Pediatrics

School-Age G&D (6-12 yrs)

6-12 yrs Physical: last period in which boys and girls are close in size, fat gives way to muscle, child appears leaner, jaws change, teeeth lost, meds metabolized easier, girls may have spurt at 9 and boys later, permanent teeth coming in, concept of conservation Grow 3-5lbs a year, 1 1/2- 2 1/2 in, enjoys crafts, plays cards and board games, rides two wheeler, jumps rope, roller skates, can read, able to concetrate, Loss of literal translations

Defects obstructing systemic flow

939

Defects causing increased pulmonary flow

923 PINK o Increased pulmonary BF (causing L to R shunting) ♣ Patent ductus arteriosus (PDA)- part of fetal circulation, hard to detect bc it should close withing 1st 24-48 hours of birth. Pressure & O2 should help it close ¬ Normal fetal circulation conduit fails to close between the pulmonary artery and the aorta ¬ Murmur: loud, continuous "washing machine" heard in systole over 2nd left intercostal space (PULMONIC) ¬ Wide pulse pressure & bounding pulses ¬ May be asymptomatic- usually no symptoms & they are pink. Become SOB, breathe a little faster, sometimes tachycardic ¬ This child commonly gets resp infections, because there will be more fluid in the lungs than the child can handle and you hear crackles (increased fluids) and this provides a medium for infection to take place ¬ Interventions (excellent prognosis, <1% mortality) o Medical: Ibuprofen or Indomethacin (prostaglandin inhibitor) successful in closing a PDA in some preemies & newborns [ibuprofen is an NSAID and helps with closure and is used for constriction... don't give it to mom before she gives birth) o Surgical: Ligation of patent vessel via left thoracotomy o Interventional cath: coils to occlude the PDA (allows it to close off) o Preemies, small infants, or children with large or unusual PDAs may require surgery ♣ Atrial septal defect (ASD)- hole found in between the atrium, foramen ovale doesn't close causing an ASD....hole is somewhere along the atrial wall & its easy to close. If child is doing very badly they wont grow, they feel faint, dizzy, and commonly get resp infections ¬ May be asymptomatic ¬ Loud, harsh systolic murmur heard in pulmonic area ¬ May develop CHF - from fluid back up ¬ At risk for atrial dysrhythmias (possibly caused by enlarged right atrium)- especially when theyre older ¬ Because left atrial pressure exceeds right then blood flows from the left to the right atrium...causing an increased flow of oxygenated blood into the right side of the heart (and consequently not out into the body) ¬ Interventions (excellent prognosis) o Digoxin and diuretics for CHF (check apical for dig & make sure to monitor K+ levels with diuretic) o Surgical: for irregular defects, for bad defects- if valves are involved must get surgery o Smaller defects may be repaired in cardiac cath (Amplatzer Septal Occluder most commonly used) ♣ Ventricular Septal Defect (VSD): hole found in the ventricle (anywhere along the septum) ¬ Prognosis: good (not as high as ASD) ¬ Highest risk with surgical closure during infancy (younger the age, the worse they do) ¬ Depends on location of defect, number of defects & other associated cardiac defects. {small VSD close within 1st 6 months of life, if it doesn't close they go in and do pulmonary banding- go into pulm artery & put a little band around it, to keep so much blood from going up in there (because of all the blood going into lungs you want to perform PA banding) ¬ Multiple muscular defects can carry higher risk. [complication= right bundle branch block] ¬ Interventions o Palliative: pulmonary artery banding to decrease pulmonary blood flow for infants with multiple VSDs or complex anatomy o Surgical procedure of choice: CP bypass for both~ small repaired with suture ~ large require knitted Dacron patch sewn (sewn in the hole) o Nonsurgical: closure in cardiac cath (investigation in some settings at present) ♣ Atrioventicular Canal Defect (AV canal) or AV septal defect ¬ ASD + VSD= one big gaping hole (canal). Most commonly seen in downs babies (70% have this defect) ¬ Low ASD & high VSD... allows blood to flow between all 4 chambers ¬ CHF most severe with complete AV canal (absolutely no septum in between at all) ¬ Mild cyanosis with crying ¬ At risk to develop pulmonary vascular obstructive disease ¬ Interventions (operative mortality <5%) o Palliative: pulmonary artery banding done for small infants with severe symptoms o Placed on prophylactic antibiiotics for LIFE!!- keeps them from getting endocarditis. You want to limit their feeding time (nipple time)- because when they eat, they use up a lot of calories (15 min of feeding and the rest down NG tube) o Surgical: Patch closure of septal defect and reconstruction of AV valve tissue. o Complication: heart block, CHF, mitral regurgitation, arrhythmia, pulmonary hypertension Obstruction of blood flow ♣ Aortic stenosis: aorta is skinny and narrow. Trying to get blood through is difficult • Interventions (mortality is <1% but can die of sudden death) ¬ First-line procedure: balloon dilation in cath lab [doesn't last forever, they have to keep coming back] ¬ Palliative: valvotomy (25% require add'l surgery in 10 yrs)- aortic valvotomy in older children. May need to put in a pig valve (may eventuall need to be replaced as they grow). ¬ Aortic valve replacement when stenosis severe (sometimes in aortic valve the leaflets wont open, they can go in and cut them open but may cause regurgitation ♣ Coarctation of the Aorta (COA)- see above ♣ Pulmonic stenosis- in pulmonary vein. If severe child will be cyanotic ¬ Narrowing of pulmonary valve or pulmonary artery (cyanotic with severe narrowing) & murmur present ¬ Right ventricular enlargement (hypertrophy) ¬ Exercise intolerance- they don't have enough oxygen to play ¬ Narrowing at entrance of pulmonary artery...causing right ventricular hypertrophy and decreased pulmonary blood flow. [pulmonary vein constricted= they can enough blood up into the lungs to be oxygenated= BLUE] ¬ Occasionally the resistance will reopen the foramen ovale - shunting deoxygenated blood in to the left atrium = systemic cyanosis [blood doesn't go into lungs, it goes back into RV, causing pressure on RA, then the blood back up into liver/or extremities, opening up the foramen ovale ¬ Interventions (mortality <1%) o Angioplasty: -Infants: Brock procedure (closed valvotomy) valvotomy= cutting open the leaflets -Children: pulmonary valvotomy (with by-pass) o Nonsurgical : Balloon angioplasty o Surgery: rarely indicated due to balloon angioplasty option

Kawaski

Acute febrile, systemic inflammatory disorder that effects small and midsize arteries including the coronary arteries. Leading cause of acquired heart disease in children- majority under 5. More males , asian, pacific islanders, followed by blacks and hispanics. Etiology: Unknown - associated with an infectious agent. Seasonal distrubition during winter and spring. Appears to result as an exaggerated immune response in genetically susp child, but also results in signs consistent with toxin-mediated disease. Can cause aneurysms and lead to stenosis of coronary arteries leading to reduced blood flow and protential infarcts. CM: Three stages of the disease are acute, sub acute, and convalesence Acute: Lasts 1-2 weeks; Irriability, high fever for more than 5 days, conj hyperemia, red throat, swollen hands and feet, maculopapular or erhythema multiformlike rash on trunk and peri area., unilateral enlargement of cervical lymph nodes, diarrhea and hypeatic dysffunction Subacute: 2-4 weeks; cracking lips and fissures, desquamation of skin on the tips of fingures and toes, joint pain, cardiac disease, and thrombocytosis. Red tongue Convalesence- 6-8 weeks; Normal but lingering signs of infflammation Some cases have atypical presentation: arthalgias (joint pain), abdominal pain, diarrhea, and vomiting, hepatic dysfunction, gallbladder hydrops (fluid in galbladder), uveitis (middle layer of eye), urehtritis (uretheria), aseptic meningitis. DX: No specific; Elevated erythocyte sedimation rate creater than 40mm, C reactive protein greater than 3mg; Elevated WBC, PT,T, mild anemia, elevated alanine amino level, hypoalbum, wbc in urine. Echo for vascular changes. Cliical Therapy:IV Immunoglobin 2g/kg within 10 days of onset with oral aspirin (80mg x4) while fever high- decreased to 2-5mg/kg once daily after fever dropped. If given before 10th day decreases lesions and anurysms, decreased fever and inflammation, If fever persists after first immuo, give second dose. If still not effective give corticosteroids. Hospitalize for at least 3 days. Nursing mngt: Temp Q4, assess extrem for reddness ad desquam every 8 hours. Examine eyes and mm for inflammation, monitor diaerty, daily weight, HEART SOUNDS. infusion rate should not be over 1ml/minute - IF REACTION STARTS STOP THIS IMMEDIATELY . Lubricate lips, col compress, change linens frequently, small feedings of soft foods and loquids, passive ROM, rest periods. Teach parents: aspriin daily, temp daily, report fever above 100, avoid contact sports, limit strenous activity . POSTPOSTONE LIVE VIRUS VACCINES FOR 11 MONTHS AFTER IMMUNOGLOBIN . Flu vaccine can be given.

Fontanels

Anterior and open sutures palpable to 18 mo Posterior closes between 2-3 mo Anterior is diamond shape and usually smaller than 2 in at 6 mo Should feel FLAT, FIRM, INSIDE THE BONY EDGES Sutures not palpable after 2 yrs

Hydrocephelus

Body's response to an mbalance between the production and aborption of CSF leading to an increase in the volume. Congenitial and associated with other nervous system disorders - usually spina bifida. mAY DEvelop after iv hemorrhage in a preterm infant. Etiology: CSF produced in choroid plexus; Usually absorbed by subarachnoid spac into venous circulation. CSF must pass through cambers and pathways between ventricles around brainstem and spinal cord untill it reaches this space. When CSF absorbed less than its produced, ventricles enlarge. May be communicating or noncommunicating and congenital or acquired. Communicating: flow freely between ventricles, normal channels, and pathways. but absorp of csf in the sub and villi is impaired. After acquired from postinfectious meningitis, iv hemorrhage, or cong malformation of the sub. Noncomm: most common; obstruction of vent system that impedes flow of the csf and prevents it from entereting the sub. infection. hem, tumor, structial deformity causes. CHIARI 2 MALFORMATION ( SPINA BIFIDA - symptoms may begin as stridor, weak cry, apnea, weakness, difficulty swallowing, vocal cord paralysis, breath holding episodes, aspiration), aqueduct of Sulbius stenosis and Dandy walker syndrome (4th vent enlarged) CM: Etiology: Cong strutucal defect in Infancy Dandy walker Chiari 2 Aqu stenosis Iv Hemmorage in infancy CMS: Early: rapid increasing head circumference, tense full or bulging fontanel, split sutures, bossing, face disproprortaionate, difficulty holding head up, Macewens cracked pot sign, dstended scalp veins, increased tone or hyperflexia, brisk DTF, Babinksi sign, decrease LOC Late: apnea, shrill, difficulty swallow or feed, vomit, FTT, regression, sunsetting (sclera visible above the iris), sixth cranial nerve palsy, paralysis of uppper gaze, cardiopulonoary depression ETiology: Acquired in older children after close of sutures Post infection Tumor Hemmorage CMS: Signs of ICP headache with rising , nv, fussy, sleeplessness, confusion, apathy, altered loc No head enlargement Irritability, leth, poor app, personality change poor judgement, school worsening, ataxia, visual problems due to pressure on sixth cranial nerve (double vision, strabismus) DX: us, ct, mri, ect Therapy: acetazolamie; surgery, remove obstruction or create new pathway for CSF. A cath or shunt is placed in the vent and passes the csf to the peri cavity or alt location such as the right atrium or pleural space of the lungs. The shunt system consists of four parts: vent cath, pump chamber/resevoir, one way pressure valve, and a distal cath. The resevoir is palpable at the burr hole. Tubing may be palped from the burr to the inesertion point in the chest or abdomen. Shunt usually placed early in infancy. New shunts programmable with a magnent- no mris. Mechanical complications: kinking, blockage, shunt failure, infection (appendicitis, peritonitis; shunt will be removed and vent drainage system put in place) Endoscopic third vent is alt surgery for from a tumor or aquad stenosis that flows around the blockage- complications may include hemm csf leak sub hematoma bardy diabetetes ins increased app loss of thirst and amenorhea. Nursing mgt: HEAD CIRCUMFERENCE EACH VISIT+ OBSERVE SIGS OF AILURE AND INFECTION Following surgety vital signs, loc, icp, leakage, infection, nuchal ridigity, neck or back pain, photobia. I&O Signs of infection: changes in responsiveness, irritability after fever is controlled, malaise, headach,e n, redness, abdominal disc, or apnae. Daily head measurements if shunt failure suspecte. Op: position careful, no strain on neck muscles, good skin care, may not be able to hold child sheepskin or lamb wool blanket, because prone to vomit: frequent small feedings/buring. Post op keep flat, head elevated over a day or two, vitals Q2-4, asapetic technoque Teach: no foward facing care safety seats- increases risk for cervical spin injury and death. High contact sports discouraged: try tennis or swimming; always wear helmets; MANAGE CONSTIPATION - INCREASES PRESSURE!! Small frequent feedings, hob flat - raise over 2 days; vitals every 2 hours, aseptic,

Cleft Lip/Palate

CARE PLAN PAGE 1132 Can occur singly or together; Fourth most common birth defect; palate is less common 4:10k; Native americans and asians Etiology: Cleft lip" failure of maxillary proccesses to fuse with the elevations on the frontal prominence during 6th week of gestation; Usually union copleted by 7th week; Fusion of the secondary palate occurs between 5-12 weeks. Failure of tongue to move downward at correct time will prevent palatine proccesses from fusion. Palatte: IU dvp of hard and soft completed in first trimester; during this time that other organ systems develop so 10% will also have an associated syndrome. whEN IT OCCURS ALONE, AN ASSCIATED SYNDROME INCREASES TO 30-50% (like ONLY cleft lip or ONLY pallette = uh oh) Increased incisnce of otis media, hearing loss, speech problems, dental deformity. Family hx, environment, genetics. folate decreases risk. Smoking, anticonv, and steroids increase risk CM LIP: Uni or bilateral, may be associated with cleft palate, complete extends into the nostril floor, incomplete has a bridge of tissue connecteing the central and lateral lip Pallette: Occurs anywehre from the incisor foramen to the uvula, incomplete mainly the solft pallate invovled; DX: US, visualize; May also be involved with ear deformities, skeletal, heart defects, and GU; Therapy: repaired around 3 months; Diagnal incision or zplasty; Immolbilize elbows; early closure for infants to form better seal around nipple for feeding; sucking strengthens muscles for speech; long nippples or enlarged holes helpl; Prone to reccurent otitis mediia which can lead to hearing problems; Nursing mngt: facilitate feeding, provide emotional support, preop post op, assist parents with coordinating care, maintain healthy home env and make referals Phsyiological assessmente xtremely important to determine correct method of feeding and catch additional defects psychosocial : familys reaction , can be devestating. Promote bounding by explaining nature of defect and procedure for correction. Speak to infant, point out positive attributes, Facilitate feeding: Usually able to breastfeed or bottle feed with assitance of lactation consultations and education relateed to positioning and feeding tehiniques; if its not possible: pump breasts in order for the milk to be fed by a spcial nurser. For infants needing help, wide based nipples, squeezable bottles, special bottles, device in mouth to enable them to establish suction. Clinical tip: point of infants positive aspects: Look at his long beautifal hair Post op: Vital sounds, MAINTAIN AIRWAY, i&o, When clear fluids are staRted give through a dropper or special feeder. Sitting position when feeding to prevent aspiration; After each feeding clean the suture line with water or normal saline. Maintain suture line: prevent infant from rubbing, keep her in supine position, elbows immoblized, steri strips on lip, antiobtioic oiintment, avoid use of metal utensls or straws cuz they disrupt the surgial line. Bundle infant, front sling for baby; Complications on 1130 Keep elbows immoblized, maintain suture line with stero strips over incision, place ointment on the site, minimize infant sterss, no metal utensils Boxes 1137-1138

Meningitis Assessment Skills

Etiology -Acute inflammation of the meninges and CSF - Haemophilus influenzae type B (Hib vaccine) -Neonatal: group B streptococci- can cause meningitis from mother not treated Pathophysiology -Infection extends to the ventricles, thick pus in brain, fibrin or adhesions may occlude the narrow passages and obstruct the flow of CSF. Diagnosed by Lumbar puncture- legs curled up head pulled toward stomach, lying on side {lumbar puncture= flat for 4 hours) Clinical Manifestations Onset abrupt [fever, chills, headache, vomiting] - LP unless contraindicated - then CT [ ICP] -rapid treatment, isolation -Cephalosporins superior for CSF sterilization & reduced severe hearing impairment -10-15% fatality, neonates most vulnerable Aseptic (just inflammation)no pus in brain -Onset more gradual, treat symptoms: N/V, HA, irritable, photophobia, -private room; fluid restriction, padded siderails, ER equipment, seizure precaution (decatron- decrease inflammation) What will CSF tell you? [24-72 hours for culture] o Bacterial- increased WBC's, increased protein, decreased glucose, culture will be positive, pussy looking fluid (bacteria eats glucose in CSF) o Viral- slightly elevated lymphocytes, protein normal, glucose normal, color of fluid may be cloudy or clear ¬ Clinical Manifestations: o Kernig's: raise childs leg with knee flexed, extend childs leg at knee, if resistance or pain then this is positive o Brudzinski's: flex childs head while supine, if knees or hips flex then this is a positive sign o Nuchal rigidity: put chin to chest, don't want to move (This is opithotonic position; they are most comfortable like this) head to chest; resistance to neck flexion Infants: fever, poor feeding, v/d, anterior fontanel bulging or flat, alert restlass lethargic ect, nothing calms them down Older: febrile, confused, impaired LOC, irritable, lethargic, muscle and joint pain, vomit, hemorrhagic rash, necrotic patches, headache, back pain, photobia, DIC, shock, ICP, hydrocephelus Treatment: antibiotics, corticosteroids, iv fluids Reduce stimulus, side lying position, osilate the child use standard and droplet precautions, Give HIB, pneumonoccocal, and meningococcal vaccines Care plan on 1337

GERD

Etiology: Band of smooth muscle does not relax to prevent reflux. The return of gastric contents into the eso, result of relaxation of lower eso sphincter. Higher in premi and males. Some spitting up is normal in infants after feeding, but if it continues and increases in freq, it may be caused by GER. GERD is more serious manifestation of GER- pathologic manifested by poor weight gain, reccurrent vomiting, genrealized irritability, refusal to feed, arching. and resp symptoms such as wheezing. At risk: neuro disorders, syndromes, trisomy w1, brochopulm dysplisia, and trach fistula Three mechanisms: Transient lower eso sphincter relaxations (triggered by eating), hypotensive or incompetence lower eso sphincter, and anamatomic disruption of the eso junction. (hiatal hernie - puts pressure on the eso). Infants also have delayed gastric emptying CM: Reguritgation after feeding, vomiting, hungry, irritable, eat but lose weight, history of vomit and upper resp infections and are at risk for aspiration and apnea. Severe: aspiration, failure the thrive, esophagitis Collab: ID the reflux, prevent complications through diet and pharm or surgiery. Dx: feeding patterns, ph pribe, catheter in eso for 24 hours to measure ph, nuclear medicine scintiscan (gastric emptying study). Test for cow milk protein allergy since its associated (cutaneous, eosinphil smear of nasal, igG levels, and biopsy) Clinical therapy: Generally feeding mod, thickened feeding, positioning in milder cases. Smaller feeding volume to avoid distention; Rice cereal; BREAST MILK WILL NOT THICKEN WITH CEREAL. Do not enlarge nippple hole with formulas. Forumlas Protein hydrolysate: Pregestimil, Nutrramigen, Alimentun; Other forumla with rice: Enfamil AR Curvature of stomach (fundus) ariund the distal eso (Nissen Fundoplication) in severe cases. Practice alert: Best feeding poosutuin for postprandial infant with GERD is prone. Only use this position when baby is awake and alert to not cause SIDS. Hold baby up 20-30 minutes after feedings. Car seats increase intraabdominal pressure and promotes reflex Nursing mgtm: support nutritional intake, reduce complications and support family. Thorough assessment, plot grwoth, RR dustress, keep mouth free from emesis, initially smaller feedings, elevate head, gtube, teach parents to cuddle during feedings, pacifier helps teach how to suction if vomit CM table on 1144 Meds on 1145

Wilms Tumor (Nephroblastoma)

Intrarenal tumor ; Abdominal tumor Doubles in size in 11-13 days 90% survival with chemo CM: Asymptomatic, firm, lobulated mass located to one side of the midlne in abdomen; Hypertesion caused by increased renin, hematuria, abdominal pain DX: US, CT, MRI, look for mets,BUN, creatine Surgery to remove tumor, chemo, radiation Side effects on 1107 Nursing: DO NOT PALPATE THE ABDOMEN DO NOT SPREAD THE CANCER CELLS BRO!!!!! Postrenal surgery: pain management and fluid monitoring, frequent repositioning, daily weight i& o, ug, Chemo: side effects, infections, function of kidneys Staging on 1108

Labs and Vitals

Labs: Skim 1568 RR : 1579 HR: 1581 https://shp.missouri.edu/pt/pdf/emergency.pdf ?? Idk maybe look in ATI

Vaccines for Infant and Toddlers

Look on study guide for exam 2 Too long here

Nursing Care Seizure Disorders

Maintain airway, supplement oxygen, IV benzo, careful monitor electrolytes glucose blood gases Pg 1327 for emergency Ketogenic Diet: high fat, adequate protein, low carb ; ONLY USE NORMAL SALINE SOLUTION Turn on side, monitor oxygen, provent injury, mEDS 1329- 1330 Families 1333

Fragile X

Mental retardation Long face, prominent jaw, karge ears, frequent ottis media, large testicles, epithcantal eye folds, strabismus, high arched palate, scoliosis, pliable joints Genetic Developmental screenings Tip on 1428 Prevention and family enhancement

Lethargy

Profound slumber in which speech and movement are limited. Te child can be aroused with mod stimulation but falls asleep once stimulation removed

Cardiac Surgery

Prior to Surgery: Physiologic assessment ( failure to gain weight and means increased metabolic rate and inability to consume enough calories, length and head circ to determine condition on growth, Psycological assessment (parents coping skills), Planning (pg 945), Education (general info, genetic and env, sample cases with good and bad prognosis, overview of childs prognosis and timing of medical intervention, and interventions), Support (pastor), Home care (managed at home till surgery (Encourage feeding, breastfeeding or forumula for up to 30 minutes, supplement breast milk with calories if needed, feedings through tube- give some formula orally when doing this to provide positive oral stimulation). Monthly prophylaxis for respiratory synctial virus with palivizumab during peak session. Give pt pictures of the ICU to prepare for surgery. During surgery/Post op:: careful hx, phsyical, behavioral patteerns, cardiac function, resp function, weight, fluid status, pg 917 for more. Critical care: they go to ICU ppostop: invasive hemo monitoring, labs (abgs, hct, elect), physical, prevent low cardiac output. Monitoring cardiac out is important because hx of pulmonary blood flow can result in increased pulmonary vascular reactivity associated with pulm artery hypertesion. ASSESS FOR TACHYS. May be on intubator. Dont elevate body temp it increases metabolic rate, oxygen consumption, neuro injury, seizures, and arrythmias. Enternal nutrition support. Pro antiobiotics. IV Pain meds 1-2 days post op, General nursing unit: assessment, and signs of infection. Fever, excessive pain, spreading readness, and drainage beginning 3-4 days postop = infection. Auscultate for irregular heart or BRADYcardia= REDUCED CO. DECREASED UO= DECREASE CO. Encourage parents to bring favoriate foods to help Teaching: info about defect and prognosis, medications and admin, care of incision, ID of bad symptoms, health promotion, bacterial endo pro; over several days and more than once,

Erikson's Stages and Examples

Trust vs mistrust (birth-1yr) - baby establishes sense of trust when basic needs met; hold hospitalized baby often, offer comfort during painful procedures, parents in room, meet food and hygiene needs. shouldn't be too trusting either. Autonomy vs shame and doubt (1-3)- Increasing independence and autonomy by controlling body excretions, saying no, and directing motor activity Critisism will cause shame (like during toilet training); allow self feeding, encourage to remove own clothes, brush teeth, if restraint for procedure is needed do it quickly and explain and comfort; Must recognize feelings and needs of others, an excessive autonomy can lead to disregard and inability to work with others Inititative vs guilt (3-6) Exploring the world; Assumes responsibiities and becomes aware of guiding principles for actions; Critisism for the activities leads to guilt and lack of purpose; Initiate play activitities; offer medical equipment to play to lessen anxiety, assess concerns through their drawings, accept the child's choices and expression of feelings; Starts new projects but may not finish them Industry vs Inferiority (6-12) Develoes new interests; Does sports and community stuff; Developing sense of industry helps child find a purpose and confidence; If they do not achieve things then they feel inferior Gains sense of self worth from involvement in activties; encourage to continue schoolwork during hospitalization, bring favorite pastimes to hospital, help adjust to limitations on favorite activities; Learn that you can't be the best at everything Identity vs role confusion- search for self ID leads to independence from parents and reliance on peers; provide seperate rec room for teens, take health exam without parents in room, introduce to other teens with same problem; Tries out roles and examines what fits them best; If they can't find meaningful definition of who they are, they will experience confusion; Some confusion is good because it leads to self-examination and leads to developing an ID.

Acute Renal Failure

Unable to concentrate urine and secrete wastes May be Reversible Azotemia - accumulation of nitrogen wastes in blood Oliguria- reduced urine volume Anuria- no volume urine Sudden loss; cant clear metabolic wastes, regulate ecf volume, sodium balance, and acid base balance . Etiology: Prerenal: decreased perdusion to kidneys; hypovolemia secondary to dehydration is generally the cause; alterations in cardiac or renal vasculature; This is the MOST COMMON TYPE Primary damage: *intrinsic*- infection, diseases, hemolytic uremic syndrome, glomernep, cortical necrosis, drugs, ect. Acute tubular necrosis is most common type of this Postrenal: obstruction of urinary flow from both kidneys; posterior urethral valves or a neurogenic bladder CM:Non specific symptoms like nv, edena, hematuria, hypertsion, uremia, HYPERKALEMIA is the most life threatening electrloyte disorder associated; catastrophic events and tissue damage cause potassium levels to rise HYPONATREMIA affects central nervous system resulting in symptoms ranging from fatigue to seizures Symptoms of uremia: headache, seizures, lethargy, confusion DX: BUN, serum creatine, sodium, K+ , Ca; Therapy: STOP THE CAUSE! Emergeny 20 ml/kg of Lactated Ringers over 5-10 minutes to ensure renal perfusion and stabilize BP; If oliguria persists after restoration of FV then renal damage is suspected; If they have fluid overload give diueretics. Once child is stablized you want ZERO WATER BALANCE ; Patho 1227 CMS 1228 Meds on 1229 Nursing: promote fluid and electrolute balance, prevent complications, and support the child and family Vitals, lOC, neuro, urine, UG, I&O 3 times a day, bP 3 times a day, daily weight, The aim of maintaining a fluid balane is to achieve a stable serum sodium cocnetration and a decreased body weight by 0.5-1% a daty If oliguria: lIMIT FLUIDS! about 1/3 of fluid requurements; Raise by 12% for each degree of fever Drug dosages should be reduced because of impaired renal Discharge: may have to restrict sodium, protein, water, K+ and phosphorus LOOK AT LABS LOOK AT clinical tipes in 1230

Toddler Pain

1- 3 yrs Lack understnding of what causes pain and why they might be experiencing it, demonstrates fear of painful situations, resistance of entire body, localized withdrawal, agressive behavior, disturbed sleep, cry, scream, cant describe insensity, uses owie and booboo as words for pain

Psychosocial Development during Toddlerhood

1-3 yrs: Refines fine motor skills by use of cloth books, large pencil and paper, wooden puzzles, facilitates imitative behavior, learns gross motor activities like riding tricycle, develops cognitive skills through TV music books, increasingly enjoys talking, expo growth of vocab, neeeds to release stress through pounding board gross motor actitivies and temper tantrums, likes contact with other children By 3 yrs old knows over 1000 words and uses short sentences, expressive jargon

School-Aged 10-12 y/o Pain

10-12 (transitional) Have better understanding of the relationship between an event and pain, have more complex awareness of physical and psychological pain, such as moral dilemmas and mental pain, may pretend comfort to project bravery, may regress with stress and anxiety, able to describe intensity and location with more characteristics, able to describe psychological pain

Leukemia

1111 Most common malignancy\ Acute lymphoblastic Acute nonlymphoblastic Rare Chronic More common in whites and boys Stem cells in bone marrow produce immature WBCs that cant function; proliferate by cloning instead of normal mitosis causing marrow to fill with abnormal wbcs; wbcs replace other cells; stem cells turn into clones which results in anemia; bla bla ends up leaving body vulerable to infection CM: fever, pallor, overt signs of bleeding, lethargy, malaise, anoerexia, large joint or bone pain, petchacia, frank bleeding, joint pain are signs of bone marrow failure; enlarged liver and spleen, lymph, headache vomiting papilledema, 6th cranial nerve palsy, testicle enlargement DX: 25% lymphoblasts is definite of disease ; neutropenia, thrombocytopenia, and anemia are comon; elevated uric acid, calciu, potasium and popshorus; Chemo: READ SERIOUSLY on 1112-1113 Chemo 1114 Side effects of chemo on 1089 Nursing Care plan on 1090; 1093 Keep urine gravity below 1.010 to prevent hematuria ; recieves 1.5 x fluid for at least 6-8 hours and at least 1.5 hours after admin; UG Q 8 hrs Look in book again! read more

Adolescent G&D (12-18 yrs)

12-18 yrs Puberty at 10 for girls, 12 for boys,sweat more, sex interactions Girls: 15-55 lbs, 2-8 in Boys: 15-65 lbs, 4/12-12 in skills are well developed, new sports activities attempted and muscle development continues, some lack coordination common during growth spurt, sensory fully developed

Psychosocial development during adolesence

12-18 yrs Sports, school activities, quiet activitis Increase communication and time with peer group, movies dances driving, ect Applying abstract thought and analysis in conversations at home and school

Adolescent Pain

13-18 y/o (formal operations) Have a capacity for sophisticated and complex understanding of the causes of physical and mental pain, recognize that pain has both qualitiative and quantitative characteristics, can relate to the pain experienced by others, want to behave in socially acceptable manner, show controlled behavior response, pain causes conflict with need for indep and body control, may not complain if nurses act like should be tolerated, more sophisticated descriptions as experience is gained, use common meanings like pain hurt ache, may think nurses know when they are in pain

Psychosocial Development during Preschool years

3-6 yrs Associative play is facillitated by simple games, puzzles, ec, dramatic play by dolls ect, stress relieved by pens paper glue, cog growth by TV shows music stories books, All parts of speech developed and used, occasionally incorrectly, communicates with many people, play with other kids is their fav Verbalize and explain procedures, use drawings and stories to explain care, use accurate names for body functions, allows the child to talk ask questions and make choices

Preschool G&D (3-6 yrs)

3-6 yrs Physical: grows slow and steady, long bones in arms and legs, short chubby toddler goes into a slender long legged preschooler, becomes interested in body function (so teach hand hygiene ect), symbols or words are used to represent objects and people Gains 3-5 lbs a year, 1 1/2- 2 1/2 in a year, uses scissors, draws O square X, six part person, art projects, ties shoes, buttons, brushes teeth, spoon fork knife, throws overhand ball, climbs, tricycle, visual acuity improving, focus on letters and numbers, kicking a ball without falling down, vocab of over 2,000 words, literal interpretation for things, collective monologue

Preeschool Pain

3-6 yrs (preoperational) Pain is a hurt, do not relate pain to illness but may relate pain to injury, often believe pain is a punishment, unable to understand why a painful procedure will help them or why an injection takes the pain away, active physical resistanec, directed aggressive behavior, strike out physically and verbally when hurt, low frustration level, have the language skills to express pain on a sensory level, Can ID location and intensity of pain, deny pain, or may believe pain is obvious to others

Psychosocial Development During School-aged years

6-12 yrs Gross motor development fostered by ball sports, skating, dancing, ect Sense of industry through music instruments, collections, video games, ect Cog growth by reading, crafts, school work, ect Mature use of language, ability to converse and discuss topics for increasing length of time, spends many hours at school with friends or sports, Assess child's knowledge before teaching, allow to select rewards after procedures, teach techn such as counting or visualization to manage difficult situations, include both parent and child in decisions

School-Aged 7-9 y/o Pain

7-9 yrs (concrete operations) - No clear understanding of the cause of pain, understand simple relationships between pain and disease, understands the need for painful procedures to monitor or treat disease, may associate pain with feeling bad or angry, may recognize psychological pain related to grief and hurt feelings, passive resistance, clench fists, hold body rigid, suffers emotional withdrawal, engage in plea bargaining, can specify location and intensity of pain, can describe pain physical characteristics in relation to body parts

Asthma

878 Chronic inflammation lung disorder with airway obstruction; Cough, wheeze, breathless, cough at night, labored breathing, ect, head bobbing in young children, use of accessory muscles, pulsus paradoxus (arterial BP during expiration 10 mm higher than inspiration) Classification of Severity : 881 Clinical tip: 881 Classification of Severity: 881 Daily Med and PERF: 883 Daily Med: 884 Daily Med: 885 Medications for asthma: 886-887 Med Admin: 889 Technique: 890 Home care: 891 Care Plan: 893 ABC's FIRST Monitor growth if they are on inhaled corti steroids, teach child about the lungs, teach about importance of daily meds, teach that it is CHRONIC and PROGRESSIVE, a plan: daily control meds, the quick acting during flares, and when to call the doctor; wash mouth out after inhaler,

Cystic Fibrosis

893 Common inherited autosomal reessive disorder of the exocrine glands that results in physiologic alterations in the respiratory, GI, and reproductive systems Body produces thick mucus in the lungs, clogs the pancreas, stops food from being digested properly, cough because lungs are filled with mucus and cilia cant clear it, air trapping, hyperinflation, atelectasis, lung inflammation, chronic lung infections, bronchiectasis, respiratory failure, pancrease may stop producing insulin (DM), ileus, obstruction, abdominal distention, vomiting, sterility, altered metabolic function, salty skin CM: SALTY SKIN IS FIRST SIGN, meconium ileus, fatty stools, frothy, foul smelling, floating, constripation, chronic moist cough that is productive, frequent infections, headaches, nasal discharge, clubbing, huge appetite but no weight gain, delayed bone age, short, delayed puberty, chronic pain (late), chest pain (unilateral is pneumothorax), hemopyotsis, hypercarbia, hypoxia Maintain respiratory function, manage infection, promote nutrition, prevent obstruction Clinical Therapy: 897 Meds: 898 Nursing mngt: Partner with families to manage the disease by promoting optimal nutrition and reduce the incidence of infection; Physical assessment focuses on respiratory, then evaluate child's growth (malnourished?), appetite, vitamins taken, pancreaatic enzymes, GI stuff, and pain Respitatory therapy: chest physio 3 times per day before meals to facilitate removal of secretions; bronchodilators, DNase, hypertonic saline, oscilatting vest for 30 minutes x2 is an option, exercise Antibiotics for at least 14 days, renal function tests, Pancreatic enzyme supplements (sprinkles and capsule) with meals Vitamins A,D,E,K, must be taken as water soluble form NG tubes, high calorie moderate fat intake, extra salt

Defects causing decreased pulmonary flow

930 Decrease pulmonary BF ♣ Tetralogy of fallot (TOF): see above ♣ Tricuspid Atresia: tricuspid valve doesn't even open!. CANT get to the lungs, blue baby!!! Don't want to give oxygen, because it will close PDA (want that to be open)- give prostaglandin E to keep it open. Go put a hole in the atrium to allow more blood to come through ¬ Complete closure of tricuspid valve ¬ No flow from right atrium to right ventricle ¬ Chronic hypoxemia = clubbing for older children ¬ Failure to thrive and growth retardation ¬ Heart failure ¬ Severe cyanosis within hours of birth (increasing as PDA closes)

Strep Throat

Acute Pharnygitis 829 Bacterial is known as strep throat- caused by group A beta-hemolytic streptoccocus (GABHS) Sore throat, throat red, pain, exudate, mild lymph, low grade fever. DIFFICULTY SWALLOWING OR DROOLING IS A SIGN OF EPIGLOTTIS Rapid test then traditional test to verify if negative If child wont cooperate: hold hands on their head and use a tongue blade Abrupt onset, tonsillar exudate, painful lymph, anoerxia, nv, abdominal pain, severe sore throat, headache, malaise, 101 fever, petechial mottling of soft palate Nursing: symptomatic relief: Tylenol, ice, popsicles, humidifcation, gum, gargle 5g :240 ml of salt water, replace toothbruh

Hirchprungs

Also known as congentital aganglionic megacolon; congenital anamoly in which inadequate motility causez mechnica obstruction of the intestine. 1 in 5k births; more common males; can occur as single anamoly or in combo with cong heart defects and chrom abnorm such as down syndrome Etiology: congenital abence of ganglion cells of rectum and colon; RET prootoncogene major gene for disease; absence of autonomic parasymp ganglion cells prevents peristalsis at that portion of intestine; this causes distention and obstruction; Usually limited to the rectosigmoid colon CM: Vary depend on age of onset; Newborns: failure to pass meconium in first 48 hours, abdom dis, and bilious vomiting; If not treated: bloody diarrhea, fever, abd distention, and ENTEROCOLITIS Older infant/child: failure to gein weight, malnutr, chronic progressive constriptation, and fecal impactation. Pencil thin stools Collab: ID disease, remove section, promote nutrition, and have normal bowel patterns Diagnostics: history, bowel patterns, anorectal manometry (reaction of anal sphincter to distention of the rectum Absence of relaxation of sphincter = not normal, radiographic contrast studies (distended small bowel and proximal colon with an empty rectum, and r biopsy for gang cells (MORE RELIABLE TEST, absence of cells and presence of hypertrophi nerve trunks). Clinical therapy: Infancy: removal the bowel effected through endorectal pull through procedure; may new colonstomy temperoary ; Close before 2-5 months Children: may not be able to repair, depends on bowel. Depends on amount of bowel involved; May persist after surgery; Enterocolitis = complication: IV, antiobtioics, NG tubes Preop: monitor for infection, pain mngt, hydration, measure abdominal circumf, provide support. Cear fluids before surgery. Rectal irrigation may pe performed Post op: Maintain IV fluids, ng tube, and monitor i&o; pain meds and asses every hour; asses stoma and return of bowel function; mAY DEVELOP MALABSORPTION; If it was a pull t hrough procedure - DO NOT PLACE ANYTHING IN THE BUTT. A SIGN SHOULD BE PLACED ON THE DOOR TO ALERT STAFF; If child needs rectal dilations, wait three weeks. Clinical tip: following colonstomy closure the peri area is not accustomed to contact with stool so breakdown is likely - skin care, change diapers, cleanse carefuler, and barrier with each diaper change;

Nephrotic Syndrome

Alteration in kidney function secondary to increase glomerular basement membrane perm to plasma protein Clinical state with edema, massive protenuria, hypoalbumin, HYPOproteonm HYPERlipid, and altered immunitiy Congenital nephrotic syndrome Primary is result from disease or drugs Primary disease of minimal change nephrotic syndrome in most children Etiology: Unknown, upper respiratory infection precedes by 2-3 days; Gloms appear normal; Albumin able to go through and be secreted through urine Hypercoagulity Immunoglobins are lost Liver responds by increasng lipidproteins Acute renal failure is a rare complication Patho on 1214 CM: Edema over several weeks, peri edema, fluid shifts to abdomen during the day to lower extremities too; Snug clothing, pallor, hypertesion, irritability, anorexia, hematuria, decreased UO, malaise; Frothy foamy urine; Resp distress DX: Hypoalbumin of less than 25 and urinary protein excretion of greater than 40 is the criteria Relapse testing of 2+ on dipstick for 3 ays Tip on 1215 Therapy: Corticosteroids; levels fall within 2-3 weeks then continue for 6 weeks if responding; If replase they can take immunosuppressents; Give immunoglubin for chickenpox within 72 hours if not immune and give pneumono vaccine Meds 1216 Nursing: daily weight, hydrations, vitals every 4 hours, urine tested each shift, monitor for side effects of steroids ( moon face, increased app, increased hair growth, abdominal distention, mood swings, hypertesion, n, hyperglycemia). Severe edema treated with loop, thiazide, and K sparing diuretics Prevent infection!!! hand hygiene, prevent crowded areas Regular protein low salt diet Teach: weight weekly, bone density scans

Epiglottitis (Supraglottis)

Bacterial Most life threatening medical emergency for 2-8 y/o; progresses rapidly (hours) may progress to complete airway obstruction CM: High fever (<102.2), URI, intense sore throat, dysphagia, drooling, increase P and RR, respiratory distress, pt appears toxic, prefers to be upright and tripod with chin thrust, cherry red epiglottis Inflammation of tissues surrounding the epi, the long narrow structure that closes off the glottis during swallowing. Edema obstructs and occludes the trachea. Strep, staph, or HiB (GET VACCINE! DECREASES RISK) Four classic signs: dysphonia (hoarse or muffled voice), dysphagia, drooling, distressed respiratory effort with inspiratory stridor Therapy: endotrach tube, antibiotics, rifampin for 4 days if not immune Nursing management: VISUAL INSPECTION IS CONTRAINDICATED !!!!!! Focus on airway, level of con (sign of hypoxia), allow them to maintain upright so they can breathe, quiet environment to decrease anxiety, no invasive procedures (crying blocks airway), humidified o2, IV fluids, trach removed after 2 days THE QUIETER THE KID IS THE BIGGER THE CONCERN

Psychosocial development during Infancy

Birth-3 mo: prefers visual stimuli of mobiles, black and white patterns, mirrors, music boxes, tape players, soft voices, moves legs and arms while adult sings or talks, responds to rocking and cuddling, likes varying stimuli; coos babbles and cries for communication 3-6 mo: noisemaking objects like rattles, stuffed animals with contrasting colors, vocalizes during play and familiar people, laughs, cries less, squeals, babbles 6-9 mo: teething toys, increase social interaction, soft toys that can be manipulated by mouth, increase vowel and consonant sounds, links sylllables, speechlike rhythm 9-12 mo: large blocks, toys that pop apart and go back, nesting cups, laughs at suprise toys, peek a boo, push and pull toys, understands no and simple commands, dada and mama, one or two words, receptive speech suprasses expressive speech

Osteomyelitis

Bone infection Usually long bone of legs 1-12 yrs Staph Trauma, surgery CM: Bone pain, edema, decreased mobility of infectedd joint, fever , redness, refuse to walk, lump RAPID dX: History of resp infection, blunt trauma, leukocytosis, elevated ESR, c-reactive protein elevated, Therapy: aspirate, treat with clindamyicin or vanomycin for 3-4 weeks, iv fliids, Nursing: strict aseptic techiiques , dont touch the bandages, High protein, high vit c Box on 1464

Hip Dysplasia

Brace care on 1446 Femoral head and acetbulum arent aligned Hip instability Dislocation (bone from normal articulation of joint) sUBLUXATION (PARTIAL) Dysplasia (abnormal cellular deevlopment leading to instability) Genetic, Unknown Pregnancy- MOTHERS estrogen, left hip against sacrum, how infant is carried CM: limited abduction of the affected hip, asymmetry of gluteal and high fat folds, telescoping or pistoning of thigh Most resolve by 2 mo No xray till 4 mo Paliv harness under 6 mo- ensures hip flexion and abuction but doesnt allow hip extension or adduction If greater than 6 mo do closed reduction (force back) A shirt should be worn under harness Plastic lining to protect cast edges during elimination, small dispolsable diaper, tucking edges benath cast, change diapers Post op: pain priority, hold, rock, ect, ice bag on top of cast, if pain not controlled then compression may be happening NV assessment every 2 hour Change position every 2 hours while awake Moleskin to protect from edges Tape around perineal opening Increase fluids DO NOT USE THE BAR IN BETWEEN CAST TO LIFT THE CHILD Harness worn 23 hours a day, Feed infant upright Transport on 1450 Harness teaching 1451 Cast teaching on 1444

Osteogenesis Imperfecta

Brittle bone disease Connective tissue disorder Biochemical defect in collagaen Genetic CM: multiple fx, blue sclera, thin soft skin, increased joint flex, enlarged of the anterior ontanel, weak muscles, soft pliable bones, short, conductive hearing loss Classified by phenotype 1: blue sclera, fraginle bones, weak teeth, hearing loss 2: ribs and skeleton involved, die in utero or birth 3: newborn and infancy sustains numerous fx, and manifests blue sclera, die of cardioresp failure 4: bow legs, fx, No cure, high vit D, braces, high calcium, stemm cell transplant HANDLE THE PT CAREFULLY!! Use a blanket when lifting for more support High vit C, D, Calcium to encourage healing Lowest calories possible cuz fat Encourage swimming

Pain Scale for newborn and infants

CRIES neonatal post op - crying, requires 02 <95, expression, sleeplessness rated 0-2 Neonatal Infant Pain Scale (nIPS)- face expression 0-1, cry 0-2, breathing patterns 0-1, arm movements 0-1, leg 0-1, state of arousal 0-1 Premature infant pain profile - 28-40 weeks; gestational age, behavior, heart rate, oxygen, brow bulge, eye squeeze, and naso furrow 0-3 each

Phimosis

Cant retract foreskin of penis May obstruct urine flow Balantitis : inflammation of glans penis Paraphimosis: most serious , cant return foreskin ever causing ischemic damage- MEDICAL EMERGENCY Collab: circumsision Practice alert on 1241 Partering: 1242 <---- Bethamethasone creamed Q2 daily for 8 weeks is an alternative Nursing: do not force skin to retract, frequent diaper changes,

Congestive HF

Cardiac output cant meet body's needs Weight losss, lack of normal weight gain, tires during feeding, sweating, frequent resp infections, skin color changes, tachys, grunting, nasal flaring, S3 gallop, fluid overload, face edema, JVD, cardiomegely occurs as heart attempts to maintain CO; weak pulses, cyanosis, cool extremities, ect CMS on 944 Meds on 945 Care Plan on 947 Clinical Tip on 949 Care Plan on 951 - skim

Eczema (Atopic Dermaitis)

Chronic, relapsing superficial inflammatory skin disorder w/ itching Unknown cause, enviromental, IgE levels Cytokines and chemokines Env changes Xorisis - dry skin Groin and armpit not affected CM on 1505 Ointment Q4, topical corticosteroids X2 daily for 2 weeks, oral steroid for severe exhacberation, but there is a roubound effect Practice alert on 1505 DIAGNOSTIC CRITERIA ON 1505 BOX <---- meds on 1506 Usually dont scar No cure Bathe once a day, lotion within 3 minutes Apply ASAP after sports and apply ointments ID food allergies Health promotion on 1508 Partnering on 1509

Hypospadias and Epispadias

Congential abnormalities involving an abnormal location of the urethral meatus; more often in males Failure of urethra folds to fuse completely over groove; Genetic; Hypo occur with congenital chordee Undescended testes and partial absence of foreskin may also happe Epispadias and bladder extrosphy are same condition, epi is just milder CM of hypo: pee hole underneath the penis; located in scrotum if severe Surgery within first year, NO CIRCUMSISION BECAUSE FORESKIN USED TO REPAIR THE PEEPEE, urethral stent, catheter to relieve pressure from sutures, CLINICAL TIP O 1206 Nursing: penis wrapped in simple dressing and a stent and cath, bloody at first but should become less over few hours, hourly i&o, notifty provider if no urine within 1 hour, anticholergenics to prevent bladder spasm pain, antibiotics till stent gone, Partnering on 1207 <----

UTIs

Cystitis is lower UTI Pyelnophritis is upper Acute or chronic Second most common infection Ecoli, staph, kleb, proteus, pseudo arego, enteros, Urinary statis increases risk Neurogeonic bladder Teach to go pee Have good hygiene Wipe correctly UnCircumision care Vesicourteral reflex (backflow of urine) Renal scarring form hydronephrosis (accumulation of urine in renal pelvis) CMS on 1201 DX only confirmed with sterile sample from catheter Toddler may regress back to diaper No tight underwear No baths No sex Partnering on 1203

Stupor

Deep sleep or unresponsiveness in which the child can be aroused only when repeated vigorous stimulation such as pain; Child returns to unresponsive state once stimulus is removed

Play

Developmental play: play is the work of children. Children express feelings and fears through play. Functions of play affect all areas of the child's development. Solitary play (infants)- play by themselves Parallel play (toddler)- child plays independently among other children with toys that are like those children around him/her are using, neither influencing or being influenced by them. There is no group association. Play helps to develop- sensorimotor, intellectual, social, creativity, self-awareness, morals, and is psychotherapy for children. Assists in developing social skins Expressive play - painting, drawing, - allows them to put feelings into pictures. Grows fine motor activity Associative play- (preschool)- interacts with others and participating in groups (glue and scissors ) Dramatic play (preschool) using props to renact human life Imaginative play Cooperative play (school aged) cooperation with others and ability to play a part in order to a unified whole. Promotes growth and development and is crucial for mental health of children "work of of children." Confirms what child knows about the world and allows them to explore the rest. Allows them to take an active role

Confusion

Disorientation to time, place, or person. The child has loss of clear thinking. Answers to simple questions may be correct, but responses to complex ones are inaccurate

Club foot (Talipes Equinovarus)

Downward - equinus Hintfoot inward - varus Forefoot curcle toward the heel (adduction) and turns upward in partial supination Talipes refers to foot and ankle Spina bifa bay have short achilles Serial casting, timing is critical Long leg cast changed eveyr 1-2 weeks for 12 weeks Crossbar between shoes (Denis Browne Splint) Steel pins Simple Achilles tenotomy then foot abducation brace Surgery between 3-12 mo Soak cast the night before cast change Bring bottle when taking cast off Special brace or shoe worn for 6-12 mo Postop NV Q2 for first 24 Ive bags to foot and elevate ankle for 23 Teach how to give sponge bathh One piece snap suits Keep toys in reach Report slippage ASAP Umbrella strollers NOT STURDY ENOUGH!! Brace on 1446

Mono

Epstein Barr Irritable, asymptomatic, mailaise headache anorexia abd pain fatigue , fever for 3 days, followed by lymph ,, sore throat, hetpasplenogmely, lasts 2-3 weeks Treated at home, standard precautions, Antipyretics, analgesics Salt water to gargle Bed rest during acute phase Let them decision on some care Go back to school once fever is gone and they can swallow NO KISSING till fever gone for several days No contact sports for 4 weeks - spleen and liver may pop If splenmel - no alcohol for 3 months after LFT return to normal pg 644

Pain Scale for Infants and Young Children

FLACC - acute pain after surgery; 2mo - 7 yrs ; face, legs, activity, cry, and consolability; obeserve for 1-5 minutes If 3+ y/o, can localize pain if given body outline facing front and back

Pain Scale Preschool and School Age Children

Faces pain rating - 7 cartoon faces- Wong-Banker scale - older than 3 y/o, selects face Oucher - visual analogue thats vertical with faces Poker chip scale - quanitifies pain ; 4-7 y/os

Toddler Injury

Falls - gross motor skills improving, supervise, provide safe climbing toys, teach acceptable climbing places Poisoning- medicines, cosmetics, need to be locked up; poison control, child resistance containers Burns- tall enough to reach, turn handles away , do not burn fires without supervision, fire screen Drowning- buckets, pools, toilets, ect. Supervise, swimming classes DO NOT PROTECT THEM FROM DROWNING, use child resistance pool covers, life jackets, empty buckets when not in use MVC- might undo seatbelt, insist on safety on all trips Look at table made

Slipped Capital Femoral Epi

Femoral head displaced from neck COmmon during growth spurt, more boys and blacks, OW Etiology: sport injuries, overweight, trauma, radiation, encorine disorders Can create deformed hip with LROM CM: Limp : knee, thigh, groin, hip, loss of rom, ot toeing Acute : less than 3 weeks, sudden pain, cant bear weight Chronic: longer than 3 weeks, milk aching, limp Acute on chronic: additional slippage form chronic Surgery: stablize with a screw Complications: avascular necrosis, chondrylysis (reabso cartilage) Nursing: increase proteins, carb, calcium, weight loss, no pressure , upper body exercises,

Hydrocele

Fluid filled mass in the scrotum (like a hernia) Peri sac precedes testicle descent; Lower sac enflords to beome the tunica vaginalas and upper sac atrophies before birth; Fluid may become traped in the tunica CM: PHysical exam, palpate scrotum to reveal round smooth non tender mass which is noted with either a hernia or hydrocele; Interm bulge DX: Transillumination; MOre visible when straining Therapy: OP; After 3 mo; to reduce risk of incarceration (PRACTICE ALERT ON 1244) which is aN EMERGENCY!!!!! Nerve blocl; MOST HYDROCELES WITHOUT INGUINAL HERNIA RESOLVES SPONTANEIOUSLY WITHIN 1-2 YEARS Covered with sealant, frequent diaper changes, may look bruised after surgery, encourage to hold normally

Tetralogy of Fallot

Four defects: pulmonic stenosis, right vent hypertrophy, vent septal defect, and overriding of aorta; may have open foramen or atrial septal defect ; elevated pressures in the right side of heart cause a right to left shunt CM: As ductus closes, infant becomes cyanotic Systolic murmur heard in the pul,onic area and transmitted to suprasternal notch; Palpated thrill Polycthemia, hypoxic episodes, metabolic acidosis, poor growth, clubbing, exercise intolerance Toddlers squat to decrease return of systemic venous blood to heart Dx: 932 Therapy: Knee-chest, calm child. 02, morphine, propranol, total repair before 6 mos, pallitative shunt (Balock-Taussig), infective endo propho See what the other disorders are Nursing mgmt: cardiac surgery

Fractures/ Traction

Fractures on 1476 Growth problems 1477 Complications 1477 Patho 1478 When in doubt apply a splint Extent of injury, degree of pain, and citals Compartment syndrome - increased pressure in a limit space which compromises circulation and nervous inerveation - MEDICAL EMERGENCY!!!! REMOVE CAST ASAP CM of CS on 1480 TYPES ON TRACTIONS ON 1481!!!! Maintain proper allignment, NV status every 14 minutes for 2 hours then every 1-2 hours after, cast above heart level, promite mobility Nursing care of traction on 1482 Nursing care of cast on 1443

Thrush

Fungal infection of mouth Candida albicans White patches that look like coagulated milk and may bleed when removed MILK CAN REMOVED GENTELY, THIS CAN NOT Parochycia - nail infection Nystatin Use a swab to apply suspension to oral muc and tongue, they CAN SWALLOW THE REST Sterilize your stuff Cream around your nipples if BF Antiseptic spray on toys

Labs for renal function and UTIs

GRF on 1231 Urine specific gravity Creatine on 1569 Erythopoetin on 1569 Urea clearance on 1570 Nitrogen on 1570 Uric Acid on 1570 All other urine stuff on 1573

Sickle Cell Disease

Genetic hemoglibinopathy - partial or complete replacement of normal hemoglobin with abnormal hemoglobin S in red blood cells causing occlusion of small blood vessels, ischemia, and damage to orgams; Trait affects 1 in 12 black people and 1 in 16 hispanics; 1 normal trait 1 sickle; Sickle Cell anEMIA is most common type (Hb SS) Mutation in which amino acid valine replaces the amino acid glutamic acid; If both parents have gene then risk is 25%; Crescent shaped cells Sickling may be triggered by fever, hypoxia, emotional stress, physical stress; Precipitated by low fluid intake or low oxygen tension (high altitudes) Spleen first affected, stroke, acute chest syndrome, pulm hyp, pulp infect, aplastic crisis, tempt cessation of bone marrow, priapism -sustainted erection- gallstonesl Return to normal when rehydrated and reoxygenatied- cell life is 15 days Box on 1034, 1035, 1036, 1037, 1038, 1039, 1040 Clinical tip on 1040 Dilaudid, morphine, taradol, motrin q 6, prevent, recieve shots, peniccilin prophro to strep pneumonia, blood transfusions, deferoxamine over 12 hours 3-7 days a week to bind to excess iron, oral deferasox does same thing, hydroxurea- causes neutropenia thrombo headaches dizzy nv, stem cell transplant INFECTION IN A CHILD WITH SICKLE CELL IS AN EMERGENCY Practive alert 1042 CM on 1043 Care plan on 1044 Partnering on 1047 Nursing: height, weight, FTT, pain,;;;; any neuro changes, fever or respiratory means EMERGENCY, only use saline for blood transfusion to prevent clotting, they come every 3 week, if small child it may be infused w/o saline, schedule play periods and rest periods because we dont wanna increase metabolism too much, promote hydration, manage pain, NO HOT OR COLD COMPRESSES- WILL RECIEVE A BURN INJURY!!!!, prevent infection, ensure folic acid and vitamin c, high protein, high calorie, monitor for crisis - pallor vital sign changes loc enlarged spleen No contact sports MAKE SUR EYOU READ ALL BOXES

Cephalocaudal development

Head downward Controls head and neck before the trunk and limbs Arm movement before hand movement Hands before finger movements Hold up head before sitting Sit before standing

Pyloric Stenosis

Hypertrophic obstruction of the circular muscle of the pyloric Canal. COmmon, more male, more whites. Etiology: unknown, family hisotyr, hypergastremia (too much gastrin in blood), prostaglandin E infusion, oral erhythromycin for 1 month olds. Hypetrophy results in stenosis of passage between stomach and dudo, obstructing the lumen of stomach. Luman becomes inflamed and edema which narrows opening till obstruction complete. CM: 2-8 weeks after birth, appears well or regurittates slightly, good eat who vomits occassionaly, formula intolerance or allergy assumed (wrong), or gastroreflex may be suspsected. As disease progresses- PROJECTILE VOMIT UP TO 3 FEET. nonbilious and may be bloody because of irritation to eso, innfant appears hungry especially after throughup, fails to gain weight, small stools, loss of gastric secretions result in dehydration and metabolic ALKALOSIS,, peristalic waves on abdomen, and olive sized mass in URQ. DX: Thickened pylorus of greater than 4 mm X 18 MM, Metabolic alkalosis, hypocholeremia Therapy: surgery asap - pylormyotomy Observe for peristaltic waves, bowel sounds are hyperacticve, history, NPO w/ IB, minimize weight loss with slow increamental increases in feedings, promote rest, prevent infection, provide supportive care Home care 1143

Juvenile Arthritis

Idiopathic Chronic inflammation Etiologies on 1008 CM: fever, rahs, lymph, splenomeg, hepatomo, slow growth, limp, ueven extremities, pain stiffness, lom, swelling in knees, symmetric movements in hands, DX: ANA, ESR, CRP EYE EXAMS EVERY 3 MO TO TEST FOR UVEITIS IF POSITIVE FOR ANA ROM, stretching, wrist splints when lifting, dont get fat, aspirin and steroids may lead to gastric irritation so admin with food and milk (BE AWARE OF REYES) Meds on 1010 Partnering on 1011 Mobilit on 1012

Cyanotic Heart Disease

Increase in HgB, HcT and RBC due to the kidneys producing more erythropoitenin - compensation for not enough 02 so body makes more. Cyanosis occurs when artierial saturations are less than 79%. Polycythemia- hct OF 50% Or higher is common in children with cyanotic heart defects. Increase RBC production, Hgb greater than 20g/ is extreme. Hct of 50-60% increases the viscosity of blood increasing chance of thromboembolism, especially if child becomes dehydrated . Normal lab values : 1568 Hgb 12, Hct 40 max, rbr 5.3 max CMS of congestive heart failure: 944

Head Injuries

Infants: shaken baby syndrome, child abuse, falls, MVC Toddlers/Pre: falls down stairs, out of window, climbing, pedestrian v mvc, mvc School aged: MVC, bikes, in line, skating Adolesents: mvc, struck by an object, sports related, firearms Primary(right then) or secondary (biochemical cellular response) Coup - direct blow Countrecoup - swings back CMs: 1370 Different types of injuries: 1371 Clinical therapy: oxygen, mechanical ventilation first 24 hours, hypothermia may be used, keep head of bed flat for hypovolemic shock, keep ICP less than 20 - if ICP HOB 30 degrees no hip flex head midline or side lying with log roll, mannitol or hypertonic saline Cushings triad: bradycard, irregular respirations, increased systolic bP with widening pulse Meds on 1374 Mild brain injury: not back to normal for 6 weeks Mod and severe: tell parents to be role models, look for playgrounds with wood chips May be decoricate (flex), decebreate (extend), areflexic (no reponse), or flaccid

Assessment of infant

Keep parents close, make sure room is warm, smile, talk soothingly, use a pacifier or toy, begin with feet and hands before moving to the trunk, Measure with the child in a supine or recumb position, measure with a baord, record to the nearest 0/5 cm, take two measurements, measure on scale, remove diaper and clothing, distract the infant, record weight to the nearest 10g; measure head right above the ears, Move hand quickly to do blink test, hold toy 6 in away from face to track if they can track,, the ability to find and pick up small toys is a good indicator of vision for children under 3 To test hearing get a noisemaker and stand 2 feet away

Assessment of toddler

Let them hold an object or sit in parents lap. Do developmental or cranial nerve assessment first Do not ask if you can do something. Go from feet to head. Eyes ears mouth done LAST Measure with the child in a supine or recumb position, measure with a baord, record to the nearest 0/5 cm, take two measurements, measure on scale, remove diaper and clothing, distract the infant, record weight to the nearest 10g; measure head right above the ears, Move hand quickly to do blink test, hold toy 6 in away from face to track if they can track,, the ability to find and pick up small toys is a good indicator of vision for children under 3 Offer APPROPRIATE choices Liver edge 2-3 cm below right costal margin Bowlegs- no more than 1.5 in Nockknees - no more than 5 cm n To test hearing get a noisemaker and stand 2 feet away

Bronchiolitis & Respiratory Synctial Virus

Lower resp tract illness that causes inflammation and obstruction of the small airways, the brionchioles. RSV most common cause, but can also be caused by adenovirus, parainfluenza, human meta. Cells die and burst, clogging bronchioles and irratitating airways Transmitted through direct contact with RR secretions - shed by child for 8 days and incubation period is 2-8 days Wheezing, crackles, alectasis, air trapping, hyperinflation, hypoxemia bc of VQ mismatch, respiratory failure, apnea, pulmonary edema CM Rhinitis, cough, low grade fever, wheezing, tachyp, poor feeding, v/d, appears sick, not playful, won't feed, Severe: >70 breaths, grunting, retractions, wheezing, nasal flaring, poor fluid intake, distended abdomen, DECREASING BREATH SOUNDS DX: history,physical, immunoflurescent or enzyme immunoessay techinqiue from a posterior nasopharnygel sample, viral cell culture, chest radiograph (hyperinflation atelectasis and inflammation) Supportive therapy Dexamethasone doesnt work Ribavirin contreversal Resolves in 5-7 days - after effects for months IM palivizumab (Synagis) used for high risk children ( under 24 mo with chronic lung disease who have required med therapy within 6 mo of RSV, congenital heart disease, preterm infants under 35 wks) Nursing mngt: resp and cardio monitoring, sat below 90 is best indicator of severe disease Signs of lifethreatening: central cyanosis, >70 rr, listlessness, apneic episodes, chest hyperinflation, breath sounds dimisnhed Clear nose of snot to help air flow, elevate HOB,inform physician of ANY CHANGE IN RR STATUS, small frequent feedings, ngt if aspiraiton risk Care Plan: 867 Discharge Teaching: 869

Meningitis Vaccines

MPSV4: Meningococcal polysaccharide vaccine licensed for those 2 years of age and older MCV4: Meningococcal conjugate vaccine licensed for 9-month olds to 55-year olds FOR CHILDREN Meningococcal conjugate vaccine (MCV4) is recommended for children 9 months through ten years of age who are at increased risk for meningococcal disease. Children may be at increased risk due to certain medical conditions or because they are traveling to a country with high rates of meningococcal disease. Booster doses may be recommended if your child remains at increased risk. Talk to your child's health care provider for more information. FOR PRETEENS/TEENS Meningococcal conjugate vaccine is routinely recommended for all 11 through 18 year olds. The first dose should be given at 11-12 years of age and a booster dose at 16 years of age. For adolescents who receive the first dose at age 13 through 15 years, a one-time booster dose should be administered, preferably at age 16 through 18 years, before the peak in increased risk. Adolescents who receive their first dose of meningococcal conjugate vaccine at or after age 16 years do not need a booster dose.

Glomerulonephritis

Most common inflammation of the glomeruli of kidneys Reponse to group A beta hemo step infection of skin or throat (strep) 2- 6 Y/os Antibody antigen becomes loged in the glomeruli leading to inflammation and obstruction leading to decreased GRF, increased vascular permiability causing edema CM: Asymptomatic, flank or midabd pain, micro hematuria, edemma of face, acute hypertesion may cause enceph causing headaches irriability nv lethargy and seizures DX: Elevated bUN and creatine, hypoalbumin, sedimentiation rates elevated, hyperlipid, ASO antibodies, anemia, stuff in urine, Treatment: bed rest, sodium restriction, hydrazine or diazoside for emergency, antibitics to treat original infection, Nursing: monitor fluid status, prevent infection, prevent skin breakdown, meet nutritional needs, provide emotional support Frequent bp, urine, ascities measurements, limit fluids, No salt low protein diet Care plan on 1222

Coarcation of Aorta

Narrowing in the descending aorta near the ductus arterious or left subc artery obstructs systemic biood outflow. Common . Common with Turner syndrome. CM: Many asymptomatic and grow normally, but if severe: cyanosis in lower extremities, heart failure, and sock as the ductus arteriosus closes. Infants with mod may have poor feeding, failure to thrive, increased RE, and CHF. Reduction i nblood flow through the descending aorta causes low bloood pressure in LEGS and higher in ARMS NECK AND HEAD. In cases with sig reduction, renal failure and necro enterio. Brachial and radial pulses are bounding, femoral are weak. May complain of weakness in legs or pain after exercise. S2 is loud and single on auscultation. Systolic ejection murmur may be heart at UR and middle or LL sternal border. Thrill may be palpated on suprasternal notch. dx: Chest radio may reveal cardiomegaly, pulm venous congestion, and indentation of desc aorta. Rib notching rarely seen before age 10. ECG - left v hyper, rv hyper. MRI or CT to see aortic arch and collaterial circulation Clinical therapy: Surgical repair b/c risk for aneurysm and recorcitaiton. Balloon dilation during cardiac cath for recoartcitation Endovascular stents. These are all pallative cares- can and might reccur.. Prognosis: Chronic systemic hypertesion more likely to occur if older than 1 at time of repair Nursing mngt: see cardiac surgery

Pain management

Nonpharmacologic management • Parental involvement • Play • Distraction • Relaxation/guided imagery • Heat/cold • Positioning • Favorite toy, pillow, TV show Cutaneous stimulation - rub area; swaddle Sucrose solution - up to 1 month age Distraction Guided imagery - encourage child to relax, explore favorite place, for 6 years +, Relax techiniques- pain aggravated when muscles are tense; taught to tense and relax different muscles started with hands and feet; 10 seconds each Breathing: holds for 5 seconds then breaths out; or shallow breaths through nose Hypnosis Cognittive behavior therapy- prep with dolls, role playing, practiving behavior Heat and cold- do not apply heat first 24 hours after surgery; Electroanalgesia- Acupunction Pharm: Opoids: severe pain; oral and IV preferred for hchiildren; causes sedation, nv, constipation, urinary retention, and pruititis (537); Withdrawal (physical signs and symptoms), physical dependence (physiologic adaptation), and tolerance (shorter duration and effectiveness) Withdrawal: irritablitity, tremoros, hyperactive DTF, clonus. Inability to concentrate, frequent yawning, sneezing, delirium, hallic, N, feeding intol, V, cramps, poop, no suck and swallow, tachys, increased BP, nasal stuffiness, lacrimation, chills and hot flashes, sweating, fever, salviation MGT of withdrawal: slowly wean the child off over 2-4 wks; reduce daily dose by 10%-20% over several days; Clonidine; Naxolone for RR depression Resp depression: sleepiniess, small pupils, shallow breathing; mostly occurs when child is sleeping NSAIDS- Mild to moderate pain and chronic pain; bone inflammatory and connective disorders; tylonel also used Pain meds every 3 hours to prevent breakthrough pain; PCA Pump Regional pain management- catheter inserteted ; do not give other parenteral or enteral pain medications; nerve blocks; does not have side effects like oral/IV pain meds Pain assessment 30 mn, 60 min after ; 1 hr after oral; every 2 hours for regional Meds 539 Care plan 544 PAIN MANAGEMENT BY AGE PG 547!! Chronic pain Complex regional pain - burning sensation probably after injury Cancer pain- nsaids, tylenol, then opoids Sickle Cell- nsaids and opiods Sedation - medically controlled depressed state light - deep Anxiolysis - minimal sedation cog and motor functions are impaired Moderate sedation - maintains protective reflexes amd ability to maintain airway, and can response to stimul Deep sedation - airway lost, but can still feel pain Meds on 554- quick skim

Infant Nutrition

Nutrition teaching pg 375 Preterm infant Pg 274 All boxes and practice alert on 275-277 Supplemental iron 1 mg.kg/day Foods introduced around 6 mo- once they can eat 1/4 cup of cereal twice daily, then veges and fruits, wait severel days before introducing something else By 8-10 mo - most fruits and veges introduced, strained meats or other protein can be added; Finger foods introduced first year second half Breast feed pure through 6 mo, through 12 mo - Always used iron fortified formula for first year No cow till 1, no egg till 2, no nut fish or shellfish till 3 No honey Offer cup around 9 mo to start "weaning" Table on 278

Pain Scale older children/adolescents

Pain intensity @ 8 y/o Visual analogue - vertical 10 cm line 0-10; 5 y/os Word-Graphic Scale- horizontal line; mark on line closest pain felt; 5 word achor Adolescent Pediatric pain tool - human drawing, word graphic rating, and desriptove words; 8 -17 y/os

Health Assessment

Patient Info Physiologic data (health problems and diseases) Chief Complaint History of Present Illness Past history Current Health Status (health promot, meds, allergies, immunizations, safety, activtivies, exercise, nutrition, sleep) Family History Review of Systems Psychosocial Data (family composition, economics) Developmental data Physical General Aprasail Measurements

Seizure Disorders

Periods of abnormal electrical discharges in the brain that cause involuntary movement and behavior and sensory alterations Epilepsy is a chronic disorder Etiologies: Partial/Focal: abnormal electrical activity in one side; symptoms displayed on the region affected Generalized: diffuse electrical activity that begins in both hemispheres and spreads throughout the cortex into brainstem; Bilateral and symmetric movements Febrile: fever, illness sensitivity; 6 mo-3 yrs peaks at 18 mos Newborn: central nervous system disease, CNS infection, inborn errors, asphyxia, electrloyte disorder, ect Status elipticus: acute illness, febrile, progressive CNS, prior history. Airway compromised during tonic. Child becomes pale and cyanotic because increase metabolic rate - hypoglycemia and hypoxia Tonic: unconciousness, continuous muscle contractions, sustained stiffness Clonic: alternating muscle contraction and relaxation Postictal: level of cons is decreased Intractible seizure: continues after 3 or more meds CLINICAL MANIFESTATIONS ON 1325

Autism

Pervasive developmental disorder Fragile X syndrome can cause Genetics CM: impaired social interactions, communication, cant adapt to new situations, attention span and organizes responses Delay in milestones Unable to relate to people Sterotypo - rigid and obessive behavior Echolalia - parroting of what is heard Uses "you" instead of 'I" EXTREME TOUCH AVERSIONS No bright lights or noises Must have routine Big head CMS on 1400 Screening tools on 1401 Box on 1402 No meds are really affective Stabilize enviromental stimuli, give routine during their normal schedule, enhance communication with short direct sentences and visual aids, maintain SAFETY with helmets hand mits,

Infant Injury

Pg 384 Falls- do not leave infant unsecured in infant seat, do not place in high places, use gates, standing walkers cause injury Burns- infant is dependent; check temperature of water and foods, do not hold infant while drinking hot beverages, cover outlets, supervise so they cant play with cords MVC- dependent; car seat , rear facing, Drowning- cant lift head or swim, never leave alone in water even if its only 1 inch, flotation devices are NOT certified life preservers Poisoning- keep harmful substances out of reach: medicines, cleaning products, plants, poison control 1 (800) 222-1222 Choking- infant explores; avoid foods that cause choking, keep small toys away Suffocation - minimal head control; sleep on BACK, no objects near head, no plastic, no latex balloons Strangulatioon- slides through railings, curtain, blinds; 6 cm spacing or less (2 3/8 inch), mattress fit tightly Injury topics by age on 385 Look at table made

Digoxin

Pg 946 Partnering & Practice Alert

Infant G&D (0-1 yr)

Physical: Birth weight doubles by 5 mo and triples by the end of the first year.Grows 12 in taller, teeth @ 6 mo, 8 teeeth by end of first year. Birth - 1 mo: Gains 5-7 oz a week, grows 1/2 in a month, head circumference increase 1/2 in a month, holds hand in fist, draws arms and legs to body when crying, inborn reflexes such as startle and rooting are predominate, may lift head briefly if prone, alerts to high-pitched voices, comforts with touch, prefers to look at faces and black/white geometric designs, follows objects in line of vision 2-4 mo: Gains 5-7 oz a week, grows 1/2 in a month, head circumference increase 1/2 in a month, posterior fontanel closes, ingests 120 ml/kg/hr (2oz/1bs/24hrs), holds rattle when placed in hand, looks at and plays with own fingers, brings hands to midline, moro fading, can urn from side to back and then return, decrease in hed lag, sits with head midline with some bobbing, when prone holds head up and supports weight on forearms, follows objects 180 degrees, turns head to look for voices and sounds 4-6 mo: Gains 5-7 oz a week, doubles birth weight at 5-6 mo, growth 1/2 in a month, head circ increases 1/2 in a month, teeth may begin erupting, ingests 100 ml/kg/24 or 1 1/2 oz/lbs/24, grasps rattle and other objects at will; drops them to pick up another; mouths objects, holds feet and pulls to mouth, holds bottle, grasps with whole hand (palmar grasp), manipulates objects, head steady when sitting, no head lag, turns from abd to back by 4 mo thn back to abd by 6 mo, when held standing supports own weight, examines complex visual images, watches the course of a falling object, responds readily to sounds 6-8 mo: gains 3-5 oz a week, growths 1 cm/month, growth rate slower than first 6 mo, bangs objects, transfers objects from hand to hand, beginning pincer grasp, most inborn reflexes gone, sits alone steadily without support by 8 mo, likes to bounce on legs when held in standing position, recognizes own name and responds by looking and smiling, enjoys small and complex objects at play 8-10 mo: Gains 3-5 oz/week, 1 cm/month higher; picks up small objects, uses pincer grasp, crawls or pulls whole body, creeps by using hands and knees to keep trunk off floor, pulls self to standing and sitting by 10 mo, recovers balance when sitting, understands words like "no" and "cracker", may say one words in addittion to mama or dada, recognizes sound without difficulty 10-12 mo: gains 3-5 oz a week, 1 cm a mo, head circumference equals chest, triples birth weight by 1 year, may hold crayon or pencil and make mark on paper, places objects into containers through holes, stands alone, walking holding onto furniture, sits down from standing, plays peek-a-boo and patty cake

Toddler G&D (1-3 yrs)

Physical: Eat less, longer leads, smaller heads, bot belly, 33 mo should have 20 teeth, object permanence by 1, preop thought by 2 1-2 yrs: Gains 8 oz a month, 3-5 inches a year, anterior fontanel closes, by end of second year can build a tower of four blocks, scribbles on paper, can undress self, throws a ball, runs, shows growing ability to walk and finally walks with ease, walks up and down stairs, push and pull toys, visual acuity is 20/50 2-3 yrs: Gain 3-5 lbs a year, 2.5 in a year, draws a circle and other forms, learns to pour, undresses self, jumps, kicks ball, throws ball overhand

Intusseption

Portion of the intestine prolapses and then invaginates or telecoposes into another. Most frequest cause of obstruction 4:1k; more common in males; 80% In children less than 2 Etiology: Multifactoral, direct cause unknown; Proceeded by a virus of GI; most common site is the ileocecal valve; Telescoping obstructs passage of stool; Intestine walls rub together causing inflammation, edema, and decreased blood flow which can lead to NECROSIS!!!!!!!!!!!! CM: usually ABRUPT; Acute abd pain, v, brown stool, periods of comfort between episodes of pain till condition worsens; Stools become red and look like CURRANT JELLY B/C OF MIXTURE OF BLOOD AND MUCUS; Palpable mass URQ OR MU; Rectal bleeding Collab: Reduce bowel compression and restore fluid and elec balance DX: History and radiographs and US of abdm. Contrast enema using barium or air can be dx and therapeutic; Moves bowel back into place Clinical therapy: NG tube, surgical interven tion to reduce IV bowel and remove nectrotic tissue; surgery usually corrects but intussecuption can recur after hydrostatic reduction or surgery. Nursing mngt: maintain fluid and elect; IV initated immediately ; continue elect monitoring; Preoop: vitals, abdom distention, bowel sounds Q4, Iv intake, UP, vomitus, characteristics of stools, elect; Passage of brown stool may mean condition is reduced so report finding to doctor ASAP so treatment can be altered; mng pain and maintain NG patency Postop: vitals bowel, i&o, surgical incision, signs of infection, pain mngt, NG tube; clear fluids or Breast feed after normal bowel returns; Feedings are then advanced to half strength milk and other foods as tolerated; discharge after full feedings

Iron Deficency Anemia

Primary by increased physiological demands Pica ( eating led inhibits absorption of iron) Secondary Caused by blood loss, malabsoprtion, or poor nutrition intake Anemia of prematurity - smaller iron stores that run out at 6 mo; dont consume adequate solid foods at 6 mo HgB 9.5-11 is mild 8-9.4 is moderate Less than 8 is severe Test children's poop for occult - only if they drink cow milk Iron Supplements: 2-6mg/kg/day for 4 weeks, reevaluate, then continue for 2 mo Screen @ 9-12 mo, then 15-18 mo Iron fortified foods, restrict cow milk if they refuse to eat Older children can eat hamburgers, dried fruits, ect Med on 1032 Food Sources on 1033

Meckel's Diverticulium

Results when the omphalomestrenic duct, which connects the midgut to the yolk sac during embryonic development, fails to atrophy. An outpouching of illeum remains, usually by the ileoccecal valve. The pouch contains gastric or pancreatic tissue that secretes acid and causes irritation and ulceration. One of the most common GI malformations. CM appear by 2 yrs: painless dark or bright red rectal bleeding which results from the obs and ulceration. Blood passed without stool. May have symptoms of intussuception, incarcerated herniea, vovlulus, or obstruction. If untrreated it will lead to perforation and peritinitis. Collab: dx based on history, radionuclide imagining, trt is surgical excision of the diver and removal of involved bowel. Good prognosis Nursing mgt: Preop: iv to correct fluid and elect imbalamce, i&o, occult blood, bed rest, vitals Q2, signs of shock. Post oop: same as any adominal surgery

Scoliosis

S or C curve of the spine CM: truncal assymetry, ueven shoulder and hip height, one side rib hump, prominent scapula, no pain, , hip pain, back pain, lung comprpmise, dyspnea DX: Sclopmeter, inclometer: anything off by 5-7 degrees needs investigaiton MILD: 10-20, exercise to improve posture and muscle tone, build strength on outsiede surve while stretching inside curve; doctor every 3 mo, radiograph every 6 MOD: 20-40, BRACING, boston brace, 23 hours per day Examine children ever 6-9 months for scoliosis After surgery: follow up 4-6 weeks, then eveyre 2-4 months for a year, then 1-2 years after CARE PLAN ON 1458!!!!

Obtunded

Similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states. WORSE THAN LETHARGY, BUT NOT COMA

Growth hormone

Somatropin - regulates metabolic processes related to growth Deficiency/ Hypopituitarism Decreased activity of pituitary gland GH stimulates height, bone density, all tissue growth, protein synthesis in lver, isulin growth factors, CM: Normal birth weights and heights, but by 1 yr they are in the 3rd percintcile for gwoth; ess than 2 inches a year Cherubic, high pitched voices, ripply abdominal fat, decreased muscle mass, delayed skeletal maturaion, delayed sexual maturation, FCFE DX: 2-3 SD below the mean Bone age Alternate daily SQ Stop when child reaches acceptable height or growth velocity drops to less than 2 cm a year Endocrine visits every 3-4 mo SE of GH: muscle pain, reduced insulin sensitivity, SCFE , avascular necrosis of femoral head, man boobs, scoliosis, hypothyroid, pancreatitis, adnreal insuff, ICP Play sports that dont depend on size Growth excess: Hyperpituitarism Grow to 8 feet tall Acronmelagy- abnormal hands and feet, jaw, nasal bones, and teeth spaced Increased IGF

Vision Impairements

Starts on 795 CMS of each on 797 Instilling eye drops on 795 Retinopathy - blood vessels become necrotic and constrict Signs and causes on 804 Promote safety and prevent impairements Developmental screening every 2 mo during infancy, then evry 6 mo for ages 1-5 Call the childs name and speak before touchinng Tell them when you are leaving Describe what it will feel like Let them touch equipment Describe what foods are present and where they are Partnering on 807

Hearing impairements

Symptoms: 817 Screening on 818 Cochlears on 820 Techniques on 820 Early ID tested by 1 mo Touch them or say name, position your face 3-6 feet from theres, normal rate and tone, facial expressions, rephrase if they dont understand, specific explainations, position 3 feet away from hearing aids, if they are getting feedback check for wax, picture boards, sign, fingerspells Sit up front of class, same IQ , Health promotion on 823 Care of hearing aid on 825

Family Centered Care

The family is a source of consistency in the child's life. Note the needs of the entire family, not just the child. Enable and empower the family. Family should be involved in collaboration. Care must be unbiased. Must respect diversity. Not all families cope the same way. Need other families as a support system. Families need home, hospital, and community collaboration. All families have strengths and weaknesses.

Burns

Top 5 leading cause of death Thermal- most common; flames or hot object Chemical- touch or ingest agents Electrical- wires Radioactive- substances or sunlight Full-thickness burn can happen if water is 140 for 5 seconds; 5 minutes if temp is 120 Infants: thermal Tooddlers: thermal, electrical, contact, ingesting chemicals Preschool: scaling or hot School aged: thermal burns, electrical, chemical Adolescent: all Burn > vasocontrsriction > vasoactive hormones > fluid shift to interisital spaces > decrease in fluid volume Needs more calories and water Partial: can regenerate and heal (first and second burns) Full: cant regenerage (third degree) Eschar comes off about 1-2 weeks after Body area burn percentage : 1528 FIRST: ABCS, STOP burning process (remove clothing or whatever), relieve pain, fluid replacement therapyy Tettanus shot if more than 5 years have past CM of burns on 1528 Parkland: 4 mL x kg x %burned = 24 hour replacement Carva or Galv: 5,000 ml/m2 burned area + 2,000 ml/m2 of total body surface area = 24 hours HALF OF TOTAL VOLUME IS INFUSED IN THE FIRST 8 HOURS Eternal feedings within 6 hours of burns!! Escharotomy if circumferential Facial burns - maintain airway Hands : special splinting and PT Peri burns: higher infection, frequent dressing change, cath removed once hydration status stable Wound: remove necrotic tissue, speed wound debridement, maintain moist wound conditions, adequate circulation, concerve body heat and fluids, protect from infection, control scaring and contractures Allograft: cadaver Auto: self Nursing: are they in danger? history,phsyical assessment (fluid imbalances - hypo in first 24, overload after) Pulses distal to burns CARE PLAN ON 1532 Clip any hair within 2 inchges High protein high calories Garmet worn 23 hours a day for 6 mo For superficial burns at home: moist soak or stop the burning, antibiotic ointment, ace, Caring for Burns on 1537 CC on 1537

Cryptochidism

Undescended testes Normally during 7-9 mo gestation May be result of testosterone def. Infertility and malignancy No testes felt on exam, may have hernia inguinal; Most will descend by 3 mo CT MRI Orchiopexy done by 1 year to get balls down; Sealent peels off in 5 days; GET BALLS CHECKED YEARLY FOR LIFE FOR TUMORS!!!!!!! Nursing: ice on balls, diaper cleaned well each time, sponge bath 2 days post op, tub after that, NO MEDICINE OR OIINTMENT ON INCISION, ibuprophen or tyolenol, NO STRADDLING INFANT AND NO RIDING TOY FOR 2 WEEKS post op

SIDS

Unexpcted death under 1 yrs old No explaination on autospsy Most between 2-4 mo Sleep on back or side Reassure parents that they are not responsible Ensure siblings that it wont happen to them First candle organization Risk factors on 855 Pacifiers when sleeping pREVENTS SIDS Supervised tummy time

Assessment of School- Aged

Willing to cooperate Sit on the table Patient gown to cover underwear Let them decide if they want parents in the room Tell what youre doing and why Offer choices Teach, let them listen Standard vision test if over 3 - pen light, confrontation test, ect Scoliosis? Test hearing by standing a foot away and whispering micky mouse or whatever and ask them to repeat Use a sadiometer to measure height, weght them in their underclothes or street clothes according to age;

Infant Pain

under 6 mo: no apparent understanding of pain; responsive to parental anxiety, generalized body movements, chin quivering, facial grimacing, poor feeding, cry 6-12 mo: memory of pain, responsive to parental anxiety, reflex withdrawal to stimulus, facial grimacing, disturbed sleep, irritable, restless, cry

Fluid Maint

• For someone dehydrated- want IV fluids (normal saline or lactated ringers), theyre isotonic, but you want their VOLUME! Without volume their electrolytes will be messed up. They will have hypernatremia, hyperkalemia. • Fluid requirement for a child in a 24 hour period (must have their weight in Kg) o 100ml/kg for first 10kg o 50ml/kg for next 10 kg o 20ml/kg for remainder o Example: pt is 52kg.......ml/hr= 89 (for 24 hours= 2140)

Defects with mixed blood

♣ Transposition of the great arteries (TGA) or Vessels (TGV): this surgery 1-3wks (long term arrhythmias ¬ The aorta is connected to the RV instead of LV ¬ Pulmonary artery in connected to left ventricle instead of right ¬ No communication between the systemic & pulmonary circulation ¬ Murmur ¬ Severe cyanosis hours to days after birth (increases as PDA closes) ¬ Cardiomegaly and HF ¬ Why would you immediately begin Prostaglandin E to a baby with transposition of the great arteries?? Keep the Ductus Arteriosis open!! ¬ What else can be done to promote increased O2 mixture?? A balloon septostomy ¬ Treatment (mortality <2%) o Surgical: Anastomosis of pulmonary artery to proximal aorta OR re-implantation of coronary arteries ♣ Truncus Arteriosus ¬ Failure to create both pulmonary artery & aorta, resulting in one vessel that overrides the ventricles ¬ Single large vessel: empties both ventricles & provides pulmonary, systemic & coronary circulation ¬ VSD usuall present & Murmur ¬ Moderate to severe CHF, Cyanosis, poor growth & activity intolerance ¬ Treatment (mortality >10% o Surgical: closure of VSD & Homorgrafts to provide conduit between right ventricle & pulmonary artery ♣ Hypoplastic Left heart syndrome (no systemic flow): left ventricle is very small...hypertrophy of the muscle. PDA is open & aorta is small. ¬ Underdeveloped left side of heart. (these kids usually end up with a heart transplant ¬ An ASD or patent foramen ovale allows saturated left atrium blood to mix with right atrium blood > to lungs > ductus arteriosus into the aorta > to body= Hypoplastic left ventricle and aortic atresia ¬ Most blood from the left atrium flows across the patent foramen ovale to the right atrium to the right ventricle and out the pulmonary artery. ¬ The descending aorta receives blood from the PDA to supply systemic blood flow ¬ Mild cyanosis and CHF until PDA closes then progressive deterioration > cyanosis > CO ¬ Neonates require mechanical ventilation, Prostaglandin E to maintain ductal patency