can have bilateral or unilateral with bacterial and viral Allergic: always bilateral!! watery/thick drainage. more swelling! never purulent!. not usually itchy but may be irritating

Types of apnea

Central- Complete cessation of breathing-no attempt - this is infant apnea. Seen in SIDs too. Obstructive-Absence of nasal airflow when resp efforts are present. Seen in sleep apnea (hear snoring)

Respiratory muscle functions: compromising conditions

Chest wall trauma Fatigue Spinal cord / Neuromuscular issues Hyperinflation Abd distension

Bronchiolitis: Incidence

Children < 2 years old Epidemics January through May 65% first winter 35% 2nd winter so 100% of kids get it

Epiglottitis: Incidence, ages, prevention

Children > 4 years old Common in ages 4 - 7 yrs Peds incidence falling due to HiB vaccination Can occur in adults, particularly elderly Incidence in adults is increasing

Alertness

Children are on continuum from : Normal--> anxious ---> irritable ---> lethargic

Factors influencing child health: Genetics

Chromosomal alteration: occur during cell division and alteration in structure or number Gene alterations (muscular dystrophy and sickle cell anemia) Principles of inheritance: Mendelian, Polygenic, Multifactorial, Variations Nursing care: Collaborative care, may include genetic testing, diagnostic procedures; family risk assessment (genetic family history); addressing psychosocial issues, advocacy

Asthma sx: classic signs, cough, breathing, status asthmaticus

Classic Signs: - Dyspnea (shortness of breath) - Wheezing - Cough Cough --> cough with mild wheeze-> worsening wheeze - With mild difficulty with breathing - particularly with exertion-> difficulty with breathing with severe wheeze at rest Status Asthmaticus -Unrelenting, respiratory distress w/ bronchospasms unresponsive to tx measures

Coarseness of breathing

Coarseness (stridor) isn't an issue with all patients. It indicates obstruction to flow above the lungs-Upper airway obstruction On a continuum Only when crying->only with deep breathing->with each breath-> with each breath and with associated increased WOB

exercise with CF

Combination therapy with CPT Stimulates cough Helps loosen mucous Results in deep breathing Builds up strength and endurance of respiratory muscles Improves cardiovascular fitness Improves well-being Builds self-confidence, enjoyable, time for a kid to be a kid and have fun without thinking about being "different"

Chronic lung colonization: Common Pathogens in CF

Common organisms - Pseudomonas aeruginosa - Staphylococcus aureus - Haemophilus influenza - Escherichia coli - Klebsiella pneumonia Recurrent exacerbations and resp infections result in progressive lung damage

Interventions

Communication and education ( be aware of reading level) Medication administration: developmental issues, dose calculation, routes IV therapy: medications, fluids, insertion, maintenance, discontinuing Nutritional support: enteral or parenteral

pulmonary blood flow: compromising condition

Congenital Heart Disease, Pulmonary Hypertension, Pulmonary emboli

Ethical & Legal issues

Consent: informed consent, special situations (emergency and parent not available), exceptions (mature minor and emancipated minor), and parental refusal of medical treatment (religious or cultural beliefs conflicting with vaccines and procedures) Assent: the child's participation in the decision-making process Advance directives - DNR/DNAR (do not attempt ressucitation) Confidentiality - exceptions include situation that require disclosure (such as reporting suspected abuse)

Lung Transplantation

Consider lung transplant when FEV1 less than 30% of predicted 50% survival at 5 years post-transplant "one chronic illness in place of another"

Pneumonia - BACTERIA etiology

Consider the age, immunization status and health status of the child Strep pneumonia, M. pneumonia, staph (some MRSA) H. influenza type b Generally think bacterial if lobar pneumonia

Hand-Foot-mouth disease

Coxsackie virus A16 Droplet, Fecal-oral, or skin-oral transmission Communicability: 2 days prior to and 2 days after rash &/or after fever resolves Incubation: 3-6 days Supportive nursing care: extremely painful. Give lots of fluids (popsicles, water) and analgesics (ibuprofen and tylenol) - looks like chicken pox - prodromal: fever and malaise - Enanthems appear in mouth, then vesicles on palms and plantar surface of feet - main complication: dehydration (don't want to drink bc of enanthems) - life threatening to neonate bc of dehydration - can rarely cause meningitis and encephalitis in immunocompromised neonates

Andrew Wakefield

Created a scare through his false scientific research stating the MMR vaccine was linked to autism. - multiple studies failed to duplicate his studies - his study were discredited. - 2010: he came out saying he was funded by autistic families - Wakefield and his team = found guilty of falsfying info and being a fraud for financial gain - unfortunately, some parents still believe in this and cause debate

Even more specific treatments and nursing interventions for scoliosis

Curvature of: •<25° does not require treatment •30 °- 45° in an actively _growing_ child—bracing •Growing adolescents with curves 45 °- 50 °—surgical correction •Activity restrictions— no bending or twisting of the torso, return to school 2-4 weeks, resume normal activities over 3 months-1 year •Pain control— gradual reduction of pain medication (bc of narcotics) •Support body image concerns

covid 19

Data to date suggests that children are infected with COVID -19 less frequently than adults and when infected will have less severe disease. At this time breastfeeding moms should continue to breastfeed despite being positive or suspected to be. More likely to pass on covid 19 through respiratory secretions. Mom should wear mask while breastfeeding and pumping.

barlow test

Detection of unstable hip by adduction and extension of hip. The "feel" of dislocation is felt as femur leaves acetabulum. The femur is adducted and depressed, dislocating the hip posteriorly.

IBD: dx, management, and nutrition

Dx: clinical presentation, endoscopy, colonoscopy with biopsy - lab findings: occult blood (stool), anemia, elevated ESR, hypoalbuminemia, and elevated WBC count management: - hospitalization for flare-ups and complications - nursing management: abx (cipro), steroids, immunosuppressants - medication therapy - surgical removal of colon may be necessary in UC if unresponsive to medications - education and emotional support - maintain skin integrity nutrition: dietary supplements, protein shakes, high-calorie meals, limit fiber intake, TPN (to let intestines heal)

Status Asthmaticus: Signs/Symptoms

Dyspnea Signs of respiratory distress - Nasal flaring - Tracheal tugging - Accessory muscle use - Suprasternal, intercostal, epigastric retractions - Hypoxemia

Documentation example of GCS: KNOW THIS!

E3 M5 V2 = GCS 10 - must include all of this in the one blank on test

Pre-school health promotion

Early learning and school readiness: Encourage parents to read to their child. Picture books and books with one or two words per page capture the preschooler's attention. Carrying on conversations and asking preschoolers open-ended questions help develop language skills. Oral: brush their teeth twice a day with a pea-sized amount of fluoridated toothpaste. Parents should have children spit the toothpaste out but not rinse their mouth play: imaginary and creative play. sleep: 10 to 13 hours of sleep per day including one nap discipline: If the child breaks the rules, the consequences must be logical and timely. Consistency is also paramount to establishing appropriate behaviors in preschoolers.

Newborn Temperament

Easy - quickly establishes regular routines. - generally happy and adapts easily to new situations. Difficult - require high levels of activity to keep calm. - happiest in fast-moving infant swings or when being constantly walked around. - Fussiness and crying are common in infants with a difficult temperament. - have a hard time establishing routines and find it difficult to adapt to new situations. Slow to Warm Up - tend to be fussier than infants with an easy temperament but less fussy than infants with a difficult temperament. - have an initial negative reaction to new situations but adapt over time.

Prevent For Environmental Triggers

Encase pillow & mattress-dust mite Wash linens & stuffed toys (hot water)-dust mite Remove carpet-dust mite Eliminate damp areas-mold Remove animals from home or keep outside-dander Use air conditioner-pollen Smoking cessation -irritant

Airway Clearance Techniques

Encourage coughing ¢Most natural way to clear airways of mucous (not contagious) Daily routine of CPT percussion ¢Manual percussors ¢High frequency chest compression w/mechanical VEST (mainstay tx) Flutter (mucous clearance device) Aerosolized Bronchodilators (Albuterol) & mucolytic Agents Dornase Alfa (Pulmozyme)

School Age Social/Emotional Development

Encouraging parents to help their children develop a positive view of themselves will allow the children to deal with different pressures in social situations. Friendship: typically identify a best friend. Children at this age want to be accepted by their peers and must learn to deal with peer pressure School: A teacher's support and positive attitude help the child to complete the task of industry and develop a positive self-esteem. Parents can assist in the transition to school by encouraging separation through positive reinforcement. Body image = It is important for the school-age child to be accepted by peers. Having the right clothes, shoes, and accessories becomes important to the child's self-image, especially during the late school-age years. Gender Identity and Dysphoria: some children may identify with a gender that is different from their biological sex. Gender dysphoria in the prepubescent period tends to resolve by the end of adolescence. However, children with gender dysphoria may grow up to identify with the opposite sex and/or to identify as gay, lesbian, or bisexual in orientation

Hydrocephalus: ventricles

Enlarged lateral and third ventricles caused by obstruction of circulation—stenosis of aqueduct of Sylvius

Laryngotracheobronchitis (Croup): Inflammatory, etiology, ages, signs, management, indications for intubation

Etiology: Parainfluenza virus Occurs in children ages 3 months to 3 years Barking cough. Narrow airway = steeple sign (KNOW THIS SIGN) Progresses slowly, very rarely requires intubation Medically managed with oxygen and mist therapy, racemic epinephrine nebulizer (for emergency tx = strong vasoconstrictor) and IV dexamethasone (0.25-0.5mg/kg). Cold air (freezer air) helps because it's a vasoconstrictor to reduce swelling. Indications for intubation: progressive intercostal retraction, obvious respiratory fatigue, and central cyanosis-very, very rare

Pincer Grasp development

Example of fine motor development (general to specific) •Grab on with whole hand mostly a reflex (palmar reflex) •Purposeful grab (still whole hand) •Use fingers to grab and hold toys (crude grasp) Also use fingers to "Rake" objects to them •Finally begin using 2 fingers to grab and hold objects by around 10mos = pincer grasp; if not by 15 mos = CONCERN!

GCS Case Study 3 year old child hit by a car as he ran out to get this ball that had rolled into the street. He is agitated, only makes grunting sounds and opens his eyes when mother calls his name and locally withdraws to pain

Eye opening = to verbal command (3) Motor response = localize pain (5) - withdraws to pain is not the same as localized pain. withdraw is moving pain area away. - typically start nail bed pressure on left hand with kids, the kids starts to get his right hand to push your hand off or moves his body away = localized pain - nail bed pressure on left hand = tries to move his left hand away without attempt to remove stimulus= withdrawal Verbal response = grunts (2) total = 10

Patient Teaching: 15.2 Safety Concerns

Falls •Never leave an infant alone on an elevated surface. •Make sure infants are buckled in swings and bouncy seats. •Once an infant is mobile, use safety gates at the top and bottom of stairs. •Do not allow infants to use a baby walker. Suffocation/Strangulation •Make sure the infant's bed is free of any loose items. •Keep the crib away from pull cords on curtains and blinds. •Crib slats must be not more than 23⁄8 in (6 cm) apart. •Keep plastic bags away from infants. Electrocution •Mobile infants may stick objects in outlets. •Cover electrical outlets. •Keep infants away from electrical cords. Choking •Keep small objects away from infants. •Make sure floors are clean once an infant is mobile. •Cut food into small pieces. •Foods with high choking risks: ᴑCarrots ᴑPopcorn ᴑHard candy ᴑGrapes ᴑMarshmallows ᴑHot dogs Burns •Do not carry hot liquids while carrying an infant. •Make sure the hot water heater is set to no higher than 120°F (48.8°C; AAP, 2012). •Never leave hot beverages on coffee tables Poisoning •Keep all cleaning products out of reach or in a locked cabinet. •Keep all medications out of reach. •Keep houseplants out of reach. •Have the poison control number readily available. Drowning •Never leave an infant unattended in the bath. •Do not leave any standing water such as in a bucket. Motor Vehicle Safety •Never leave an infant alone in a car for any amount of time. •Infants up to 12 mo old and 20 lb should ride in a rear-facing car seat with a 5-point harness •Do not place an infant in a front seat with an airbag.

Puberty: females

Females age of onset is between 8 and 13 with average around 11. This ages has continued to decrease over the past 10-15 years which they believe is d/t hormones and extra fat and sugar in our diet. Current recommendation is to refer girls to endocrinologist for precocious puberty if age 7 or less in Caucasians and 6 or less in AA. We do see that females who are obese tend to start puberty a lot earlier Thelarche is breast development Menarche is beginning of menstruation

Bacterial meningitis clinical manifestations (* = in both bacterial and aseptic)

Fever Change in feeding pattern Vomiting Or Diarrhea Bulging or flat fontanel Irritability or change in LOC Musculoskeletal pain Hemorrhagic rash *Headache* *Nuchal rigidity* *Kernig or Brudzinski 's signs* *Decreased glucose in CSF* = helps determine bacterial or aseptic

Scoliosis: figures

Figure 22.30 (A)Note right shoulder, scapula, and hip elevation as well as discrepancy in waist curvature. (B) Note right upper back hump Figure 22.31 Log-roll the postoperative spinal fusion child to prevent spine flexion

A TYPICAL PLAN FOR A PATIENT MAY BE:

Flovent 110 - 2 puffs twice daily with spacer. Special mouthpiece for babies (has mask with spacer) Singulair 5 mg daily by mouth Albuterol MDI, 2-4 puffs every 4 hours as needed only Call / provider or go to ER for severe or worsening symptoms Contact provider for symptoms lasting more than 2 days

BF Pocket Guide: p. 48-67

Focus on nutrition now turns to Safety!! Physical growth begins to slow, Cognitive, speech and refinement of motor skills Pot belly d/t underdeveloped abdomen muscles By 24mos should be able to kick a ball, scribble/paint starting to be turn knobs=safety esp oven stoves By 3 can run easily, turn pages in books, able to copy a circle with pencil Cannot take turns and play by "game rules" until after around 3 yrs Imitation is huge, both in play and in general-parents need to be aware (esp bad words.) Speech: From Receptive (understanding) to Expressive language (able to communicate wants) Repeat almost everything till about 3 then the Why's start

Circulation of newborn

Foramen ovale shuts Ductus ateriosus constricts Ductus venous constricts Lungs inflate w/ first breath Low pulmonary vascular resistence Blood flow to lungs increases + serves to oxygenate entire baby + see pink color

LCP Disease: 4 stages

Four stages (Table 27.2, p. 561) 1. AVN: avascular necrosis lasts for several mos; blood supply is cut off femoral head and osteoblast/clasts are damaged. fem head becomes flattened or deformed 2. Fragmentation/resorption: body removes dead bone and replaces with new bone that is softer and more susceptible to injury; takes 1-2 years 3. Reossification: several years; stronger bone forms to proper shape 4. Healing: fem head is reshaped (may not be fully round); growth is complete

Diagnosis of CF

Genetic Screening - Prenatal Care\Newborn screening Positive sweat Chloride test (>60meq/L) = GOLD standard CF DNA (Ambry) IRT (immunoreactive trypsinogen). If repeat IRT remains positive, the child is referred to an accredited center for a sweat chloride test- special device that is placed on the pt's skin which stimulates the production of sweat for electrolyte evaluation. Other tests include a stool for elastase to check for pancreatic insufficiency

Fine Vs Gross Motor Skills

Gross Motor develop Cephocaudal Fine Motor develop Proximodistal

Scarlet Fever

Group A beta hemolytic streptococci Respiratory secretion transmission. Typically caused by untreated strept throat. - prodromal: fever, sore throat, headache, abdominal pain. - enathem: white strawberry tongue, followed by a red strawberry tongue. Also have an exudative pharyngitis - exanthem: erythmatous, maculopapular, pinpoint rash. FEELS LIKE SANDPAPER, just on trunk and intense on skin folds. no blanching. Lasts about 5 days Communicability: usually 10-21 days. Infected individuals can no longer transmit the infection within 24 to 48 hours after the initiation of antibiotic therapy. Incubation: 2-5 days Treatment: Antibiotics (penicillin or rocephin). Pushing fluids. Soft foods. complications: rheumatic fever and heart disease, glomerular nephritis

Early increased ICP signs (know this)

Headache, Irritability, poor feeding Vomiting: with or without nausea Visual disturbances, diplopia, blurred vision Seizures, Dizziness or vertigo, Slight change in vital signs Pupils not as reactive or equal Eyes: setting-sun sign Slight change in level of consciousness Behavioral signs, fatigue, restlessness

Physical Growth

Heart doubles in size by first year B/P steadily increases, HR and RR decrease over the first year Stomach increase in size, bladder capacity increases Muscle growth slowly occurs (loss of baby fat) Breast development

Pulse and respiratory

High = distress Low = late and ominous sign

Respiratory rate

High = distress Low = late and ominous sign

Roseola Infantum

Human herpes virus Type 6/7 Respiratory droplet/saliva transmission oral, nasal. - prodromal: fever for 6-8 days and lymphadenopathy - rash appears when fever disappears! - enathem: nagayama spots = red papules on the soft palate (common in Asian) - exanthem: pale-pink maculopapular rash starts on trunk to extremities; not on face Communicability: about two days before the fever starts until 1 or 2 days after the fever is gone, even if the rash continues. Incubation: 9-10 days Supportive nursing care: tylenol and ibuprofen for fever complication: febrile seizure before rash bc of high fever

Erythema Infectiosum (Fifth's disease)

Human parvovirus Droplet, blood, cord transmission Communicability: 1 week prior to rash Incubation: 4-28 days Supportive nursing care; avoid sunlight -typically do not recognize till no longer contagious - stage 1: flu-like = low grade fever, cough, aches - stage 2: exanthem: slapped cheek rash that is erythamous and macular that looks lacy. can be on extremities and trunk - stage 3: rash reappears with sunlight complications: fetal hydrops fetalis (accumulation of fluid = ascites and pleural or pericardial effusion), aplastic crisis (neural failure)

Muscle tone classifications

Hypotonia •Low muscle tone Hypertonia •Increased muscle tone

Giving injections

IM: most vaccines, antibiotics, sites (vastus lateralis or deltoid), separate multiple injections by 1 inch SubQ: varicella and MMR

After identifying the key components of respiration, the next step is:

Identify problems that compromise any of these respiratory components

O2 administration

If on O2, will need to be monitored Wean slowly- if have to go back on start low then work up (give time to tolerate) In resolving illnesses, sats will drop during deep sleep Always check patient rather than relying totally on monitor

Not only are respiratory conditions the most common cause of pediatric arrest, they are also the most common reason for inpatient hospitalization and a major cause of mortality in pediatric patients.

In children less than 1 yr of age, bronchiolitis is the most common cause for admission. It is for this reason that nurses must be proficient with pediatric respiratory assessment so that we can intervene before the child develops respiratory failure.

pulmonary exacerbation

Increased cough Increased sputum production Decreased energy Decreased exercise tolerance Decreased FEV1 Weight loss or decreased appetite

Viscous Mucus in CF

Increased viscosity of mucous causes greater resistance to ciliary action, slowing the flow rate of mucous and causing mucous plugging Impaired mucociliary clearance=frequent productive cough & difficulty clearing the secretions. The highest concentrations of CFTR are in the sub mucosal glands of the airways, pancreas, salivary glands, sweat glands, intestines and reproductive tract lung problem = biggest problem

Bronchiolitis: Signs/Symptoms

Infant < 1 year old Recent upper respiratory infection exposure Gradual onset of respiratory distress Expiratory wheezing and crackles Extreme tachypnea (60 - 100+/min) Cyanosis Typically worsen for 5 days

Infant Apnea

Infant's normal breathing pattern is irregular with pauses up to 15 secs Defined as cessation of breathing >20secs, or pause associated with cyanosis, marked pallor, hypotonia, or bradycardia

PNA history: sx for infants < 3 mos and increased age

Infants < 3 months: Tachypnea, cough, retractions, grunting, isolated fever As age increases, symptoms are more specific: Chest crackles on exam Fever and chills Cough or wheezing Chest pain, abdominal pain

Pneumonia ppt slide: patho, sx, dx, complications

Inflammation of the lung parenchyma - Viral, bacterial, mycoplasma or fungus Symptoms: Fever/chills, productive cough, wheezing, crackles, chest pain DX: CXR shows infiltrates Complications: - Bacteremia, pleural effusion, lung abscess & pneumothorax

Meningitis: patho, types, transmissions

Inflammation of the meninges Bacterial -More virulent, sometimes fatal -Children less than one year of age most susceptible -Often occurs as a secondary infection Transmitted as droplet infection from nasopharyngeal secretions - 70% before age 5 but can be seen in college age bc of overcrowding in dorms

CONTROLLER MEDICATIONS (just know types)

Inhaled corticosteroids (ICS) (takes 2 weeks to go into effect) Long-acting bronchodilators(LABA)- Foradil, Serevent Leukotriene modifier-Singulair/Montelukast Oral Prednisone-long term -rare Allergy shots-desensitization to allergens -if allergies play a major role

Pulmonary Manifestations in CF

Initial - Recurrent wheezing - Dry, non-productive cough Progressive - Overinflated, barrel chest - Progressive decline in lung capacity - Blebs (ruptured alveoli from lung damage: no more gas exchange) ---> pneumothorax - Cyanosis - Clubbing of fingers and toes - Recurrent bronchitis and pneumonia

Physical examination (table 23.2 p418)

Inspection and observation: color, hydration status, abdominal size/shape, mental status auscultation: all 4 quadrants. listen for 5 min before labelling absent. (hyperactive = DA, gastrolitis; hypoactive = obstructive issue) percussion palpation: reserve for last, light to deep, tenderness is abnormal

Increased Intracranial Pressure (ICP) (no need to know difference, just know they work together)

Intracranial Pressure: Force exerted by brain tissue, CSF, and blood within the cranial vault 1. *increase in ischemia* 2. *increase in edema and tissue pressure* 3. *increase ICP* - *untreated and continuous = herniation of the brain * Cerebral Perfusion Pressure: The amt of pressure needed to ensure adequate O2 & nutrients are delivered to the brain - decreases with increased ICP

Focal seizures (Aka partial seizures)

Involve half of the brain Typically have an aura Occur in 60% of epilepsy patients Can be conscious or lose consciousness - Half of EEG is wacked up description of seizure depends on consciousness, area of the brain affected, and progression of severity of seizures

Generalized seizures

Involve the entire brain Typically lose consciousness Manifestations: -Tonic: muscle contraction -Clonic: relaxation Tonic-Clonic Post-ictal Period

Aseptic Meningitis clinical manifestations (* = in both bacterial and aseptic)

Irritability or change in LOC *Fever* Malaise *Headache* Photophobia URI symptoms *Vomiting or diarrhea* *Nuchal rigidity* *Kernig or Brudzinski's Signs*

*Loss of milestones is never normal!

Just as you would not expect a baby to shrink in size, you also should not see a child who was sitting not able to sit, or a child who was starting to say several words unable to say anything.

Intellectual Development

Learning math, reading, writing, speaking Piaget Cognitive Theory suggests this occurs in stages.

Social Development

Learning to relate and interact with other people. starts with Trust vs Mistrust stage of Erikson. Trusting that your needs are being met will help you interact later.

School age health promotion

Learning: Being in school helps children learn to follow rules, adapt to new situations, and work with others .Allow the child to make choices in the types of books to read. Parents should determine the appropriateness of the books for their child and consult with teachers regarding appropriate reading level. Safety: #1 death cause = unintentional injury and mVA. Oral: brush their teeth with fluoridated toothpaste twice daily for a full 2 minutes each time. Parents can set a timer near the sink so the child knows how long to brush. Another way the child can estimate 2 minutes of time is to sing the song "Happy Birthday" twice in a row. Flossing once a day is also important to prevent dental caries. Initially, children may need supervision with flossing. play: cooperative play. understand rules and are able to play team sports and participate in other organized activities. sleep: 9-12 hours per night discipline: When children calmly express their feelings of being upset or frustrated, parents should praise them for it. However, if they break the rules, they should still receive consequences for their actions.

Asthma triggers

Lower airway hypersensitivity to: - Infection (viruses) - Irritants - GERD - Allergies - Cold air - Exercise By completing a thorough history we can identifying and understand what triggers an asthma attack so that they can take steps to avoid them completely, or prepare for increased symptoms in the case they cannot be avoided.

Respiratory alkalosis (alveolar hyperventilation)

Lowers arterial PaCO2 decreases carbonic acid, thus increasing pH ¢Most common cause is anxiety, fever, pain, hyperventilation Clinical signs: early paresthesia; if severe, may have hyperactive reflexes, tetanic convulsions, dizziness VCO2 - CO2 production in ml/min

Specific lesions

Macules-flat (non-palpable) pigmented lesion; can be red, brown, dark -freckle, petechiae, rubeola, purpura Patch-Macule greater than 1 cm -Mongolian spot (darkened area of the skin that is seen with people of darker skin color, often mistaken for abuse bc it's on upper butt) Papule-raised and firm lesion may or may not be pigmented; nothing inside it, just solid. - warts, moles Wheal-irregular raised solid area of inflammation (will blanch! and weird shape) -urticaria, hives, insect bites Vesicle-raised clear-fluid filled lesion - chicken pox, herpes simplex Pustule- purulent filled vesicle - acne, impetigo Bulla-vesicle larger than 1 cm - burned blisters

Jones criteria (modified) for RF

Major: carditis, migratory polyarthritis, subQ nodules, erythema marginatum (on trunk and reappears after warm washcloth), syndenham chorea Minor: arthralgia, fever, elevated ESR (erythrocyte sedimentation rate = inflammation) or CRP (C-reactive protein = infection) Must have 2 major plus one minor to be dx with RF OR 1 major and 2 minors!

Partial obstruction interventions

Make child comfortable Administer humidified oxygen Encourage child to cough (tend to present with severe coughing) Have intubation equipment available Transport to hospital for removal with bronchoscope

Management of tet spells

Manipulate pulmonary and systemic resistance - raise knees to increase systemic resistance and administer oxygen at 100% to increase systemic tone -nasal fentanyl first then IV - 0.1 mg/kg morphine! can also be given IM; morphine decreases pulmonary vascular resistance

Management of PI & Nutrition

Maximize diet: Continuous g-tube @ night ¢High protein & high calorie ¢Supplemental oral feeding or enteral feeding Maximize pancreatic enzyme replacement therapy ¢Can sprinkle enzymes on food or give with applesauce - Always administer enzymes at the beginning of a meal for optimum absorption - Usually 1-5 capsules with a meal, less with a snack- adjusted for normal growth and bowel regimen - More enzymes are required with high fat foods Vitamin supplementation ¢A, D, E & K ¢Fat soluble vitamins: cannot absorb fats so decreased levels of fat soluble vits (A, D, E & K) in body with PI

Principles of inheritance

Mendelian - Dominant v Recessive - Inheritance risk - X-linked Polygenic & Multifactorial - ex: congenital heart defects, cleft/lip, neural tube defects

Croup: Management for mild, moderate, and severe

Mild Croup - Reassurance - Moist, cool air Moderate Croup - Steroid - Racemic Epinephrine Severe Croup - Humidified high concentration oxygen - IV KVO (keep vein open) if tolerated - Nebulized racemic epinephrine - Anticipate need to intubate, assist ventilations-this is rare

Laryngomalacia ("softness of voice box")

Most common congenital laryngeal anomaly Most frequent cause of stridor in infants and children Stridor appear at 2 weeks of life Increase in severity up to 6 months Diagnosis: flexible bronchoscopy (5%) bc tx is just observation, they will outgrow Treatment: observation

Cystic Fibrosis ppt

Most common life-shortening genetic disorder Affects approximately 30,000 people in the US Average life-expectancy age 47 1/1,800 infants will born with C.F. 1/15 carriers --> we probably have carriers in room causes recurrent lung infections and progressively limits the ability to breathe

Mid airway: Asthma = incidence, characterization

Most common reason for childhood hospitalization Chronic with acute exacerbations Asthma is a chronic lung disease that can be controlled but not cured. Asthma is the most common chronic disease in adults and children affecting over 300 million people worldwide (4.5%). Asthma is characterized by airways inflammation and hypersensitivity, which results in swelling and narrowing within the lumen of the airway

Pathophysiology of CF

Mutation of the gene on chromosome 7 -Prohibits movement of water across cell membranes - Interferes with sodium-chloride cell transport Results in presence of 'salty' sweat on the skin 'Salty sweat' is a hallmark of CF A defective gene causes a reduced ability of the membrane to excrete chloride which leads to impaired na and cl secretion resulting in abnormally thick sticky secretions. One of the classic features of CF is excessive salty skin which is why we use the sweat chloride test as the gold standard for diagnosis.

Asthma Severity Classification

National Asthma Edu & Prevention Program Tx & edu based on severity classification: - intermittent - mild persistent - moderate persistent - severe persistent Classifications Table: based on symptoms, lung function, interference with normal activity and how often using rescue inhaler

Nature vs. Nurture

Nature is the genetic or hereditary capability of an individual Nurture refers to the effects of the environment Mutual interactions between the child and these One is not considered to be important than the other. Children are raised on both.

Medications for status asthmaticus

Nebulized albuterol (intermittent or continuous) to decrease bronchospasms Oral or parenteral corticosteroids given (orapred, prednisone, solumedrol) to reduce inflammation Oxygen - titrate up High flow systems Subcutaneous epinephrine or terbutaline if poor response Intubation if still having problems Heliox is mixture of helium and oxygen which reduces air flow resistance within the bronchial tree in turn reducing the work of breathing and improves overall gas exchange

clinical presentation of Bronchopulmonary Dysplasia (BPD): signs, physical exam, CXR, clinical course

Need for supplemental oxygen. Hypoxemic and hypercapneic. Exam: tachypnea, retractions, scattered crackles CXR: diffusely hazy with alternating areas of atelectasis and hyperexpansion; streaky densities or cystic areas, edema CLINICAL COURSE: Tend to slowly improve and wean off respiratory support. May have intermittent episodes of acute deterioration if severe disease. Need increased calories to grow. May also develop pulmonary hypertension when severe

"Children are not just small adults"

Need to take account for: -Growth and development -Knowledge of differences in anatomy and physiology - Differences in disease presentation - Chronic illness - Care is the context of family, not just the patient - Different causes of morbidity/mortality - Safety, injury prevention - Anticipatory guidance - Ethical Dilemmas

Meningococcus

Neisseria meningitidis Respiratory droplet transmission - prodromal: abrupt onset of flu-like symptoms; extreme exhaustion and neurologic complications in severe cases - enanthem = koplik spots (just like measles): clustered, white lesions surrounded by red ring on the buccal mucosa (opposite the lower 1st & 2nd molars) - exanthem: maculopapular rash that begins behind ears then to trunk and extremities Communicability: 7 days prior to rash and until 24 hours after starting antibiotic Incubation: 1-10 days Treatment is IV antibiotics, IV fluids Prevention via meningococcal vaccine rapid onset and high mortality rate. 10-15 out of 100 people die despite treatment. - causes meningitis and meningococcal septicemia = enters blood stream and damages vessel walls, causing bleeding into skin and organs -risk: ages 2 -11. spleen removal. AA have a higher risk of fatality and contracting illness. Recommended to get vaccine before college and military camps. - complications: 10-20% severe morbidity, limb loss bc of gangrene, mortality rate higher in age 11+

mortality in children

Neonatal & infant - number of deaths in relation to 1,000 live births •Used as an index of a country's general health •Varies from state to state and between ethnic groups •Risk factors: preterm births and low birth weight Childhood—number of deaths per 100,000 children between the age of 1-14 •Varies by age group •Preventable injuries are a leading cause

Tx of PDA

Non- surgical treatment -indomethacin/motrin - 50% effective Surgical tx - closed heart surgery to tie it up - 100% effective

Kids BP

Normotensive: systolic or diastolic <90% for G/A/H (gender, age, height). Look at growth curve/chart! Prehypertensive: systolic or diastolic b/w 90 and 95% Hypertensive: systolic or diastolic > 95% for G/A/H

The Nose

Nose is responsible for 50% of total airway resistance at all ages Infants are obligatory nose breathers. blockage of nose = respiratory distress

Asthma tx

O2, Inc HOB, IV (rehydration, steroids, antibx) aerosol c bronchodilators SQ epi if needed monitor pOx, BGs NPO for may need to intubate

Patient Teaching: 17.1 = safety in preschoolers

Outdoor •Check outdoor playground equipment for loose screws and sharp edges. •Have preschoolers wear helmets when they ride a tricycle or bicycle. •Teach children to look both ways before crossing the street. •Have children wear sunscreen or clothing that protects them from the sun. Strangers •Teach children to say "no" to strangers. •Have children memorize their address and phone number. •Teach children about who are safe people to go to when in crowded places. Falls •Do not allow children to climb on furniture. •Lock doors to dangerous areas. •Supervise children when they are on playground equipment. Poisoning •Keep all cleaning products out of reach; use cabinet locks if kept in low cabinets. •Keep all medications out of reach. •Have the number for poison control easily accessible. Water •Have a fence around backyard pools. •Supervise children when they are around water. •Do not leave buckets of water around. Car Seats •Children can ride facing forward in a seat with a five-point harness until they are 4 y old. •At 4 y old, children can move to a booster seat with a regular seat belt.

Cystic Fibrosis

Over the last decade there have been significant advancements in the management of CF. Since I first began working with CF patients in 2008, the average life expectancy has increased from 27 to 47 years!!! This is an exciting time for those living with CF as new medications indicated to treat the underlying defect associated with CF are being approved by the FDA. Though there have been remarkable achievements in research, however, many patients with CF continue to battle this ugly disease.

PACERS: a practical assessment

P Pulse A Alertness C Coarseness of Breathing E Effort R Respiratory Rate S SaO2

5 P's

Pain Pulse Pallor Paresthesia Paralysis

Pancreatic Insufficiency in CF

Pancreatic duct blocked by thick mucous Insufficient pancreatic enzymes ¢Protease = Proteins ¢Amylase = Carbohydrates ¢Lipase = Fats 85-90% of people with CF have PI (pancreatic insufficiency)

Vomiting: patho, assessment, and management

Patho: forceful expulsion of gastric contents through the mouth; a symptom of another disorder Assessment: - onset and progression of sx, hx of contents/character of emesis, hx of effort and force of episodes, hx of timing - bilious emesis (green) is never normal = obstruction - associated events (diarrhea) - hydration status, mental status changes, bowel sounds, palpation of abdomen Management: - slow oral rehydration: withhold oral feedings for the first 1-2 hours after emesis - IV fluids may be necessary - antiemetic meds (Zofran) if needed

Diarrhea: patho, assessment, and management

Patho: most commonly viral in children, also be bacterial/parasitic/abx use/other causes - "toddlers' diarrhea" = sippy cup with juice and sugar = increases DA - acute or chronic Assessment: - hx (number/freq of stools; duration of sx; associated sx) - blood or mucus in stools - exposures: travel, farm animals, well water, daycare, age - physical exam, lab/diagnostic tests (KUB = bowel xray) Management: - supportive: maintain fluid balance and nutrition - probiotic supplementation - regular diet (but may also see BRAT (bananas, rice, apples, and toast) or other diets recommended = resume normal diet as tolerated)

Bronchopulmonary Dysplasia(BPD): age, treatment, signs, patho

Persistence of lung disease after premature birth requiring respiratory support Typically found in infants w/birth wt <1000g & gest age <30 wks Infants treated with O2 &/or PPV (positive pressure ventilation) for resp distress or failure DOE (dyspnea on exertion) to immature lungs and lung damage Decreased septation and alveolar hypoplasia leading to fewer and larger alveoli, so less surface area for gas exchange Dysregulation of vascular development leading to abnormal distribution of alveolar capillaries and thickened muscular layer of pulmonary arterioles

Functioning alveoli: compromising conditions

Pneumonia, Atelectasis (can lead to tracheal deviation from lung collapse), BPD, pneumothorax

Behaviorism

Positive reinforcement, behavioral techniques to get the behaviors you want (Pavlov, Skinner, Watson) use positive reinforcement to get children to do the right things; consequences to deter from negative behavior. (i.e. in potty training, giving medication, even in getting a child to drink contrast for a test).

Osteomyelitis: presentation, assessment, and treatment

Presentation: • general/vague symptoms of infxn (fever, chills, malaise, fatigue) • site swelling, redness, warmth • other assesment (CSM = circulation, sensation, movement, labs) •Treatment: IV antibiotics followed by 3 weeks of oral antibiotics - long-term issue

Goals of Treatment: Asthma

Prevent acute asthma episodes Prevent chronic symptoms Normalize lung function Normalize life Allergy proof the home Correct med administration and technique

Atraumatic care actions

Prevent or minimize physical stressors (pain, discomfort, sleep deprivation, inability to eat/drink, and changes in elimination.) - Avoid or reduce painful procedures - Minimize physical distress (noise, smells, restraints, sleeplessness, etc.) - Pain control Prevent or minimize parent-child separation - treating the fam as patient - research findings relation to keeping parents and child together Promote a sense of control - promote partnership, empowerment, and enable family care for child - educate at developmentally appropriate level - provide opportunities for control whenever possible

Prevention and Promotion

Prevention *Screening *Immunizations *Parent Education Promotion *Identifying Risks *Education for prevention or change in lifestyle *Anticipatory Guidance *Community Education These go hand in hand Healthy People 2020 Bright Futures Promoting healthy eating/weight; oral care; personal hygiene; safe sun exposure

Nursing Implications: Acute Epiglottitis = prevention and nursing considerations.

Prevention - H. influenza type B vaccine (Hib) Nursing Considerations - Airway management - Calm environment: stand doorway if child is agitated and tell mom what to do - IV access

Treatment: Prevention of BPD

Prevention: - Prenatal care - Avoidance of preterm birth

Acute Epiglottitis, cont... complications (prolonged vs complete obstruction) and management

Prolonged obstruction leads to hypoxia, hypercapnea, and acidosis Complete obstruction leads to sudden death=MEDICAL EMERGENCY Intubation and Antibiotics: - Swelling decreases after 24 hrs of antibx therapy (may not have that much time to treat it) - Do not examine throat! unless immediate intubation can be performed

17.2 (Nutrition) box: preschoolers

Protein: 3-5 oz ᴑLean meat ᴑEggs ᴑFish ᴑBeans •Fruits: 1-2 cups ᴑFresh, whole fruits ᴑFrozen or canned fruits with no sugar added ᴑDried fruits •Vegetables: 1.5-2.5 cups ᴑWhole, fresh vegetables ᴑCanned vegetables ᴑProvide a variety •Grains: 4-6 oz ᴑWhole grains ᴑLimit refined grains such as white flour and pasta •Dairy: 2.5 cups ᴑLow-fat dairy products

VSD treatments: repair or palliative

REPAIR - heart catheter: to measure pressure and fix issue - small VSD: may wait up to a year to close it bc small ones usually close on their own - large VSD: causing lots of respiratory distress. They can do open heart surgery and repair VSD with patch on big ones and pursestring stitch on smaller ones. If they show signs of failure to thrive, the baby may need surgery. PALLIATIVE -arterial banding: palliative procedure to buy time and stabalize child. take a band and wrap it around pulmonary artery to slightly tighten it to: 1) blood that is overloading the lungs now has pressure so it does not flow as much to lungs and 2) pressure in the RV resonates to the ventricular septum, so decreases the amount shunted from left to right Arterial banding can make heart stronger for open heart surgery. Once off the anesthesia, band can be too tight leading to crashing VS. They will undo the sutures and loosen the band till the flow is adequate for oxygenation but not too much to mess up the palliative treatment.

West nile

RNA Flavivirus Mosquitoes -prodromal: most are asymptomatic or may get fever, weakness, N/V for 2-3 weeks/. 1% may have severe neurological illness. - exanthem: nonspecific maculopapular rash Incubation: 2-14 days Supportive nursing care Prevention through insect repellant Complications: encephalitis, meningitis, 1% ends in death - available spray to kill mosquitoes.

What are some examples of safety concerns at this age? (from BF pocket guide) Milestones?

Redflags: daytime control of bladder and bowel control by 24-30 mos Not able to speak recognizable words by 2yrs. HUGE RED FLAG. Twins seems to speak their own language and it's difficult to pull them out of that. Consider speech therapy or hearing issues.

crackles

Represent abnormalities in distal airway - Sound is produced as collapsed alveolar sacs pop open - Almost always on inspiration - Associated with pneumonia, BPD and CF

wheezes

Represent small airway abnormalities On a continuum: End expiratory only --> throughout expiration --> on inspiration and expiration --> wheeze with minimal breath sounds

Compensation: Restoring pH to normal

Respiratory acidosis (hypoventilation) ¢Renal retention HCO3- raises pH toward normal Respiratory alkalosis (hyperventilation causes it) ¢Renal elimination HCO3- lowers pH toward normal Metabolic acidosis ¢Hyperventilation ↓CO2, raising pH toward normal Metabolic alkalosis ¢Hypoventilation ↑CO2, lowering pH toward normal

pediatric respiratory disease

Respiratory conditions are the most common cause of Pediatric Hospitalizations (excluding prematurity) Respiratory conditions are the most common cause of Pediatric Intensive Care Admissions Respiratory conditions are the most common cause of Pediatric Arrest

Pediatric Respiratory Disease: How Big A Deal Is It?

Respiratory conditions are the most common chronic disease group in children. Childhood asthma is the most common chronic illness, and in children, accounts for more admissions than any other single condition.

LOWER AIRWAY: Bronchiolitis/RSV (respiratory synsictal virus) = causes, how long to subside, characterisation

Respiratory infection leading to inflammation and increased mucus production in lungs Usually caused by RSV virus ( >50%) Other viruses-metapneumovirus, influenza Starts as upper respiratory infection then moves into chest taking 2-4 weeks to subside Characterized by cough, wheezing, SOB, thick secretions, worse in <1yr of age

Air embolism may form in venous system, traveling directly to the brain by way of the arterial system, in the child with:

Right to Left shunt

Resiliency

Risk factors & Protective factors •(ability to function with healthy responses)—a crisis provides a source of stress that the child or family must deal with. Protective factors provide strength & assistance; risk factors contribute to the challenge. This is huge in nursing care...assess these factors and intervene/educate as needed. •Positive factors can include family support, faith, good financial stability •Risk factors can include lack of support systems, poverty, a child who needs complex care, etc How do people react to a crisis (minor cold, terminal illness, etc.)?

Rubella "German measles"

Rubella Virus Nasopharyngeal secretion (respiratory droplets) and fomite transmission - prodromal: low grade fever and rash - exanthem: pink-red papule and macule rash that appears first on face then spread quickly to trunk and extremities - headaches and Coryza (nasal inflammation) - Forcheimer spots = enathem! pinpoint red macules and petechiae over the soft palate and the uvula Communicability: 7 days prior to and 7 days after onset of rash Incubation: 12-23 days Supportive nursing care: not a huge threat Prevention via MMR main complication for fetus = congenital rubella syndrome: sensorineural deafness, retinopathy, cataract, congenital heart disease, spleen, liver, or bone marrow problems, intellectual disability, microcephaly, low birth weight - can also cause polyarthritis and arthralgia in adolescents

Measles (Rubeola)

Rubeola Virus Respiratory droplet transmission; very contagious; can remain in air of hospital room for up to 2 hours - airborne precaution Communicability: 3-5 days prior and 4-6 days after onset of rash Incubation: 10-12 days Risk factors: immuno-deficient state, malnutrition, pregnancy Tx: Hydration, respiratory support Prevention via MMR -prodromal: high fever (104!) and red-watery nose and itchy eyes; cough - Koplick spots = very distinguish enanthems; bright red with white centers in mouth (little grains of sand with red rings). Appear 1-2 days before exanthem - Exanthem: dark red-purple maculopapular rash. Starts on face behind ears then spreads to trunk then extremities. Start to fade the order it appears. - complications: otitis media, pneumonia, encephalitis - risk factors: preg women = fetal defects and death; make sure women are vaccinated and have a safe environment

Mumps (parotitis)

Rubulavirus Respiratory secretions/saliva transmission; respiratory isolation - prodromal: fever, headache, sour taste and chewing pain bc of parotid swelling - exanthem: parotid swelling seen on outside Communicability: 1-7 days before and 4-9 days after parotid swelling Incubation: 12-25 days Treatment is hydration. Analgesics for pain and fever Prevention via MMR complications: sensorineural deafness, orchitis in postpubertal males leading to sterility issues, embryonic and fetal death

Ventriculoperitoneal Shunt (VP shunt): signs of malfunction and infection fluid being directed to peritoneal cavity from ventricles to be reabsorbed

S& S of Malfunction (Emergency) (can be from blockage of tubing, or clogging, or separation, or kinking) •Increased ICP Symptoms •Worsening neurologic status/ level of consciousness S& S Infection •Shunt malfunction signs •Fever and inflammation of tract (and redness) •Abdominal pain if placed as infant, lifelong or childhood issue. Shunt has to be replaced as child grows

MIS-C symptoms and common presentations

SYMPTOMS - Persistent fever, inflammation, evidence of organ dysfunction or shock Common Presentations - Kawaski disease-like features: conjunctivitis, swollen glands, coronary artery enlargement, GI issues, swollen hands and feet - Toxic shock syndrome-like features - Abnormal clotting - Poor heart function - Diarrhea - Other GI Sxs - Acute kidney injury - SOB suggestive of CHF - give IVIG, steroids, biologic, antibiotics to help the organ systems

Toddler Health Promotion

Safety: watch for cars as crossing street. look at safety concerns oral: first dentist visit at 1 year. pea-sized toothpaste. <3 should only use a smear of flouride toothpaste play: parallel play sleep: 11-13 hours (9 hours at night with naps!)

Pediatric Glasgow Coma Scale

Score of 15: unaltered LOC Score of 3: extremely decreased level of consciousness (worst possible score on the scale) - divided up between infants and children - will have copy of scale on exam - should know scores of memory 3 main sections: eye opening, motor response, verbal response 13-14 = mild brain injury 9-12 = moderate injury 8 or less = severe injury 3-4 = vegetative state

Late increased ICP signs (know this)

Significant decrease in level of consciousness Cushing's Triad: Increased systolic blood pressure and widened pulse pressure, Bradycardia, Irregular respirations Fixed and dilated pupils Decreased motor response to command Decreased sensory response to painful stimuli Papilledema (optic nerve swelling secondary to increased ICP) Decerebrate or decorticate posturing Cheyne-Stokes respirations

texture

Skin should be smooth, soft, and dry when palpated Abnormalities include: •Roughness •Indurations (areas of thickness with distinct border) •Lesions •Abnormal skin color •Dampness (clammy) chronic abnormal, dry, scaly, rough = endocrine disorders excessive sweating (esp in infants) = something is wrong! fever! bronchopulmonary dysplasia, congenital/congestive heart disease

Society affecting child health

Socioeconomic status: poverty and homelessness (no shelter = behavior disorders, victim of abuse chances are higher) Media: safety and influence Global society: worldwide events, disease, disasters

Patient Teaching: 18.1 = safety for school-age children

Sports •Have children wear necessary sports equipment while playing. •Learn to recognize signs of a concussion. •Make sure children stay hydrated. •Learn to recognize signs of dehydration and overheating. Water •Never allow children to swim alone. •Have children learn how to swim. •Have children wear life jackets in bodies of water other than a swimming pool. Bike •Have children wear a helmet at all times when riding a bike. •Make sure the helmet fits securely and is buckled when worn. •Teach children to watch for cars when riding on the road. Car •Children less than 4 ft 9 in tall should be in a booster seat with the regular car belt. •Children may use a seat belt only when the lap belt fits on the hips and the shoulder belt is across the shoulder rather than the neck. •Children under the age of 12 y should sit in the back seat. Pedestrian •Teach children to stop at the curb and look both ways before crossing a street. •Have older children hold younger children's hands when walking on or near streets. Firearm •Store firearms in a locked cabinet. •Teach children the danger of firearms. Household •Keep dangerous tools locked in a cabinet or shed. •Warn children of harmful household products. Fire •Teach children how to be safe around campfires. •Supervise children using matches. •Have a fire escape plan for the home. •Practice fire escape routes at home.

Patient Teaching: 19.1 = Safety for Adolescents

Sports •Wear necessary sports equipment while playing. •Learn to recognize signs of a concussion. •Stay hydrated. •Learn to recognize signs of dehydration and overheating. Water Sports •Acquire proper licensure before driving a watercraft. •Operate watercrafts safely. •Wear a life jacket when in any body of water other than in a swimming pool. Car •Always wear a seatbelt. •Avoid distracted driving. •Follow the speed limit. •Follow state driving laws. Firearm •Store firearms in a locked cabinet. •Learn how to safely use firearms. Fire •Learn how to be safe around campfires. •Use matches safely. •Have a fire escape plan for the home. •Practice fire escape routes at home. Sun •Use sunscreen when outdoors. •Wear a wide-brimmed hat when in the sun. •Do not use tanning beds.

Isolation Precautions

Standard: hand hygiene, cough ettiquette, clean technique Airborne: most serious; spread through air; droplet and dust spread; measles and varicella, tuberculosis (specific respirator needed) - room should have negative air pressure ventilation - door kept close - if no negative air pressure, pt needs to be masked along with healthcare workers Droplet: contact with respiratory droplets or mucous membrane; pertussis, mumps, flu; private room; mask within 3 feet Contact: direct or indirect contact with secretions; MRSA, lice, diptheria; want glove and gowns and private room

Effective Respiratory Assessment

Step 1 is identifying "at risk" patients Key to identifying "at risk" patients is to understand essential components of respiration and then identify patient conditions that will negatively impact this component

Adolescent common developmental concerns

Substance use disorder = classified as mild, moderate, or severe. Adolescents with SUD find it hard to change their behavior regardless of the consequences. tobacco and nicotine = Inform adolescents that although Juuls may not contain cancer-causing tobacco, the high nicotine content may result in addiction. Teach adolescents that tobacco use is the number-one cause of preventable deaths in the United States alcohol = use CRAFFT or SBIRT tool illicit drugs = Treatment for drug abuse in adolescence is multidisciplinary and includes counselors, social workers, nurses, physicians, and mental health specialists. CRAFFT or SBIRT violence = Determine whether the adolescent feels safe at home, at school, and in the neighborhood. Educate parents about violence in the media and online. eating disorders = recognize and treat eating disorders early. Early referral to treatment is essential for the adolescent with an eating disorder. Encourage the family to be involved in the treatment plan. depression =defined as a daily disruption of mood and loss of pleasure in activities that lasts 2 weeks or longer. Unless there is an immediate threat, treatment begins with intensive psychotherapy. If there is no improvement after 4 to 8 weeks, pharmacotherapy is warranted. suicide = determine the risk for suicide in an adolescent with depression. Tell parents to remove all firearms from the house, regardless of whether they are locked in a cabinet. Parents should remove all prescription medications with lethal potential from the home, as well. Educate parents to monitor their child's social media accounts for mention of suicidal ideation. media = Remind them to get at least an hour of daily activity per day. Overuse of media puts adolescents at risk for sleep disorders, anxiety, and depression. Educate adolescents not to sleep with media devices in their room. Remind adolescents not to engage in unnecessary media use while doing homework. Encourage parents to have media-free time, such as at family dinners

Bronchiolitis: Management

Suction, position, avoid over stressing Humidified oxygen Monitor cardiac apnea monitoring IV fluids (NPO) if poor intake or tachypnea

Breathing Cessation illnesses

Sudden infant death syndrome (SIDS) Apnea of the newborn/prematurity Acute Life Threatening Event

physical exam for PNA

Tachypnea is the best single indicator of pneumonia (must factor in fever) Age in months = Upper limit of Normal RR: < 2 = 55 2-12 = 45 > 12 = 35

Newborn common development concerns

Teething = 4 - 7 months. Use cold teething rings or washcloths or topical oral analgesics if severe pain Colic = inconsolable crying for at least 3 hours for 3 days a week; no treatment. Parents need a break and should not shake baby. Lay baby in crib when crying. Spitting up = normal first few months of life. Spitting up may be improved with increased frequency of burping during feeds. Decreasing the amount of each feed and increasing the frequency of feedings may help, as well. Media = no screen time during infancy

Puberty: males

Textbook will say males can begin puberty around 9-14 with average age around 12. 9 is pretty early! Def refer if puberty is showing 8 or less for precocious puberty. Unlike in females, obesity will delay puberty in boys

Differences in the Pediatric Airway

The narrowest portion of the pediatric airway is below the cords, at the cricoid cartilage (foreign body gets trapped, viral illness affects cricoid, elective and nonelective surgeries can irritate smallest passageway with ET tube) The mid airway (trachea) has a much smaller diameter The lower mid airway diameters are approximately ½ the size of adults. - It is important to remember that a child's tongue is larger in proportion to the mouth compared to adults (always think about airway obstruction) - Larynx is FUNNEL shaped (narrowing the airway) A newborn has 24 million alveoli, an adult has 296 million. Nutrition is important in newborns to grow alveolar sacs. Children have a much higher metabolic rate. The oxygen requirement per pound for a child is twice that of an adult.

Conjugate Vaccines

These are made by combining a weak antigen (typically polysaccharides) with a strong antigen (typically proteins) to illicit the immune response. Example: Prevnar (small pneumonia vaccine), Hib Our immune system cannot fight infections well until age 2 (that is why these populations have more ear infections). Conjugate vaccines are used for the youngins. Pneumonia for infants dropped by 30% when this vaccine was made

Effort of breathing

Think about external s/s and ausculatory findings External signs of Respiratory Distress: -Retractions- where do they occur -Abdominal breathing- think about age -See Saw Respirations- never good -Use of Accessory Muscles -Tripod, grunting, and head bobbing

Toddler Common Developmental Concerns

Toilet training = signs that they are ready are being dry for at least 2 hours, having words for urine and stool, bringing clean diaper, being discontent with soiled diaper. Positive reinforcement is needed to teach. Temper Tantrums = Reward good behavior and ignore unwanted behavior. One exception to the rule is that biting and hitting should never be ignored but should be addressed by giving the child a time-out. Regression = Common causes include a new sibling, a new day care, a new home, or hospitalization. Regression can manifest as different behaviors. Toddlers who are toilet trained may begin having accidents. Other behaviors include wanting a bottle or a pacifier after the toddler is weaned. Media = Children under 18 months of age should not watch television or digital media. For children 18 months or older, parents should limit screen time to 1 hour/day

Neuro difference and children and the significance (KNOW THIS) neuro problems are common in peds bc of variations

Top heavy, head is large in proportion to body; neck muscles not well developed = Prone to head injuries with falls; neck may not be able to support large head Thin cranial bones that are not well developed; unfused sutures = Not prone to fracture until ossification occurs (Access injuries carefully in case of abuse, story fits injury) Highly vascular brain; subarachnoid space small; dura firmly attached but can slip away from pericranium = Brain prone to hemorrhage; there is less cerebrospinal fluid to cushion the brain Excessive spinal mobility; muscles, joint capsules and ligaments of cervical spine immature = Greater risk for high cervical spine injury at C1-C2 level Wedge-shaped cartilaginous vertebral bodies; ossification of vertebral bodies incomplete = Greater risk for compression fractures of vertebrae with falls

Developmental dysplasia of the hip: tx, expected outcomes, discharge planning

Treatment • early intervention • pavlik harness • closed-reduction surgery: children 6-24 mos; general anesthesia; then spica cast • open reduction surgery: older than 2 or unsuccessful with closed surgery • spica cast post-op: for 6-8 weeks •Expected outcomes: reduction of hip, full ROM, ambulating without difficulty or pain •Discharge planning - Cast care: spica cast covers one or both legs and extends to torso with opening for toileting; teach parents to not lift abducter bar - Toileting: diapers inside cast on both side and use a smaller diaper inside the larger; cover groin area of cast with waterproof tape and cover opening of cast with plastic lining during elimination

Rickets: Tx goals and parent education

Treatment goals •Maintain healthy _vitamin_ _D_ levels •Increased exposure to _sunlight_ •No muscle weakness •Minimal bone deformities (big deformities = surgery) Parent education: give supplements and dietary sources: eggs, fortified dairy, fatty fish. give daily outdoor time

Communicable diseases

Types: Viral, Bacterial, Zoonotic/Vector incubation: time from exposure to symptoms communicability: time when patient is contagious

Recombinant Vaccines

Use genetic altered form of the microbe instead of the whole organism. Helped take away side effects but immune state may not last as long. ex: Hep B, Pertussis vaccine

Catch-Up Schedule

Use min. acceptable interval b/t doses when trying to "catch-up"; do not count doses inside min. If a child is more than 1 month behind a vaccine, use this to determine which and when. No vaccine record or unknown history = restart vaccines. not harmful to restart. No need to repeat a confirmed, documented series of vaccines. Just start where they left off.

Killed Virus Vaccines "inactivated vaccines"

Use organisms that have been killed but still can elicit an immune response. §Although it cannot cause the disease, it does provide a weaker response, therefore boosters become necessary. §Example: Inactivated Polio US has been polio free, so we can use inactivated vaccines. If you go to a polio country, you need a live one.

Toxoid vaccine

Use the actual toxin for the vaccine instead of the organism itself to begin the antibody process. Example: Tetanus

varicella (chickenpox)

Varicella-zoster virus Respiratory secretions, Airborne of vesicular fluid, and direct contact with lesion transmission Communicability: 1-2 days prior to onset of rash and until all lesions are crusted Incubation: 10-21 days Treatment is antiviral medications (w/in 24 hours for IC patients / antipruritic lotions and antihistamines (calamine lotion and oatmeal baths. keep them occupied from itching) Prevention via varicella zoster vaccine - lesions have to be crusted to know when communicability stop - prodromal stage: fever, rash with intense pruritis - exanthem: red macule that proceeds to papule then vesicle blister (dew drop on rose petal). Vesicle erupts and causes an ulcer that will crust over - more worrisome for newborns, pregnant women, and immunocmpromised - can lead to pneumonia, secondary skin infections, growth retardations

Keeping Lung Disease in Check

Vigorous airway clearance - daily Use of Hypertonic saline, Pulmozyme, inhaled antibiotics MWF Zithromax for anti-inflammatory Large volume nasal washes Annual flexible bronchoscopy with IV antibiotics (2 weeks +)

Tx for bronchiolitis

Virus won't respond to antibiotics, respiratory treatments or steroids In our hospital we give a trial of albuterol and racemic epinephrine and label as responder or non-responder

adults need to have their pertussis vaccine updated!

WATCH VIDEOS in ppt!

Educate at Every Visit

When & how to take rescue actions - Long-term meds suppress inflammation - Quick-relief meds are rescue meds Skills: Inhaler/spacer use, self-monitoring tests Help identify triggers Long term meds- prevention Quick relief- tx symptoms & exacerbations Often used in combination CPT- chest physiotherapy

Why is O2 important?

Without it, your cells cannot effectively produce energy and transform glucose (or other nutrients) into accessible ATP-cells then rapidly die

Macule

a change in the color of the skin. It is flat, if you were to close your eyes and run your fingers over the surface of a purely macular lesion, you could not detect it.

Papule

a solid raised lesion that has distinct borders and is less than 1 cm in diameter. Papules may have a variety of shapes in profile (domed, flat-topped, umbilicated)

Types of seizures

absence seizures (stare into space, just not there for a few seconds, mislabeled as ADHD) atonic (sudden loss of muscle tone) myoclonic (repetitive or singular movement of one group of muscles)

fomite

an inanimate object (as a dish, toy, book, doorknob, or clothing) that may be contaminated with infectious organisms and serve in their transmission

Pneumonia: patho, s/sx, ages, most common type, symptoms, dx, tx, and education

an infection that inflames the air sacs in one or both lungs. The air sacs may fill with fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and difficulty breathing. PNA can be caused by bacteria, viruses and fungi. Pneumonia can range in seriousness from mild to life-threatening and is most serious for infants and young children, people older than age 65, and people with health problems or weakened immune systems. Community-acquired pneumonia is the most common type of pneumonia meaning it occurs outside the hospital setting Symptoms: cyanosis following coughing, productive cough, use of accessory muscles, tactile fremitus, wheeze/rales and/or diminished BS, Dx: infiltrates are inflammatory cells, cell debris, and foreign organisms Less severe tx @ home: if PO stable and WOB is WNL Severe: hospitalization Edu: preventing aspiration Chronic kids at high risk- pneumococcal vaccine

Vector

an organism, typically a biting insect or tick, which transmits a disease or parasite from one animal

Story about paul

baby had transposition ○ Medications: prostaglandins to keep the vessels open to supply oxygen to the body ○ Wanted to make sure the ASD, that used to be the foramen ovale, stays open ○ You do a heart catheter to tear the septum open so you don't risk the septum closing ○ For stabilizing for a transposition - you want to allow all the pressure changes to stabilize within the body, give it a week to equilibrate to living alive not on a placenta ○ For surgery, they cut off the vessels and switch them to where they should be ■ For kids that did not survive, this is usually what they died from where this process went wrong

secondary brain injury (know this)

biochemical and cellular response to the initial insult secondary to hypoxia, hypotension, edema, change in the blood-brain barrier, or hemorrhage. -typically rapidly occurs over days to weeks - initial compensatory mechanism = displacement of CSF to spinal canal, displacement of venous blood to jugular veins; help prevents increased ICP shortly - after compensatory mechanisms stop working = increased ICP, compromised cerebral perfusion, further worsening of the cerebral edema which can cause herniation or death

Asthma: Pathophysiology

bronchospasm, increased mucus production, bronchial edema

Koplik spots

clustered, white lesions on the buccal mucosa (opposite the lower 1st & 2nd molars)

coup-contrecoup injury

coup injury occurs at the point of first impact; contrecoup injury occurs on the opposite side of impact, as the brain rebounds.

Regression

developmental behaviors such as using the potty, thumbsucking, sleeping in own bed, using cup instead of a bottle. This can occur from some type of stressor. It can be as simple as being sick in or out of the hospital, birth of a sibling to more serious stressors like abuse and death of family members. Important to educate parents not to be alarmed that their 3 yr old who has been out of diapers for 8 mos now is now having to use diapers in the hospital. They will regain their behaviors. Try to ignore the new behavior and praise them when they return to appropriate behavior.

GI Manifestations from pancreatic insufficiency in CF

difficulty absorbing nutrients, which affects respiratory Steatorrhea ¢Frothy (bulky), Fatty, Foul-smelling stools ¢Prolapse of the rectum - due to lack of pancreatic enzymes to break down food

VSD diagnosis

echocardiagram or heart cath to measure pressures

neurogenic shock tx

fluid resuscitation, atropine for bradycardia, inotropes for hypotension prevent complications - neurogenic bladder and bowel: straight cath - pressure injuries: monitor skin - address nutritional deficits

no drug for

foramen ovale

Cephalocaudal

head to toe development of nerves and muscle An infant would first be able to hold her head up alone. Then, she will hold core up to sit up. Next, she will crawl with her legs. Last, she will walk or stand.

general to specific growth pattern

holding a crayon and scribbling to actually coloring and drawing holding a ball to throwing a ball

aspiration (wet) or laryngospasm (dry) from drowning lead to

hypoxia then anoxia then cerebral edema then increased ICP

delirium

in between confusion and obtunded. state of disorientation, fear, agitation, hyperactivity, anxiety; can be agitated, anxious, and not calm

kernig sign

inability to fully extend the knees with hips flexed. - pull leg up with knee flexed and then extend leg out - resistance = +

Newborn health promotion

includes assessing the infant's environment and the parent's or caregiver's willingness to learn. Parental teaching is a large part of health promotion during the first year of life. Anticipatory guidance includes information about growth and development, healthy sleep, safety concerns, immunizations, oral health, and nutrition, as well as common developmental concerns. oral = use a soft washcloth to wipe an infant's gums and after tooth eruption to use a very small amount of fluoridated toothpaste either with an infant toothbrush or with a washcloth to brush the infant's teeth twice a day. play = solitary play sleep = room-share for 6 mos. do not sleep in same bed. By 6 months of age, most infants sleep a 6- to 8-hour stretch at night with two naps during the day, for a total of 14 to 16 hours of sleep in a 24-hour period. By the end of the first year of life, infants sleep 10 to 12 hours at night with two naps during the day Discipline = teaching rather than punishment. Distraction is an appropriate discipline

Growth

increase in physical size, in size of the body and the various organs /quantitative changes of body - height, weight (kg to lbs for parents), head circumference (cm but to inches for parents), organ size, etc.

Catarrh

inflammation of a mucous membrane

Kawasaki disease: sx and tx

inflammation of blood vessels, hence the strawberry tongue, causes coronary artery aneurysms. - rash around groin area - strawberry tongue (very bright red!) - mouth has sores, cracking lips, bleeding lips - peeling of skin - hyperemia of sclera - IV tylenol usually bc PO meds hurt

Coryza

inflammation of the mucous membrane of the nose

Fluid balance: insensible fluid loss

insensible fluid loss = cannot measure - fever: increases fluid loss by 7ml/kg/day for each 1 degree C sustained rise in temp (do not need to know by how much..but) - skin: 2/3 of insensible loss - larger body surface area - basal metabolic rate higher - renal immaturity: risk for dehydration or overhydration

Prostaglandin is administered to the newborn with a congenital heart defect to

keep ductus arteriousus open Prostaglandin is a hormone to keep ductus arteriousus open. When we have a defect when we need more blood flow to lungs, then a prostaglandin drip will be given to the newborn. They can apnea, tachycardia, etc, so they have to be monitored.

skin

largest organ of the body - composed of skin, nails, hair & hair follicles, and sweat glands

Table 8.1 Suggestions for Atraumatic Care

look at it - minimize blood draws by doing it correctly

Table 8.2: Alternatives for confusing or misunderstood terms

look at it!

Table 8.3 communicating effectively with children

look at it! sitting at the child's level and allowing the child time for self-expression. communication or teaching with a doll may be useful with younger children

Variations in alignment

lower limbs - flat feet till about 6 years - in-toeing: toes are turned in - bow-legged appearance (straighten out by 2 years old); waddling gait - locked knees

Pre-school common developmental concerns

lying: encourage parents to teach children that lying is never okay. Before punishing the child for lying, the parent should find out the reason for the lie and then explain to the preschooler that telling the truth will get them in less trouble than lying. praise them for telling truth masturbation: Getting angry and punishing the behavior may result in the behavior occurring more frequently. Excessive or aggressive masturbation or acting out sexual intercourse should be further explored because it may be a sign of sexual abuse media: Parents should avoid programs with violence or frightening content. Because of preschoolers' vivid imagination, this type of content could lead to behavioral problems or nightmares. Preschoolers should have no more than 1 hour of media exposure per day.

Promotion

maintaining or enhancing the health of the child. Examples? oral hygiene, nutrition, water safety, gun safety, vaccines, drug prevention

pediatric cardiopulmonary arrests

majority: respiratory then shock and cardiac

The Development of immunizations

may be one of the most beneficial scientific contribution to the world of modern medicine. - save thousands of children, but there are still millions of children affected from preventable diseases - mumps (parotid swelling) can cause auditory nerve issues. - polio issues occur as well, leading to permanent disabilities

What medications can be administered to close the patent ductus arteriosus?

motrin indomethacin: problem = not specific to ductus tissue; it can close down other vessels, specifically in gut's mesentary, leading to necrotizing enterocolitis (NEC). - works fairly quickly - do not feed babies for a while so you don't stress their gut!

Types of Pediatric restraints

mummy, elbow, extremity, abdominal, jacket, mitten or finger

No evidence that a healthy child will be

negatively affected by receiving a lot of vaccines lots of vaccines are combined now.

stridor

o Caused by partial blockage or narrowing of large airway whistling or 'seal like' sound - If inspiratory - it is extrathoracic - If expiratory - it is intrathoracic

Freud Psychosocial Development

oral stage: birth to 1 year. babies are soothe by sucking. During painful procedures, parents are encouraged to give bottle, pacifiers, and soothies (disposable pacifiers with sugar water).

Maturation

overall process of growth and development from infancy to adult Everyone has an inborn timetable and blueprint for maturation and it is unique to each person. In normal circumstances maturation cannot be altered or stopped (if a baby does not come in contact with toxins or accidents, then their growth and development should follow their timetable). red flags = delays. What are they not doing by a certain age? Ex: a 9 month old cannot sit up.

Fetal circulation

oxygenated, nutrient-rich blood from placenta carried to fetus via umbilical vein → half enters Ductus venosus (allows blood to bypass the liver) →carried to inferior vena cava → RA → RV → Ductus arteriosus (conducts some blood from the pulmonary artery to the aorta [bypassing the lungs/fetal pulmonary circulation]) → aorta. Other half enters liver/portal vein → RA → Foramen ovale (allows blood to bypass pulmonary circulation by entering the left atria directly from the right atria since there is no gas exchange in fetal lung) → LA → LV → aorta.

Brudzinski's sign. Bruh, my neck

pain with resistance and involuntary flex of hip/knee when neck is flexed to chest when lying supine - leg moves up when neck is flexed - nucchal/neck rigidity = + sign of meningitis as well - watch video

Adolescent social/emotional development

parents = Positive and supportive communication with parents seems to lessen the negative effects associated with excessive screen time in adolescence. Parents can set rules in conjunction with the adolescent, and the rules should not be too strict or too loose. Parents should be aware of who their adolescent's friends are and where they are when not at home. peers = peers can influence how adolescents dress, talk, and act and what activities they participate in. Peers have also been shown to influence an adolescent's diet and physical activity dating= Parents should notice any change in their adolescent's behavior and encourage him or her to talk about any experiences, positive or negative, in the relationship. Dating can have either a positive or negative effect on self-esteem and academic performance, depending on the nature of the relationship. gender identity = Gender identity refers to how adolescents see themselves, as male or female, regardless of their biological gender. Sexual orientation refers to attraction and whether the adolescent is attracted to males, females, or both body image = Educate adolescents that what is posted on social media is not always a true depiction of reality. Body image is also influenced by the development of secondary sexual characteristics. Males become concerned about muscle development, facial hair, and the size of their penis. Females become concerned about the size of their breasts and starting menstruation.

Dehydration: patho, assessment, management

patho - varies based on underlying cause, occurs more quickly in infants and children - early recognition is essential - bc can lead to hypovolemic shock assess - hx of present illness, past med hx (DM, burn, fever), hydration status (turgor, mucosa, fontanels = sunken with dehydration, tears when crying) - children compensate well initially; (UOP should be 1ml/kg/hr). - HR increases in moderate dehydration; BP decreases in severe dehydration (late sign) management - goal: restore appropriate fluid balance & prevent complications (and treat underlying disorder) - risk for overhydration

For effective care we must understand

pediatric respiratory diseases and be able to identify problems / deterioration early on

basilar fracture signs

periorbital edema, bruising around eyes (Ecchymosis), battle sign = bruising behind ear, CSF draining from ear (otorrhea), Halo sign of CSF

Forchheimer spots

pinpoint red macules and petechiae over the soft palate and the uvula

Kohlberg's Theory of Moral Development

preconventional, conventional, postconventional -some people may not reach the highest level. Used as a framework to help understand moral decision making (right & wrong)

Prodrome

precursor to enanthem/exanthema

Opisthotonos

prolonged arching of back, with head and heels bent backward, and meningeal irritation - head hyperextended with legs pulled up behind them - position of comfort to relieve meninge pressure

Enanthem

rash inside the body

Exanthem

rash on the body

Nagayama's spots

red papules on the soft palate

Effort of breathing pt 2

respiratory distress: •Retractions w/resp distress - up until 6 years of age 1. Intercostal muscles immature; ribs cartilage - makes chest wall flexible. •Nasal flaring also a sign of resp distress- primarily infants & toddlers. •Abdominal breathing normal Cyanosis is a late sign of respiratory distress. TRIPOD position to maximize breathing

Tet spells

results from a transient increase in resistance to blood flow to the lungs with increased preferential flow of desaturated blood to the body. Tet spells are characterized by a sudden, marked increase in cyanosis followed by syncope, and may result in hypoxic brain injury and death.

Posture: Decorticate posture (abnormal flexion)

results from damage to one or both corticospinal tracts in cerebral hemispheres. Arms are adducted and flexed, with wrists and fingers flexed on the chest. Legs are stiffly extended and internally rotated, with plantar flexion of the feet. - deCORticate = arms across CORE

Posture: Decerebrate posture (abnormal extension)

results from damage to the upper brain stem. Arms are adducted and extended, with the wrists pronated and the fingers flexed. Legs are stiffly extended with plantar flexion of the feet - typically considered to be more serious

shunts of newborn baby

right to left, or left to right - shunts haven't closed. - ductus arteriosus doesn't close till a couple of weeks. - foramen ovale: shunts in opposite direction (left to right now) bc lung pressure goes to high to low and systemic pressure goes to low to high. Foramen ovale will begin to close once shunting stops in hours.

questions from zoom

roseola: fever before rash 5th disease: slapped-cheek rash enanthem: rash inside of the body, usually in mouth and tongue exanthem: rash outside of body on skin

Adolescent health promotion

safety = MVA, substance abuse, and firearms - sports safety = baseline concussion testing to establish cognitive function - motor vehicle safety = Distractions while driving include texting, talking on the phone, and eating, among other things. - not wearing seatbelts, driving with other adolescents in the car, reckless driving, and driving at night. - firearm safety: locked and stored in a separate area risk reduction: sexual activity, pregnancy, STIs, and substance use, it is appropriate to ask the adolescent's parents to leave the room. pregnancy and STIs = the dangers of STIs and how they are passed from partner to partner, including through oral sex. Explain that abstaining from sexual activity is best practice, but also teach adolescents about safe sexual practices. substance use = Teach them how being under the influence of alcohol or drugs leads to poor decisions, such as driving while under the influence or engaging in unprotected sex. Educate adolescents about the dangers of tobacco use, and inform them that e-cigarettes are not necessarily safer than are traditional cigarettes. Provide education and materials on how they can resist peer pressure to engage in substance use. oral = Adolescents should continue to visit the dentist every 6 months. Ensure that the adolescent brushes his or her teeth twice daily. personal hygiene = menstruation and body odor screenings: Teach adolescent females to do breast self-exams and let their healthcare provider know of any changes, such as development of a lump. Cervical cancer is often caused by HPV and can be prevented with the HPV vaccine. Testicular cancers often occur in younger males. Teach adolescent males how to do testicular self-exams. school = Inform adolescents and their families of school options after high school, including 4-year colleges, 2-year colleges, and trade schools. Encourage the adolescent's participation in making choices about his or her future. sleep = 8-10 hours a night discipline = Parents should establish a consistent set of rules for their child in early adolescence. The adolescent should have a clear understanding of the consequences of breaking the set rules. As the child enters middle adolescence, parents can collaborate with him or her to establish rules and consequences for breaking those rules. This collaboration teaches the adolescent responsibility and fosters his or her growing independence in a healthy manner.

school age common devlpmental concerns

school refusal = Treatment of school refusal begins with determining the underlying problem or problems deterring the child from going to school. Barring any safety issues for the child at school, the primary objective of treatment is to return the child to school as soon as possible bullying = verbal and social. Children who are bullied experience changes in sleep and eating behaviors, depression, anxiety, social isolation, loss of interest in previously enjoyed activities, and vague health complaints. cyberbullying: Encourage children to talk about mean messages that are posted online. If possible, take a screenshot of the message or picture for evidence. Report bad behavior through the reporting mechanisms on social media platforms. Talk with school counselors and refer children and families to resources available for bullying. obesity = having a BMI in the 95th percentile or greater for age. Treatment for overweight and obesity focuses on lifestyle changes and nutrition rather than on weight loss. cheating = Competitiveness among school-age children is often the reason for cheating. lying = Have parents emphasize that the child will get in less trouble if he or she admits to lying and subsequently tells the truth. stealing = If possible, the child should return the stolen item to the owner. Discuss with the child the reasons he or she stole. media = Overuse of media puts children at risk for obesity, poor school performance, Internet addiction, sleep problems, and cyberbullying. The best way to teach children the appropriate use of digital media is role modeling

Adequate respiratory rate: compromising conditions

sedation, apnea

Congenital rubella syndrome

sensorineural deafness, retinopathy, cataract, congenital heart disease, spleen, liver, or bone marrow problems, intellectual disability, microcephaly, low birth weight

Development

sequential process by which infants and children gain various skills and functions. A change of function as a result of growth. It is a progress in skills and abilities and is measured in stages. it is qualitative aspects measured through ability to sit, run, add, talk, subtract, etc.

differences of breathing cessation illnesses

sids - unidentified cause infant apnea/prematurity - immature respiratory center alte- secondary cause

skin assessment: temperature and turgor

temp: Skin should be warm to the touch -Increase in temperature= fever, inflammation -Decrease in temperature= prolonged cold exposure, shock (infants can't regulate temp as well, so they may just need to be wrapped up with clothes) turgor: - Skin should be elastic and mobile. •Skin turgor should show immediate recoil after pinching up. - Abnormal turgor will tent or slowly return to baseline (dehydration)

spinal muscular atrophy: unique sign

the very narrow chest, beginning xiphoid depression, and relatively enlarged appearance of the abdomen in this infant with type 1 spinal muscular atrophy

Hypoplastic Left Heart Syndrome

underdevelopment of the left side of the heart, usually resulting in an absent or nonfunctional left ventricle and hypoplasia of the ascending aorta. - not compatible with life before surgeries were developed; die in home or hospital - Norwood procedure surgery: multi-step and takes years to complete; series of surgeries were shunts are created

Variations in pupil size

unilateral dilated pupil = III nerve compression (90% ipsilateral to hematoma) - however if dilated and reactive = *intracranial mass* - if fixed = impending brain stem herniation bilateral dilated pupils = midbrain injury - fixed and not reactive = *brain stem herniation has already occurred from increased ICP* irregular pupils = orbital trauma conjugate gaze deviation = frontal lobe lesion small/pinpoint = pontine injury, opiate administration - sunsetting-sclera shows over the top of the iris (only half or less or iris is shown and it looks like they are looking down) d/t increased ICP - figure out if it is unilateral or bilateral issues, esp if pupils are reactive light

Figure 22.21: Pavlik harness

used to keep the knees flexed and hips abducted to allow the hips to grow normally in a child with developmental dysplasia of the hip - infants < 6mos - 24/7 for 3-4 mos - requires compliance

VAST majority of pneumonias are

viral - RSV most common- but . . . Must consider bacterial possibility in many - particularly sicker pt or with lobar density

Erikson Stage 4: Industry vs. Inferiority

virtue: Competence •6-12: More receptive to feedback from adults/peers. Gains a sense of self-worth from involvement in activities; Negative feedback can lead to low self-esteem, but must be balanced by a realistic perspective (cannot be the "best" at everything); Remember this age, school work and succeeding at school is most important.

Erikson Stage 5: Identity vs. Role Confusion

virtue: FIDELITY •12-20: Setting boundaries between parents and peers/romantic relationships. Tries out roles, to find their place in the adult world. examines what fits; redefines self, family, peers, community. If unable to establish a meaningful definition of self, will experience confusion with roles.

Erikson's stage 1: trust vs mistrust

virtue: HOPE Depend on parents/caregivers for all basic needs= Developing trust as needs are met=hope that people can be trusted and world is safe place

Erikson Stage 3: Initiative vs. Guilt

virtue: PURPOSE •3-6: setting goals and working towards these goals. Sense of purpose; assert power and control over environment; desire to tackle new tasks, learns to assume new responsibilities; initiates play activities, but may not finish; Not being able to meet these goals can lead to guilt of not reaching these goals. constant criticism leads to feelings of guilt and lack of purpose.

Erikson Stage 2: Autonomy vs. Shame and Doubt

virtue: WILL •1-3: Learn to do things on own. Giving children at this stage chance to do things will lead to self-sufficient adults; Saying no when asked to do something; potty training, control of body excretions,

Care of Children with Respiratory Disorders

we must have expert assessment skills so that we can recognize deterioration early and intervene early in the course of an illness before respiratory failure develops.

Encephalitis (inflammation of brain can be caused by viruses, vectors, pathogens) Clinical Manifestations

}Malaise }Severe headache/dizziness }Stiff neck }Nausea/vomiting }*Ataxia* (unable to move muscles properly) }*Speech difficulties (diff than meningitis)* }Acute onset of high fever }*Disorientation/stupor/ coma* }*Seizures/spasticity* }Ocular palsies }Paralysis }URI symptoms }Altered LOC (Delirium is common)

LEVELS OF CONSCIOUSNESS (know the order!)

Ø FULL CONSCIOUSNESS: alert and oriented x 3 Ø CONFUSION: just orientation to time, place, OR person. Cannot answer complex questions, but alert to simple qs. Lethargic and sluggish speech Ø OBTUNDED: arouse with stimulation but limited response to environment. Fall asleep very quickly if you are not stimulating them. Ø STUPOR: deep sleep or unresponsiveness but will respond to vigorous or repeated stimuli. More painful stimuli Ø COMATOSE: cannot be aroused even with painful stimuli. Ø PERSISTENT VEGETATIVE STATE: permanent loss of cerebral cortex function. Only having reflexive responses - When documenting, do not just use label, include what they can or cannot do when providing a stimulus

CAUSES OF ALTERED LEVEL OF CONSCIOUSNESS

Ø Hypoxia and Trauma: usually goes together Ø Infection Ø Poisoning Ø Ventriculoperitoneal shunt malfunction Ø Seizures Ø Endocrine or metabolic disturbances Ø Electrolyte, acid-base, or biochemical imbalance Ø CNS pathology Ø Congenital structural defect Ø Alcohol or substance abuse = in teenagers mainly

Nursing Care of the Unconscious Child

Ø Outcome and recovery of unconscious child may depend on level of nursing care & observation skills Ø Emergency management = emergency equipment Ø *Airway Management= Primary Concern* - if unpatent aiway, cerebral hypoxia can cause irreversible brain damage - hypoxia > 4 hours = irreversible damage - make sure CO2 does not get too high, or else vasodilation occurs and increases cerebral blood flow, increasing ICP; so hyperventilate these kids to blow off CO2. These kids may have minimal gag or cough reflexes so beware of aspiration. Ø *Pain Management* - *uncontrolled pain can increase ICP* - also look at reduction and control of ICP, tx of shock = do frequent assessments based on severity of injury

Nursing Care for Child with Increased ICP

Ø Patient positioning: monitors, tubes, and wirings must be watched (flat as possible, must stay in specific position) ØAvoid activities that may increase ICP: any painful stimuli (do all interventions at once so you do not disturb child) ØEliminate or minimize environmental noise and lights ØSuctioning issues ØIV administration of fluids and parenteral nutrition: do not overhydrate!! can give osmotic diuretics (mannitol or glycerol) ØCaution with over hydration ØLater begin gastric feedings via NG or GT ØPatient may continue to have risk of aspiration: often given paralyzing agents to keep them still ØElimination, Hygienic care ØPosition and exercise, Stimulation (do not want bright lights or lots of visitors, whisper to patient, avoid arguments) ØFamily support: help their child with baths, give blankets, help with care

Wet Drowning

Ø*Aspiration of fluid into the lungs* ØMost Common

Dry Drowning

Ø*Hypoxemia resulting from laryngospasm, with small or insignificant amounts of fluid aspirated*

encephalitis: patho, complications, associations

Ø*Inflammation of the brain usually caused by a virus or by a vector borne pathogen* (other causes: west nile, rabies, epstein barr, and enterovirus) Ø Secondary inflammation of the meninges is also common ØHerpes encephalitis is associated with a high mortality rate ØEpidemics in warm weather due to vector-borne pathogens

Meningitis Nursing Management

Ø*Prepare family & child for diagnostic tests: spinal tap test education! not pleasant but is a short term pain* ØAssessment: LOCs, VS, Neuro checks q 15 min ØMonitor Respiratory & Neurological Status ØReport changes in condition and status ØAseptic: Care is symptomatic Ø*Bacterial: Antibiotic Therapy (typically IV)* Ø*Respiratory droplet isolation: 1st 24 hours of antibiotics. Need to be in isolation till negative meningitis tests* - Non bacterial isolation till without fever for 24 hrs unless proven negative meningitis tests.

Seizure nursing management

Ø*Stay calm & remain with child, provide privacy, look at time to see how long seizures last, look for type and severity (consciousness, continence, post-ictal)* ØAssess LOC, observe and document seizure ØMaintain airway & provide supplemental oxygen ØEnsure safety: Raise side rails and provide padding on headboard and rails ØAdminister medications ØProvide emotional support to family ØEducation for family and patient: - CPR training - Activity restriction on individual basis - Safety: Helmets, No swimming alone; may be recommended to not ride bikes

Febrile seizures: cause, 911, meds

Ø*Transient, most common in children benign, educate parents that there are no long term damages* ØCause unknown ØUsually temp higher than 101.8 F, quick rise or fall in temps cause the seizures Ø95-98% of children with febrile sezures will NOT have epilepsy or neurologic damage ØCall 911 if lasts more than 5mins!! ØVigorous use of antipyretics to reduce fever (tylenol or ibuprofen is good, ice bath is not recommended!) ØRectal Diazepam if becomes prolonged ØProphylaxis Meds typically not necessary - typically grow out of this, not in adults

Drowning (*Actually die within 24 hours*) and Near-Drowning (*survive for at least 24 hours after submersion*) (know the difference)

Ø90% occur in fresh water; #1 cause of unintentional death in 1-4 y/os. #2 cause in 1-14. ØCan occur with even a small quantity of water!!! even a tbs of water (toilets, bath tubs, buckets) ØSecond leading cause of injury-related death (1yr-14yrs) ØTypically less than 4 years of age ØBoys 5X more likely than girls to die (preteen and teenager years)

Traumatic Brain Injury (TBI)

ØAny trauma involving the scalp, cranial bones or structures within the skull resulting from force or penetration. ØOne of the leading causes of acquired disability and deaths in infants and children ØIn the United States, the highest combined rates of TBI-associated emergency department visits, hospitalizations, and deaths occur in the youngest children, followed by adolescents, and older adults. ØCan be d/t Unintentional or Intentional (Abuse or assault)

Hydrocephalus dx and clinical therapy

ØCT or MRI (diagnosis) ØRemove obstruction (tumor) ØVP shunt placement: creates new pathway for fluid to go to; catheter in ventricle and runs to peritoneal cavity to drain

TBI: types of injuries = primary brain injuries (know this)

ØConcussions ØSkull Fractures ØHypoxic brain injury ØCerebral Contusion: bruising of cerebral tissue that can be from direct blow to head but can also see with shaken baby syndrome ØIntracranial hematoma ØGun shot wounds

Drowning nursing management

ØEDUCATE PREVENTION!! life-vests, safe water floatation devices, watch children!, drowning is silent! - kids do not splash and scream for help ØEmergency resuscitative efforts at the scene ØManagement is based on degree of cerebral insult Ø*Aspiration is frequent complication = lung damage* (less lung damage with laryngospasm) ØMonitor ØHelping parents cope - help reduce guilt

Pain Management for LP

ØEMLA (Lidocaine/Prilocaine), a local anesthetic cream, is placed under an occlusive dressing to decrease pain of lumbar puncture. The site is located by drawing an imaginary line from the top of the iliac crest that crosses the spine at the appropriate needle insertion site. - can take 20-30 min to start working, but sometimes that is too much time - *Topical only numbs skin, does not help with needle past skin; explain that the pt will feel some pain* Ø*Conscious sedation may also be used* - but altered LOC may occur, do not do if altered LOC is already an issue

TBI complications = secondary injuries

ØEpidural hemorrhage ØSubdural hemorrhage ØCerebral edema ØIncreased ICP ØInfection

Skull Fractures

ØGreat deal of force required to produce skull fracture in infant ØFracture on underside of skull can tear meningeal artery causing severe hemorrhage with hypovolemic hypotension - location and severity determines reversibility

TBI Nursing Management (know)

ØHistory/Physical ØNeuro Assessment: LOCs, GCS scale, neuro checks, VS ØLab studies: CBC, electrolytes ØRadiologic studies: Skull x-ray, then CT or MRI ØAdequate oxygenation ØPrevention of cerebral edema ØMaintain cardiopulmonary function ØPrevent complications

PI interventions

ØHuge appetite w/ no weight gain --> eat well but lose most of calories through stool ØHigh-calorie, high protein diet ØEnzymes-adjusted according to stool form ØVitamin supplements ØG-tubes w/nighttime feeds for severe malnutrition Those with pancreatic insufficiency usually have less pulmonary complications

Concussion management (know this)

ØImmediate break from sport, but do not completely eliminate all activity. Small amounts (Walk, read) of activity is helpful to heal. ØNo need to take prolonged time away from school work ØAvoid electronics!!

TBI: signs and symptoms (know this)

ØLoss of consciousness ØAmnesia regarding the event ØHeadache ØNausea ØVomiting ØSigns of increasing ICP ØRetinal Hemorrhages

Hydrocephalus Nursing Management

ØMeasure head circumference (1-2x day if in hospital for shunt replacement, esp preop and postop.) - Malfunction is more typical in first year of placement. Blockage is the most common cause. S/sx of increased ICP ØAssess for signs of increasing intracranial pressure ØAssess for signs of shunt failure and infection ØMonitor cardiopulmonary status ØMonitor neurologic status ØEducate family and help in coping - lifelong issue or damage if not caught in time

Seizure Disorder (watch videos!): patho, causes

ØPeriods of abnormal electrical discharges in the brain that cause involuntary movement, and behavior and sensory alterations. ØApproximately 20 % of all cases develop by 5 years of age. ØCauses: *CNS infection, head trauma*, fever, metabolic disturbances, hypoglycemia, toxins, tumors, emotional stress, anxiety, fatigue

Hydrocephalus clinical manifestations

ØRapid Head growth in infants ØSigns of increased ICP

Acute Flaccid Myelitis

ØSerious condition that causes weakness in the arms and legs, then specific damage to spinal cord; relatively new ØAKA "Polio-like Virus" ØNon-polio Enteroviruses, still not sure if that is the only thing (possible adenovirus or west nile virus) ØSpecific damage to the spinal cord=severity and location of weakness. Typically paralyzed for life. ØCan cause breathing issues requiring ventilation Ø*No specific treatment with exception of supportive care, esp bc no specific causes yet* ØExtensive PT ØSupport for the family - very small portion of children able to regain ability to walk or move arms

Hydrocephalus: patho, association

ØThe body's response to *an imbalance between the production and absorption of CSF*, commonly associated with myelomeningocele ØMay not be apparent at birth, may appear after primary closure of defect; CHECK HEAD CIRCUMFERENCE, can be from tumors and other pathological issues ØResults from disturbances in dynamics of CSF

concussion talk of town bc repetitive of military, football, gymnastics

ØTransient and reversible (Acute concussion) ØResults from trauma to the head ØInstantaneous loss of awareness and responsiveness lasting for seconds to minutes to hours ØGenerally followed by amnesia and confusion

status epilepticus: patho, emergency interventions, meds

ØWhen a seizure lasts longer than 5 minutes or when seizures occur close together and the person doesn't recover between seizures. ØEMERGENCY SITUATION ØEstablish IV access (phenytoin) ØMAINTAIN AIRWAY ØPrepare for respiratory support ØHigh dose sedatives (mat diastat (diazepam), or versed (midazolam) intranasally or rectally) ØMeds (valproic acid or IV push of phenytoin)

Primary Brain Injury (know this)

Øoccurs at the time of insult ØResults from a direct blow ØAcceleration-deceleration movement (coup = acceleration, countrecoup = deceleration)

Cast care (27.1 pg 553)

• reduce swelling • assess for drainage/bleeding, infections, tightness, cast edges, and tissue ischemia (5 P's) • keep cast clean and dry • teach child and parents; do not put anything in cast • educate on removal (when appropriate)

HPV vaccine

•4 specific types of HPV have been found to be most responsible for cancers. HPV 16, HPV 18, HPV 6, & HPV 11 Gardasil is a recombinant vaccine intended to prevent the initial infection of HPV and therefore preventing cancer and includes all 4 types. •Recommended for children 11-12 •Intended for BOTH boys and girls. •It is a series of 2 shots intended to be given within 6-12 mos if given before age of 15. women can get vaccinated till age 26 men can get vaccinated till age 21

INFANT skin

•40-60% thinner than adult -can cause tearing with minimal friction and makes it harder to regulate temperature. - earlier the child is born, the thinner their skin will be •Sebacious glands and Eccrine glands are functional at lower rate (no sweat with fever) •Apocrine glands do NOT function (this is why infants smell good) •Decreased amount of melanin (infants have a lighter skin color)

Neural Tube Defects (NTD): patho, types, risk factors

•An opening along the _neural tube_ where _central_ _nervous_ _tissue_ is not encased and protected •Open—nervous tissue contained in a sac outside the body •Occult—covered with skin, so not easily observed •Risk factors: genetic influences, in utero exposure to certain medications, folate deficiency, maternal diabetes, maternal obesity, hyperthermia early in conception •Most common are: spina bifida, encephalocele, anencephaly

Compartment Syndrome (27.2): assessment and signs pg 553 and 554

•Assess: neurovascular status (5 P's) - pain: OLDCART - pulses: distal to casted extremity (pedal for leg) - pallor: area below cast - paresthesia: numbness, tingling, tactile stimuli - paralysis: can they move it? Signs: • pain out of proportion with injury and unrelieved by opioids • pain with movement (passive) • persistent deep aching pain • paresthesia (onset within 30 mins) • pallor • decreased sensation • muscle weakness • paralysis

Legg—Calves—Perthes Disease: patho, characteristics, assessment, dx

•Blood supply to the _femoral_ _head_ is temporarily disrupted --> AVN or death of the bone cells •*Children ages 6-10, boys 4-5 times more than girls* •Exact cause unknown, but there are suspected risk factors •Limping with or without pain •Pain location may be _hip_, _thigh_, or _knee_ •Four stages (next slide) •Assess for: limping, pain, muscle spasms (tight pain in leg), loss of muscle mass (front of thigh of affected leg), shortening of affected limb -xrays for definitive dx

Scoliosis: treatment and postop care

•Bracing: severe curvature or at risk of worsening, depend on growth potential, pattern of curve •Surgical correction—spinal fusion Post-operative care • neuro status • turn every 2 hours (logrolling technique) • pain control

Fractures: etiology, periosteum, epiphyseal plate, clinical presentation, assessment

•Children's bones are more _porous_, and so are more likely to buckle or bow than to _break_ •_Periosteum_ is thicker and stronger, so usually more stable and more likely to heal on their own •_Epiphyseal plate_ (_growth_ _plate_) involvement --> higher risk for complications with healing and deformity •Types of fractures: Box 27.2 (p. 568) (no need to memorize types) •Present with pain, swelling, inability to move extremity •Assessment: hx (what happened?), neuro status (CSMs), radiological studies •Be aware of fractures that may indicate abuse - do not match hx

Boxes: 17.1 (Toys): preschoolers

•Clothes for playing dress-up •Art and craft supplies such as a pair of scissors, chalk, crayons, clay, paper, and pencils •Blocks for building and stacking •Dolls with clothes that can be taken on and off to practice dressing, undressing, and buttoning •Puzzles with large pieces •Simple board games •Kitchen sets with pretend food and plastic plates, forks, and spoons •Cars, trucks, and dolls •Dollhouses •Tricycles, bicycles, and other riding toys

Aspirated Foreign Body/ Foreign Body Aspiration basic info: common in..., causes, common items

•Common among the 1-3 age group who like to put everything in their mouths •Running or falling with objects in mouth •Inadequate chewing capabilities •Common items - gum, hot dogs, grapes and peanuts

Pectus excavatum: patho, sx, tx, cause

•Congenital deformity of the _ribs_, causes the sternum to go _inward_ •_depression_ or _concave_ appearance •Varying degrees of severity; _increases_ during growth spurts •Assess for associated cardiopulmonary difficulties (reduced exercise intolerance, chest pain, SOB, heart palpitations, fatigue, numbness) •Treatment depends on severity (if asymptomatic, may be no tx) Surgery for cardiopulmonary issues to reshape sternum and relieve pressure. Postop care = splint, pain control, PT to strengthen weak chest wall - unknown cause; associated with Marfan's syndrome, Rickets, Scoliosis; boys are more affected

Spinal Cord Injury: patho, types, sx, interventions

•Damage to the spinal cord that results in loss of physical and/or sensory function (MVA: 50%, firearms, sports injuries, falls, abuse) •Two factors determine the type of lesion: mechanism of injury and direction of forces •SCIWORA (spinal cord injury without radiographic bone abnormality)—no _fracture_, but damage is done to _spinal_ _cord_ •Types of injury; complete vs. incomplete •Varying symptoms depending on the _level_ _of_ _injury_and whether it is _complete_ or _incomplete_ •_spinal_ shock (occurs at time of injury, transient suppression of nerve function below level of injury, so full assessment of function can't be made till this resolves usually around 72 hours) & _neurogenic_ shock (life-threatening event, loss of vasomotor tone and sympathetic innervation of the heart, resulting in hypotension, bradycardia, and peripheral vasodilation, diaphragm paralysis, resp compromise) •Concurrent injuries •Immobilization, stabilization •Interventions are _developmentally_ based and depend on _symptoms_ / _severity_ - will be on cervical collar and immobilized on back board initially and remain immobilize till radiographic evidence confirms that there is an injury or not

Cerebral palsy: etiology and types

•Developing brain _fails_ to _form_ _correctly_ or receives some type of _insult_ •Congenital (damaged to brain before or during birth; 85-90% of cases) vs. acquired (within first 28 DOL; outside insult = infxn, head trauma) Four main types: • spastic (80%): stiff, rigid, difficult to move • dyskinetic : increase and decrease tone alternating; VOLUNTARY movements are difficult • ataxic: difficulty with coordination and steady gait - mixed: combination of 1 or more types

Cerebral palsy: clinical presentation and diagnostics

•Developmental delay (not loss)— usually fine or gross motor due to movement difficulties •_feeding_ difficulties from spasticity and difficulty moving • seizures •_cognitive_ delay: from brain injury or defect - spastic muscles, weakness, lack of muscle control (voluntary muscles) •Diagnosis: periodic screenings, physical exam, Xrays, CTs, MRIs, EEG of brain, metabolic studies, genetic testing

Cerebral palsy: interventions & evaluations/outcomes

•Developmental physician •OT/PT/ST (speech therapy) Outcomes: •Attain maximum physical abilities •Promote growth and development •Successful communication •Adequate nutrition •Social, academic, and recreational activities appropriate for development

Encephalitis Nurse Management and Diagnositcs

•Diagnostic Tests and Interventions: - radiologic pictures show areas of white - test CSF fluid - nasal and stool cultures depending on cause - CT, MRIs, *EEGs* •Monitor cardiorespiratory function •*Seizure precautions* •Neurologic assessment and monitoring

Rickets: patho, dx by what age, and assessment findings

•Dietary deficiency of _vitamin_ _D_ •Compounded by lack of _sunlight_ •Diagnosed by 1 year old - low incidence in US bc formula has vit D - more common in BF babies, dark-skinned, limited exposure to sunlight, don't receive vitamin supplements Assessment findings: •Weakness or difficulty walking •Skeletal deformities: protruding chest,

DMD (Duchenne muscular dystrophy) tx, med and purpose, monitor what functions, assess what status

•Early diagnosis and initiation of therapy •Glucocorticoids to slow the loss of ambulation, prevent scoliosis, preserve lung function •Physical therapy: passive and active exercises •Monitoring and preserving _lung_ _function_: prevent atelectasis, mucus plugs, resp inefficiency, and resp failure; exercise to increase lung volume; assist with coughing; ventilator support for later stages; monitor resp function •Monitor _cardiac function_: dystrophin deficiency leads to a weak myocardium that cannot keep up with demands of the heart leading to cardiomyopathy and arrythmia and cardiac failure; annual cardiac exams: ECGs, MRIs •Assess _growth_ and _nutritional_ status, may need _feeding_ _tube_ to maintain adequate caloric intake, weight loss, and malnutrition; needs regular growth assessment

Spinal Muscular Atrophy: Tx

•Early initiation of PT (exercises, stretching, braces, orthotics) •Pulmonary interventions: started early and proactively; promote drainage and airway clearance: oral suctioning, ventilator support •Nutrition: dysphagia, reflux, and constipation; may need enteral feedings - frequent aspiration, get tired easily, may need a G or J tube •Scoliosis repair: help with resp function •Support groups and resources for families

Preschool years: BF Pocket Guide: p. 68-81

•Erikson-develops conscience, begins to feel remorse •Piaget - Displays animism, egocentric although less towards 4yrs, understands hot/cold; active imagination, observe and imitates to learn •Kohlberg—decisions made based on the desire to please others and avoid punishment if parents do not discipline will continue bad behavior •IMAGINATION is huge •Short, chubby toddler to longer preschooler •Throws ball overhand, hop on one foot by 4 yrs •REDFLAGS: not able to perform self-care(wash hands, simple dressing, daytime toileting); lack of socializaiton, unable to play with other children, unable to follow directions during the exam •By 30mos should have all baby teeth-oral hygiene with child safe toothpaste around age 2

•Too much to put on slides, refer to book for charts for most important growth stages and milestones Bright Futures

•Focus is on nurtrition Babies NEED Fat for nerve synapsis development! •Cannot start solid foods until tongue thrust reflux is gone approx 4-6mos. Start with iron fortified cereal in bottle then progress to vegies, fruits, then meats. NO COWS milk until age 1 (or else bloody diarrhea can occur) •Sippy cup around 6-8 mos better to avoid non-spill cups d/t sucking and increase in dental carries •Begin gum/dental hygiene no toothpaste. Use washcloth with warm water twice a day against gums. •Infants should double birth weight by 6mos and triple by 12mos •WARNING FLAGS: Not able to hold head up by 3-4 mos, not sitting with assistance by 6mo, sit alone by 9mos, not crawling or stand with support by 12mo, pincer grasp by 15mos, walk alone by 18mos - cruising = walking while holding something Iron fortified formula is continued in infants until 12 months of age at which time children are switched to whole milk.

Osteogenesis Imperfecta: patho, types, signs, tx

•Fragile bones that break easily •Genetic _type I collagen (body connective tissue) disorder_. •Eight types, but Type I is the most common and mildest form •Bone fractures present even with_mild_ _injuries_ (even blood pressure cuff) when the child begins walking •May see fractures in various stages of healing •Differentiate from child abuse TX: palliative = manage sx; use mobility aids; encourage appropriate exercise (non-weight bearing); teach parents to pick up infants by hips instead of arms

Hib (haemophilus influenzae type b)

•Given IM •Start at 2mos, and will get 2-3 doses (depending on brand) by 6mos. •Booster recommend 12-15mos of age #1 cause of meningitis and deaths under age of 5 - US has a 95% decrease in these cases - epiglittitis, bacterial pneumonia, bacteremia, cellulitis, infectious arthritis, ear infection, bronchitis = diseases that can occur without vaccine

Muscle Strength Scale

•Grade 0/5: no muscle movement •Grade 1/5: small flicker of movement •Grade 2/5: movement with gravity eliminated •Grade 3/5: movement against gravity •Grade 4/5: movement against gravity and with some external force applied •Grade 5/5: movement against gravity and with good external force applied

HPV

•Human Papillomavirus is the most common STI, and is spread through vaginal, anal, and oral sex with an infected individual •Very common virus, 1 in 4 Americans are infected with HPV. -Approx. 75% of all new HPV infections are found among the ages of 15-24. Not reportable disease, numbers are not accurate. Just based on procedures and any info doctors send to CDC

DTap/Tdap (Diptheria, Tetanus, Acellular Pertussis)

•Inactivated Vaccine •Given IM •Redness, pain, swelling at site, fever, fussiness, anorexia up to 2 days of injection. Not too concerning with these common adverse effects. Can take tylenol or ibuprofen. •Given in the form of Dtap or Tdap •5 doses by Kindergarten (by age 5 or 6) upper and lower cases indicate level of concentrations. - DTap: more diptheria and tetanus. Start with children <7 - Tdap: more tetanus. Recommended for expecting mothers at around 27-36 weeks. Do not give children <7 - p: low levels of pertusis Tetanus = toxoid portion

Developmental Dysplasia of the Hip: patho, dx

•Inadequate coverage or dislocation of the _ball_ of the _femur_ from the _socket_ of the _hip_ _joint_ •Most often diagnosed during the newborn exam - can occur during or after birth - dx usually by first YOL; or when child is walking; more common in females

BF Pocket Guide: 94-111; 123 (including Tanner Staging/Sexual Development): Adolescents

•Increase in height and weight, accompanied by sexual maturity signs (see BF guide) •Puberty begins near the end of the school age period. •Growth spurt in girls is accompanied by an increase in breast size and growth of pubic hair; menstruation occurs last. •In boys, growth spurt is accompanied by growth in size of penis and testes, and growth of pubic hair. Deepening of voice and growth of facial hair occur later. •Interview without parent present; much of education is geared toward the child at this point. Talk to teenager and get their respect. •Safety, risk reduction are huge...drugs, alcohol, STI's, trauma, driving distractions, social media safety. •Erikson-struggle to be on own but depend on parents, peer acceptance huge, •Piaget-able to think more abstractly, thinks invincible-goes to safety (drugs, driving); develop critical thinking skills Kohlberg-morals based on peers, family etc, towards end of teens develop own sense of morals (may cause family issues)

documentation

•Informed consent must be documented •Manufacturer •Lot # •Date given •Site/Route given •Name/title of administer (RN)

muscular dystrophy: patho, symptoms, and dx testing

•Inherited disease, no cure, terminal •_Progressive_ muscle weakness, muscle fiber degeneration, muscle wasting •_Duchenne_ muscular dystrophy (DMD)—X-linked (passed on from mom so screen women for carriers), affects males only; dystrophin (protein that provides stable, strong muscle) is gone and muscle fibers break down and lose function •_Gower sign_ , _gross_ motor delay, muscle _wasting_, difficulty or inability navigating stairs, clumsiness, elevated CK level, hypertrophic calf muscles, unable to keep up with peers and age appropriate activities - loss of ambulation - progressive loss of muscle lead to resp or cardiac failure •Genetic testing for diagnosis

Spinal Muscular Atrophy: patho, symptoms, cause of death

•Inherited disorder, mutation in survival motor neuron (autosomal recessive mutation) •Degeneration of the _motor_ _neurons_ in the anterior horn cells of the spinal cord •_Progressive_, _symmetrical_ muscle weakness and atrophy of _proximal_ muscles •Varying degree of severity Four types (Type 1, 2, 3, 4) •_Resp_ _failure_ is the usual cause of death

sprains: patho, sx, and tx

•Injury to a _ligament_ from force exceeding its' strength or ability not to break •_pain_ and _swelling_ to affected site, difficulty _bearing_ _weight_ and _moving_ the joint TX: •_RICE_ technique (R= rest and no weight bearing for 24-48 hours, I = ice packs for 20 min at least 3x day, C = compression with elastic bandage, E = elevate above heart while resting) for the first few days after injury •_NSAIDs_, may need _immobilization_ (brace, splint, walking shoe)

Slipped Capital Femoral Epiphysis (SCFE): patho, sx, RFs, treatment

•Intermittent pain to the _hip_, _knee_, or _groin_ on the affected side; _limping_ •Stable (can walk) or unstable (can't walk) •Gradual or acute onset •Risk factors: OBESITY, OVERWEIGHT •Considered a _MEDICAL_ _EMERGENCY_ (risk for _avascular necrosis_ [AVN] to affected hip) •Surgical correction ASAP, crutches, "toe-touch weight bearing," and limited activity for 6 weeks - most common hip disorder in adolescents, more in boys than girls. - more common if obese, overweight, fam hx, pituitary disorders, thyroid dz

Measles, mumps, & Rubella

•Live Virus Vaccine •Given SQ (all live virus vaccines) •NO LONGER contraindicated with egg allergic patients! •Can cause a transient rash, fever, redness or pain at site of injection 1-2 weeks after the injection, but can happen within 24 hours

BF Pocket Guide: 82-93

•Long bones grow, leg length increases; fat gives way to muscle; body organs and immune system matures. Growth spurts may begin (around 9-10 for girls, a year or so later for boys) •Able to participate in organized sports both physically and cognitively Erikson: interested in things how they work, begin interest in school subjects sports etc. Need support when fail at something Piaget -No abstract thinking, begins to understand characteristic and classification, begins collections (rocks, hotwheel) *Kohlber*-things are either right or wrong, and punishment is for wrong doing. Doesn't necessarily understand reason behind the rules. REDFLAGS: lack of friends, school failure, social isolation, aggressive behavior (fighting, fire setting, animal cruelty)

LCP Disease: Treatment and goals

•Long recovery time (_several_ _years_) •Depends on age at time of diagnosis (see table 27.3, p. 562) - ex: younger child may just need rest and NSAIDs and activity restrictions. Younger children heal faster and have more time to regrow bone; older child may need braces, traction, and surgery. The closer they are to the growth spurt, the more prompt tx •Goals: pain control, maintain shape of femoral head, restore hip movement, preserve bone density

Overuse Syndromes: patho, stages, examples, treatments

•Micro-trauma damage to bone, muscle, or tendon from: repetitive stress without allowing time to heal •Damage occurs in four stages 1. pain after physical activity 2. pain during activity without performance restriction 3. pain with activity and performance restriction 4. chronic underlying pain at rest •Children are at higher risk because they are still growing •Examples: sever's disease (inflammatory of heel growth pain causing heel pain during adolescent growth spurt), osgood-schlatter disease (inflammation in front of knee growth plate/upper end of tibia and disappears after growth spurt), patellar tendonitis (jumper's knee; pain in patella from repetitive contraction of quadriceps muscle; treat with stretching), throwing injuries (elbow), and stress fractures (muscles are fatigue and transfer stress to bone and forms a crack) •Treatment: RICE, NSAIDs, stretching exercises, supportive devices •_rest_ and _compliance_ to prevent deformity and long-term damage!

Nursing considerations

•Mild fever or mild illnesses such as a cold are not contraindications to receiving immunizations (as long as temp is not over 102). •Redness, swelling, and pain at the site of injection along with mild fever after immunization is normal. •Some vaccinations can cause other "normal" reactions (rashes from MMR or varicella) •Prophylactic Tylenol is NO longer recommended bc it lowers the immune response (give after injection when symptoms are shown) •Injectable Live Virus Vaccines MUST be given SQ. •Inactive Virus Vaccines are typically given IM but can be given SQ in some instances. Never give vaccines in gluteus maximus, only thigh and arm. Live vaccines must be given 4 weeks apart if they are not given at the same day. Bc immune response will need time to reset. They can be given at the same time tho. Vaccines can be given on the same day.

Spina Bifida patho, risks, impairment, other complications

•Most common NTD •Failure of the neural tube to fuse in the lower spinal area --> open vertebral arches ---> sac protruding from the spinal area or a lesion covered with skin •Three types (next slide) •Risk for _infection_ and _trauma_ during gestation and birth •Neurological impairment— paralysis below the level of defect, orthopedic difficulties, potential cognitive disabilities •May also have Chiari II malformation, hydrocephalus

Cerebral palsy

•Most common physical disability in childhood •Umbrella term •_multifactorial_, _nonprogressive_, _permanent_ disability •_varying_ degrees of disability

Nursing Management

•Must obtain parental consent this includes providing parents with information on the vaccines being given. •Know patient's medical history. Do they have any chronic illnesses that would prevent a certain type of vaccine? Are they immmunocompromised so no live vaccines? •Has child had a previous serious reaction? •Previous Vaccination Record for the child. •Document appropriately •Report any Adverse Events (fever = tylenol and ibuprofen. NO effects = document!)

Congenital and Developmental disorders: MSK

•Pectus Excavatum •Polydactyly and Syndactyly •Osteogenesis Imperfecta •Blount Disease •Congenital Clubfoot •Developmental Dysplasia of the Hip

Prevention

•Primary— primary care visits (vaccinations), monitoring developmental milestones •Secondary—screening, addressing illness or delays early (early intervention = speech and physical therapy) •Tertiary—improve quality of life and reduce symptoms of a disease already present

Scoliosis: patho and classifications

•Progressive _lateral_ curvature of the spine •Classified by location (_thoracic_ or _lumbar_) or by cause (_congenital_, _idiopathic_, or _neuromuscular_) - congenital caused by embryological malformation where vertebrae failed to develop or separate - neuromuscular caused by neurological CNS diseases; occurs at any age; can cause compression of internal organs •_adolescent_ _idiopathic_ is the most common; unknown cause; 80% of cases - infantile: <3 years - juvenile: 3-10 years - most common: adolescent idiopathic = 10+ year old; around puberty

Neuro: General Nursing Interventions

•Promote skin integrity (vulnerable so reposition frequently) •Maintain effective ventilation (Clear secretions) •Prevent falls •Maintain adequate nutrition (lack of appetite, difficulty swallowing, high-calorie meals with adequate time, height and weight) •Promote pain relief, comfort, and rest (spasticity can cause pain, braces, antispasmodics, pharm and nonpharm) •Provide emotional and psychosocial support to the child and parents

MSK nursing interventions

•Promote: pain relief, comfort, and rest (including nonpharm techniques) •Prevent: infection (assess postop sites) •Maintain: body alignment and function: may need assistive device •Promote: physical ability (depends on age, underlying conditions, and any treatment that they had) •Promote: growth and development (esp: schoolwork for school age; allow visitors for adolescents) •Educate families on: therapeutic interventions •Specific disorders

Diagnosis of Atopic Derm will Include

•Pruritic rash!!!! Plus 3 of the following: •History of flexural dermatitis •History of respiratory allergic condition in first degree relative •History of dry skin in last 1 year •Rash before age 2 (flexor surface: 2+) •Visible rash on cheeks, forehead, flexoral, or extensor areas in infant

Acquired MSK disorders

•Rickets •Slipped Capital Femoral Epiphysis •Legg—Calve—Perthes Disease •Osteomyelitis •Scoliosis

spinal curvature

•Scoliosis—"C" or "S" shaped from behind, _lateral_ curvature •Kyphosis: seen from side in thoracic area •Lordosis: seen from side in lumbar area

Adolescent skin (more similar to adult)

•Skin thickens to full thickness -therefore less likely to have injury with minimal friction. •Eccrine glands fully functional •After puberty males sweat more. •Apocrine glands are fully functional after puberty. •Melanin is now at adult levels providing full skin color and protection against UV light

congenital disorders

•Spina Bifida •Muscular Dystrophy •Spinal Muscular Atrophy

Spina bifida: 3 types

•Spina bifida _occulta_—skin intact, no obvious protrusion; bony abnormality; hair tuft in area of defect •Spina bifida with _meningocele_—Obvious protrusion of meninges •Spina bifida with _myelomeningocele_—obvious protrusion; sac contains meninges and spinal cord

Musculoskeletal Injuries

•Strains and Sprains •Fractures •Overuse Syndromes

strains

•Stretched or torn _muscle_ or _tendon_ •Tx = Rest

Neuromuscular: Variations in Anatomy & Physiology

•Structures are fully formed (but immature) at birth, fully developed near adulthood •The majority of _gross_ and _fine_ _motor_ _skills_ develop by age 2 •Gradual maturation • Developmental milestones •Intrinsic (genetic defect) and extrinsic factors (toxins: lead)

Cerebral palsy: discharge planning & teaching

•Support & resources for parents •Education (parental): case manager, seizures and spasticity management •Education (child, IEP) •Early intervention: programs available •Medications •Assistive & safety devices (adaptive technology to manage communication and promote ability): gait belts, car seats, strollers, wheelchairs

Spina bifida: management

•Support _oxygenation_, _ventilation_, _thermoregulation_, and _prevent_ _infection_ at birth •Cover lesion with _sterile_, non-permeable gauze soaked in warm SALINE •Prevent _head_ and _fluid_ loss •Surgical closure (within 24-36 hours) of spine to prevent trauma and infection •Serial head circumference measurements

Review

•Table 23.1 in Tagher & Knapp pg 417

Congenital Clubfoot: medical term, patho, presentation, dx, tx

•Talipes equinovarus •Heel of affected foot tilts _in_ _and_ _down_, the forefoot turns in so the bottom of the foot faces inward or upward •Foot and calf are smaller & the Achilles tendon is shorter on the affected side •Diagnosis made at birth or in utero •Non-surgical treatment: serial casting (ponseti method)daily stretching - (weekly stretching of foot followed by application of long leg cast; for 4-8 weeks till foot is corrected; tendon is lengthen; wears a brace for a few years)! these work best if they happen early. COMPLIANCE is essential •Surgical correction: if deformity reoccurs or non-surgical doesn't work

HPV types

•There are more than 200 different types of HPV. •HPV can cause many types of cancers in both women and men. -HPV is the most common cause of Cervical CA -Vaginal CA-75% from HPV -Vulvar CA-69% from HPV -Penile CA- 63% from HPV -Anal CA-91% from HPV -Oropharynx CA (back of throat)-72% from HPV

Blount Disease: patho, presentation, associated with, assessment, tx, postop

•Tibia vara (_bowed_ _legs_ aka internal tibial torsion) - normal in toddlers but straighten out by 2 years old - by age 3, this dx is suspected is bowed legs still; can reoccur after tx - often associated with excess body weight, early walking, vitamin D deficiency, or genetic deformities •Disorder of the _tibial_ growth plate •Presents with inward turning of the lower leg, leg length discrepancy, and knee pain •Assess the curvature of the lower leg with the child standing and walking •Treatment: BRACING EARLY or surgery; postop care = assess neuro; tibia is prone to compartment syndrome! •Assess _neurovascular_ _status_ of a child in cast (Compartment syndrome, DVT esp if obese)

Scoliosis: assessment and dx confirmation

•Truncal asymmetry: uneven shoulders, raised hips, rib hump •Adam's _forward_-_bending_ test; bend forward to see side; note if one spine is higher and is straight or curved •Some back pain •Scoliometer to measure degree of curvature •Diagnosis confirmed through radiographs

Neuro assessment

•Varies depending on age •Thorough history: prenatal, natal, neonatal, fam, developmental •Developmental _milestones_ (Table 28.1 pg 575) •Developmental _reflexes_ (Table 28.2; do not need to memorize!!) •Cranial nerves •Posture: symmetry, back arching •_coordinated_ movements ("G & D Check" 28.1): a deficit in one area can affect others •Sensory function: pain, light touch, temp, proprioception, sensation •Tendon reflexes: intact/normal, absent/diminished, symmetrical, exaggerated/asymmetric •Muscle tone

spinal muscular atrophy: presentation/assessment

•Varying degrees of _motor_ delays, _hypotonia_, and absent _reflexes_ •_delayed_ _motor_ _milestones_ (sitting, walking, etc.) - depending on type •Signs of _respiratory_ compromise •Inadequate weight gain due to inability to consume enough calories •Scoliosis, contractures, lax joints, immobility

Peds Neuro Exam

•Vital Signs: 3 main neuro ones = HR, RR, BP (these change with change in neuro status or increase in ICP) - increased systolic pressure and widened pulse pressures along with brady cardia and irregular respirations with neuro issues and increased ICP •Cognitive Function: posture and movement through Glasgow Coma Scale •Posture/Movement: decerebrate/decorticate •Level of Consciousness: one of the most important. Responsiveness and awareness to stimuli - 2 parts: alertness and arousal to stimuli, ability to respond to that data •Pupils •Fontanel/Suture lines

Osteomyelitis: patho, dx

•_Inflammation_ of the _bone_ secondary to bacterial infection •Most common organism is S. aureus; causative organism often not identified •Bone biopsy provides definitive diagnosis

botulism: patho, presentation, assessment, treatment

•_Neuroparalytic_ illness from toxins produced by Clostridium botulinum •Infant botulism—age <1 week to 1 year •_Symmetric_ _descending_ _flaccid_ _paralysis_, beginning in muscles supplied by _cranial_ _nerves_ •May present with: poor feeding, weak sucking, drooling, floppy appearance, constipation, respiratory symptoms •Assessment focus: _neuromuscular_ and _respiratory_ function •Treatment: supportive care, respiratory support (ventilation may be necessary), botulism immune globulin

Polydactyly and Syndactyly: patho, digits composed of..., tx

•_polydactyly_—extra digits on hands and/or feet •_syndactyly_—digits fail to separate, giving a fused or webbed appearance •Digits may be composed of skin, soft tissue, bone, joints, or a combination •Syndactyly may involve nerves and muscles •Treatment: depends on severity; Surgery to remove extra digits or separate digits; more complex surgery if muscles and nerves are involved

Fractures: treatment

•_reduction_ (open vs. closed) •immobilization •Prevent infection (_osteomyelitis_) •_neuro_ status (prevent compartment syndrome!) • pain control •Patient and family education (cast care) •Traction (p. 570, Figure 27.13)

Screening

•brief assessment and/or procedures that help identify normals or those that need further evaluation

Temperament

•innate qualities; research demonstrates that personality characteristics seen during infancy are often consistent with later in life (About 35% have characteristics of all three). •Easy—moderate in activity, shows regularity in patterns (eating, sleeping, elimination), usually in a positive mood when subjected to new stimuli (40%) •Difficult—irregular in schedule/patterns (eating, etc.); adapts slowly to new people or circumstances; predominantly negative mood; intense reactions to the environment are common (10%) •Slow-to-warm-up—reactions of mild intensity, slow adaptability to new situations; initial withdrawal followed by gradual/quiet/slow interaction with environment. (15%)

Surveillance

•the continuous process in which skilled observations are carried out in collaboration with all involved (families, childcare workers, health professionals)

Dyslipidemia management

● Need very aggressive tx and interventions to make a difference in these children's lives ○ These children can't make a change in what they are eating ○ Do the parents have enough money to have healthy food or enough time ○ Are the kids left to fend for themselves for meals ● Obesity is the number one cause of dyslipidemia ○ If parents are able to do dietary modifications, lipid levels can be lowered 15-20% and then we start reversing those cardiovascular changes that have occurred ○ It isn't easy to teach families ● Primary - genetic dyslipidemia ● Secondary - environmental factors

Types of ICP Monitors

◦Intraventricular catheter ◦Subarachnoid bolt ◦Subdural screw: can ICP monitor and remove excess CSF ◦Epidural sensor: least invasive; goes into skull of dura matter ◦Anterior fontanelle pressure monitor (Don't have to know types just know that each monitor is specific to area that it is reading, and you treat the child the same)